Prior review (prior plan approval, prior authorization, prospective review or certification) is the process Blue Cross NC uses to review the provision of certain behavioral health, medical services and medications against health care management guidelines prior to the services being provided. Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, and prescription medications may be subject to prior review.
You can search for services and durable medical equipment, or medications that require authorization for all places of service, including when performed during any inpatient admission, including both planned inpatient admissions and emergent inpatient admissions.1
Reviews may confirm:
- Member eligibility
- Benefit coverage
- Compliance with Blue Cross NC corporate and Blue Medicare medical policies regarding medical necessity
- Appropriateness of setting
- Requirements for use of in-network and out-of-network facilities and professionals
- Identification of comorbidities and other problems requiring specific discharge needs
- Identification of circumstances that may indicate:
- a referral to concurrent review, discharge services, case management or the Healthy Outcomes Condition Care Program
- a referral to a second opinion, continuity of care, case management or the Member Health Partnerships program
- a referral to chronic case management
