Physicians/Specialists
Facilities/Hospitals
Ancillary
Publication Date: 
2020-01-13

We want to clarify which mental health and substance use services require prior authorization from Blue Cross and Blue Shield of North Carolina (Blue Cross NC) for commercial (excluding the State Health Plan), Federal Employee Program (FEP), and Blue Medicare members.

Key Points

  • As a reminder, all mental and substance use services must be medically-necessary and part of the member's benefit plan to be covered.
  • As of January 1, 2020, some services no longer require prior authorization. These include, but are not limited to intensive outpatient, methadone treatment, outpatient detoxification, outpatient therapy, and partial hospitalization.
  • Please only request prior authorization for services that require an authorization. Our claims systems, as well as our appeals staff, do not look for an authorization unless one is required. Making unnecessary requests can lead to needless administrative efforts.
  • Effective January 1, 2020, the services that do require prior authorization from Blue Cross NC, according to line of business, are as follows (click here for additional details):
Service Commercial Members FEP Members Blue Medicare Members
Inpatient Psychiatry and Substance Use Disorder Yes Yes Yes
Residential Treatment Center Yes Yes No
ECT (all settings) Yes No Yes
TMS (all settings) Yes No Yes
Psychological and Neuropsychological Testing
(all settings)
Yes No Yes
Autism (ABA/ABT) (all settings)* No Yes No

*Please note – ABA/ABT is not covered on all policies. Please check members' benefits to determine if coverage is available.

Questions?
Please contact the Provider Blue Line at 1-800-214-4844.