Physicians/Specialists
Facilities/Hospitals
Publication Date: 
2020-10-08

Effective October 1, members and providers could experience changes in what services may require prior authorization. Additionally, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is shifting its post-service medical necessity reviews for investigational services to prior review to assist with decision making. This shift aims to benefit both providers and members through transparency and collaborative business practices.

Members and providers will have the opportunity to know what is covered upfront because the review process will be completed before the service has been rendered. We do not want a provider to find out a service was denied as not medically necessary after the service has already been completed.

Note: Prior authorization does not mean a service will be approved for coverage. This utilization management tactic is a review process.

These changes apply to all Blue Cross NC commercial plans — including individuals (under-65), fully insured group customers and self-funded (ASO) group customers — and State Health Plan (SHP) members. These changes do not affect Federal Employee Program (FEP), Medicare Advantage (including Experience Health) or IPP Host members.

For more information

Services requiring prior authorization are listed in the database of the Prior Plan Review page on BlueCrossNC.com.

More information on why prior authorization has been added for certain services can be found on the Medical Policies page on BlueCrossNC.com.