Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is extending existing authorizations for in-network providers for all commercial elective inpatient admissions and most commercial outpatient services to be performed on or before October 1, 2020.
Blue Cross NC recognizes that call volume from patients likely will increase post-pandemic and that providers have delayed elective services to help flatten the curve. This measure seeks to support providers by eliminating the need to conduct additional medical necessity review on a procedure that has already been approved. Please see below for details.
Please Note: Elective procedures still require a medical necessity review and are not part of recent prior authorization waivers. Providers scheduling procedures that have not been previously authorized should submit a prior authorization for review utilizing the normal process.
Commercial elective inpatient admissions:
No additional medical necessity review will be required for all elective inpatient admissions for in-network providers that were previously approved with service dates on or after March 1, 2020.
However, the provider must call 1-800-672-7897 before the date of the procedure to advise of the new service date so that claims will pay appropriately. By doing so, the authorization will be updated to reflect the re-scheduled service date. Blue Cross NC will send a new authorization letter reflecting this change after the provider calls.
Commercial outpatient services:
Blue Cross NC will automatically extend authorizations for most commercial outpatient services for in-network providers.
For services approved with service dates on or after March 1, 2020, and expiring before September 30, 2020, no action is needed from providers for commercial members. Authorizations will be updated with an end of service date of October 1, 2020.
Excluded from this automatic extension are skilled nursing visits, DME rentals, private duty nursing and medical pharmacy drugs. Continue to follow normal processes for these commercial outpatient services.
You should continue to utilize the current process for all pharmacy drugs.
Services for Blue Cross NC Medicare Advantage (MA) and Federal Employee Program (FEP) members:
Elective outpatient and inpatient authorizations will not be automatically extended for members of Blue Cross NC MA plans, the MA plan that Blue Cross NC administers for Experience Health, and the FEP plan that Blue Cross NC administers. However, providers can notify us of the new service date and the existing authorizations will be updated to ensure that claims will pay appropriately.