Publication Date

Publication Date: 

In September, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) announced our commitment to offer Affordable Care Act (ACA) plans in all 100 North Carolina counties in 2017.  We made this decision to help ensure ACA plans continue to be available to all North Carolinians, including those who purchase coverage through the Federal Health Insurance Exchange (Marketplace).

Since we are the only health insurer choosing to stay in all 100 NC counties, we need your help, now more than ever!  Given the tremendous challenges we face due to the addition of approximately 260,000 new members from United Healthcare (UHC) and Aetna, we’re asking providers to help prepare for their patients transitioning insurance coverage and continuing health care service needs. Starting in October, we began publishing a series of articles about how we can work together to make the 2017 Annual Enrollment Period (AEP), as smooth as possible.  Here is the second article in the series.

Reminder: During November, please do the following:

  • In November, instruct your patients to visit and click on the Find a Doctor log-in to pick health plans that include you, along with their other doctors.
  • Please remind them to pay their binder payments--so they’ll have continuous coverage and access to services.
  • Remind patients that Blue Cross NC drug formularies might be different than their current UHC and Aetna formularies, and suggest they review plan formularies before choosing new plans.

Care Management and Operations 1-800-672-7897

The Blue Cross NC Care Management and Operations department works with physicians and members to facilitate the most medically appropriate, cost-effective, quality care for our members.  By directly calling 1-800-672-7897, Care Management and Operations staff are available to assist with the following services.

  • Prior review and authorization / certification
  • Discharge planning
  • Pharmacy quantity limitations and restricted access
  • Transplants
  • Medical director reviews
  • Reconsideration requests of an initial medical necessity denial
  • Peer-to-peer line

Please note, mental health and substance abuse services for Blue Cross NC’s commercial and State Health Plan members is handled outside of Blue Cross NC Care Management and Operations.  Please refer to the member’s Blue Cross NC identification card for their specific mental health and substance abuse management, contact information. To learn more about Care Management and Operations services, processes or policies, please refer to Chapter 7 of the BlueBookSM Provider e-manual.

Other things to consider

Ask your patients if their Blue Cross NC health plans are changing for 2017, and if not changing consider obtaining authorizations well in advance of any January and February planned dates-of-service for procedures. Most authorizations can be requested up to 60 days in advance of an actively enrolled member’s planned procedure date.

Some of your patients currently enrolled with UHC and Aetna, and who are transitioning to Blue Cross NC for their health care coverage needs in 2017, may have conditions requiring continued care management and medication access requiring authorizations or other interactions.  Blue Cross NC can assist with managing your patients continuing health care needs, as soon as an individual patient’s Blue Cross NC enrollment is complete and we can confirm their eligibility as a Blue Cross NC member.  Situations to consider when you are treating a patient who has confirmed eligibility with Blue Cross NC and who has complex health needs, may include when:

  • You are treating a patient with a condition that may be eligible for Blue Cross NC case management services. You can refer your patients to a Blue Cross NC Case Manager by calling 1-800-218-5295 extension 55547—for services beginning on or after their January 1, 2017 enrollment date.
  • You are treating a patient who is currently on an active transplant list. Please call 1-800-672-7897 extension 52942, as soon as their eligibility as a Blue Cross NC member can be confirmed.
  • You are treating a patient who is currently being seen and may qualify for Continuity of Care. Please provide that patient with a Continuity of Care Form and ask they obtain information about eligibility criteria by contacting Blue Cross NC using the Customer Service number that’s listed on their Blue Cross NC member identification card.
  • Your patient has services scheduled on or after January 1, 2017, which require authorization from Blue Cross NC. Please verify the patient’s Blue Cross NC eligibility and benefits and if the intended service(s) require prior authorization, make the request in advance of January 1, 2017, when appropriate for the patient’s condition.
  • Your patient is currently taking an authorization required medication and may need the prescription re-filled on or after January 1, 2017. Please verify the patient’s Blue Cross NC eligibility and benefits and if the medication(s) require prior authorization, make the request in advance of January 1, 2017, when appropriate for the patient’s medication needs.

Free electronic solution for making medication authorization requests

Many offices can experience as much as a 43 percent increase in prior authorization (PA) requests in January.  This spike is due to changes in patient prescription coverage, formulary modifications, and renewal requirements.  To assist, the web-based electronic solution for placing PA requests through CoverMyMeds is offered free to participating providers.

CoverMyMeds allows you to submit PA requests for any drug, electronically in your workflow.  By submitting an electronic prior authorization (ePA) request, you will save your practice time and money while getting patients the medications they need, faster.

Benefits of using CoverMyMeds:

  • Eliminate paper forms and faxing to increase visibility and reduce administrative waste
  • Receive faster determinations—often within moments
  • Increase medication adherence and get patients on their needed therapy as soon as possible
  • Manage requests for all drugs, including commercial RX and Part D for Blue Cross NC members
  • Comply with state mandates. To learn about ePA legislation, visit

Visit to learn more about CoverMyMeds or to create your free account.  Once you create an account you can start a PA request, or complete any PA request started for you by one of the more than 47,000 pharmacies who use CoverMyMeds.  If you have questions or need help getting started, reach out to the CoverMyMeds’ team of PA experts by calling 1-866-452-5017 or live chatting when visiting the web address above.