Update December 1, 2022 - The effective date has been updated. The new communication is available here.
Please note, this communication applies to Healthy Blue + MedicareSM (HMO D-SNP) offered by Blue Cross and Blue Shield of North Carolina (Blue Cross NC).
Effective February 1, 2023, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Blue Cross NC for our members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining
coverage. Non-compliance with new requirements may result in denied claims.
Prior authorization requirements will be added for the following code(s):
- 0117U - Pain management, analysis of 11 endogenous analytes (methylmalonic acid, xanthurenic acid, homocysteine, pyroglutamic acid, vanilmandelate, 5-hydroxyindoleacetic acid, hydroxymethylglutarate, ethylmalonate, 3-hydroxypropyl mercapturic acid (3-HPMA), quinolinic acid, kynurenic acid), LC-MS/MS, urine, algorithm reported as a pain-index score with likelihood of atypical biochemical function associated with pain
- K1021 - Exsufflation belt, includes all supplies and accessories
Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers on the provider website at provider website > Login or by accessing Availity* at http://availity.com. Providers who are unable to access Availity may call our Provider Services at 833-540-2106 for assistance with PA requirements.
*Availity, LLC is an independent company providing administrative support services for Healthy Blue + Medicare providers on behalf of Blue Cross and Blue Shield of North Carolina.
BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is an independent licensee of the Blue Cross and Blue Shield Association. All other marks are the property of their respective owners.
NCBCBS-CR-007786-22-CPN7360 November 2022