Physicians/Specialists
Facilities/Hospitals
Ancillary
Publication Date: 
2019-11-19

As a reminder, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will manage behavioral health services for commercial, Federal Employee Program (FEP), and Blue Medicare members, effective January 1, 2020. Please note – this change does not apply to State Health Plan (SHP) members.

The following information can help you understand more about how to process utilization management (UM) or “prior plan approval/prior authorization” requests before and after January 1, 2020:

Effective January 1, 2020, what requires UM from Blue Cross NC?

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 the member’s benefits to determine if coverage is available

Where should requests for services go?

UM Dates of Service Please Send Requests To
Services initiated before December 31, 2019

Magellan Health

Inpatient services starting in 2019 and continuing to 2020

For Commercial and FEP Members:

  • Magellan – until the patient is no longer inpatient, or until January 10, 2020
  • Blue Cross NC – for recertification (on/after January 1, 2020), starting January 11, 2020

For Medicare Members:

  • Magellan – until the patient is discharged or stepped down to a lower level of care

Services initiated on or after January 1, 2020

Blue Cross NC

Blue Cross NC will begin accepting prior plan approval request for services that will occur in 2020 on December 16, 2019.

How should authorization requests be submitted to Blue Cross NC?

Members Submission Instructions
Commercial Members (excluding SHP)

Blue Cross NC created fax forms with the necessary information for us to process PPA requests.

  • Please submit completed fax forms to the number provided on the bottom of the fax form.
  • Fax forms for 2020 services will be available here on December 16, 2019.
  • Questions? Please contact us at 1-800-672-7897.
  • Providers will be notified via fax about PPA decisions.
FEP Members

Blue Cross NC created fax forms with the necessary information for us to process PPA requests.

  • Please submit completed fax forms to the number provided on the bottom of the fax form.
  • Fax forms for 2020 services will be available here on December 16, 2019.
  • Questions? Please contact us at 1-800-672-7897.
  • Providers will be notified via fax about PPA decisions.
Blue Medicare Members

Blue Cross NC created fax forms with the necessary information for us to process PPA requests.

  • Please submit completed fax forms to the number provided on the bottom of the fax form.
  • Fax forms for 2020 services will be available here on December 16, 2019.
  • Questions? Please contact us at 1-888-296-9790, option 6.
  • Providers will be notified via fax about PPA decisions.