Blue Medicare

 

Blue Medicare HMO
Blue Medicare PPO

Prior Plan Approval

 

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Prior Plan Approval Code List:

This list is updated on a quarterly basis, within the first 10 days of January, April, July, and October. If there is no update within this time period, the list will remain unchanged until the following quarter. Unlisted and miscellaneous health services codes should only be used if a specific code has not been established by the American Medical Association.

Requirements for utilization of in-network and out-of-network facilities and professionals must be verified in conjunction with obtaining prior plan approval.

Blue Medicare may authorize a service received out-of-network at the in-network benefit level if the service is not available in-network or if there is a transition of care issue.

Services not covered by Original Medicare are not covered by Blue Medicare.

2018 Codes that require Prior Approval PDF Icon
2019 Codes that require Prior Approval PDF Icon
2020 Codes that require Prior Approval PDF Icon

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Request Prior Plan Approval

For other services and procedures:

  • By fax:
    • Episodic Case Management (acute inpatient rehab, DME, home health, etc.): 336-659-2945
    • Concurrent Review/Discharge Planning: 336-794-1555
    • Pre-certification, including behavioral health services: 336-794-1556
  • By phone: Blue Medicare Utilization Management: 1-888-296-9790 Monday - Friday, 8 a.m. - 5 p.m., Eastern time

2020 Prior Authorization Guidelines PDF Icon
2019 Prior Authorization Guidelines PDF Icon
2018 Prior Authorization Guidelines PDF Icon

The following services and procedures received in a nonemergency situation on an outpatient basis require prior plan approval.

  • Behavioral health (mental health or substance use disorder) treatment (contact Blue Medicare HMO / PPO at 1-800-266-6167)
    • Fax forms for services starting January 1, 2020 are available to request prior authorizations of certain behavioral health services and providers are encouraged use them.
  • Non-emergency ambulance services
  • Certain durable medical equipment (DME): ***Prior approval codes for DME are available from Customer Service, Utilization Management or your Blue Cross NC Network Management representative.
    • Blue Medicare HMO/PPO DME
      Fax forms are available to request prior authorizations of certain durable medical equipment and providers are encouraged use them for applicable items.
    • Experience Health Medicare Advantage SM (HMO) DME
      Fax forms are available to request prior authorizations of certain durable medical equipment and providers are encouraged use them for applicable items.
  • Home health, including nursing and home infusion
  • Investigational and Experimental Services
  • Surgery and/or outpatient procedures, including but not limited to:
    • Lung volume reduction surgery
    • Morbid obesity surgery
    • UPPP, surgical management of obstructive sleep apnea
  • Procedures potentially cosmetic, including but not limited to:
    • Reconstructive surgery, including but not limited to dermabrasion
    • Breast surgeries including insertion and removal of silicone breast implants, reduction mammoplasty, and gynecomastia
    • Blepharoplasty
    • Abdominoplasty
    • Therapy of superficial veins, such as varicose veins
    • Orthognathic surgery

 

 

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