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Blue Cross NC Home Providers Prior authorization Providers Prior authorization

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) reviews certain behavioral health, medical services, equipment, and medications against health care management guidelines prior to the services being provided.1

Why we require the process

We may require prior authorization reviews to confirm:

  • Member eligibility
  • Benefit coverage
  • Compliance with Commercial and Blue Medicare medical policies regarding medical necessity
  • Appropriateness of setting
  • Requirements for use of in-network and out-of-network facilities and professionals
  • Identification of comorbidities and other problems requiring specific discharge needs
  • Identification of circumstances that may indicate:
    • a referral to concurrent review, discharge services, or case management
    • a referral to a second opinion, continuity of care, or case management
    • a referral to chronic case management
  • Services on the Prior Authorization Code List that are rendered emergently or urgently during an inpatient admission are still subject to medical necessity criteria.
Find out if we require prior authorization

Use our search tools to determine if we need prior authorization and how to submit authorization requests.

CPT / HCPCS codes

Search for services and durable medical equipment for plans requiring prior authorization.

Search by Commercial Codes Search by Medicare Codes
Prescription drugs

Search for prescription drugs for plans requiring prior authorization.

Search by Commercial Drugs Search by Medicare Drugs
Medical policies and supporting documentation

Medical policies, medical necessity criteria, and medical record submission requirements play a part in informing our prior authorization decisions. Review these policies and what you may need to submit with prior authorization requests.

Medical policies and guidelines
View medical and reimbursement policies
Care management and medical necessity
Get help arranging care for commercial members
Medical records submission and reporting
Learn how to submit patients' records
Request prior authorization
Browse request forms
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Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.

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© 2025 Blue Cross and Blue Shield of North Carolina. ®, SM Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. All other marks and names are property of their respective owners. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.