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Prior Plan Approval Search
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Prior review (prior plan approval, prior authorization, prospective review or certification) is the process Blue Cross NC uses to review the provision of certain medical services and medications against health care management guidelines prior to the services being provided. Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, and prescription medications may be subject to prior review.
Reviews may confirm:
- Member eligibility
- Benefit coverage
- Compliance with Blue Cross NC corporate medical policy 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, case management or the Healthy Outcomes Condition Care Program
Services Requiring Prior Plan Approval - Request a Prior Review:
Admissions and private duty nursing
Including skilled nursing facility admissions and private duty nursing service.
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Diagnostic imaging
Including CT/CTA, PET and MRI/MRA scans and nuclear cardiology studies.
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Prescription drugs
Including medications to treat Hepatitis C, ADHD, weight loss, biologics for arthritis and psoriasis, and restricted access drugs.
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Other services and procedures
Including home health care services, durable medical equipment, mental health/substance abuse and the Prior Review List.
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Medical Oncology Program
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