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Quality assurance programs

Quality assurance programs

  

Prior plan approval

This is the process by which Blue Cross and Blue Shield of North Carolina (Blue Cross NC) reviews health care services and prescriptions before they occur in order to provide approval to perform the service or prescribe the medication. Network providers request prior plan approval on behalf of the member. Members who choose to visit out-of-network providers are responsible for making sure that prior plan approval is obtained.

For a complete list of services, procedures and prescription drugs requiring prior approval, and instructions on submitting a request for approval, review the prior plan approval section.
Concurrent review

This process is performed by Blue Cross NC nurses while a member is hospitalized to verify that the member is in the most appropriate setting. Concurrent review nurses also work with the Blue Cross NC discharge services staff to help arrange any care necessary after the member is discharged from the hospital.
Retrospective review

In unusual instances, this process occurs when medical services, including hospital services, are reviewed for approval after the services have taken place. The process evaluates a members' medical history to identify any treatment issues. Alerts are provided by mail to physicians, addressing patient treatment practices that are considered unsafe, ineffective or otherwise inconsistent with evidence-based standards of care.
Case management program

This program is designed for members with very serious, chronic or complicated health care conditions. A Blue Cross NC case manager works with the member, as well as the member's family, and health care providers to coordinate and facilitate the availability of appropriate resources to result in optimal health outcomes for the member.
Continuity of care assistance

This process is designed to assist members with acute, chronic or terminal illnesses or those who are in the second trimester of pregnancy with receiving care from a provider when the member changes health plans or when the provider no longer participates in network. To be eligible for continuity of care, one of the following conditions must apply:

  1. Member has a chronic illness or condition - a disease or condition that is life-threatening, degenerative or disabling and requires medical care or treatment over a prolonged period of time.
  2. Member is in the second or third trimester of pregnancy or completing postpartum care.
  3. Member is terminally ill - a medical prognosis that the individual's life expectancy is six months or less.

Blue Cross NC must authorize services in advance in order for the services to be covered at the in-network benefit level. Members should work with their providers to request prior approval from Blue Cross NC or may contact Customer Service on their own to obtain a continuity of care request form within 45 days of either their effective date or the date they receive notification of a provider's termination from a Blue Cross NC network.

If a member currently is receiving care for mental health or substance abuse, and is enrolling in Blue Care or Blue Choice plan, the member may call 800-359-2422 to determine if continuity of care is applicable.

If a member has a concern about the final certification decision, the member has the right to appeal the decision.

For more information about the Blue Cross NC quality assurance programs, please call 800-359-2422 or write to:

Health Coaching and Interventions Department
Blue Cross NC
P.O. Box 2291
Durham, NC 27702

Access to utilization management review staff:
800-672-7897 (toll free)

Blue Cross NC Customer Service:
800-446-8053 
Monday to Friday 8 AM–9 PM 

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Medicare health care services
Prospective review

The process of reviewing health care services before they occur in order to receive certification. It is the provider’s responsibility to contact Blue Medicare HMO and Blue Medicare PPO for authorization for those services requiring prior approval. For a list of services requiring prior approval, see the Prior Authorization section of the Provider Blue Book Manual.
Concurrent review

A process performed by Blue Medicare HMO and Blue Medicare PPO nurses while a patient is in the hospital to try to make sure the patient is in the most appropriate setting. Concurrent review nurses also work with the hospital staff to help arrange any care after the patient is discharged from the hospital.
Retrospective review

When medical services, including hospital services, are reviewed for certification after the services have taken place.
Case management program

Designed for members identified at risk for serious and complex medical conditions or with complicated health care needs. This program provides a nurse case manager who can assist physicians and health care team members to coordinate delivery of healthcare services for members in the most effective manner. Case managers are also available to assist members in navigating through the health care system, educate members regarding their medical condition, and promote members’ compliance with the physician directed treatment plan.

Learn more

Utilization management The member's rights and responsibilities

Blue Cross and Blue Shield of North Carolina is an HMO, PPO, and PDP plan with a Medicare contract. Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal.