We want to ensure that all physicians are aware of the criteria and guidelines utilized by Blue Cross NC to make medical necessity decisions for membership enrolled in our commercial products. In these decisions we are guided by evidence-based care guidelines from MCG Health and Blue Cross NC corporate medical policy.
Our licensed nurses use MCG to authorize coverage for inpatient services, home care and rehabilitation services. MCG are updated annually and practitioners can obtain a copy of a specific MCG or a Blue Cross NC medical policy by calling our Care Management department at 800-672-7897, ext. 57078. Our medical policies are also available through our website at Blue Cross NC.com via the "Provider" portal. If a nurse cannot approve a service, a Blue Cross NC medical director (who is licensed in North Carolina) will review the case and may approve or deny coverage based on MCG or Blue Cross NC medical policy, along with clinical judgment. Only a medical director can deny coverage for a service based on medical necessity. We encourage you to take part in a "peer-to-peer" consultation regarding a case before or after a determination, because a discussion between physicians can help clarify a situation and affect the determination. A Blue Cross NC medical director is always available during regular business hours and can be reached by calling 800-672-7897, ext. 51019.
Did you know that there are standards in place that protect health care consumers? The National Committee for Quality Assurance (NCQA), a not-for-profit organization that accredits Blue Cross NC, has developed standards that do just that. NCQA and Blue Cross NC want you to know that:
Blue Cross NC medical directors are available to discuss clinical problems and benefit issues with network providers particularly where there are issues that complicate the management of the patient's condition.
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.
© 2023 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. Blue Cross NC is an abbreviation for Blue Cross and Blue Shield of North Carolina. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.