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Care management and medical necessity


The Blue Cross NC Care Management Department works with physicians and members to facilitate the most medically appropriate, cost-effective, quality care for our members. By calling 800-672-7897, Care Management staff are available to assist with arranging care for services for our commercial and State Health Plan members. Care Management staff can assist you with arranging:

  • Certification requests
  • Prior review requests
  • Discharge planning
  • Pharmacy quantity limitations
  • Transplants
  • Medical director reviews
  • Reconsideration requests of an initial medical necessity denial
  • Peer-to-peer line

The following utilization management services are available:

  • Staff members are available during normal business hours, excluding holidays. Call us at 800-672-7897 to discuss utilization management issues.
  • After normal business hours, providers and members have access to a voice-mail system by calling us at 800-672-7897.
  • Staff members will identify themselves by name, title and organization name when initiating or returning calls.
  • TDD/TTY services are available at 800-442-7028 for members who need hearing assistance.
  • Language assistance is also available for members who need to discuss utilization management issues by calling us at 800-672-7897.

To learn more about Blue Cross NC's Care Management services, processes or policies, please refer to our provider Blue Book℠ (PDF).

Available SupportDayHours
RepresentativeMonday through Friday8 a.m. to 5 p.m.
Voice-Mail System7 daysOutside of regular business hours

How are medical necessity decisions made?

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 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.

Protecting your patients' health care needs

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:

  • Any decisions made by Blue Cross NC about coverage for care or service are based on your patient's benefit plan, Blue Cross NC medical policy and information from the doctor about the patient's medical condition.
  • The Blue Cross NC doctors and nurses who review your or your patient's requests for service or coverage are not rewarded for denying or limiting coverage.
  • Financial incentives for UM decision makers do not encourage decisions that result in underutilization.
  • At Blue Cross NC, we are committed to making appropriate coverage decisions about our members' health care that meet the terms of their health benefit plan while meeting their medical needs.

Peer to peer review

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.

  • A peer to peer review is a clinical discussion between a requesting physician and a Blue Cross NC medical director.
  • If you have questions about a certification request, you may request to speak directly to a medical director by calling  800-672-7897, ext. 51019.
  • A peer to peer review may also be requested by a Blue Cross NC medical director in order to obtain more clinical information from an attending physician before making a final determination.
  • The purpose of the peer to peer discussion is to give the requesting physicians an opportunity to discuss the clinical details of a requested service.