Prior review (prior plan approval, prior authorization, prospective review or certification) is the process Blue Cross NC uses to review the provision of certain behavioral health, 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.
You can search for services and durable medical equipment, or medications that require authorization for all places of service, including when performed during any inpatient admission, including both planned inpatient admissions and emergent inpatient admissions.1
Reviews may confirm:
- Member eligibility
- Benefit coverage
- Compliance with Blue Cross NC corporate 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, case management or the Healthy Outcomes Condition Care Program
- a referral to a second opinion, continuity of care, case management or the Member Health Partnerships program
- a referral to chronic case management
Prior review policies and procedures
- Blue Cross NC may authorize a service received out-of-network at the in-network benefit level if the service is not reasonably available in-network as determined by Blue Cross NC's access to care standards or if there is a continuity of care issue.
- Requirements for utilization of in-network and out-of-network facilities and professionals must be verified in conjunction with obtaining prior review.
Members plans affected by prior review policies
- Blue Advantage
- Blue Care
- Blue Value
- Blue Options (including 1-2-3, HSA, etc)
- Blue Medicare HMO/PPO
- Experience Health Medicare Advantage℠ (HMO)
- Prior review for Classic Blue® is also required for employees of Morgan USA and Martin Marietta.
In case of emergency, prior approval is not required. An emergency is an instance in which the absence of medical attention could jeopardize a person's life, health, or ability to regain maximum function, or could subject a person to severe pain.
Services on the Prior Review Code List that are rendered emergently or urgently during an inpatient admission are still subject to medical necessity criteria.
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.