These forms are intended for service requests requiring prior plan approval, pre-certification, or certification when being reimbursed through the member's benefits. These include Acute Inpatient Admissions, Elective Inpatient Admissions and PPA Code procedures or services, both outpatient and inpatient. Also included are medical plan drug requests and any quantity limit requests for these medications. View the prescription drug page for more details.
For State Health Plan members, use the commercial fax forms.
The fax forms below are for services in January 1, 2020, and later, and only apply to Blue Medicare HMO and Blue Medicare PPO.
For other services and procedures:
Blue Medicare Utilization Management: 888-296-9790 Monday – Friday, 8 a.m. - 5 p.m., Eastern time
Some services and procedures received in a nonemergency situation on an outpatient basis require prior plan approval.
The fax form below is for services in January 1, 2020 and later.
Below are the essential forms that are required to be completed prior to rendering services such as general pre-certification forms, behavioral health treatment and refund requests.
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.