Skip to main content
Shop Plans Learn more about our coverage options including health, Medicare, dental and vision options for you, your family or your employees. Get Started Individual & Family Medicare Employer Vision Dental International Travel Find Care FAQ Blog Members Stay on top of your health care with helpful member resources. Members Home Medicare Health Dental Vision Find Care Member Knowledge Center Member Forms Medicare Forms Library Make a Payment Federal Employees Student Blue Healthy Blue Providers Access tools, policies and the latest information to help you care for our members. Providers Home Network Participation Networks & Programs Claims, Appeals & Inquiries Prior Authorization Services & CPT codes Prescription Drug Search Forms and Documents Policies, Guidelines & Codes Provider News Provider FAQ Contact Us Employers Learn about our coverage options for small and large employers, and access tools and resources for your group. Employers Home Shop Employer Plans Employer Portal Support Member Forms & Resources Find Care Blog Agents Access the tools you need: rate quotes, applications, forms, the latest industry news, marketing materials and more. Agents Home Agent Services Check Eligibility Find Care Member Forms & Resources Medicare Forms Library
Contact Us
Log In
I am ... Please select A member A provider An employer An agent
Log in to Agent Services
Log in to Employer Services Register for Employer Services I'm registered but need portal access
Username Forgot username? Continue to Log In Register for Blue Connect Need help? Learn how to log in.
Log in to Blue e Register for Blue e Log in to Dental Blue
Blue Cross NC Home Providers Prior authorization Request prior authorization Providers Request prior authorization

Find forms to request prior authorization for various services for Commercial and Blue Medicare HMO and PPO members.

Commercial forms Medicare forms

Commercial request forms for specific services

In Network Benefit Reivew Request Prior Review/Certification Fax Form (PDF) Adaptive Behavioral Treatment For Autism Spectrumdisorder/Applied Behavioral Analysis (Aba/Abt) Authorization Request Form (PDF) Behavioral Health Care Length Of Stay Extension Authorization Request Form (PDF) Eating Disorder Inpatient Or Residential Treatment Authorization Request Form (PDF) Electroconvulsive Therapy (ECT) Authorization Request Form (PDF) Facility Based Crisis Services for Behavioral Health Fax Form (PDF) Inpatient Behavioral Health Care (PDF) Intensive Outpatient Program (IOP) Authorization Request Authorization Request (PDF) Non-Hospital Medical Detox Services for Behavioral Health Fax Form (PDF) Partial Hospitalization Programs (PHP) Authorization Request Form (PDF) Residential Treatment for Behavioral Health Authorization Request Form (PDF) Residential Treatment for Substance Use Disorder Authorization Request (PDF) Transcranial Magnetic Stimulation (TMS) Authorization Request Form (PDF) Diagnostic Imaging and Specialty Care Authorization Request (Log In to Blue e)

Drugs that require prior authorization are listed on the Prescription Drugs page. Use the prior authorization drug search tool to find the drug and to see its coverage criteria and prior authorization forms for each formulary.

Commercial Prior Authorization Drug Search
Rehabilitation Program Prior Authorization Request (Log In to Blue e) Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), and Long Term Acute Care Hospital (LTACH) Treatment Plan Update Authorization Request Form (PDF) Prior Authorization Request for Services Form (PDF) Avalon Prior Authorization Request Form (PDF) Facet Joint Denervation Authorization Request Form (PDF) Intensity Modulated Radiation Therapy (IMRT) Authorization Request Form (PDF) Laparoscopic Radiofrequency Ablation (RFA) of Uterine Fibroids: Acessa™ Authorization Request Form (PDF) Musculoskeletal Program Authorization Request (Log In to Blue e) Prostatic Urethral Lift Authorization Request Form (PDF) Topical Negative Pressure Therapy for Wounds Authorization Request Form (PDF) Topical Negative Pressure Therapy for Wounds Extension Authorization Request Form (PDF) Trigger Point and Tender Point Injections Prior Review Request for Services Form (PDF) Medical Oncology Program Authorization Request (Log In to Blue e) Sleep Management Program Authorization Request (Log In to Blue e) Surgical Program Authorization Request (Log In to Blue e)

Medicare request forms for specific services

General Precertification Request Form (D-SNP) (PDF) Overpayment Refund Notification Form (D-SNP) (PDF) Recoupment Authorization Form (D-SNP) (PDF) Electroconvulsive Therapy (Ect) Authorization Request Form (PDF) Experience Health Electroconvulsive Therapy Authorization Request Form (PDF) Experience Health Inpatient Psychiatric Care Authorization Form (PDF) Experience Health Psychological and Neurological Testing Authorization Request Form (PDF) Experience Health Transcranial Magnetic Stimulation Authorization Request Form (PDF) Inpatient Psychiatric Care Authorization Request Form (PDF) Medicare Intensive Outpatient Programs (IOP) Authorization Request (PDF) Medicare Partial Hospitalization Programs (PHP) Authorization Request Form (PDF) Medicare Psychological and Neuropsychological Testing Prior Authorization Request Form (PDF) Psychotherapy Blue Medicare HMO / PPO Prior Authorization Request Form (PDF) Transcranial Magnetic Stimulation – Tms (Including Repetitive Tms – Rtms) Medicare Prior Authorization Request Form (PDF) Diagnostic Imaging and Specialty Care Authorization Request (Log In to Blue e)

Drugs that require prior authorization are listed on the Prescription Drugs page. Use the prior authorization drug search tool to find the drug and to see its coverage criteria and prior authorization forms for each formulary.

Medicare Prior Authorization Drug Search
Bi–Level Positive Airway Pressure (Bipap) For Treatment Of Breathing Related Sleep Disorders Prior Authorization (Pa) Request Form (PDF) Bi–Level Positive Airway Pressure (Bipap) For Treatment Of Obstructive Sleep Apnea Prior Authorization (Pa) Request Form (PDF) Continuous Positive Airway Pressure (Cpap) Rental Or Purchase Prior Authorization (Pa) Request Form (PDF) Durable Medical Equipment (Dme) Repair Or Replacement Prior Authorization (Pa) Request Form (PDF) Knee Orthosis Prior Authorization (Pa) Request Form (PDF) Lumbar Sacral Orthosis (Lso)/Thoracic Lumbar Sacral Orthosis (Tlso) Prior Authorization (Pa)Request Form (PDF) Oxygen Prior Authorization (Pa) Request Form (PDF) Medical Oncology Program Authorization Request (Log In to Blue e) Sleep Management Program Authorization Request (Log In to Blue e) Surgical Program Authorization Request (Log In to Blue e)
About Us Newsroom Blog Member Forms COVID-19 Transparency in Coverage Find Care Rights & Responsibilities Policies & Best Practices Privacy Policy Website User Agreement Fraud & Abuse Technical Information Contact Us Locations Careers

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.

Information in other languages: Español   中文   Tiếng Việt   한국어   Français   العَرَبِيَّة   Hmoob   ру́сский   Tagalog   ગુજરાતી   ភាសាខ្មែរ   Deutsch   हिन्दी   ລາວ   日本語

© 2025 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. All other marks and names are property of their respective owners. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.