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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)
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