Medicare Advantage - Provider Notification for Utilization Management Authorization Rule Operations Workgroup Item 1907

Please note, this communication applies to Healthy Blue + Medicare^SM (HMO D-SNP) offered by Blue Cross and Blue Shield of North Carolina (Blue Cross NC).

On October 1, 2021, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) prior authorization (PA) requirements will change for A0426 and A0428. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services (CMS) guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

Prior authorization requirements will be added for the following codes:

• A0426 – Als 1
• A0428 – Bls

Not all PA requirements are listed here. PA requirements are available to contracted providers on the provider website or by accessing Availity. Once logged in to the Availity website, select Patient Registration > Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry, as appropriate. Contracted and noncontracted providers who are unable to access Availity may call the number on the back of the member’s ID card for assistance with PA requirements.

Note: Availity, LLC is an independent company providing administrative support services for Healthy Blue + Medicare providers on behalf of Blue Cross and Blue Shield of North Carolina.

For more details on member eligibility, claim status, claims entry and more, visit the Blue Cross NC providers page. 

BNCCARE-0144-21 June 2021    519127MUPENMUB