Temporary Prior Authorization Waiver for Skilled Nursing Facilities, Home Health Services and RTCs

Sept. 16, 2021 Update: This communication has been updated to include revised policy expiration dates. This policy was originally set to expire on September 22, 2021. The measure will now be in effect through October 31, 2021. The original communication was posted on August 20, 2021. 

Due to the recent spike in COVID-19 cases and hospitalizations, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will waive prior authorization requirements for post-acute care covered services incurred by Blue Cross NC members in North Carolina home health settings, in-network skilled nursing facilities (SNFs) or residential treatment centers (RTCs). This applies to all conditions, including non-COVID-19 conditions. (While this measure is in place, Blue Cross NC requires notification only, rather than prior authorization, for these services.)   

Please see below for details:   

• This temporary change is effective August 21, 2021 through October 31, 2021.   
  
• This waiver applies to home health services, services incurred at in-network SNFs and RTCs for members discharging from inpatient level of care. Medical necessity review is required for length-of-stay extensions beyond the days allowed on the initial approval.   While prior authorization is not required, providers remain obligated to follow all Blue Cross NC medical policies regarding any inpatient stay at these facilities. 
• This measure applies to fully insured, self-funded employer groups (including State Health Plan) and Medicare Advantage plans offered or administered by Blue Cross NC, including Experience Health. This does not apply to Federal Employee Program members. 
• This measure applies to Blue Cross NC members receiving care in North Carolina only.  It does not apply to Blue Cross NC members receiving care outside of North Carolina. It also does not apply to members of other Blue Cross Blue Shield plans receiving care in North Carolina.  

This temporary change is in addition to these other measures to support members, providers and our communities during the COVID-19 pandemic.  

Additional COVID-19 measures that are still in place  

• Waiving Cost-Sharing for COVID-19 Testing: Blue Cross NC will continue waiving member cost-sharing (copays, deductibles and coinsurance) for COVID-19-related screening visits and testing until the public health emergency is over. This measure applies to Blue Cross NC’s fully-insured, Medicare Advantage (including Experience Health), and Federal Employee Program members and ASO groups that did not opt out. Members should contact the Blue Plan listed on their ID card for information about their COVID-19 benefits.  
  
• COVID-19 vaccines, including boosters, that are FDA approved, including for emergency use authorization (EUA), are available at no cost to all Blue Cross NC members.
• Expanded Telehealth (Virtual Care) Policy: Blue Cross NC is extending its expanded reimbursement policy for doctor visits by video or phone, through December 31, 2021, and will continue covering these telehealth visits the same as face-to-face visits. This measure applies to all Blue Cross NC commercial plans and Medicare Advantage plans offered and administered by Blue Cross NC. Blue Cross NC has been covering telehealth for more than 20 years and will continue to do so after the pandemic. COVID-19 is driving long-term changes in how doctors and patients use and value telehealth. Blue Cross NC will use data and insights gained from this period of increased virtual visits to update its telehealth policy later in 2021 to best serve its members. This review period will ensure that telehealth remains a tool that improves health, increases access to health care, and lowers costs for members.