Prior Authorization Requirement Changes Effective April 1, 2023 (Healthy Blue + Medicare HMO D-SNP)

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

Effective April 1, 2023, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Blue Cross NC for Medicare Advantage members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.

Prior authorization requirements will be added for the following code(s):

• 0736T - Colonic lavage, 35 or more liters of water, gravity-fed, with induced defecation, including insertion of rectal catheter
  
• 30468 - Repair of nasal valve collapse with subcutaneous/submucosal lateral wall implant(s)
• K1019 - Monthly supplies for use of device coded at k1018

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers on the provider website at Healthy Blue Medicare > Login or by accessing Availity. Providers who are unable to access Availity may call our Provider Services at 833-540-2106 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 information, visit Healthy Blue + Medicare.

NCBCBS-CR-013632-22-CPN13014 November 2022