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Prior Authorization Requirement Changes (Healthy Blue + Medicare HMO D-SNP)

Update December 1, 2022 - The effective date has been updated. The new communication is available here. 

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

Effective February 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 our 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):

  • 0117U - Pain management, analysis of 11 endogenous analytes (methylmalonic acid, xanthurenic acid, homocysteine, pyroglutamic acid, vanilmandelate, 5-hydroxyindoleacetic acid, hydroxymethylglutarate, ethylmalonate, 3-hydroxypropyl mercapturic acid (3-HPMA), quinolinic acid, kynurenic acid), LC-MS/MS, urine, algorithm reported as a pain-index score with likelihood of atypical biochemical function associated with pain
  • K1021 - Exsufflation belt, includes all supplies and accessories

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers on the provider website at provider website > Login or by accessing Availity* at Providers who are unable to access Availity may call our Provider Services at 833-540-2106 for assistance with PA requirements.

* 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-007786-22-CPN7360 November 2022