Reinstating Temporary Prior Authorization Waivers for Skilled Nursing Facilities, Home Health Services and Residential Treatment Centers - Effective January 10, 2022

As the COVID-19 pandemic surges in North Carolina due to the highly contagious Omicron variant, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will waive prior authorization requirements for post-acute care 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. This will ensure that claims process correctly and eligibility and benefits are verified. 

Please see below for details

• This temporary change is effective January 10, 2022 through February 28, 2022.
• This measure applies to home health services, services incurred at in-network SNFs and RTCs for members discharging/transferring from the in-network inpatient level of care (i.e. a direct admit from home to SNF/RTC would require full medical necessity review). 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 waiver only covers Home Health services as a result of a discharge from Observation, Emergency Room or Inpatient settings. 
• 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. For Federal Employee Program members follow current process as it relates to the requested service(s). 
• Benefits must be verified at time of notification prior to issuing an authorization.  
• Approval for SNF/RTC authorization: 
  • Commercial: Initial approval will be authorized for seven (7) days after which time concurrent review will be required to assess medical necessity for a length of extension request.  
  • Medicare Advantage: Initial approval will be authorized based on notification of admission based on existing process by naviHealth for authorization.   
• 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 measure that are still in place

• Waiving Cost-Sharing for COVID-19 Testing: Blue Cross NC will continue waiving member cost-share (copays, deductibles, and coinsurance) for COVID-19-related screening visits and testing. This measure applies to Blue Cross NC’s fully insured, Medicare Advantage (including Experience Health), 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 March 31, 2022, and will continue covering these telehealth visits the same as face-to-face visits. The policy applies to all Blue Cross NC commercial plans and Medicare Advantage plans offered and administered by Blue Cross NC, including the State Health Plan. Members of the Federal Employee Program have telehealth covered at parity with in-person visits until further notice. The extended policy does not apply to Blue Cross NC members getting care from out of state providers.