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

Update posted 4/24/23: For more information, view our updated communication.

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 July 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 Healthy Blue + Medicare 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):

• 81328 - SLCO1B1 (solute carrier organic anion transporter family, member 1B1) (for example, adverse drug reaction), gene analysis, common variant(s) (for example, *5)

Not all PA requirements are listed here. Detailed PA requirements are available to providers on Healthy Blue + Medicare on the Resources tab or for contracted providers by accessing the Availity website. Providers may also call Healthy Blue + Medicare 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. 

Blue Cross and Blue Shield of North Carolina Senior Health, DBA Blue Cross and Blue Shield of North Carolina, is an HMO D-SNP plan with a Medicare contract and a NC State Medicaid Agency Contract (SMAC). Enrollment in Blue Cross and Blue Shield of North Carolina Senior Health depends upon contract renewal.

NCBCBS-CR-020700-23-CPN20040 March 2023