Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is committed to being a valued health care partner, and we are always looking for ways to achieve better health outcomes, lower costs, and deliver a better health care experience for our members. One way in which we can achieve this is to partner with providers to utilize care sites beyond the hospital when performing some surgical procedures.
Effective October 1, 2025, when prior authorization is requested for certain minor surgical procedures, including digestive, urinary, eye, ocular adnexa and ear, a site of care review will be performed when the request is for a hospital-based outpatient setting.
Carelon will evaluate the clinical information against the appropriate Carelon clinical guidelines to determine if the procedure requires the service to be rendered in a hospital-based outpatient setting. Learn more about these guidelines.
Current Surgical Guidelines | Carelon Clinical Guidelines and Pathways
When medical necessity criteria for these minor surgical procedures in a hospital-based outpatient setting are not met, an alternative less-intensive site of care should be utilized, such as an ambulatory surgery center (ASC) or provider office. Carelon is available for a peer-to-peer discussion before or after the decision, in the event your office wishes to speak with Carelon.
Please note, for digestive surgical procedures, Carelon currently performs medical necessity review of the upper endoscopy procedures, which will continue to be a requirement for these services, in addition to the site of care review when the hospital-based outpatient setting is requested.
The surgical site of care review only applies to select procedures of the below systems when performed in an outpatient hospital setting:
- Digestive
- Eye, Ocular Adnexa and Ear
- Urinary
View a complete list of procedures subject to site of care review.
Members included in the Site of Care Program
This program will apply to all Commercial Fully Insured plans receiving services in North Carolina. It does not apply to our Medicare Advantage plans, Dual Special Needs Plan (DSNP), Employer Group Waiver Plan (EGWP), Federal Employee Program (FEP) plan, and Administrative Services Only (ASO) plans or Fully Insured members receiving services outside of North Carolina.
How to Submit a Request for Review
Starting September 8, 2025, providers can begin submitting requests for review or verify order numbers using one of the following methods:
Online
Access Carelon’s portal through Blue e, which is available 24/7, fully interactive, and processes requests in real-time using clinical criteria.
By Phone
Call Carelon Medical Benefits Management toll-free at 866-455-8414 Monday through Friday between 8:00 a.m. – 6:00 p.m. EST.
Provider Training Opportunities
Prior to the Carelon Call Center and Provider Portal going live on September 8, 2025, there will be webinar sessions for providers and office staff to learn more about each program and how to use the Carelon Provider Portal. We strongly encourage office staff and providers to participate, even if you are already familiar with Carelon and the Provider Portal through other health plans or specialty programs.
Live webinar sessions with Q&A will cover topics such as:
- How the program and preauthorization request process work
- Which members and services will require preauthorization
- Demonstration of the Carelon provider portal and how to enter order requests
- Share additional resources
- Q&A with our Solution Operations Leaders
Please register to attend at least one training session. Carelon solution-specific training content will be made available to you upon completion of registration and prior to attending a webinar session. Reviewing the material ahead of the training will allow your facility to bring relevant questions to be addressed during the training. Prior to the change going into effect, a recording of each solution training will be made available on the Carelon Provider Portal for all registered portal users.
