Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will update prior authorization requirements for Medicare Advantage (MA), Experience Health, and Dual Eligible Special Needs Plan (D-SNP) products for dates of service on or after October 1, 2026.
What is changing
- Several additional procedure codes will require prior authorization
- Codes fall into two categories:
- Molecular Genetics Testing
- Category III (investigational, experimental, emerging technology) codes
Provider action required
- Obtain prior authorization before rendering non-emergent services for impacted codes
- Submit required clinical documentation to support medical necessity
Why this change
This update follows Centers for Medicare & Medicaid Services (CMS) regulatory guidance and provides a more streamlined experience by reducing avoidable claim delays or post-service adjustments through verification that the service is verified as medically necessary, delivered by the right provider, and performed at the right level of care.
A complete list of affected codes and submission guidance are available on the Blue Cross NC services and CPT code search page.
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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