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Frequently Asked Questions

Diagnostic imaging


Q: What is prior plan approval? Top of Page

A: Prior plan approval (also called prior approval, prior authorization, prospective review, prior review, certification or precertification) is when BCBSNC reviews certain medical services or drugs before they are given to patients to make sure that the service or drug is right for the patient.

Even if a doctor gets prior plan approval from BCBSNC that says that the service or drug is correct for the patient, this does not guarantee payment. For more information, go to the prior plan approval page.

Q: When does my doctor need to get prior plan approval for high-tech scans? Top of Page

A: Any outpatient scans (scans not done in an emergency room or as part of an inpatient hospital stay) on or after February 15, 2007, need prior plan approval from BCBSNC

Q: I've had my scan scheduled for months, but it's after February 15. Do I still need to get approval from BCBSNC? Top of Page

A: Yes. If you are going to have a scan on or after February 15, 2007, your doctor needs to get prior plan approval from BCBSNC before you have the scan –regardless of when it was scheduled.

Q: What types of scans need approval from BCBSNC before they are done? Top of Page

A: High-tech scans (diagnostic imaging procedures), such as CT or CTA scans, MRI or MRA scans, PET scans or special heart scans called nuclear cardiology studies, require prior plan approval from BCBSNC. If these scans are not part of an emergency room visit or an inpatient hospital stay, then your doctor needs to get prior plan approval from BCBSNC.

Q: What are these scans and what do they do? Top of Page

A: 

  • CT scan: Computed tomography (CT) scan uses X-ray imaging to make detailed pictures of structures inside of the body.
  • CTA scan: Computed tomography angiogram (CTA) scan uses X-ray imaging to make detailed pictures of blood vessels inside the body.
  • MRI scan: Magnetic resonance imaging (MRI) is a scan that uses a magnetic field and pulses of radio wave energy to make pictures of organs and structures inside the body.
  • MRA scan: A magnetic resonance angiogram (MRA) uses a magnetic field and pulses of radio wave energy to provide pictures of blood vessels inside the body.
  • PET scan: Positron emission tomography (PET) is a test that uses a special type of camera and special nuclear medicine to look at organs in the body.
  • Nuclear cardiology studies: These are special studies of the heart.

Q: What scans do NOT require prior plan approval from BCBSNC? Top of Page

A: If you have a scan in the emergency room or as part of an inpatient hospital stay, your doctor does not need to get approval from BCBSNC for the scan.

Q: Is prior plan approval required for X-rays, mammograms or ultrasounds? Top of Page

A: No. Prior plan approval is not required for “low-tech” scans such as X-rays, mammograms or ultrasounds.

Q: Is prior plan approval required in an emergency situation? Top of Page

A: No. If you are taken to an emergency room or urgent care center for an emergency, any scans you receive during that do not need prior approval.

Q: Who is responsible for getting prior plan approval from BCBSNC? Top of Page

A: Your doctor. If your doctor is part of the BCBSNC network, he or she should contact BCBSNC and request prior plan approval for your scans. If your doctor is not part of the BCBSNC network or is located outside of North Carolina, you must tell your doctor to get prior plan approval for you. An out-of-network or out-of-state provider will not be familiar with BCBSNC's prior plan approval requirements. If prior plan approval is not obtained, BCBSNC will not pay for the scan and you will be responsible for the bill (this does not apply if you see an in-network provider). Tell your doctor to visit our Web site, www.bcbsnc.com/providers/ppa, for more information about how to get prior plan approval for your scan.

Q: How do I know if my doctor gets prior plan approval? Top of Page

A: To find out if your doctor has gotten prior plan approval from BCBSNC before the scan is done, call BCBSNC Customer Service at the toll-free number on your ID card.

Q: What if my doctor refuses to get prior plan approval from BCBSNC before my scan? Top of Page

A: If your doctor is part of the BCBSNC network, he or she is responsible for getting prior plan approval from BCBSNC on your behalf. You will not be responsible for the bill if your in-network doctor does not get prior plan approval. If your doctor is not part of the BCBSNC network or is located outside of North Carolina, you must tell your doctor to get prior plan approval for you. If your doctor does not get approval and you have the scan anyway, BCBSNC will not pay for the scan and you will be responsible for the bill (this does not apply if you see an in-network provider).

Q:  Is approval needed if I go to an out-of-network or out-of-state doctor? Top of Page

A: Yes. If your doctor is not part of the BCBSNC network or is located outside of North Carolina, you must tell your doctor to get prior plan approval for you. An out-of-network or out-of-state provider will not be familiar with BCBSNC's prior plan approval requirements. If prior plan approval is not obtained, BCBSNC will not pay for the scan and you will be responsible for the bill if the provider is out-of-network or out-of-state. Tell your doctor to visit our Web site, www.bcbsnc.com/providers/ppa, for more information about how they can request prior plan approval for your scan.

Q: What if an approval is required outside of BCBSNC's normal business hours, such as at night or on the weekends? Top of Page

A: BCBSNC is working with a company called American Imaging Management (AIM) for the approval of high-tech scans. AIM has a Web site that lets doctors request approval for high-tech scans 24 hours per day, seven days a week. If your doctor does not have access to the Internet and the request is urgent, your doctor has two business days to file the paperwork to AIM in order for BCBSNC to approve the scan. If your doctor does not file the paperwork within two business days after an urgent request, BCBSNC may not pay for the scan.

If your doctor is in the BCBSNC network, he or she is responsible for getting prior plan approval from BCBSNC on your behalf. If your doctor is out-of-network or located outside of North Carolina, you are responsible for the cost of the scan if the doctor does not obtain prior plan approval before the scan is done. Remember: You do not need prior plan approval for a high-tech scan if it is part of an emergency room visit or an inpatient hospital stay.

Q: Why does BCBSNC require prior plan approval for high-tech scans? Top of Page

A: High-tech scans are great tools for doctors to use when diagnosing patients, but they are expensive and are sometimes not used the way they should be used. By requiring prior plan approval before the scan is done, BCBSNC is trying to keep medical costs down and keep patients from having tests they don't need.

Q: Do all BCBSNC members need prior plan approval from BCBSNC for high-tech scans? Top of Page

A: Not all BCBSNC members need prior plan approval from BCBSNC before getting a high-tech scan. Please refer to your benefit booklet for specific information regarding prior plan approval on your plan. To find out if you need prior plan approval, go to our Diagnostic imaging procedures page and type your group number into the search box. Your group number is on your BCBSNC ID card.

Q: How can I find out more about the prior plan approval process for high-tech scans? Top of Page

A: Review the diagnostic imaging section to learn whether or not your policy requires prior plan approval for these services, which services require prior plan approval, and how your doctor can request prior plan approval for these services on your behalf.