Health Care Services
Prospective Review - The process of reviewing health care services before they occur in order to receive certification. It is the provider’s responsibility to contact Blue Medicare HMO and Blue Medicare PPO for authorization for those services requiring prior approval. For a list of services requiring prior approval, see the Prior Authorization section of the Provider Manual.
Concurrent Review - A process performed by Blue Medicare HMO and Blue Medicare PPO nurses while a patient is in the hospital to try to make sure the patient is in the most appropriate setting. Concurrent review nurses also work with the hospital staff to help arrange any care after the patient is discharged from the hospital.
Retrospective Review - When medical services, including hospital services, are reviewed for certification after the services have taken place.
Case Management Program - Designed for members identified at risk for serious and complex medical conditions or with complicated health care needs. This program provides a nurse case manager who can assist physicians and health care team members to coordinate delivery of healthcare services for members in the most effective manner. Case managers are also available to assist members in navigating through the health care system, educate members regarding their medical condition, and promote members’ compliance with the physician directed treatment plan.
To learn more, refer to the Utilization Management section of the Provider Manual.
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Blue Cross and Blue Shield of North Carolina is an HMO, PPO, and PDP plan with a Medicare contract. Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal. Blue Cross and Blue Shield of North Carolina does not discriminate based on race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability or geographic location within the service area. All Blue Cross and Blue Shield of North Carolina items and services are available to all eligible beneficiaries in the service area.