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 (BCBSNC) is a Medicare Advantage organization with a Medicare contract to provide HMO and PPO plans. BCBSNC does not discriminate based on color, gender, religion, national origin, age, race, disability, handicap, sexual orientation, genetic information, source of payment or health status as defined by the Centers for Medicare & Medicaid Services (CMS). All qualified Medicare beneficiaries may apply. You must be entitled to Medicare Part A and enrolled in Medicare Part B and must reside in the CMS-approved service area. You must continue to pay your Medicare Part B premium, if not otherwise paid for under Medicaid or another third party. BCBSNC is an independent licensee of the Blue Cross and Blue Shield Association.