Prospective review (also referred to as prior plan approval, prior authorization, or certification) is the process by which certain medical services or medications are reviewed against healthcare management guidelines prior to the services being performed. Reviews are done to confirm the following information:
- Member eligibility
- Benefit coverage
- Compliance with Medicare and Blue Medicare HMO and Blue Medicare PPO medical policies regarding medical necessity
- Appropriateness of setting
- Identification of co-morbidities and other problems requiring specific discharge needs
- Identification of circumstances that may indicate a referral to case management or disease management programs.
Many prescription drugs included in Blue Medicare HMO and Blue Medicare PPO Medicare prescription drug benefits also require prior approval. Visit the Prior authorization and nonformulary requests page for more information.
To learn more, visit the Prior Authorization section of the Provider Manual.
Certain high-tech diagnostic imaging procedures require prior approval. Visit the Diagnostic Imaging Management Program page for more information.
For a list of recent updates to the Prior Authorization Requirements, download the documents below:
Prior Authorization Guidelines - effective 1/1/2014 Prior Authorization Guidelines - effective 1/1/2013 Prior Authorization Guidelines - effective 1/1/2012 Prior Authorization Guidelines - effective 1/1/2011 Prior Authorization Guidelines - updated 4/1/2010 Prior Authorization Guidelines - effective 1/1/2010 Prior Authorization Guidelines - updated 12/1/2008 Prior Authorization Guidelines - updated 6/1/2006 Prior Authorization Guidelines - updated 7/1/2005 Prior Authorization Guidelines - updated 4/1/2005
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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.