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Revision/Reminder: BCBSNC prior review and certification requirements

Release Date: November 1, 2012

Release Date: November 20, 2012

Revision/Reminder:  BCBSNC prior review and certification requirements apply for both BCBSNC primary and secondary coverage plans

Note:  This article has been revised from the original version. We are providing clarification that Medicare Supplemental products designed to offer coverage for gaps in care are not included in BCBSNC’s policies pertaining to secondary coverage plans.

Blue Cross and Blue Shield of North Carolina (BCBSNC) requires that certain healthcare services receive authorization or certification by us, in advance of those services being provided to our members.  The types of healthcare services requiring certification can include medical procedures, inpatient and facility admissions, equipment, pharmaceuticals, as well as care accessed from non-participating providers.  Providers participating in the BCBSNC network are responsible for ensuring that prior review and certification approvals are obtained (when applicable) in advance of providing non-emergency services, and adhering to guidelines based upon a member’s specific BCBSNC benefit plan.  Additionally, these rules apply for BCBSNC member-services whether BCBSNC coverage is a member’s primary, secondary or tertiary coverage plan.

Services provided to BCBSNC members having Medicare as their primary coverage plan have sometimes been given exceptions from our certification rules, resulting in the member’s secondary benefits being issued without necessary prior review and certification approvals obtained.  However, beginning January 1, 2013, providers and facilities must request certification for all services requiring advanced approval by BCBSNC, even when a member has Medicare as their primary coverage and BCBSNC is the secondary plan.  This includes all services on the BCBSNC prior plan approval list, inpatient hospital admissions, and admissions to non-Medicare-certified skilled nursing facilities.  

To request prior review/certification requests: call Healthcare Management & Operations at 1.800.672.7897.

To obtain the most recent prior review list:

  • Visit our website at www.bcbsnc.com/providers
  • Contact Healthcare Management & Operations at 1.800.672.7897.
  • Log-in to our internet-based application, Blue eSM.

When certification requests are received, BCBSNC typically assigns authorization numbers for services that meet eligibility and are authorized in advance by us.  However, unlike certification requests placed for other BCBSNC members, not all services authorized for Medicare primary members receive authorization numbers.  Providers can expect:

  • When a service, medication or supply requires prior authorization from BCBSNC and all eligibility criteria are met, BCBSNC will assign an authorization number for the authorized service(s).
  • When certification is requested for an inpatient stay, which also includes a request for authorization-required services and/or procedures to be performed during the patient’s stay of care and all eligibility criteria are met, BCBSNC will assign an authorization number.
  • When certification is requested for an inpatient stay that does not include any additional services and/or procedures requiring prior authorization from BCBSNC, no authorization number will be assigned.  Instead, BCBSNC makes a notation in our systems to record that certification was requested and allows Medicare to make the initial review of hospital necessity.  If Medicare disallows the hospital admission, BCBSNC can then use the notation from our system if making an additional review.

Failure to request an authorization or certification for services requiring advanced approval may be denied or providers may receive reduced payments by BCBSNC, depending upon the structure of a member’s benefit coverage plan.  

BCBSNC’s prior review list is updated quarterly to display any new services and/or service codes that are no longer effective.  The most recent prior review list can be viewed at our website bcbsnc.com.  To access the list, select the provider section and choose the prior authorization category.  Providers can also contact Healthcare Management & Operations at 1.800.672.7897.  In addition, the most recent prior review list can be obtained via our internet-based application, Blue eSM

Providers that obtain prior review/certification in advance of providing services are helping ensure their patient’s plan of treatment meets medical necessity criteria under the member’s health benefit plan.  Additionally, providers are helping facilitate a member’s receipt of their fullest benefit coverage allowance.  Providers can reference BCBSNC’s Blue BookSM Provider eManual available at www.bcbsnc.com/providers for additional information regarding our prior review approval and certification requirements.

Please note that Medicare Supplemental products are product offerings designed exclusively to provide coverage for gaps in Medicare coverage and are not included in BCBSNC’s policies pertaining to secondary coverage plans. A Medicare Supplement policy typically pays for expenses not covered under Medicare due to deductible or coinsurance amounts or other restrictions under the Medicare program. To ensure your patients secondary coverage is through a Medicare Supplemental plan, providers should always verify benefits prior to rendering services.