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Reminder of Prior Approval Requirements for Blue Medicare HMOSM and Blue Medicare PPOSM Benefit Plans


In order to be eligible for reimbursement, a health care professional's plan of treatment must meet medical necessity criteria under the member's health plan. Prior Approval - also referred to as pre-authorization, pre-certification, prior authorization or pre-notification - ensures the criteria are met. Blue Cross and Blue Shield of North Carolina (BCBSNC) uses Milliman Care Guidelines, BCBSNC Medical Policy, and CMS National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) to establish the medical necessity of services listed on the Prior Approval Guidelines.

Health care professionals should always review the most recent guidelines carefully to ensure the services on the list are approved before a service is provided to Blue Medicare HMO and Blue Medicare PPO members. If a service you are providing appears on the Prior Authorizations Requirements listing, you will need to contact BCBSNC at 1-888-296-9790 or 1-336-774-5400 to obtain prior plan approval. Please have all pertinent clinical information available when contacting BCBSNC to request prior approval. Not having the clinical notes available at the time of the request delays the authorization process for the member and your health care facility, as well as the Plan. A listing of the most recent updates to the Prior Authorization Requirements are available on the BCBSNC Web site at: http://www.bcbsnc.com/content/providers/blue-medicare-providers/policies-and-responsibilities/index.htm. Health care professionals can also contact their designated Strategic Provider Relations representative to request a current copy.

Additionally, hospital admissions, both elective and urgent/emergent, require BCBSNC notification and medical necessity review. Hospitals are required to notify BCBSNC and submit clinical information for a medical necessity review prior to an elective admission or within one business day of an urgent/emergent admission. Failure to notify the Plan can result in a denial of service and in claims not being paid. Please remind your business office and utilization management to notify BCBSNC of these admissions by calling 1-888-296-9790 or 1-336-774-5400.

It is important for our network of health care professionals to remember Blue Medicare HMO and Blue Medicare PPO members have no responsibility for obtaining prior approval/pre-certification for services. Therefore, members covered under these benefit plans have no financial responsibility when prior approval/pre-certification is not obtained prior to services being rendered.

To learn more, visit the Prior Authorization and Pre-Admission Certification section of the Blue BookSM Provider Manual - Blue Medicare HMO and Blue Medicare PPO Supplemental Guide - available on the Web at: www.bcbsnc.com/providers.