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Prior Plan Approval

Prior review (prior plan approval, prior authorization, prospective review or certification) is the process BCBSNC uses to review the provision of certain medical services and medications against health care management guidelines prior to the services being provided. Inpatient admissions, services and procedures received on an outpatient basis, such as in a doctor's office, and prescription medications may be subject to prior review.

Reviews may confirm:

  • Member eligibility
  • Benefit coverage
  • Compliance with BCBSNC corporate medical policy regarding medical necessity
  • Appropriateness of setting
  • Requirements for use of in-network and out-of-network facilities and professionals
  • Identification of comorbidities and other problems requiring specific discharge needs
  • Identification of circumstances that may indicate a referral to concurrent review, discharge services, case management or the Healthy Outcomes Condition Care Program

Services Requiring Prior Plan Approval - Request a Prior Review:


Admissions and private duty nursing

Including skilled nursing facility admissions and private duty nursing service.
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Diagnostic imaging

Including CT/CTA, PET and MRI/MRA scans and nuclear cardiology studies.
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Prescription drugs

Including cox-2 inhibitors (celecoxib), biologics for rheumatoid arthritis and psoriasis, botulinum toxins, growth hormones and restricted access drugs.
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Other services and procedures

Including home health care services, durable medical equipment and mental health/substance abuse.
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Medical Oncology Program

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Sleep Management Program

Learn More / Submit a Request »