Prior Plan Approval

Prior review (also referred to as prior plan approval, prior authorization, prospective review or certification) is the process by which BCBSNC reviews the provision of certain medical services and medications against healthcare 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 are done to confirm the following:

• Member eligibility
• Benefit coverage
• Compliance with BCBSNC corporate medical policy regarding medical necessity
• Appropriateness of setting
• Requirements for utilization 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

For more information about which services require prior plan approval and instructions on how to request prior review, select from the categories below:

Admissions and private duty nursing Including skilled nursing facility admissions and private duty nursing service. Learn more or submit a request »

Diagnostic imaging Including CT/CTA,PET and MRI/MRA scans and nuclear cardiology studies. Learn more or submit a request »

Prescription drugs Including cox-2 inhibitors (celecoxib), biologics for rheumatoid arthritis and psoriasis, botulinum toxins, growth hormones, and restricted access drugs. Learn more or submit a request »

Other services and procedures Such as home health care services, durable medical equipment and mental health/substance abuse. Learn more or submit a request »