Certain services require prior plan approval (also known as prior approval, prior authorization, prospective review, prior review, certification or precertification) in order for you to receive benefits. These services are reviewed to make sure that you are getting the appropriate treatment based on medical guidelines.
Providers or specialists in the BCBSNC network will request prior plan approval for you. You may want to check with your health care provider to make sure that prior plan approval was obtained before you have the service or procedure in question.
Your BCBSNC benefit plan may require prior plan approval for any services performed by an out-of-network or out-of-state health care provider. These services may include inpatient admissions, some outpatient services and procedures (such as in a doctor’s office), certain prescription drugs, diagnostic imaging services (such as a CAT scan or an MRI), or mental health services.
If your services are out-of-network or out-of-state, you are responsible for having your doctor request prior plan approval from BCBSNC for any service that requires prior approval. If you do not have your doctor get prior plan approval before the service or procedure is performed, you may be responsible for the bill. Your benefit booklet has more information about prior plan approval that is specific to your policy.
For a list of services, procedures, and medications that require prior plan approval, go to:
Your health care provider can use any of the following ways to request prior plan approval:
Online: Submit request (for after hours use only)
By fax: Request form
By phone: BCBSNC Utilization Management at 1-800-672-7897
Monday-Friday, 8 a.m. – 5 p.m., Eastern Time
Diagnostic imaging services:
For more information about prior plan approval for diagnostic imaging services (such as CT/CTA scans, MRI/MRA scans, PET scans or nuclear cardiology studies), go to the Diagnostic imaging page.
Prescription drugs:
Because some prescription drugs are prescribed for different reasons, they are subject to different approval guidelines. These drugs must be reviewed to make sure that they are being prescribed correctly. For more information about prior plan approval for prescription drugs, go to the Prescription drugs prior plan approval page.
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