When to Request Prior Review
Prior review and certification is also known as…
- Prior plan approval
- Prior authorization
- Prospective review
In case of emergency, prior review and certification is NOT required. BCBSNC should be notified of an urgent or emergency admission by the second business day of the admission.
Prior review and Certification code list:
This list is provided for member information only. It is a provider tool and is updated on a quarterly basis, within the first 10 days of January, April, July, and October. If there is no update within this time period, the list will remain unchanged until the following quarter.
Certain services require prior review and certification from BCBSNC before they can be covered by your health insurance plan.
Responsibility for Requesting Prior Review and Certification
For In-Network Providers
North Carolina providers or specialists in the BCBSNC network will request prior review for you. You may want to check with your health care provider to make sure that prior review was obtained before you have the service or procedure in question.
For Out-of-Network Providers
You are responsible for ensuring that out-of-network doctors have requested prior review and certification from BCBSNC before the service is performed. The physician or her office should request the review from BCBSNC. This also applies to BlueCard® providers (out of state providers who contract with another Blue Cross Blue Shield plan) outside of North Carolina. Your Benefit Booklet has more information about prior review and certification that is specific to your policy.
Why is prior review and certification necessary?
Prior review and certification ensures that:
- Your benefits cover the service in question
- The service is medically necessary according to BCBSNC medical policy
- The service is performed in the right health care setting
- The provider is correctly identified as in- or out-of-network
- Special medical circumstances are identified that require specific types of review and follow-up
Note: BCBSNC may certify a service received out-of-network at the in-network benefit level if the service is not reasonably available in-network or if there is a continuity of care issue.
What types of procedures may require prior review and certification?
Whether prior review and certification is required may depend on your BCBSNC benefit plan. Always check your Benefit Booklet for specific information about your plan. The following procedures typically require prior review and certification:
- Inpatient admissions (with the exception of maternity admissions) — elective, planned in advance or not related to an emergency.
- Inpatient maternity stays longer than 48 hours after vaginal delivery or 96 hours after a C-section
- Private duty nursing, skilled nursing facility, acute rehabilitation admissions (short-term inpatient recovery), home health care (including nursing and some home infusion).
- Services performed by an out-of-network or non-BlueCard® out-of-state health care provider
- Air ambulance services (emergency air ambulance does not require prior review)
- Certain durable medical equipment (DME)
- Transplants — solid organ (e.g. liver) or bone marrow/stem cell
- Surgery and/or outpatient procedures
How can my provider request prior review and certification?
Your health care provider can use any of the following ways to request prior review and certification:
- By phone: BCBSNC Utilization Management at 1-800-672-7897 Monday to Friday, 8 a.m. — 5 p.m. ET
- By fax: Request form