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Prior Plan Approval
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. Inpatient admissions, some outpatient services (like in a doctor's office) and procedures, and certain prescription drugs may require prior plan approval.
Prior plan approval is necessary to make sure 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 or is not participating in BCBSNC's network.
- Special medical circumstances are identified that require specific types of review and follow-up.
For more information about the services that require prior plan approval, select from the categories below:
| Admissions and private duty nursing | Diagnostic imaging | Prescription drugs | Other services and procedures |
|---|---|---|---|
| Including skilled nursing facility admissions and private duty nursing service. Learn more » | Including CT/CTA,PET and MRI/MRA scans and nuclear cardiology studies. Learn more » | Including cox 2 inhibitors, antigfungals, weight loss and allergy drugs. Learn more » | Such as home health care services, durable medical equipment and mental health. Learn more » |
To find out how your health care provider can request prior plan approval on your behalf for any of the above services, please go to the prior plan approval request forms page.
Important note: In case of emergency, prior approval is NOT required. An emergency is an instance in which the absence of medical attention could jeopardize a person's life, health, or ability to regain maximum function, or could subject a person to severe pain.
If an in-network provider in North Carolina orders one of the tests listed above, the provider will be responsible for obtaining prior plan approval on your behalf. However, if you use out-of-network providers or providers outside of North Carolina, you will need to make sure that your providers obtain prior plan approval on your behalf before ordering high-tech diagnostic imaging procedures. They can review our prior plan approval list online at www.bcbsnc.com/providers/ppa. If prior plan approval is not obtained in these cases, you may be responsible for the cost of the procedure.