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Prior Plan Approval
Admissions and private duty nursing
Services that need prior plan approval are:
- Inpatient admissions – elective, planned in advance or not related to an emergency
- Private duty nursing
- Skilled nursing facility and acute rehabilitation admissions (short-term inpatient recovery)
- Transplants – solid organ (e.g. liver) or bone marrow/stem cell
Prior plan approval policies and procedures:
- BCBSNC should be notified of an urgent or emergency admission by the second business day of the admission.
- Maternity admissions do not require prior plan approval for the first 48 hours for vaginal delivery or the first 96 hours for a C-section. Any inpatient maternity stay longer than this requires an authorization from BCBSNC.
- Any other admission (by choice or planned) must have prior plan approval from BCBSNC before admission.
Prior plan approval policies apply to members on the following plans:
- Blue Advantage®
- Blue Care®
- Blue Choice®
- Blue OptionsSM
- Classic Blue®
Please note that some plans may have different prior approval policies. Always check your benefit booklet for specific information about your plan.
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.