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Prior Plan Approval

Quality assurance programs

To make sure that you get the best quality of care possible, BCBSNC uses many programs, such as:

Prior plan approval – This is the process that BCBSNC uses to review requests from your doctor for health care services, procedures and prescriptions before they are received or performed. It is also known as prior approval, prior authorization, prospective review, prior review, certification or precertification. Providers who contract with BCBSNC are responsible for getting prior plan approval on your behalf. If you choose a provider who does not participate in BCBSNC's network or is out-of-state, you will be responsible for telling your health care provider that prior plan approval is required for certain services.

Please go to the prior plan approval section for more information.

Concurrent review – BCBSNC wants to make sure that you are in the right place to get the right treatment you need. Our concurrent review nurses work with the discharge services nurses at the hospital to help set up any care you may need after you are released from the hospital.

Retrospective review – This process is used after all services, including a hospital stay, have been performed or completed. Your medical history is reviewed to see if there were any treatment issues that need to be identified. Your doctor may be contacted if any treatment was found to be unsafe, ineffective or not typical of evidence-based standards of care.

BCBSNC case management program – This program is available to you if you have a very serious, chronic or complicated health problem. A BCBSNC case manager will work with you and your family as well as any providers that are treating you. The case manager will help with finding all of the resources that will result in the best recovery possible.

Continuity of care assistance – This process (also known transition of care) helps you get care from a provider if you change health plans or if your provider decides not to participate in the BCBSNC network. You can use this program if you are in the following condition:

• Chronic illness or condition – a disease or condition that is life-threatening, degenerative or disabling and requires medical care or treatment over a prolonged period of time.
• Second or third trimester of pregnancy or completing postpartum care.
• Terminally ill – a medical prognosis that the individual's life expectancy is six months or less.

BCBSNC must authorize services before they are given in order for you to receive services at the in-network benefit level. You should work with your provider to have him/her request prior plan approval. You can also contact BCBSNC Customer Service to get a continuity of care form. To get these benefits, you must get approval within 45 days of the date that your provider leaves the BCBSNC network or when you receive notice that your provider is leaving the network.

If you are currently receiving care for mental health or substance abuse, and you are a Blue Care^® or Blue Choice^® member, you can call 1-800-359-2422 to find out if you are eligible for continuity of care benefits.

If you have any concerns about any final authorization decision from BCBSNC, you have the right to appeal the decision.

For more information about any of the above programs, please call us at 1-800-672-7897 or write to us at:

Health Coaching and Interventions Department
BCBSNC
P.O. Box 2291
Durham, NC 27702