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Prior Plan Approval

Other services and procedures

Prior plan approval | Admissions and private duty nursing | Diagnostic imaging | Prescription drugs | Other services and procedures | PPA Forms | Quality

Prior plan approval code list:

This list 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. Unlisted and miscellaneous health services codes should only be used if a specific code has not been established by the American Medical Association.

The Prior Review (prior plan approval) code list has been modified effective January 1, 2008. To notify providers 90 days in advance of changes to the prior review code list, the list now contains an additional column that captures the effective date of when a current code becomes a prior review code.

The ineffective date column remains the same and it refers to the date the code is no longer valid. However, a claim can be submitted for up to 18 months past the ineffective date for services rendered prior to that date.

Prior plan approval code list

Prior plan approval policies and procedures:

  • *Blue Care® plan: BCBSNC may authorize a service received out-of-network at the in-network benefit level if the service is not available in-network or if there is a transition of care issue.
  • Blue Advantage®, Blue Choice® and Blue OptionsSM plans: BCBSNC may authorize a service received out-of-network at the in-network benefit level if the service is not available in-network or if there is a transition of care issue.
  • **Blue Advantage plans: Prior plan approval is not required for mental health or substance abuse services.
  • ***Prior approval codes for DME are available from Customer Service, Utilization Management or your BCBSNC Network Management representative.
  • Requirements for utilization of in-network and out-of-network facilities and professionals must be verified in conjunction with obtaining prior plan approval.

Request prior plan approval:


For other services and procedures:

  • Online: Submit request Opens new window.
  • By fax: Request form
  • By phone: BCBSNC Utilization Management - 1-800-672-7897 Monday - Friday, 8 a.m. - 5 p.m., Eastern time

The following services and procedures received in a nonemergency situation on an outpatient basis require prior plan approval.

  • Blue Care: Any service received at an out-of-network provider1
  • Mental health or substance abuse treatment (except for Blue Advantage)**
  • Non-emergency air ambulance services
  • Certain durable medical equipment (DME)***
  • Home health, including nursing and home infusion
  • Surgery and/or outpatient procedures, including but not limited to:
    • Lung volume reduction surgery
    • Morbid obesity surgery
    • UPPP, surgical management of obstructive sleep apnea
    • Vertebroplasty and kyphoplasty
    • Percutaneous treatment of HNP
    • Orthotripsy
  • Procedures potentially cosmetic, including but not limited to:
    • Reconstructive surgery, including but not limited to rhitidectomy, dermabrasion, scar revision
    • Breast surgeries including insertion and removal of silicone breast implants (not resulting from mastectomy), reduction mammoplasty, and gynecomastia
    • Otoplasty
    • Blepharoplasty
    • Abdominoplasty
    • Therapy of superficial veins, such as varicose veins, telangiectasias
    • Orthognathic surgery
    • Rhinoplasty

Please note: In addition to the services listed above, prior plan approval may be required for diagnostic imaging services. For instructions on requesting prior plan approval for diagnostic imaging, see diagnostic imaging services Opens new window.

 

1 An "out-of-network" provider is a health care provider that does not participate in a BCBSNC network.

2 Transition of care occurs when a provider chooses to leave the BCBSNC network to become an out-of-network or nonparticipating provider. BCBSNC will work with its members to ensure appropriate transition of care in these situations.

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.