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Request prior approval form

During regular business hours, providers can request prior approval by contacting BCBSNC toll free at (800) 672-7897.

For prior approval of an non-emergency admissions or outpatient services and procedures outside of regular business hours, please complete and submit the form below.¹ If you are not a service provider, please visit the member prior approval page.

For instructions on requesting prior approval for diagnostic imaging services, see the diagnostic imaging section. For mental health and substance abuse services, please refer to the information on the member’s BCBSNC ID card.

Emergency Care Information

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.

Prior Approval Request Form (*required fields)
Requestor Information
*First Name	Middle Initial	*Last Name	*Phone Number
			( ) -

Patient Information
*First Name	Middle Initial	*Last Name	*Date of Birth (mm/dd/yyyy)
			/ /
*Policy Type		Subscriber # Letters	*Subscriber # Numbers

Provider Information
*Hospital/Facility Name	*Provider Name	*Provider ID

Hospital/Facility Street Address	Hospital/Facility City	*Hospital/Facility State

Admission/Procedure Details
*Admission Date (mm/dd/yyyy)	*Admission Status	*Diagnosis	Procedure/Procedure Code
/ /
Comments (max 256 characters)

Subscriber ID card illustrating the letters and numbers of the Subscriber #

1. Requesting prior approval does not guarantee approval will be granted.