How to request prior review and authorization

Insurance companies use prior authorizations to help keep health care costs under control while making sure members get quality medical care.

Note: Blue Cross NC may approve a service received out-of-network at the in-network benefit level:

• If the service is not reasonably available in-network.
• If there is a Continuity of Care issue, such as when the patient's provider used to be in-network but is now considered out-of-network.

Your insurance provider will review all prior authorizations to decide if certain services, treatments, and prescription drugs are within the acceptable health care management guidelines of your plan. Typically, the prior review process includes several steps:

• Your health care provider will submit the prior authorization to your health insurance company.
• Your health insurance company will review the prior authorization and decide if it should be approved or denied.
• Approved prior reviews are sent back to your provider. Your provider and / or your insurance company will let you know if it is approved.
• Denied prior reviews are sent back to your provider with a reason for denial and information about how to submit an appeal to the insurance company.
• You must get a prior review approved before the services, treatments, or prescription are provided.

Your insurance provider may deny the authorization if it believes the service, treatment, or prescription isn't medically necessary. However, you have the right to appeal a denied prior authorization, and your provider can submit an appeal to the insurance company.

Whether prior review and authorization is required may depend on your health insurance plan. For Blue Cross NC members, you can check your Benefit Booklet in your member portal for specific information about your insurance plan.

• Inpatient admissions (except maternity admissions), elective, planned in advance, or not related to an emergency
• Inpatient maternity stays longer than 48 hours after vaginal delivery or 96 hours after a C-section
• Private duty nursing, skilled nursing facility, acute rehabilitation admissions (short-term inpatient recovery), home health care (including nursing and some home infusion)
• Services performed by an out-of-network or non-BlueCard^® out-of-state health care provider
• Air ambulance services (emergency air ambulance does not require prior review)
• Certain durable medical equipment (DME)
• Transplants, solid organ (for example, liver) or bone marrow / stem cell
• Surgery and / or outpatient procedures

• Commercial prescription drugs, including treatments for attention-deficit / hyperactivity disorder (ADHD), Hepatitis C, biologics for arthritis and psoriasis, restricted-access medicines, and weight-loss drugs
• Medicare prescription drugs
• Medicare Part B Step Therapy and Prior Authorization drug list
• Drugs with severe side effects
• Drugs that potentially cause addiction
• Drugs used for cosmetic purposes
• Expensive drugs that have a lower-cost alternative

This code list is informational only. It's a provider tool and 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 next quarter.