Providers
Healthy Blue + Medicare (HMO-POS D-SNP)
Learn how to check eligibility, submit prior authorization, file appeals, and more for patients with our Healthy Blue + Medicare℠ plan.
We've insourced the administration of Healthy Blue + Medicare as of January 1, 2026. We're seeing an increase in incorrect claim submissions – providers using clearinghouses should ensure claims with member prefix L7H and dates of service on or before December 31, 2025 are submitted to Elevance.
Participating in the Medicare Advantage network
Medicare Advantage enrollment continues to rise nationally, and being in-network ensures you can serve this expanding segment.
Because D-SNP is part of the existing Medicare Advantage umbrella, providers who are already in-network for Medicare Advantage plans do not need to re-enroll to participate in D-SNP. Make sure to follow the terms in your contract and the Medicare Advantage Blue Book.
Providers interested in joining our MA network will follow the steps for credentialing, contracting, and enrollment. Once completed, you’ll participate in both MA and D-SNP.
Model of Care training
Our Model of Care explains how the plan coordinates and delivers care for members with complex, chronic health needs. Each provider practice or facility must have a representative attest annually to completing the Model of Care training.
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Step 1
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Complete Model of Care training
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Our training includes strategies to improve overall health outcomes.
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View Training Document (PDF)
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card-1-356dbdba1a-c31f56a151-Complete Model of Care training
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Step 2
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Attest to completing training
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After completing training, complete and submit the attestation form to Blue Cross NC.
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Submit Attestation Form
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If you have trouble completing the attestation form online after reviewing the Model of Care training, you can print the form, fill in all required information, and fax it to 919-765-7109. Alternatively, you can email the completed form to DSNP_ProviderAttestations@bcbsnc.com.
Eligibility
Check your patients’ coverage before providing care. Verifying eligibility ensures services are covered, claims are processed correctly, and patients receive their benefits.
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Elevance
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Dates of service on or before December 31, 2025
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Use Availity, the Elevance provider portal, to check patient eligibility.
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Log In to Availity
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Blue Cross NC
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Dates of service on or after January 1, 2026
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Look up patient eligibility across all local plans, including HMO-POS D-SNP, with the Blue e provider portal.
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Log in to Blue e
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Contact us
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Contact us
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Medical policies
Medical policies are based on clinical guidelines, CMS requirements, and evidence-based practices. Use them to confirm which services are covered under a patient’s plan and verify the criteria for medical necessity.
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Elevance
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Dates of service on or before December 31, 2025
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Expand the archived Elevance policies below for prior dates of service.
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Blue Cross NC
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Dates of service on or after January 1, 2026
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Stay informed and aligned with the latest clinical guidelines from Blue Cross NC.
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Review Medical Policies
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- Appropriateness Guidelines: Effective October 20, 2025 (PDF)
- Blue Cross and Blue Shield of North Carolina Expands Specialty Pharmacy Recertification List (August 2024 Pt. 2) (PDF)
- Blue Cross NC Expands Specialty Pharmacy Precertification Lists (PDF)
- Carelon Medical Benefits Management, Inc. Updates Effective September 2024 (PDF)
- Carelon Medical Benefits Management, Inc. Updates Effective February 8, 2025 (PDF)
- Carelon Medical Benefits Management, Inc Updates Effective March 23, 2025 (PDF)
- Carelon Medical Benefits Management, Inc. Updates Effective July 1, 2025 (PDF)
- Carelon Medical Benefits Management, Inc Updates Effective July 15, 2025 (PDF)
- Carelon Medical Benefits Management, Inc. updates effective July 26, 2025 (PDF)
- Carelon Medical Benefits Management, Inc. Updates effective October 1, 2025 (PDF)
- Carelon Medical Benefits Management,Inc. Updates Effective November 14, 2025 (PDF)
- Carelon Medical Benefits Management, Inc. Updates Effective November 15, 2025 (PDF)
- Carelon Medical Benefits Management, Inc. Updates Effective December 20, 2025 (PDF)
- Clarification to Carelon Medical Benefits Management, Inc. Updates Effective September 1, 2024 (PDF)
- Clinical Criteria Updates Effective October 12, 2024 (PDF)
- Clinical Criteria Updates Effective January 31, 2025 (PDF)
- Clinical Criteria Updates Effective February 17, 2025 (PDF)
- Clinical Criteria Updates Effective May 4, 2025 (PDF)
- Clinical Criteria Updates Effective May 27, 2025 (PDF)
- Clinical Criteria Updates Effective May 28, 2025 (PDF)
- Clinical Criteria Updates Effective September 4, 2025 (PDF)
- Clinical Criteria Updates Effective September 13, 2025 (PDF)
- Clinical Criteria Updates Effective October 27, 2025 (PDF)
- Clinical Criteria Updates Effective December 19, 2025 (PDF)
- Clinical Criteria Updates Effective December 26, 2025 (PDF)
- Clinical UM Attestation and Use Guide - FAQ (PDF)
- Expanded Specialty Pharmacy Precertification List Effective Date November 1, 2025 (PDF)
- ICD-10-CM Excludes1 Notes (PDF)
- Important Change to Your Patients’ Specialty Prescriptions (PDF)
- Important Information About Specialty Prescriptions (PDF)
- Kroger Specialty Pharmacy Acquisition (PDF)
- MCG Care Guidelines 29th Edition (PDF)
- Medical Policies and Clinical UM Guidelines
- Medical Policies and Clinical Utilization Management Guidelines Update Effective December 10, 2024 (PDF)
- Medical Policies and Clinical Utilization Management Guidelines Update Effective February 13, 2025 (PDF)
- Medical Policies and Clinical Utilization Management Guidelines Update Effective June 15, 2025 (PDF)
- Medical Policies and Clinical Utilization Management Guidelines Update Effective August 5, 2025 (PDF)
- Medical Policies and Clinical Utilization Management Guidelines Update Effective October 24, 2025 (PDF)
- Medical Policies and Clinical Utilization Management Guidelines Update Effective December 30, 2025 (PDF)
- Medical Policy and Clinical Utilization Management Guidelines Website Instructions (PDF)
- Medicare Part B Preapproval Expands with New Drug Additions (PDF)
- Medicare Part D Overhaul: What's New in 2025 for Your Prescription Drug Costs? (PDF)
- Medication Safety: Reducing Risks with Thoughtful Prescribing and Monitoring (PDF)
- Medicare Risk Adjustment Provider Documentation and Coding Guide (PDF)
- National Drug Codes (NDC) Are Required for Outpatient Claims (PDF)
- National Drug Codes (NDCs) Are Required for Professional and Outpatient Claims (PDF)
- New Specialty Pharmacy Medical Step Therapy Requirement (PDF)
- New Specialty Pharmacy Medical Step Therapy Requirements (July 1, 2025) (PDF)
- North Carolina 2025 Medicare Advantage Plan Changes (PDF)
- Notice of Change: Part D Rx HCCs (PDF)
- Pharmacy Clinical Criteria
Clinical criteria documents for all injectable, infused or implanted prescription drugs and therapies covered under the Healthy Blue + Medicare medical benefit (Part C). - Shortage of Repackaged Bevacizumab for Ophthalmic Use (PDF)
- Specialty Pharmacy Preapproval List Update (PDF)
- Specialty Pharmacy Precertification List Expansion (Effective April 1, 2025) (PDF)
- Specialty Pharmacy Precertification List Expansion — Key Updates (PDF)
- Specialty Pharmacy Precertification List Expanded (PDF)
- Specialty Pharmacy Precertification List Expanded Effective December 1, 2025 (PDF)
- Specialty Pharmacy Precertification and Step Therapy List Expansion (Effective April 1, 2025) (PDF)
- Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines Effective October 20, 2024 (PDF)
Prior authorization
Confirm coverage and medical necessity before delivering care to prevent claim denials and ensure patients receive appropriate, cost-effective treatment.
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Elevance
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Dates of service on or before December 31, 2025
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Continue using current Elevance prior authorization forms for dates of service before the end of the year. Remember to submit these requests via Availity.
Provider services for medical and drug prior authorization
Phone: 844-895-8160
Fax: 877-799-4129
Healthy Blue + Medicare
PO Box 60007
Los Angeles, CA 90060-0008
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Blue Cross NC
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Dates of service on or after January 1, 2026
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For dates of service in 2026, follow Blue Cross NC's requirements. Prior authorization requests can be sent via Blue e or an established trading partner, like a clearinghouse.
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Check Requirements
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Search by Code
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Search by Code
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- Behavioral Health Concurrent Review Fax Form (PDF)
Please complete for any concurrent review. - Behavioral Health Discharge Note (PDF)
Form provides information when member will be discharged from behavioral health treatment. - Electroconvulsive Therapy Prior Authorization Request (PDF)
ECT services require prior authorization and form must be submitted prior to rendering treatment. - General Precertification Request (PDF)
Form can be used to request prior authorization for inpatient admissions. - Initial Note Review (PDF)
Request for an initial case for behavioral health. - Mental Health Outpatient Treatment Report (PDF)
Services require prior authorization and form must be completed prior to rendering treatment. - Neuropsychological Testing (PDF)
Request for Authorization-services require prior authorization and form must be submitted prior to rendering treatment. - Overpayment Refund Notification Form (PDF)
Please complete this form when refunding money and include all necessary documentation. - Psychological Testing Request for Authorization (PDF)Services require prior authorization and form must be completed prior to rendering treatment.
- Recoupment Authorization Form (PDF)
Please complete this form and mail with supporting documentation authorizing adjustments to be offset / recouped from future claims payments, do not enclose a check for the amount to be refunded when submitting this form. - Transcranial Magnetic Stimulation (TMS) Request Form (PDF)
Please complete this form in its entirety and submit for prior review when rendering TMS services. - Prior Authorization Requirement Changes Effective December 1, 2024 (PDF)
- Prior Authorization Requirement Changes Effective January 1, 2025 (PDF)
- Prior Authorization Requirement Changes Effective February 1, 2025 (PDF)
- Prior Authorization Requirement Changes Effective July 1, 2025 (PDF)
- Prior Authorization Requirement Changes Effective July 1, 2025 (Additional changes) (PDF)
- Prior Authorization Requirement Changes Effective November 1, 2025 (PDF)
- Precertification/Prior Authorization Requirement Changes Effective December 1, 2025 (PDF)
- Precertification/Prior Authorization Requirement Changes Effective January 1, 2026 (PDF)
Reimbursement
Access reimbursement guidelines for both Elevance and Blue Cross NC. Reimbursement will continue based on your existing Medicare Advantage agreement with Blue Cross NC.
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Elevance
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Review downloadable PDF documents outlining Elevance reimbursement policies. These policies apply to claims with specified dates of service and provide detailed guidance on payment rules and requirements.
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Blue Cross NC
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Our reimbursement policies are published as web pages for easy access and navigation. Visit the Blue Cross NC policies page for the complete list.
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Review Reimbursement Policies
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- A Quick Guide to Understanding JW and JZ Modifiers (PDF)
- Abortion (Termination of Pregnancy) (PDF)
- Claims Requiring Additional Documentation (PDF)
- Claims Submission - Required Information for Facilities (PDF)
- Claims Submission - Required Information for Professional Providers (PDF)
- Claims Timely Filing (PDF)
- Code and Clinical Editing Guidelines (PDF)
- Consultations (PDF)
- Corrected Claims (PDF)
- Diagnosis-Related Group (DRG) Inpatient Facility Transfers (PDF)
- Diagnosis Used in DRG Computation (PDF)
- Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU) (PDF)
- Documentation Standards for Episodes of Care (PDF)
- Drug Screen Testing (PDF)
- Duplicate or Subsequent Services on the Same Date of Service (PDF)
- Durable Medical Equipment (Rent to Purchase) (PDF)
- Eligible Billed Charges (PDF)
- Emergency Department Leveling of Evaluation and Management Services (PDF)
- Emergency Services: Nonparticipating Providers and Facilities (PDF)
- Facility Take-Home DME and Medical Supplies (PDF)
- Genetics Tests: Once per Lifetime (PDF)
- Global Surgical Package (PDF)
- Hysterectomy (PDF)
- Inpatient Readmissions (PDF)
- Maternity Services (PDF)
- Maximum Units Per Day (PDF)
- Medical Recalls (PDF)
- Modifier 22 (PDF)
- Modifier 24 (PDF)
- Modifiers 25 and 57 (PDF)
- Modifiers 26 and TC (PDF)
- Modifiers 50 and 51 (PDF)
- Modifier 63 (PDF)
- Modifier 66 (PDF)
- Modifier 76: Repeat Procedure by the Same Physician (PDF)
- Modifier 77 (PDF)
- Modifier 78 (PDF)
- Modifiers 80, 81, 82, and AS: Assistant at Surgery (PDF)
- Modifier 90 (PDF)
- Modifier 91 (PDF)
- Modifiers LT and RT (PDF)
- Modifier Usage (PDF)
- Multiple Delivery Services (PDF)
- Multiple Procedure Payment Reduction (PDF)
- Multiple Radiology Payment Reduction (PDF)
- New Reimbursement Policy: New Genetic Tests: Once Per Lifetime (PDF)
- Nurse Practitioner and Physician Assistant Services (PDF)
- Portable/Mobile/Handheld Radiology Services (PDF)
- Preadmission Services for Inpatient Stays (PDF)
- Preventive Medicine and Sick Visits on the Same Day (PDF)
- Professional Anesthesia Services (PDF)
- Proof of Timely Filing (PDF)
- Prosthetic and Orthotic Devices (PDF)
- Provider Preventable Conditions (PDF)
- Reduced and Discontinued Policies (PDF)
- Reimbursement for Items under Warranty (PDF)
- Reimbursement Policies Disclaimer (PDF)
- Reimbursement Policies Overview (PDF)
- Sanctioned and Opt-Out Providers (PDF)
- Skilled Nursing Facility — Vaccine Serum Compensation (PDF)
- Split Care Surgical Modifiers (PDF)
- Sterilization (PDF)
- Technology Assisted Surgical Procedures (PDF)
- Transportation Services: Ambulance and Nonemergent Transport (PDF)
- Unlisted and Miscellaneous Codes (PDF)
HEDIS measures and other resources
Healthcare Effectiveness Data and Information Set (HEDIS) is a nationally recognized system for measuring health plan quality. During this transition, we offer both past Elevance resources and current guidelines to help providers stay informed and meet reporting requirements.
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Elevance
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Past resources
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Elevance provided resources for HEDIS measures. Browse the available PDFs to access 2025 guidelines and quality reporting information.
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Download the Guide (PDF)
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Learn more about quality improvement
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Learn more about quality improvement
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Blue Cross NC
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Current resources
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Use the MY 2026 Provider Reference Guide to find current HEDIS clinical measures applicable to all lines of business.
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Download the Guide (PDF)
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Learn more about quality improvement
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Learn more about quality improvement
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- Addressing Medication Adherence Gaps (PDF)
- Benefits of Utilization Management Attestations: A Guide from Providers (PDF)
- Bridging The Gap: Enhancing Medication Adherence For Better Health (PDF)
- Claims Guidance: Updating Inpatient And Outpatient Bill Types (PDF)
- Coding Validation Expansion: Medicare (PDF)
- COVID-19 Vaccines Covered Through 2026 (PDF)
- Drug and Biologic (PDF)
- Efficiency and the Check-in Experience with Digital Member ID Cards (PDF)
- Elevate your practice efficiency with electronic prescriber tools (PDF)
- Elevate your workflow with seamless patient chart uploads (PDF)
- Enhance Patient Coordination with Total Member View (PDF)
- Enhance Your Skills with Expanded Billing and Coding Training (PDF)
- Enhancing Patient Safety Through Medication Monitoring Enhance (PDF)
- Exciting Changes to the Availity Provider Platform Channel (PDF)
- Expanded Specialty Pharmacy Precertification List Effective Date November 1, 2025 (PDF)
- Health Outcomes Survey (PDF)
- Health Outcomes Survey: Fall Risk Management (FRM) (PDF)
- Health Outcomes Survey: How to Improve the Patient Experience (PDF)
- Health Outcomes Survey: Management of Urinary Incontinence in Older Adults (MUI) (PDF)
- Health Outcomes Survey: Physical Activity in Older Adults (PAO) (PDF)
- ICD-10-CM Excludes1 Notes (PDF)
- Important Information About Specialty Prescriptions (PDF)
- Improving Patient Outcomes: Back to the Basics (PDF)
- MCG Care Guidelines 29th Edition (PDF)
- Medical Policy and Clinical Utilization Management Guidelines Website Instructions (PDF)
- Medication Adherence 2025 (PDF)
- Medication Safety: Reducing Risks with Thoughtful Prescribing and Monitoring (PDF)
- Medicare Risk Adjustment Provider Documentation and Coding Guide (PDF)
- North Carolina 2025 Medicare Advantage Plan Changes (PDF)
- Notice of Change: Part D Rx HCCs (PDF)
- Personalized Match Update (PDF)
- Preventing Flu: Drive the Change Through Vaccination (PDF)
- Pharmacotherapy Management of COPD Exacerbation (PCE) 2025 (PDF)
- Pharmacy Clinical Criteria
Clinical criteria documents for all injectable, infused or implanted prescription drugs and therapies covered under the Healthy Blue + Medicare medical benefit (Part C). - Phishing Scam Alert - Impersonating CMS (PDF)
- Provider Manual (PDF)
- Real-Time Prescription Benefit (PDF)
- Resources to Support Diverse Patients and Communities (PDF)
- Shortage of Repackaged Bevacizumab for Ophthalmic Use (PDF)
- Streamline Your Workflow: Submit Behavioral Health (BH) Authorizations Through Availity Essentials (PDF)
- Streamlining Behavioral Health Authorizations via Availity Essentials (PDF)
- Submitting BH Authorizations in Availity Essentials (PDF)
- Time to Prepare for HEDIS Medical Record Review (PDF)
- Understanding Your Role in the Health Outcomes Survey (PDF)
Member ID cards
The design and details on member ID cards will change once Blue Cross NC becomes the sole administrator of Healthy Blue + Medicare. Check the example ID cards to quickly confirm whether your patient’s D-SNP plan is administered by Elevance or Blue Cross NC.
Elevance card
Elevance ID cards have a blue border at the top and bottom on the front of the ID card.
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Blue Cross NC sample of Healthy Blue + Medicare cards - front and back
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Blue Cross NC member ID cards have the new solid Blue Cross and Blue Shield logo.
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The front of Blue Cross NC's D-SNP member ID cards has updated solid logos.
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The back of Blue Cross NC's D-SNP member ID cards has a claims address for Durham, NC.
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