Policies, guidelines and codes

These guidelines detail when certain medical services are considered medically necessary by Blue Cross and Blue Shield of North Carolina (Blue Cross NC), and whether or not they are considered investigational by Blue Cross NC. (For more information concerning medical necessity and investigational criteria, please see these specific policies.) Our medical guidelines are written to cover a given condition for the majority of people. Each individual's unique, clinical circumstances may be considered in light of current scientific literature. Medical guidelines are based on constantly changing medical science, so we review and update our policies periodically.

These guidelines provide claims payment editing logic for CPT, HCPCS and ICD-10-CM coding. Reimbursement guidelines are developed by clinical staff and include yearly coding updates, periodic reviews of specialty areas based on input from specialty societies and physician committees and updated logic based on current coding conventions.

Benefits and eligibility are determined before medical guidelines and reimbursement guidelines are applied. Therefore, medical policy is not an authorization, certification, explanation of benefits or a contract. Benefits are determined by the group contract and the subscriber certificate that is in effect at the time services are rendered.

These guidelines provide general information regarding the definition of Medical Necessary and Investigational / Experimental services as defined by Blue Cross NC. Additionally, a policy for participation in clinical trials is available as an administrative guideline.

• Prior authorization
• Medical necessity review
• Medical policy and pre-certification/pre-authorization information for out-of-area and BlueCard^® eligible members

In certain markets, Blue Cross and Blue Shield of North Carolina, delegates the Utilization Management for PRIOR REVIEW and CERTIFICATION of specific services or benefits to other companies not associated with Blue Cross NC. Please see below for a list of these companies:

Inquiries about our medical policies can be made by mail to the addresses listed below or you can call our Customer Service Department at 877-258-3334. Members may also wish to discuss their questions and individual medical situation with their physician. Physicians may want to share documentation with the Plan about recent medical advances and guidelines that could enhance our medical policies.

Blue Cross NC
PO Box 2291
Durham, NC 27702