Change in prior authorization requirements for PPS Home Health providers

Update April 1, 2026: Effective May 1, 2026, Blue Cross and Blue Shield of North Carolina will update its prior authorization process to align with the Centers for Medicare & Medicaid Services’ (CMS) Patient-Driven Groupings Model (PDGM) payment methodology. As part of this alignment, prior authorizations will be issued in 30-day intervals, replacing the current 60-day episode authorization structure. This change was previously announced with an effective date of April 2, 2026; however, the effective date is now May 1, 2026.

Beginning April 2, 2026, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will update our prior authorization process to align with the Centers for Medicare & Medicaid Services’ (CMS) Patient-Driven Groupings Model (PDGM) payment methodology. As part of this alignment with PDGM, prior authorizations will now be issued in 30-day intervals, replacing the current 60-day episode authorization structure.

This change applies only to episodic Prospective Payment System (PPS) Home Health providers serving Medicare Advantage plans. It does not apply to Commercial plans, Inter-Plan Program (IPP) plans, or Federal Employee Program plans.