Diagnostic Imaging

Prior plan approval (also called prior approval, prior authorization, prospective review, prior review, certification or precertification) is when Blue Cross NC reviews certain medical services or drugs before they are given to patients to make sure that the service or drug is right for the patient.

Even if a doctor gets prior plan approval from Blue Cross NC that says that the service or drug is correct for the patient, this does not guarantee payment. For more information, go to the prior plan approval page.

Any outpatient scans (scans not done in an emergency room or as part of an inpatient hospital stay) on or after February 15, 2007, need prior plan approval from Blue Cross NC.

High-tech scans (diagnostic imaging procedures), such as CT or CTA scans, MRI or MRA scans, PET scans or special heart scans called nuclear cardiology studies, require prior plan approval from Blue Cross NC. If these scans are not part of an emergency room visit or an inpatient hospital stay, then your doctor needs to get prior plan approval from Blue Cross NC.

• CT scan: Computed tomography (CT) scan uses X-ray imaging to make detailed pictures of structures inside of the body.
• CTA scan: Computed tomography angiogram (CTA) scan uses X-ray imaging to make detailed pictures of blood vessels inside the body.
• MRI scan: Magnetic resonance imaging (MRI) is a scan that uses a magnetic field and pulses of radio wave energy to make pictures of organs and structures inside the body.
• MRA scan: A magnetic resonance angiogram (MRA) uses a magnetic field and pulses of radio wave energy to provide pictures of blood vessels inside the body.
• PET scan: Positron emission tomography (PET) is a test that uses a special type of camera and special nuclear medicine to look at organs in the body.
• Nuclear cardiology studies: These are special studies of the heart.

If you have a scan in the emergency room or as part of an inpatient hospital stay, your doctor does not need to get approval from Blue Cross NC for the scan.

No. Prior plan approval is not required for “low-tech” scans such as X-rays, mammograms or ultrasounds.

No. If you are taken to an emergency room or urgent care center for an emergency, any scans you receive during that do not need prior approval.

Your doctor. If your doctor is part of the Blue Cross NC network, he or she should contact Blue Cross NC and request prior plan approval for your scans. If your doctor is not part of the Blue Cross NC network or is located outside of North Carolina, you must tell your doctor to get prior plan approval for you. An out-of-network or out-of-state provider will not be familiar with Blue Cross NC's prior plan approval requirements. If prior plan approval is not obtained, Blue Cross NC will not pay for the scan and you will be responsible for the bill (this does not apply if you see an in-network provider). Tell your doctor to visit our Web site, www.bcbsnc.com/providers/ppa, for more information about how to get prior plan approval for your scan.

To find out if your doctor has gotten prior plan approval from Blue Cross NC before the scan is done, call Blue Cross NC Customer Service at the toll-free number on your ID card.

If your doctor is part of the Blue Cross NC network, he or she is responsible for getting prior plan approval from Blue Cross NC on your behalf. You will not be responsible for the bill if your in-network doctor does not get prior plan approval. If your doctor is not part of the Blue Cross NC network or is located outside of North Carolina, you must tell your doctor to get prior plan approval for you. If your doctor does not get approval and you have the scan anyway, Blue Cross NC will not pay for the scan and you will be responsible for the bill (this does not apply if you see an in-network provider).

Yes. If your doctor is not part of the Blue Cross NC network or is located outside of North Carolina, you must tell your doctor to get prior plan approval for you. An out-of-network or out-of-state provider will not be familiar with Blue Cross NC's prior plan approval requirements. If prior plan approval is not obtained, Blue Cross NC will not pay for the scan and you will be responsible for the bill if the provider is out-of-network or out-of-state. Tell your doctor to visit our Web site, www.bcbsnc.com/providers/ppa, for more information about how they can request prior plan approval for your scan.

Blue Cross NC is working with a company called American Imaging Management (AIM) for the approval of high-tech scans. AIM has a Web site that lets doctors request approval for high-tech scans 24 hours per day, seven days a week. If your doctor does not have access to the Internet and the request is urgent, your doctor has two business days to file the paperwork to AIM in order for Blue Cross NC to approve the scan. If your doctor does not file the paperwork within two business days after an urgent request, Blue Cross NC may not pay for the scan.

If your doctor is in the Blue Cross NC network, he or she is responsible for getting prior plan approval from Blue Cross NC on your behalf. If your doctor is out-of-network or located outside of North Carolina, you are responsible for the cost of the scan if the doctor does not obtain prior plan approval before the scan is done. Remember: You do not need prior plan approval for a high-tech scan if it is part of an emergency room visit or an inpatient hospital stay.

High-tech scans are great tools for doctors to use when diagnosing patients, but they are expensive and are sometimes not used the way they should be used. By requiring prior plan approval before the scan is done, Blue Cross NC is trying to keep medical costs down and keep patients from having tests they don't need.