Access to Care Standards
Through its Physician Advisory Group and Quality Improvement Committee, Blue Cross NC has established Access to Care Standards so that you'll know you can get the care you need, when you need it. Blue Cross NC and Blue Cross NC contracting physicians are committed to meeting these standards in order to provide the best service possible.
Find a Drug
Search for prescription drugs and pharmacy services, or obtain a list of pharmaceuticals.
Prior Review and Limitations for Medications
Some medications require more than a provider's prescription in order to be covered by Blue Cross NC. These medications require that you meet certain criteria. Your provider must also answer specific questions prior to coverage. This allows all of us to work together to provide you with the safest, most effective and cost-efficient medications.
Care Management and Operations
The Blue Cross NC Care Management & Operations (CM&O) Department works with physicians and members to facilitate the most medically appropriate, cost-effective, quality care for our members. In Care Management & Operations find out about:
- Access to utilization management staff
- How medical necessity decisions are made
- Peer-to-peer review
- Protecting your patients' health care needs
Healthy Outcomes Program
Blue Cross NC offers a suite of health management programs for select health conditions for our commercial members called Healthy Outcomes. This confidential program is available to eligible members at no cost. Members can visit Blue Connect for more information and to take advantage of our helpful online tools, trackers, modules and articles to help them manage their health.
Practitioner Rights
Practitioners have the right to review information submitted to support their credentialing application, as well as correct any erroneous information included in their file. Practitioners also have the right to receive status updates for their application upon request. Learn more about your rights according to Blue Cross NC and the National Committee for Quality Assurance (NCQA) guidelines.
Practice and Preventive Health Guidelines
All Blue Cross NC guidelines are based on the most current scientific evidence, and are adapted from standards published by nationally recognized authorities. In addition, each guideline is reviewed and approved at least bienially by Blue Cross NC's Physician Advisory Group.
Continuous Quality Improvement
At Blue Cross NC, we want to help improve the health and well-being of our members, as well as encourage simplicity and affordability in health care. To meet these goals we continually review our quality processes, assess member programs and offerings, and ensure care is based on strong clinical evidence. Learn more about what we're doing to improve health care quality.
Medical Policies and Coverage
- Medical Policies
- Prior Review
- Appeals
- Medical Policy and Pre-certification/Pre-authorization Information for Out-of-Area Members
Blue Connect