Medical Prior Plan Review

Blue Cross NC uses prior review (prior plan approval, prior authorization, prospective review and certification) to check the specifications of certain behavioral health services, medical services and medications against health care management guidelines prior to the services being provided. Inpatient admissions, services and procedures received on an outpatient basis and prescription medications may be subject to prior review.

Any services, durable medical equipment or medications listed on the Prior Review Code List require authorization for ALL places of service, including when performed during any inpatient admission, both planned and emergent.

Note: Services on the Prior Review Code List that are rendered in emergency care or urgently during an inpatient admission are still subject to medical necessity criteria.

Reviews may confirm:

• Member eligibility
• Benefit coverage
• Compliance with Blue Cross NC corporate medical policy regarding medical necessity
• Appropriateness of setting
• Requirements for use of in-network and out-of-network facilities and professionals
• Identification of comorbidities and other problems requiring specific discharge needs
• Identification of circumstances that may indicate a referral to concurrent review, discharge services, case management or the Healthy Outcomes Condition Care Program

Additional references:

• Prior Review (Prior Plan Approval) Code List (includes Avalon, AIM Sleep, AIM Medical Oncology - Commercial/Non-Medicare)

• Medical Oncology Program Prior Review Code List - Blue Medicare
• Diagnostic Imaging Prior Review Code List