Medicare Advantage - Provider Notification for Utilization Management Authorization Rule Operations Workgroup Item 1907

Please note, this communication applies to Healthy Blue + MedicareSM (HMO D-SNP) offered by Blue Cross and Blue Shield of North Carolina (Blue Cross NC).

On October 1, 2021, Blue Cross NC prior authorization (PA) requirements will change for A0426 and A0428. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services (CMS) guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

Prior authorization requirements will be added for the following codes:

• A0426 – Als 1
• A0428 – Bls

Not all PA requirements are listed here. PA requirements are available to contracted providers on the provider website at https://www.bluecrossnc.com/providers/blue-medicare-providers/healthy-blue-medicare > Login or by accessing Availity. Once logged in to Availity at http://availity.com, select Patient Registration > Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry, as appropriate. Contracted and noncontracted providers who are unable to access Availity may call the number on the back of the member’s ID card for assistance with PA requirements.

Note: Availity, LLC is an independent company providing administrative support services for Healthy Blue + Medicare providers on behalf of Blue Cross and Blue Shield of North Carolina.

https://www.bluecrossnc.com/provider-home
BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is an independent licensee of the Blue Cross and Blue Shield Association.
BNCCARE-0144-21 June 2021    519127MUPENMUB