Prior Review Code List:
This list is updated on a quarterly basis, within the first 10 days of January, April, July, and October. If there is no update within this time period, the list will remain unchanged until the following quarter. Unlisted and miscellaneous health services codes should only be used if a specific code has not been established by the American Medical Association.
Prior Review Policies and Procedures:
- Blue Cross NC may authorize a service received out-of-network at the in-network benefit level if the service is not reasonably available in-network as determined by Blue Cross NC's access to care standards or if there is a continuity of care issue.
- Requirements for utilization of in-network and out-of-network facilities and professionals must be verified in conjunction with obtaining prior review.
Policies Apply to Members Covered By:
Blue Advantage, Blue Care, Blue Value and Blue Options (including 1-2-3, HSA, etc). Prior review for Classic Blue® is also required for employees of Morgan USA and Martin Marietta.
Request Prior Review:
These forms are intended for service requests requiring prior plan approval, pre-certification, or certification when being reimbursed through the member's benefits. These include Acute Inpatient Admissions, Elective Inpatient Admissions, and PPA Code procedures or services, both outpatient and inpatient. Also included are medical plan drug requests and any quantity limit requests for these medications. Please refer to the Pharmacy Website for requests of any medical or pharmacy benefit medications.
Submission of this form is solely a notification for requests of services and does not guarantee approval. All requests must be reviewed using authorization requirements by the prospective review area/department before authorization is granted. Please submit this form and any required medical records, allowing adequate time for review and determination prior to services being rendered. Incomplete forms may delay processing.
By phone: Blue Cross NC Utilization Management - 1-800-672-7897
Monday - Friday, 8 a.m. - 5 p.m., Eastern time
The following services and procedures received in a nonemergency situation on an outpatient basis require prior review.
- Blue Care: Any service received at an out-of-network provider*
- Certain mental health or substance abuse treatment
- Non-emergency air ambulance services
- Certain durable medical equipment (DME)
- Home health, including nursing and certain home infusions
- Private Duty Nursing
- Surgery and/or outpatient procedures, including but not limited to:
- Lung volume reduction surgery
- Morbid obesity surgery
- UPPP, surgical management of obstructive sleep apnea
- Vertebroplasty and kyphoplasty
- Percutaneous treatment of HNP
Procedures potentially cosmetic, including but not limited to:
- Reconstructive surgery, including but not limited to rhitidectomy, dermabrasion, scar revision
- Breast surgeries including insertion and removal of silicone breast implants, reduction mammoplasty, and gynecomastia
- Therapy of superficial veins, such as varicose veins, telangiectasias
- Orthognathic surgery
Please note: In addition to the services listed above, prior review may be required for diagnostic imaging services. For instructions on requesting prior review for diagnostic imaging, see diagnostic imaging procedures.
* Blue Care plan: Blue Cross NC may authorize a service received out-of-network at the in-network benefit level if the service is not available in-network or if there is a continuity of care issue. Blue Advantage® and Blue OptionsSM plans: Blue Cross NC may authorize a service received out-of-network at the in-network benefit level if the service is not available in-network or if there is a continuity of care issue.