Prior Plan Approval

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To ensure our members have access to quality, cost-effective health care, Blue Cross NC manages the utilization or services, procedures and medications through a variety of processes and programs. Blue Cross NC evaluates the utilization of services, procedures and medications for the following:

  • Member eligibility
  • Benefit coverage
  • Compliance with Blue Cross NC medical policy regarding medical necessity
  • Compliance with nationally accepted evidence-based clinical guidelines
  • Appropriateness of setting
  • Identification of related diseases or other problems requiring specific needs at patient discharge

  • Identification of circumstances which may indicate a referral to a second opinion, continuity of care, case management or the Member Health Partnerships program.

The Blue Cross NC quality assurance programs are as follows:

  • Prior plan approval – This is the process by which Blue Cross NC reviews health care services and prescriptions before they occur in order to provide approval to perform the service or prescribe the medication. Network providers request prior plan approval on behalf of the member. Members who choose to visit out-of-network providers are responsible for making sure that prior plan approval is obtained.

    For a complete list of services, procedures and prescription drugs requiring prior approval, and instructions on submitting a request for approval, review the prior plan approval section.

  • Concurrent review – This process is performed by Blue Cross NC nurses while a member is hospitalized to verify that the member is in the most appropriate setting. Concurrent review nurses also work with the Blue Cross NC discharge services staff to help arrange any care necessary after the member is discharged from the hospital

  • Retrospective review – In unusual instances, this process occurs when medical services, including hospital services, are reviewed for approval after the services have taken place. The process evaluates a members' medical history to identify any treatment issues. Alerts are provided by mail to physicians, addressing patient treatment practices that are considered unsafe, ineffective or otherwise inconsistent with evidence-based standards of care.
     
  • Blue Cross NC case management program – This program is designed for members with very serious, chronic or complicated health care conditions. A Blue Cross NC case manager works with the member, as well as the member's family, and health care providers to coordinate and facilitate the availability of appropriate resources to result in optimal health outcomes for the member.

  • Continuity of care assistance – This process is designed to assist members with acute, chronic or terminal illnesses or those who are in the second trimester of pregnancy with receiving care from a provider when the member changes health plans or when the provider no longer participates in network. To be eligible for continuity of care, one of the following conditions must apply:

     

    1. Member has a chronic illness or condition - a disease or condition that is life-threatening, degenerative or disabling and requires medical care or treatment over a prolonged period of time.
    2. Member is in the second or third trimester of pregnancy or completing postpartum care.
    3. Member is terminally ill - a medical prognosis that the individual's life expectancy is six months or less.
       

  • Blue Cross NC must authorize services in advance in order for the services to be covered at the in-network benefit level. Members should work with their providers to request prior approval from Blue Cross NC or may contact Customer Service on their own to obtain a continuity of care request form within 45 days of either their effective date or the date they receive notification of a provider's termination from a Blue Cross NC network.

  • If a member currently is receiving care for mental health or substance abuse, and is enrolling in Blue Care or Blue Choice plan, the member may call 1–800–359–2422 to determine if continuity of care is applicable.

If a member has a concern about the final certification decision, the member has the right to appeal the decision. For more information about the Blue Cross NC quality assurance programs, please call the 1-800-672-7897 or write to:

Health Coaching and Interventions Department
Blue Cross NC
P.O. Box 2291
Durham, NC 27702

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