Prior Plan Review

Prior Plan Approval Search

Please reference the documents below to determine need for prior plan approval.

Prior review (prior plan approval, prior authorization, prospective review or certification) is the process Blue Cross NC uses to review the provision of certain behavioral health, 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, such as in a doctor's office, and prescription medications may be subject to prior review.

Please note, 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, including both planned inpatient admissions and emergent inpatient admissions*.

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

*Services on the Prior Review Code List that are rendered emergently or urgently during an inpatient admission are still subject to medical necessity criteria.

Services Requiring Prior Plan Approval