Blue Cross Prior Review Certification

bigstock--D-Person-Watching-A-Word-rev-57042881Prior Review:  Certain services require prior review and certification from BCBSNC before they can be covered by your health insurance plan. In case of emergency, prior review and certification is NOT required. BCBSNC should be notified of an urgent or emergency admission by the second business day of the admission.

Responsibility for Requesting Prior Review and Certification

For In-Network Providers: North Carolina providers or specialists in the BCBSNC network will request prior review for you. You may want to check with your health care provider to make sure that prior review was obtained before you have the service or procedure in question.

For Out-of-Network Providers:  You are responsible for ensuring that out-of-network doctors have requested prior review and certification from BCBSNC before the service is performed. The physician or her office should request the review from BCBSNC. This also applies to BlueCard providers (out of state providers who contract with another Blue Cross Blue Shield plan) outside of North Carolina. Your Benefit Booklet has more information about prior review and certification that is specific to your policy.

Why is prior review and certification necessary?  Prior review and certification ensures that:Your benefits cover the service in question:  The service is medically necessary according to BCBSNC medical policy; The service is performed in the right health care setting; The provider is correctly identified as in- or out-of-network, and Special medical circumstances are identified that require specific types of review and follow-up.

Note: BCBSNC may certify a service received out-of-network at the in-network benefit level if the service is not reasonably available in-network or if there is a continuity of care issue.

What types of procedures may require prior review and certification?  Whether prior review and certification is required may depend on your BCBSNC benefit plan. Always check your Benefit Booklet for specific information about your plan. The following procedures typically require prior review and certification:

  • Inpatient admissions (with the exception of maternity admissions) — elective, planned in advance or not related to an emergency.
  • Inpatient maternity stays longer than 48 hours after vaginal delivery or 96 hours after a C-section
  • Private duty nursing, skilled nursing facility, acute rehabilitation admissions (short-term inpatient recovery), home health care (including nursing and some home infusion).
  • Services performed by an out-of-network or non-BlueCard out-of-state health care provider
  • Air ambulance services (emergency air ambulance does not require prior review)
  • Certain durable medical equipment (DME)
  • Transplants — solid organ (e.g. liver) or bone marrow/stem cell
  • Surgery and/or outpatient procedures

For more information on health insurance coverage in North Carolina, please visit our website at or call our toll free number 888-765-5400 and speak with one of our professional agents. Our agency provides coverage for health insurance in North Carolina through Blue Cross Blue Shield of North Carolina (BCBSNC). It would be our pleasure to help you navigate through the Health Care Reform changes in accordance with the new regulations of Obama care. Call us for details.

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