How long does prior authorization take blue cross blue shield

Certain services require prior review and certification from Blue Cross NC before they can be covered by your health insurance plan.

Responsibility for Requesting Prior Review and Certification

For In-Network Providers

North Carolina providers or specialists in the Blue Cross NC 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 Blue Cross NC before the service is performed. The physician or her office should request the review from Blue Cross NC. 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.

Prior review and certification is also known as:

• Prior plan approval
• Prior authorization
• Prospective review
• Certification
• Precertification

In case of emergency, prior review and certification is NOT required. Blue Cross NC should be notified of an urgent or emergency admission by the second business day of the admission.

Prior review and Certification Code list:

This list is provided for member information only. It is a provider tool and 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.

Prior Review and Certification Code List 

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 Blue Cross NC medical policy
• The service is performed in the right health care setting
• The provider is correctly identified as in- or out-of-network
• Special medical circumstances are identified that require specific types of review and follow-up

Note: Blue Cross NC 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 Blue Cross NC 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

How can my provider request prior review and certification?

Your health care provider can use any of the following ways to request prior review and certification:

• By phone: Blue Cross NC Utilization Management at 1-800-672-7897 Monday to Friday, 8 a.m. — 5 p.m. ET
• By fax: Request form 
  

Understanding your health insurance is the best way to enjoy all its benefits. When you know what steps you need to take before treatment, things go more smoothly. One of the most important steps is prior authorization.

Many times, your doctor will need to get approval – prior authorization – before your plan will cover certain health care services and medicines. Your doctor may also call it preauthorization and preapproval. Worried getting prior authorization might be a hassle? Don’t fret. It’s easier than you think. Here’s what you need to know.

Why is prior authorization important?
Some health care services and prescription drugs must be approved by Blue Cross and Blue Shield of Texas (BCBSTX) before they are covered under your plan. This is how we support you in getting the right care, at the right place and at the right time. 

How does prior authorization work?
Your doctor will submit a prior authorization request before ordering a test or medication.If the request for prior authorization isn't approved, your insurer will let you and your doctor know. If that happens, you and your doctor may choose another treatment option or offer more info so the request can be reviewed again.

If your providers aren't in network, you'll be responsible for getting the prior authorization. If you don't, we may not cover the cost. 

Which health care services need prior authorization?
Things like diagnostic images and complex care need prior authorization before you are treated. Prior authorization for MRIs and CT scans is standard. Your care provider will know to ask first, but don’t be afraid to make sure. Each plan is different, so it's always good to ask.

Downloading the Mobile app to connect to your Blue Access for MembersSM account allows you the option to select your notification preferences to receive immediate status updates via email or text on your prior authorizations.

What prescription drugs call for prior authorization?
Drugs that may be unsafe when used with other medications need prior authorization. Also, drugs that should only be used for certain health conditions are on the prior authorization list. So are abused and misused drugs. If you have coverage with BCBSTX’s pharmacy benefits manager, Prime Therapeutics*, you can find examples that may need prior authorization. Go to myPrime.com

Medications that need approval will only be covered by your plan if your doctor gets prior authorization. 

What should I do if a drug or service needs prior authorization?
If you are seeing an in-network doctor, your doctor will need to submit a request. You may also want to call the Customer Service number on your ID card to make sure your doctor asked for prior authorization.

If you are going to a doctor who is not in your plan’s network, contact us to get prior authorization. Call the Customer Service number on your ID card to determine the next steps.

What happens if my prior authorization isn’t approved?
If coverage for a health care service or medication is denied, you and your doctor may change your treatment plans. If you get the service or drug without prior authorization, you will have to pay the costs. You have the right to appeal the decision. Find information about the appeal process in your benefits documents.

Still have questions? Ask away! Post them below or call Customer Service to talk with a customer advocate.

Originally published 5/13/2015; Revised 2021, Reviewed 2022

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