Prior Plan Review

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 - Request a Prior Review:

Admissions and private duty nursing

Including skilled nursing facility admissions and private duty nursing service.
Learn More / Submit a Request >>

Diagnostic imaging

Including CT/CTA, PET and MRI/MRA scans and nuclear cardiology studies.
Learn More / Submit a Request >>

Prescription drugs

Including medications to treat Hepatitis C, ADHD, weight loss, biologics for arthritis and psoriasis, and restricted access drugs.
Learn More / Submit a Request >>

Other services and procedures

Including home health care services, durable medical equipment, behavioral health (mental health/substance use disorder) and the Prior Review List.
Learn More / Submit a Request >>

Medical Oncology Program

Learn More / Submit a Request >>

Sleep Management Program

Learn More / Submit a Request >>

Lab Management Program

Learn More / Submit a Request >>
The Avalon portal will not be available until 4/23. Please fax the completed form to Avalon's Medical Management Department at 813-751-3760. If you have any questions, please call 844-227-5769.