What services require prior approval or a referral?
Referrals You do not need to get a referral from your primary care provider to receive covered services from a participating specialist. However, some participating specialists may require a new patient introduction from your treating doctor. BCBSNC recommends that you take advantage of your primary care provider’s expertise in coordinating your care. Prior Approval Most inpatient admissions, skilled nursing facility admissions, and all private duty nursing services require prior approval from Blue Cross and Blue Shield of North Carolina (BCBSNC). In addition, BCBSNC requires prior approval for certain other outpatient services received on or after July 1, 2007. For maternity admissions, your doctor is not required to obtain prior approval from BCBSNC for prescribing a length of stay up to 48 hours for a normal vaginal delivery or up to 96 hours for delivery by cesarean section. You or your doctor must request prior approval for coverage for additional days. Although no prior approval
When you use a participating physician or hospital, they are responsible for ensuring that any surgical procedure or inpatient admissions receive the necessary prior approval. When using a non-participating physician and hospital, it is your responsibility to receive prior approval from Blue Cross and Blue Shield of Georgia for home health care services and inpatient care (excluding maternity related care) prior to these services being rendered.
Members must obtain referrals from their PCPs. Referrals are made when the PCP deems services of a specialist medically appropriate. The PCP arranges for the referral and gives the member a completed referral form that authorizes specific treatment or services. There are certain situations where a referral is not necessary. They include: • Women may go to a network OB/GYN doctor for pregnancy, gynecological problems or annual exams without a PCP referral. • You may see a network dermatologist for covered services without a PCP referral. • You may go to a network ophthalmologist for covered services without a PCP referral. • If you have vision coverage, you may go to a network optometrist for exams, glasses or contact lenses without a PCP referral. (Note: Check your Benefit Summary, member ID card or Certificate Booklet to determine if you have vision coverage.
Prior Approval All private duty nursing, skilled nursing facility admissions and inpatient hospital admissions require certification with two exceptions – maternity (including newborn nursery care) and emergency. For maternity admissions, your doctor is not required to obtain certification from BCBSNC for prescribing a length of stay up to 48 hours for a normal vaginal delivery or up to 96 hours for delivery by cesarean section. You or your doctor must request certification for coverage for additional days. Although no certification is required for emergency situations, please notify BCBSNC of your inpatient admission as soon as reasonably possible. In addition, BCBSNC also requires prior approval for certain health care services. For more information, please refer to our Prior Approval List. Services for mental health and substance abuse must be approved in advance by Magellan Behavioral Health. Referrals You do not need to get a referral from your primary care provider to receive cov
