Blue Cross and Blue Shield of North Carolina Prior Authorization

Blue Cross and Blue Shield of North Carolina prior authorization rules are often service-specific rather than universal, so the safest workflow is to confirm the requirement in the payer's provider resources before scheduling or submitting care. The notes below summarize the most actionable provider-side guidance captured in the research set for this payer.

At a glance

• BCBSNC requires prior authorization for certain behavioral health, medical services, equipment, and medications, with decisions informed by medical policies, medical necessity criteria, and supporting documentation. Blue e / Care Affiliate is the main provider portal for authorization workflows, and Blue Cross NC has been adding self-service functionality to determine whether prior authorization is required and to submit documentation electronically. For medical drugs, BCBSNC directed providers to use the MHK portal via Blue e instead of CoverMyMeds starting January 25, 2024; pharmacy drug requests may be submitted via MHK (preferred), CoverMyMeds, or Surescripts. Some services are routed to third-party vendors (for example Carelon for certain outpatient therapy or imaging-related workflows) depending on product and code.
• Authorization requirements vary by line of business, plan, service type, and vendor pathway.
• BCBSNC has transitioned some services to third-party vendors; providers should verify code-level routing before submitting.
• The prior authorization page does not itself enumerate all codes or all product-specific exceptions.
• Some older manuals remain posted and may contain legacy processes; current provider news should be used for operational changes.

Where to verify prior authorization requirements

• Verification resource 1
• Verification resource 2
• Verification resource 3
• Verification resource 4
• Verification resource 5

How to submit prior authorization requests

• Blue e / Care Affiliate provider portal

• MHK portal via Blue e (medical drug requests)

• CoverMyMeds (pharmacy drug requests only, where still supported)

• Surescripts (pharmacy drug requests)

• Telephone/fax for some product-specific workflows

• Submission resource 1

• Submission resource 2

• Submission resource 3

• Submission resource 4

Information commonly required

• Member eligibility and benefit details
• CPT/HCPCS or drug identifier being requested
• Clinical documentation supporting medical necessity
• Relevant medical policy / criteria alignment
• Setting of care and requested service details
• For some cases, supporting records and documentation uploads within the portal

Turnaround notes and caveats

• Care Affiliate Cite AutoAuth can produce an approval or pend status within seconds for supported services.
• BCBSNC states urgent inpatient services on the prior authorization code list remain subject to medical necessity criteria.
• Product- or vendor-specific turnaround times may differ; official guidance reviewed here did not provide a single universal timeframe.
• Authorization requirements vary by line of business, plan, service type, and vendor pathway.
• BCBSNC has transitioned some services to third-party vendors; providers should verify code-level routing before submitting.
• The prior authorization page does not itself enumerate all codes or all product-specific exceptions.
• Some older manuals remain posted and may contain legacy processes; current provider news should be used for operational changes.

Provider resources

• Providers home (official)
• Contact us for providers (official)
• Prior authorization (official)
• Commercial claims, appeals, and inquiries (official)
• Medicare claims, appeals, and inquiries (official)
• Provider e-Manual (Commercial Blue Book PDF) (official)
• Dental E-Manual (Blue Book) (official)

Sources