Blue Cross and Blue Shield of North Carolina Prior Authorization

Blue Cross and Blue Shield of North Carolina publishes service-specific prior authorization guidance. Start with the payer resource below, then confirm the member's plan and the requested service before care is scheduled or submitted.

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