Certain services require prior review and certification from Blue Cross NC before they can be covered by your health insurance plan. Show
Responsibility for Requesting Prior Review and CertificationFor In-Network ProvidersNorth 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 ProvidersYou 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:
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:
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:,
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:
Basic Coverage*: Full-Time Employees *Basic Coverage includes UT SELECT (medical and prescription coverage), plus the cost of employee $50,000 Basic Life and employee $50,000 Basic Accidental Death and Dismemberment. Summary of Benefits and Coverage UT offers one medical insurance plan, UT SELECT, a self-funded PPO plan, administered by Blue Cross and Blue Shield of Texas. If you use a
network doctor, you will receive the highest level of benefits, pay much less out-of-pocket, and will usually not have to file any claims. If you use an out-of-network doctor, you will still be covered, but your out-of-pocket costs for health care services will be substantially higher. What type of insurance is Health Select of Texas?HealthSelect of Texas® is a network-based, point-of-service plan. Blue Cross and Blue Shield of Texas is the plan administrator. HealthSelect of Texas is available to employees who live or work in Texas.
Does BCBS of Texas require prior authorization?The provider is responsible for requesting prior authorization before performing a service if the member is seeing an in-network provider. Most out-of-network services require utilization management review.
Is HealthSelect of Texas A PPO or HMO?The Consumer Directed HealthSelectSM plan is a high-deductible health plan (HDHP) with a health savings account (HSA) and PPO network.
Who would benefit from HealthSelect of Texas?HealthSelect of Texas is available to members of the Texas Employees Group Benefits Program, retirees under 65, and their eligible dependents.
|