Blue Cross Blue Shield - North Carolina Prior Authorization Lookup
- Blue Cross Blue Shield - North Carolina timely filing
- Blue Cross Blue Shield - North Carolina coverage criteria
- All Blue Cross Blue Shield - North Carolina policy updates
Latest Blue Cross Blue Shield - North Carolina prior authorization updates25
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Canakinumab (Ilaris) subcutaneous injection — Medical Necessity and Prior Authorization CriteriaMedical necessity and prior authorization criteria for canakinumab (Ilaris) subcutaneous injection administered by a healthcare professional for approved autoinflammatory and inflammatory indications, governing providers and members covered by Blue Cross NC.All Blue Cross Blue Shield - North Carolina updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Durable Medical Equipment (DME) coverageDefines medical necessity, prior authorization, rental/purchase, replacement, and exclusions for durable medical equipment for Blue Cross Blue Shield - North Carolina Medicare and related members.All Blue Cross Blue Shield - North Carolina updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Guselkumab (Tremfya) — coverage criteria for IV and SC administrationDefines medical necessity, site-of-care, dosing limits, and documentation requirements for guselkumab (Tremfya) IV and SC administration across FDA-approved indications (psoriasis, psoriatic arthritis, ulcerative colitis, Crohn's disease); affects prescribers, infusion centers, and prior authorization reviewers.All Blue Cross Blue Shield - North Carolina updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Mirikizumab-mrkz (Omvoh) — Intravenous Infusion (Notification) Coverage CriteriaDefines medical necessity and prior authorization requirements for intravenous mirikizumab (Omvoh) for adults with moderately to severely active Crohn's disease or ulcerative colitis for Blue Cross Blue Shield North Carolina members.All Blue Cross Blue Shield - North Carolina updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Risankizumab-rzaa (Skyrizi) IV infusion — Induction for Crohn's disease and Ulcerative ColitisCovers medical necessity and prior-authorization requirements for risankizumab-rzaa (Skyrizi) intravenous infusion for adults with moderately to severely active Crohn's disease or ulcerative colitis; applies to Blue Cross Blue Shield North Carolina members and treating providers.All Blue Cross Blue Shield - North Carolina updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Testosterone Cypionate (Azmiro) - NotificationDefines medical necessity and prior authorization notification criteria for Azmiro (testosterone cypionate IM) administered by a healthcare professional for testosterone replacement and select indications; applies to Blue Cross NC membership.All Blue Cross Blue Shield - North Carolina updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Tocilizumab (Actemra) and Tocilizumab Biosimilars coverageMedical policy governing prior authorization and medical necessity criteria for tocilizumab (Actemra) and specified biosimilars for outpatient/inpatient use for BCBS North Carolina members.All Blue Cross Blue Shield - North Carolina updates
- Prior AuthReimbursement/Payment PolicyEff. 2026-04-01Claims and Billing Guidance for Home Health EVV - REV/HCPC/CPT CodesGuidance for institutional claims billing of home health services (EVV-related) including revenue codes, HCPCS/CPT codes, and prior authorization requirements for Blue Cross Blue Shield - North Carolina (Healthy Blue) providers.All Blue Cross Blue Shield - North Carolina updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Familial Chylomicronemia Syndrome TherapyDefines medical necessity, site-of-care, and prior authorization requirements for use of olezarsen (Tryngolza) and plozasiran (Redemplo) as adjuncts to diet to reduce triglycerides in adults with familial chylomicronemia syndrome (FCS) for Blue Cross NC members.All Blue Cross Blue Shield - North Carolina updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Intravenous Anesthetics for the Treatment of Chronic Pain and Psychiatric DisordersThis policy governs coverage of intravenous ketamine and lidocaine infusions when used to treat chronic pain conditions and psychiatric disorders for Blue Cross Blue Shield of North Carolina members; it affects providers requesting reimbursement or prior authorization for these services.All Blue Cross Blue Shield - North Carolina updates
- Prior AuthAdministrative/Operational PolicyEff. 2026-04-01Leadless Cardiac PacemakersMedical policy governing coverage and clinical criteria for leadless (transcatheter) cardiac pacemakers for Blue Cross Blue Shield of North Carolina members; affects providers requesting coverage and prior authorization for these devices and related procedures.All Blue Cross Blue Shield - North Carolina updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Omidubicel-onlv (Omisirge) — medical necessity and coverage criteria for intravenous infusionPolicy governs medical necessity coverage and administrative requirements for omidubicel-onlv (Omisirge) IV infusion for eligible patients receiving umbilical cord blood transplantation or with severe aplastic anemia, affecting providers and prior authorization for Blue Cross NC members.All Blue Cross Blue Shield - North Carolina updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Romiplostim (Nplate) — Coverage Criteria for ITP and HSARSDefines medical necessity, prior authorization, and site-of-care requirements for romiplostim (Nplate) subcutaneous injection for treatment of immune thrombocytopenia (ITP) and Hematopoietic Syndrome of Acute Radiation Syndrome (HSARS) for Blue Cross NC members.All Blue Cross Blue Shield - North Carolina updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Denosumab (Prolia, Xgeva) and Denosumab Biosimilars coverageDefines medical necessity criteria, product list, dosing/HCPCS guidance, and prior authorization requirements for denosumab (Prolia/Xgeva) and specified biosimilars for Blue Cross Blue Shield North Carolina members.All Blue Cross Blue Shield - North Carolina updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Denosumab (Prolia, Xgeva) and Denosumab Biosimilars notificationDefines medical necessity and prior authorization criteria for denosumab products and biosimilars for Blue Cross Blue Shield North Carolina members, covering osteoporosis, cancer-related indications, giant cell tumor of bone, hypercalcemia of malignancy, and related uses.All Blue Cross Blue Shield - North Carolina updates
- Prior AuthReimbursement/Payment PolicyEff. 2026-01-01HSA Preventive Drug ListLists medications and diabetic supplies designated as preventive under certain HSA-eligible and Transitional Blue HSA plans offered by Blue Cross Blue Shield - North Carolina; applies to members of employer/group and Individual-Under 65 High Deductible Health Plans that include the HSA Preventive Drug coverage feature.All Blue Cross Blue Shield - North Carolina updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Rituximab for the Treatment of Rheumatoid Arthritis - Coverage CriteriaDefines medical necessity and prior-authorization requirements for rituximab (Rituxan and biosimilars) for adults with moderately to severely active rheumatoid arthritis who have inadequate response to prior therapies; applies to Blue Cross Blue Shield of North Carolina members.All Blue Cross Blue Shield - North Carolina updates
- Prior AuthAdministrative/Operational PolicyEff. 2025-06-01Electrical Stimulation for the Treatment of ArthritisDefines BCBSNC's coverage stance on noninvasive electrical and electromagnetic stimulation devices used to treat osteoarthritis and rheumatoid arthritis for commercial members; applies to services described in this policy and to providers submitting claims or prior authorization requests.All Blue Cross Blue Shield - North Carolina updates
- Prior AuthClinical/Medical PolicyEff. 2025-01-01HSA Preventive Drug ListLists prescription drugs and diabetic supplies designated as preventive under certain HSA/HDHP-aligned benefit plans for Blue Cross Blue Shield - North Carolina; affects members whose plans include the HSA Preventive Drug coverage feature and providers/pharmacies dispensing these medications.All Blue Cross Blue Shield - North Carolina updates
- Prior AuthClinical/Medical PolicyEff. 2024-12-31Medically Monitored Inpatient Withdrawal Management (Non-Hospital Medical Detox)Defines BCBSNC coverage criteria, continued-stay and noncoverage rules, and precertification requirements for medically monitored inpatient withdrawal management (residential non-hospital detox) for adults, children, and adolescents.All Blue Cross Blue Shield - North Carolina updates
- Prior AuthClinical/Medical PolicyEff. 2024-12-31Medically Monitored Inpatient Withdrawal Management (Non-Hospital Medical Detox)Defines medical necessity criteria, coverage stance, and prior authorization requirements for non-hospital residential (24‑hour) medically monitored inpatient withdrawal management for adults, children, and adolescents under Blue Cross Blue Shield of North Carolina.All Blue Cross Blue Shield - North Carolina updates
- Prior AuthClinical/Medical PolicyEff. 2024-07-01Psychiatric Intensive Outpatient Programs (IOP) Coverage CriteriaDefines coverage, medical necessity criteria, and billing guidance for Psychiatric Intensive Outpatient Programs (IOP); affects providers seeking coverage and prior authorization for IOP services.All Blue Cross Blue Shield - North Carolina updates
- Prior AuthClinical/Medical PolicyEff. 2024-07-01Psychiatric Partial Hospitalization Programs (PHP) Coverage CriteriaCriteria, coverage stance, and billing/coding guidance for outpatient Psychiatric Partial Hospitalization Programs provided to BCBSNC members; applies to providers delivering PHP services seeking coverage determination and prior authorization.All Blue Cross Blue Shield - North Carolina updates
- Prior AuthClinical/Medical PolicyEff. 2024-06-01Prior authorization request form for intensity-modulated radiation therapy (IMRT)This document is a Blue Cross NC fax prior-review request form used by providers to request prior authorization for IMRT services across multiple cancer sites; it applies to providers and facilities submitting IMRT requests for North Carolina members.All Blue Cross Blue Shield - North Carolina updates
- Prior AuthClinical/Medical PolicyEff. 2024-01-01ACA Preventive Drug List / Preventive Medications and Vaccines CoverageList of preventive medications and vaccines that may be provided with $0 cost-share under ACA-compliant benefit plans for members of Blue Cross Blue Shield - North Carolina. It is a formulary-style listing grouped by preventive category and intended for plan members and providers to verify preventive drugs covered under the plan.All Blue Cross Blue Shield - North Carolina updates
1–25 of 77
1 / 4
Tool Description
Search Blue Cross Blue Shield - North Carolinaprior authorization policies by drug name, procedure, or policy title. Results include any policy that mentions prior authorization requirements (drug coverage criteria, imaging guidelines, site-of-service rules) not just documents titled “prior authorization.” Every result links to a full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
Filter by payer, specialty, policy type, or effective year; or search directly for a drug (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee arthroplasty”), or a policy number.
Coverage spans 110+ payers. Jump straight to the busiest prior-auth publishers: UnitedHealthcare, Cigna, Aetna, Anthem, and Centene. You can also browse the full policy updates feed.
Pair a prior-auth search with the billing code lookup to confirm the CPT or J-code on the claim, the payer lookup for plan footprint, and payer profiles for contacts and coverage context.
FAQ
Type a drug name (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee”), or a policy title into the search bar. Filter results by payer, specialty, policy type, or effective year. Open any result for the full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
Prior Authorization by Payer
Go deeper
Explore OpenPayer Data
Prior auth requirements change all the time. Keep up with every payer policy update in the live policy feed, or browse payers with prior authorization policies.
Toolbox
More OpenPayer Tools
- Billing Code LookupSearch CPT, HCPCS, J-codes, DRG, and dental codes by number or procedure name.
- Healthcare Provider & Facility LookupFind hospitals and healthcare facilities by name, taxonomy, facility type, ownership, or state.
- Health Insurance Payer LookupSearch national health insurance payers and health plans by name and state presence.
- Provider Taxonomy Code LookupSearch NUCC taxonomy codes by code, specialty, grouping, or classification.
- CPT Modifier LookupSearch CPT modifiers by code or name — descriptions, when to use them, and payer policy context.
- Timely Filing LookupFind payer timely filing policies: claim deadlines, corrected claim windows, and appeal timeframes.
- Coverage Criteria LookupSearch payer coverage criteria and medical necessity requirements by drug, procedure, or payer.
- Payer Contact DirectoryClaims, prior authorization, provider services, and appeals contacts for health insurance payers.
Published by
Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.