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Services and CPT codes

  

Commercial codes

Medicare codes

Commercial codes

The prior plan approval (PPA) link will send you to the corresponding program information regarding the specific authorization process. Additional information about these codes can be found below. Please note that the search is not updated in real time, and you should refer to the PDF lists located below the search for the most up-to-date information.

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Last updated July 3, 2024. This list is subject to change at least once per quarter. Changes will be posted to the Blue Cross and Blue Shield of North Carolina (Blue Cross NC) website by the 10th day of January, April, July, and October. Unlisted and Miscellaneous health service codes should only be used if a specific code has not been established by the American Medical Association.

  • AVALON = Avalon Lab
  • Blue Cross NC = Blue Cross UM
  • CMM = Cover My Meds

[i] = Investigational

* Prior approval is required for all drugs listed regardless of the HCPCS code submitted on the claim. The requirement is based on the drug itself – not the code chosen to submit on the claim.

Effective 1/1/2021 - LabCorp / Fortrea ASO Group members require PPA for ALL DME ITEMS over $500 (excluding hearing aids)

New to market drugs are defined as drugs that have only been available on the US market for 90 days or less from the FDA approval date. Individual drug names will be added to the PPA list as soon as possible but even if the drug is not listed by name and it is new to market prior authorization is required.

If you have questions regarding this list, please contact Blue Cross NC Utilization Management at 800-672-7897 or your provider relations representative.

Download: Carelon (formerly known as AIM) Prior Review Code List (PDF)

  • Oncology = Oncology
  • Sleep = Sleep Study
  • DIM = Diagnostic Imaging
  • Cardiology = Cardiology
  • MSK = Musculoskeletal
  • Rehab = Rehabilitation (PT/OT/ST)
  • Surg = Surgical

**If this procedure is performed at the time as an approved procedure, it will require a separate post service clinical review. To initiate post service review, please contact Carelon or log on to the Provider Portal within 10 days The results of the approved procedure will be required to complete the post service review.

If the member’s group is not enrolled in the Carelon program indicated, PPA is not required for that procedure/drug in the specified place of service. If you have questions regarding this list, please contact your provider relations representative.

  • Notice Date: The listed date is when the notice of the existing code was added.
  • Effective Date: The listed date is when the code will require prior authorization for correct claims processing. If there is no date in this field, the requirement is in effect.
  • Ineffective Date: The listed date is when the code became invalid.
  • What is a CPT® code? The Current Procedural Terminology (CPT®) codes offer doctors and health care professionals a uniform language for coding medical services and procedures to streamline reporting, increase accuracy and efficiency. CPT codes are also used for administrative management purposes such as claims processing and developing guidelines for medical care review.

Blue Medicare Prior Plan Approval code lists

Requirements for utilization of in-network and out-of-network facilities and professionals must be verified in conjunction with obtaining prior plan approval. Blue Medicare℠ may authorize a service received out-of-network at the in-network benefit level if the service is not available in-network or if there is a transition of care issue. Services not covered by Original Medicare are not covered by Blue Medicare.

Diagnostic Imaging Management Programs

  • Blue Medicare HMO℠ and Blue Medicare PPO℠ - Services such as MRI, CT, PET, and nuclear medicine. Diagnostic Imaging Management Program Services will require Prior Approval as of 4/24/2023.

Medical Oncology Program

Request Prior Plan Approval

Related topics

Medical policies and guidelines

Prior authorization