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Providers

Skilled and private nursing

  

Services requiring Prior Plan Approval (PPA)

  • Inpatient admissions – Nonemergency, elective or scheduled admissions
  • Private duty nursing
  • Skilled nursing facility and acute rehabilitation admissions
  • Transplants – solid organ or bone marrow/stem cell

Prior Plan Approval policies and procedures

  • Blue Cross NC should be notified of emergency admissions by the second business day of the admission.
  • Maternity admissions related to delivery do not require preadmission certification for the first 48 hours for vaginal delivery or the first 96 hours for C-section. Inpatient stays beyond the first 48 hours for vaginal delivery or the first 96 hours for C-section require authorization.
  • Any other elective/scheduled admissions must be approved prior to admission.

Member plans affected by these policies

  • Blue Advantage®
  • Blue Care®
  • Blue Options℠
  • Classic Blue®

Request Prior Plan Approval

For admissions and private duty nursing

  • By phone: Blue Cross NC Utilization Management - 800-672-7897
    • Monday through Friday, 8 a.m. to 5 p.m. ET
    • After hours, you may leave a voice message.

Skilled nursing facility admissions

For Blue Medicare HMO and Blue Medicare PPO, prior approval is required for covered skilled nursing facility admissions. To request prior approval, please contact naviHealth representatives.

To submit additional information via fax for a case that has already been authorized, use the following numbers.

  • Concurrent Review: 844-206-7051
  • MDS, Administrative: 844-331-4502

Find out more about naviHealth at navihealth.com. You can read naviHealth FAQ (PDF) about the naviHealth skilled nursing facility care prior approval process.