NC BCBSNC Prior Review/Certification Faxback Form 2015-2025 free printable template

() PRIOR REVIEW/CERTIFICATION FATBACK FORM INCOMPLETE FORMS MAY DELAY PROCESSING ALL NC PROVIDERS MUST PROVIDE THEIR 5DIGIT BCB SNC PROVIDER ID# BELOW PRESCRIBER NAMEPRESCRIBER NPI REQUIRED CONTACT

How to fill out NC BCBSNC Prior ReviewCertification Faxback Form

How to fill out NC BCBSNC Prior Review/Certification Faxback Form

1. Obtain the NC BCBSNC Prior Review/Certification Faxback Form from the official BCBSNC website or your healthcare provider.
2. Fill out the patient information section, including the patient's name, date of birth, and member ID.
3. Provide information about the requesting provider, including the provider's name, NPI number, and contact information.
4. Indicate the type of service being requested and the relevant procedure codes.
5. Include the specific reason for the prior review or certification request.
6. Attach any required supporting documentation, such as medical records or test results.
7. Review the completed form for accuracy and completeness before submission.
8. Fax the completed form to the specified number provided by BCBSNC.

Who needs NC BCBSNC Prior Review/Certification Faxback Form?

1. Healthcare providers requesting prior authorization for services or procedures on behalf of their patients.
2. Patients seeking to ensure their treatments or services are covered by their insurance before they proceed.

People Also Ask about

What is CPT code J7321?

J7321 Hyaluronan or Derivative, Hyalgan or Supartz, For Intra-Articular Injection, Per Dose. J7323 Hyaluronan or Derivative, Euflexxa, For Intra-Articular Injection, Per Dose. J7324 Hyaluronan or Derivative, Orthovisc, For Intra-Articular Injection, Per Dose. 2. HCPC's code J7325 is defined as 1 mg.

What is J7325 used for?

HCPCS code J7325 for Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg as maintained by CMS falls under Miscellaneous Drugs .

What is the purpose of the Synvisc injection?

SYNVISC is a viscosupplement injection that supplements the fluid in your knee to help lubricate and cushion the joint, and can provide up to six months of osteoarthritis knee pain relief with three injections.

Does Euflexxa require prior authorization?

The following Hyaluronic acid products do not require an authorization prior to use: Durolane®, Supartz FX®, Euflexxa® and Gelsyn-3®. Consider using these products first.

How do I bill CPT J7325?

Coding Guidelines When this injection is administered either unilaterally or bilaterally the injections would be billed by placing J7325 in item 24 (FAO-09 electronically) and listing the total number of mg's administered in the units field. There are 2 different products that are billed using this code.

What is CPT J7323?

J7323. HYALURONAN OR DERIVATIVE, EUFLEXXA, FOR INTRA-ARTICULAR INJECTION, PER DOSE. J7324. HYALURONAN OR DERIVATIVE, ORTHOVISC, FOR INTRA-ARTICULAR INJECTION, PER DOSE.

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What is NC BCBSNC Prior Review/Certification Faxback Form?

The NC BCBSNC Prior Review/Certification Faxback Form is a document used by healthcare providers to request prior authorization for certain medical services or procedures from Blue Cross Blue Shield of North Carolina (BCBSNC).

Who is required to file NC BCBSNC Prior Review/Certification Faxback Form?

Healthcare providers who wish to obtain prior authorization for specific services, procedures, or medications for their patients covered by BCBSNC are required to file the NC BCBSNC Prior Review/Certification Faxback Form.

How to fill out NC BCBSNC Prior Review/Certification Faxback Form?

To fill out the form, providers must enter patient information, details of the requested service, applicable medical codes, and any supporting clinical documentation. It is important to ensure all required fields are completed accurately before submitting the form via fax.

What is the purpose of NC BCBSNC Prior Review/Certification Faxback Form?

The purpose of the NC BCBSNC Prior Review/Certification Faxback Form is to facilitate the review process for medical necessity and ensure that the requested services are covered under the patient's insurance plan before they are performed.

What information must be reported on NC BCBSNC Prior Review/Certification Faxback Form?

The form must report patient demographics, the provider's details, the specific service or procedure being requested, relevant diagnosis codes, the clinical rationale for the request, and any additional information requested by BCBSNC for review.