Medical/surgical eye care
Blue Cross and Blue Shield of North Carolina
IMPORTANT UPDATE: North Carolina Department of Health and Human Services (NCDHHS) has relaxed the requirements for prior authorizations for Children and Families Specialty Plan (CFSP) members. Between 12/1/2025 and 6/30/2026, claims for covered services that meet medical necessity criteria will not be denied in the event a prior authorization is not obtained before the service is provided. Prior authorizations must still be submitted to validate medical necessity, but they can be submitted retroactively after the date of service.
Overview
Providers at your practice can provide medical eye care services up to the scope of the doctor’s license in the state they are providing care. We’ve included a brief overview of the plan-specific information here, but for more detailed information, refer to the EyeMed North Carolina Medicaid Provider Manual.
Routine and medical/surgical eye care procedures are covered for Healthy Blue and Healthy Blue Care Together Medicaid and CFSP members. Adults over 21 will have some copays for covered medical eye care services.
Claims
Claims filing overview by provider type
All routine, medical and surgical claims for MDs and ODs should be submitted to EyeMed. All facility claims should be submitted to Blue Cross and Blue Shield of North Carolina.
Medical/surgical claims submission
For all procedures that fall within the scope of medical/surgical eye care provided by optometrists in Kansas, you’ll file the claim online by selecting the “Medical” tab on the Member Eligibility page or via 837 EDI format.
You can mail hard copy medical/surgical claims to:
EyeMed/FAA
PO Box 8526
Mason, OH 45040-7111
Prior authorization
North Carolina Medicaid covers certain medical eye care procedures for Medicaid and Healthy Blue Care Together members, if medically necessary. Refer to the Healthy Blue and Healthy Blue Care Together CPT/HCPCS code classifications document (requires login to inFocus) for a full list of services that require precertification. All other medical/surgical eye care services can be performed without prior authorization.
For services that do not require precertification, claims management will crosswalk the appropriate CPT to the applicable ICD-10 for medical necessity.
NOTE: North Carolina Department of Health and Human Services (NCDHHS) has relaxed the requirements for prior authorizations for Children and Families Specialty Plan (CFSP) members. Between 12/1/2025 and 6/30/2026, claims for covered services that meet medical necessity criteria will not be denied in the event a prior authorization is not obtained before the service is provided. Prior authorizations must still be submitted to validate medical necessity, but they can be submitted retroactively after the date of service.
Submitting a prior authorization request
To submit a prior authorization request, you can submit in 1 of 2 ways:
Refer to the EyeMed North Carolina Medicaid Provider Manual for more information.
EyeMed Utilization Management turnaround time requirements
| Product | Priority | Turnaround time |
|---|
| Medicaid | Standard | 7 calendar days |
| Medicaid | Urgent | 72 hours |
| Medicaid | Retrospective | 30 calendar days |
Facility authorization
EyeMed doesn’t perform prior authorization review for facility requests. Prior authorization isn’t required for in-network facilities. It’s important to use an approved in-network facility for medical/surgical requests. Using an out-of-network facility may result in denial of your claim. Contact the health plan if you have questions about facility authorizations.
Emergency services
Emergency services don’t require prior authorization. You should notify us of any emergency eye care services by completing the prior authorization online request form or by calling 866.652.0038 on the next business day following the emergency care. You’ll need to attach to the form any medical records related to the emergency care.
UM appeals
When you or your patient aren’t satisfied with a denied UM decision, you can request an appeal along with additional medical information. The request will be reviewed by a clinical peer reviewer not involved in the initial denial determination and not a subordinate of the initial clinical peer reviewer. Clinical appeals should be submitted to the health plan.
Clinical guidelines
You are required to obtain prior authorization for the procedures and injections below. Click on the procedure to review the clinical guidelines.