Does Blue Cross NC require prior authorization for CPT 27130?

Yes. Blue Cross NC requires prior authorization for CPT 27130 (Total hip arthroplasty) under Standard commercial plans per its published clinical policy.

What documentation does Blue Cross NC require for CPT 27130?

Member benefit and eligibility verification; Blue Cross NC program-specific prior plan approval documentation; Clinical records supporting the requested service when requested by Blue Cross NC or its vendor

How much does Medicare pay for CPT 27130 in 2026?

In 2026, the national Medicare allowable for CPT 27130 is $1162.02 in an office setting and $1162.02 in a facility. Commercial allowables for Blue Cross NC are typically negotiated against this benchmark.

What if Blue Cross NC denies the PA for CPT 27130?

Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.

Prior Authorization

Blue Cross NC Prior Authorization for CPT 27130

Total hip arthroplasty · Standard commercial plans

Prior authorization REQUIREDState-specific policyLast verified May 9, 2026 · Reviewed by the D3rx Clinical Billing Team

Source

Blue Cross NC Commercial CPT/HCPCS Prior Plan Approval Search

Not medical advice. PA policies change frequently. Always confirm against the payer's current policy before submitting. d3rx pulls directly from publicly published policy PDFs and refreshes daily.

Clinical criteria

Blue Cross NC commercial CPT/HCPCS prior plan approval search lists 27130 as requiring prior approval for North Carolina commercial context, current as of 2026-05-09. Program label(s): MSK. Source description(s): Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft. Verify member benefits, BlueCard/home-plan context, FEP, Medicare, Medicaid, and program-specific requirements before submission. This listing is not a payment, coverage, or medical-necessity guarantee.

Documentation checklist

✓Member benefit and eligibility verification
✓Blue Cross NC program-specific prior plan approval documentation
✓Clinical records supporting the requested service when requested by Blue Cross NC or its vendor

2026 Medicare rate for CPT 27130

Office (non-facility)

$1162.02

Facility

$1162.02

Total RVUs (office)

34.79

Conversion factor

$33.4009

National Medicare Physician Fee Schedule amounts (GPCI 1.0). Blue Cross NC's commercial allowable is negotiated against this benchmark — see the full RVU and locality breakdown on the CPT 27130 code page.

How to submit the PA

1Verify the requirement against the current clinical policy linked above.
2Gather documentation: Member benefit and eligibility verification, Blue Cross NC program-specific prior plan approval documentation, Clinical records supporting the requested service when requested by Blue Cross NC or its vendor.
3Submit via the payer's provider portal or designated PA channel.
4Document the reference number and follow up within 5 business days if no determination is received.

FAQ

Does Blue Cross NC require prior authorization for CPT 27130?: Yes. Blue Cross NC requires prior authorization for CPT 27130 (Total hip arthroplasty) under Standard commercial plans per its published clinical policy.
What documentation does Blue Cross NC require for CPT 27130?: Member benefit and eligibility verification; Blue Cross NC program-specific prior plan approval documentation; Clinical records supporting the requested service when requested by Blue Cross NC or its vendor
How much does Medicare pay for CPT 27130 in 2026?: In 2026, the national Medicare allowable for CPT 27130 is $1162.02 in an office setting and $1162.02 in a facility. Commercial allowables for Blue Cross NC are typically negotiated against this benchmark.
What if Blue Cross NC denies the PA for CPT 27130?: Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.

Other Blue Cross NC PA lookups

CPT 17110 CPT 45380 CPT 45378 CPT 11042 CPT 36415 CPT 20610 CPT 62323 CPT 43235

All Blue Cross NC prior-authorization requirements →

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