Utilization Management

Utilization management is at the heart of how you access the right care, at the right place and at the right time. It includes:

• Prior Authorization
• Recommended Clinical Review (Predetermination)
• Post-service reviews

We use evidence-based clinical standards of care to make sure you get the health care you need.

What Is Prior Authorization?

Sometimes you may need to get approval from Blue Cross and Blue Shield of Montana before we will cover certain inpatient, outpatient and home health care services and prescription drugs. This is called prior authorization, preauthorization or prior approval. These terms all refer to the requirements that you may need to meet before treatment may begin.

Who Requests Prior Authorization?

Usually, your health care providers will take care of prior authorization before they perform a service. But, it’s always a good idea to check if your providers have the needed approval.

If your providers aren’t in network, you’ll be responsible for getting the prior authorization. If you don’t, we may not cover the cost. To make sure your provider is in network, check our find care tool.

You or your provider can request a renewal of a prior authorization up to 60 days before it expires.

BCBSMT contracts with outside vendors, including Carelon Medical Benefits Management® (Carelon), eviCore® healthcare and Magellan Healthcare for certain prior authorization services.

How You Can Request Prior Authorization

Check with us to find out if your provider has requested prior authorization before you get any services.

If your health care provider has not requested prior authorization, you can request it. Call the number listed on your BCBSMT member ID card. Our Customer Service will help you begin the process.

What Happens During the Prior Authorization Process?

BCBSMT reviews the requested service or drug to find out if it’s medically necessary and appropriate for your needs. This review does not replace the advice of your provider.

We need the following information to complete a prior authorization request:

• Your name, subscriber ID number and date of birth
• Your provider’s name, address and National Provider Identifier (NPI)
• Information about your medical or behavioral health condition
• The proposed treatment plan, including any diagnostic or procedure codes (your provider can help you with these)
• The date you’ll receive service and the estimated length of stay (if you are being admitted)
• The place you’re being treated

Do You Need Prior Authorization?

Use the search below to find out if you require prior authorization or not. Your procedure can fall under one of the 3 categories shown below.

To find the full list of services and drugs that require prior authorization, click below to download a copy of the spreadsheet. Except as otherwise noted, these prior authorization requirements are effective as of January 1, 2024.

• Current Prior Authorization Requirements (Commercial)
• Commercial Medical Surgical Prior Authorization Code List
• Specialty Drugs and Infusion Site of Care Prior Authorization Code List
• Behavioral Health Prior Authorization Code List

What Is a Recommended Clinical Review (Predetermination)?

• This is an option for utilization management review before having services.  
• Some services not requiring prior authorization may be reviewed for medical necessity before a claim is paid. 
• This review may be used if you are not sure about coverage or whether we may not consider it medically necessary.
• You will work with your provider to submit a request for recommended clinical review (predetermination). 

To find out if this review is available for a specific service, check the Recommended Clinical Review List (predetermination).  BCBSMT updates this list when services are added or removed.  You can also call BCBSMT Customer Service at the number on your member ID card.      

Recommended clinical review (predetermination) is not a guarantee of benefits.  Actual availability of benefits is subject to eligibility and the other terms, conditions, limitations, and exclusions under your benefit booklet. 

What Is Post-Service Utilization Management Review?

A post-service utilization management review happens after you receive a service. During this review, we check whether a service or drug was medically necessary and covered under your health plan. We may ask your provider for more information.

We may also conduct a post-service utilization management review if you or your provider does not get a required prior authorization before you receive services.

^*Not sure if you’re fully insured? Check with your HR department or benefits administrator. If you aren’t fully insured, check your benefit booklet to learn your list of services that require prior authorization. If you still have questions, please call the Customer Service number listed on your BCBSMT member ID card.

Carelon Medical Benefits Management (Carelon) is an operating subsidiary of Anthem, Inc., an independent specialty medical benefits management company that provides utilization management services for BCBSMT.

eviCore^® is a trademark of eviCore healthcare, LLC, formerly known as CareCore, an independent company that provides utilization review for select health care services on behalf of Blue Cross and Blue Shield of Montana.