Health Care Management
Predetermination (formerly called Prior Authorization)
Predetermination is a process BCBSMT uses to make coverage decisions in accordance with medical policy and group or member contracts for a service, supply, drug, or device used to diagnose or treat an illness or condition.
BCBSMT recommends predetermination for services if a provider is uncertain about coverage or if BCBSMT might not consider the service medically necessary.
Click here for a list of CPT, Revenue and HCPCS codes requiring special processing when submitted to BCBSMT. Examples of ‘special processing’ include “predetermination is recommended” (e.g., medical necessity criteria apply and medical records are generally necessary for processing) and codes denied experimental/investigational. Predetermination is recommended for all Clinical Trials, Genetic Testing, Transplants (except Cornea and Kidney Transplants) and all services billed with an unlisted or non-specific code.
Need Predetermination Forms? Go to our Provider Forms page.
Send predetermination requests to the address or fax on the form.
Radiation Oncology Predeterminations
Phone: contact CareCore National at 866.668.7446
Website: CareCore National
Provider Administrative Guide
Pre-authorization/Precertification (formerly called Plan Notification)
Our Medical and Behavioral reviewers partner with our members, providers, and hospitals to review all inpatient admission following national guidelines for all inpatient stays, except maternity admission for deliveries unless they stay longer than the federal mandate (2 days post normal delivery and 4 days for c-section).
Medical or surgical admissions: Notify Health Care Managemetn by calling the Enterprise Intake Unit (EIU) at 855.313.8914 or via fax at 866.589.8256.
Behavioral Health inpatient, partial hospitalization or residential treatment admissions: Notify the Behavioral Health Call Center at 855.313.8909.
For Health Care Management Services reference guide, click here.
Need Pre-authorization forms? Go to our Provider Forms page.
Pre-authorization Information for Federal Employee Program
For pre-authorization, call: 877.885.3751
To learn more about FEP updates, visit Provider Education
Pre-authorization Information for Medicare Advantage
For pre-authorization, call: 877.774.8592 or fax to 855.874.4711.
Pre-authorization/Precertification Information for Out-of-Area Members
Use our Provider Router to obtain information about Pre-authorization/Precertification for out-of-area members. This tool will route you directly to the other Plan's website to view specific Pre-authorization/Precertification requirements for an out-of-area member. Click the link below to open the tool and simply enter the member's Alpha Prefix (first three letters of the identification number) located on their ID Card to be routed to the appropriate Plan.
Click here to access the Provider Router.
Advance Member Notification
Advance Member Notification (AMN) refers to the process in which a provider informs a member that a service is not likely to be considered for compensation by BCBSMT prior to the service being performed. Through the AMN process, the member is able to understand the financial implications of receiving the service, and the participating provider is able to alter the financial liability of a service that would be denied as not medically necessary. The AMN process only applies to professional services. This process does not apply to hospital-based services, skilled nursing facilities, or home health services.
Click here to download AMN forms.
Health Care Management reference guide
The Health Care Management department at BCBSMT created the attached reference guide to help providers navigate through some recent changes in the Health Care Management processes. The guide contains information regarding Medical/Surgical Pre-Authorization and Concurrent Review; Predetermination for Outpatient Services, Drugs and Devices; the Behavioral Health program; and the Appeals Process.