EviCore Prior Authorization Program for Medicare Advantage and Healthy Montana Kids

Blue Cross and Blue Shield of Montana contracted with EviCore HealthcareTM to provide utilization management services for Medicare Advantage and Healthy Montana Kids. EviCore is an independent company that provides specialty medical benefits management for BCBSMT. Services requiring prior authorization through EviCore are outlined below.

Prior Authorization Requirements

The following services require prior authorization through EviCore:

  • Medicare Advantage Members
    • Radiology (excludes cardiology studies)
    • Molecular Genetic Testing
    • Specialty Drugs
  • Healthy Montana Kids
    • Molecular Genetic Testing
    • Radiation Therapy

It is imperative that providers obtain eligibility and benefits first to confirm membership, verify coverage, and determine whether prior authorization is required.  Prior authorization via other platforms may be required for other services.

For more information on checking eligibility, benefits, and prior authorization requirements, refer to Availity or contact Provider Customer Service at 1-855-699-9907.

Note: Please refer to the Utilization Management page for information regarding PA through Carelon Medical Benefits Management (formerly known as AIM Specialty Health) for our fully insured and self-funded benefit plans.

Refer to the EviCore Provider Resources page and select the BCBSMT health plan for Provider Resources, including Clinical Guidelines, Physician Worksheets and online forms for submission of requests, and the applicable CPT/HCPCS.

Contact Information

EviCore prior authorizations can be obtained using one of the following methods:

  • The EviCore Healthcare Web Portal is available 24x7. After a one-time registration, you can initiate a case, check status, review guidelines, view authorizations/eligibility, and more. The Web Portal is the quickest, most efficient way to obtain information.
  • Providers can call toll-free at (855) 252-1117 between 5 a.m. to 5 p.m. Mountain Time Monday through Friday.
  • More specific program-related information can be found on the EviCore Provider Resources page .

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 BCBSMT.

Prior authorization determines whether the proposed service or treatment meets the definition of medical necessity under the applicable benefit plan. Prior authorization of a service is not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations, and exclusions set forth in the member's contract, guide, or summary plan description. Regardless of any Prior authorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.