Blue Cross and Blue Shield of Montana (BCBSMT) contracted with eviCore Healthcare (eviCore)* to provide utilization management services for certain care categories: Outpatient Advanced Imaging, Molecular and Genomic Testing, and Radiation Therapy. eviCore is an independent company that provides specialty medical benefits management for BCBSMT.
Prior Authorization Requirements
BCBSMT requires prior authorization (PA) for medical necessity** review through eviCore for Outpatient Molecular and Genomic Testing, and Radiation Therapy for Healthy Montana Kids (HMK). Eligibility and Benefits: It is imperative that providers obtain eligibility and benefits first to confirm membership, verify coverage and determine whether prior authorization is required. For more information on checking eligibility, benefits and prior authorization requirements, refer to BCBSMT Claims and Eligibility for information on Availity, the online tool, 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) in 2021 for Outpatient Molecular and Genomic Testing, Radiation Therapy, and Advanced Imaging for our fully insured and self-funded benefit plans.
Refer to the eviCore implementation site 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.
Lab Management Program
In an effort to make access to the Lab Management Program information streamlined for our clients and providers, eviCore has created a new one stop link for your Lab Resources. This will house the Lab CPT codes under management, Lab Clinical Guidelines, and any additional information that may be beneficial.
eviCore prior authorization's for Outpatient Advanced Imaging, Molecular and Genomic testing, and Radiation Therapy can be obtained using one of the following methods:
- The eviCore Healthcare Web Portal is available 24x7. After a one-time registration, you are able to 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 7 a.m. to 7 p.m. (local time) Monday through Friday.
- More specific program-related information can be found on the eviCore implementation site.
- Refer to the eviCore implementation site and select the BCBSMT health plan for provider training orientation presentations.
* 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 policy certificate and/or benefits booklet and 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.