Utilization management is at the heart of how we can help members continue to access the right care, at the right place and at the right time. In this section we will review the different types of reviews – prior authorization, predetermination and post-service review.
What is Utilization Management Review
A utilization management review determines whether a service is covered under the health plan using evidence-based clinical standards of care. Utilization Management includes:
- Prior authorization
- Post-service review
What is Prior Authorization
Prior authorization, also called prior authorization or prior approval, are a pre-service medical necessity review. A prior authorization is the process where we review the requested service or drug to see if it is medically necessary and covered under the member's health plan. Not all services and drugs need prior authorization.
A prior authorization is not a guarantee of benefits or payment. The terms of the member's plan control the available benefits. Go here to learn how to submit prior authorization requests.
Who Requests Prior Authorization
Usually, the provider is responsible for requesting prior authorization before performing a service if the member is seeing an in-network provider. Sometimes, a plan may require the member request prior authorization for services. Information for members is on our member site.
Out-of-network services may require utilization management review. If the provider or member does not get prior authorization for out-of-network services, the claim may be denied, or the member may have to pay more out-of-pocket. Emergency services are an exception.
Why Obtain a Prior Authorization
If you do not get prior approval via the prior authorization process for services and drugs on our prior authorization lists:
- The service or drug may not be covered, and the in-network ordering or servicing provider or the member will be responsible.
- We may conduct a post-service utilization management review, which may include requesting medical records and review of claims for consistency with:
- Medical policies
- State and federal requirements
- Member's benefits
- Other clinical guidelines
- For Medicare members, if you don't get a prior authorization for a service or drug on our prior authorization list, we won't reimburse you, and you cannot bill our member for that service or drug.
What is 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 paid by BCBSMT before the service is performed. Through the AMN process:
- The member understands the financial implications of receiving the service.
- The participating provider can alter the financial liability of a service that would be denied as not medically necessary, experimental, investigational, or unproven.
The complete AMN policy is available on the Secure Provider Portal. The AMN form can be found on the Forms and Documents page.
What is Predetermination
- Voluntary utilization management reviews of a medical procedure, treatment or test.
- Not necessary for services and drugs on the prior authorization list. Submit a prior authorization for services and drugs on the prior authorization list, not a predetermination.
- May be used if you are not sure about coverage or whether we may not consider the service medically necessary.
- Written requests for determination of medical necessity before rendering services (in addition to checking eligibility and benefits through Availity or your preferred vendor).
- Submitting a predetermination does not guarantee services will be covered under the members' benefit plans. The terms of the member's plan control the available benefits.
- 2022 Commercial Predetermination, Post Service, Review, Non Covered (PredPSRNC) Procedure Code List - Updated 10/2022
- The medical procedure, treatment or test may not be covered, and the in-network ordering or servicing provider or the member will be responsible.
- Predeterminations may eliminate the need for a post-service review.
- Post-service reviews can include requesting medical records and reviewing claims for consistency with:
- Medical policies
- Other clinical guidelines
- The provider agreement
- Coding and Compensation policies
- Accuracy of payment
Why Obtain a Predetermination
What is Post-Service Utilization Management Review
A post-service utilization management review occurs after the service is rendered. During a post-service utilization management review, we review clinical documentation to determine whether a service, drug, medical procedure, treatment or test was medically necessary and covered under the member's benefit plan. We may ask you for the information we do not have.
If the service required a prior authorization for a Medicare member, the claim will be denied with no post-service review.
Utilization Management Program Description
The Utilization Management (UM) Program description defines the structure of the UM program for BCBSMT. Utilization Management is part of a holistic approach to address members' chronic or complex conditions. It promotes member and provider satisfaction through coverage and access to affordable, quality health care. UM prior authorization, predetermination, and post service reviews are completed using evidenced-based guidelines. This allows us to deliver fair, impartial and consistent determinations that can be easily interpreted by members and providers. We deliver timely decisions to accommodate the clinical urgency of the member's situation. Learn more about the UM Program