How to Request Prior Authorization and Recommended Clinical Review

The following outlines the process for providers to submit prior authorization requests.

Submitting Prior Authorization Requests

Step 1:

Confirm if prior authorization is required using Availity® Essentials or your preferred vendor. This will determine if prior authorization will be obtained through us or a dedicated vendor.

Step 2:

Get prior authorization:

Services requiring prior authorization through BCBSMT:

Services requiring prior authorization through Carelon Medical Benefits Management (formerly known as AIM Specialty Health) (Jan. 1, 2021 and after):

Services requiring prior authorization through eviCore®:

Services requiring prior authorization for Healthy Montana Kids through BCBSMT:

  • Call toll-free 1-855-699-9907
  • Fax line 1-855-610-5684

Services requiring prior authorization for Federal Employee Program:

  • Call toll-free at 1-877-885-3751.

Services requiring prior authorization for Medicare Advantage:

  • Submit Prior Authorization request via Availity
  • Call toll-free 1-877-774-8592
  • Fax line 1-855-874-4711.

Step 3:

Provide the following information:

  • Patient’s medical or behavioral health condition
  • Proposed treatment plan
  • Date of service, estimated length of stay (if the patient is being admitted)
  • Patient ID and name/date of birth
  • Place of treatment
  • Provider NPI, name and address
  • Diagnosis code(s)
  • Procedure code(s) (if applicable)

Step 4:

After the request is submitted, the service or drug is reviewed to determine if it:

  • Is covered by the health plan, and
  • Meets the health plan’s definition of “medically necessary.”

The results are then sent to the provider and member. If you have questions about the response, contact Utilization Management or the authorizing vendor.

Prior authorization/Precertification Information for BlueCard (Out-of-Area) Members

Use our Provider Router to obtain information about prior authorization/precertification for members of other Blues Plans (out-of-area members). This tool will route you directly to the other Plan's website to view specific prior 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.

View the Medical Policy and Precertification/Prior Authorization Information for Out-of-Area Members to access the Provider Router.

You can also refer to the Electronic Provider Access (EPA) FAQs for additional information.

Submitting Recommended Clinical Review (Predetermination) Requests for Commercial Plans

How to Submit a Request for Review via Availity:

  1. Log in to Availity
  2. Select Claims & Payments from the navigation menu
  3. Select Attachments – New
  4. Within the tool, select Send Attachment then Recommended Clinical Review Attachment
  5. Download and complete the Recommended Clinical Review (Predetermination) Request Form
  6. Complete the required data elements
  7. Upload the completed form and attach supporting documentation and photos (if required for review)
  8. Select Send Attachment(s)

If you do not have access to Availity, complete the Recommended Clinical Review (Predetermination) Request Form and mail or fax it to BCBSMT.

  • Do you need Recommended Clinical Review forms? Go to our Provider Forms page.
  • Send predetermination requests to the address or fax on the form

How to Submit a Request for Review via Fax:

  1. To request a Recommended Clinical Review by fax and/or mail, please complete the Recommended Clinical Review (Predetermination) Request Form. All applicable fields are required. If any information is not provided, this may cause a delay in the Recommended Clinical Review process. (Requests received without the member/patient's group number, ID number, and date of birth cannot be completed and may be returned.)
  2. Fax information for each patient separately to BCBSMT Fax #: 1- 866-589-8256.
  3. Always place the Recommended Clinical Review (Predetermination) Request Form on top of other supporting documentation. Please include any additional comments if needed with supporting documentation.
  4. Do not send in duplicate requests, as this may delay the process.
  5. Per Medical Policy, if photos are required for review, the photos should be mailed to the address indicated on the Recommended Clinical Review (Predetermination) Request Form and not faxed. Faxed photos are not legible and cannot be used to make a determination.
  6. Regarding major diagnostic tests, please include the patient's history, physical and any prior testing information

How to Submit a Request for Recommended Clinical Review via BlueApprovR:

  1. Use BlueApprovRSM to request recommended clinical reviews for some inpatient and/or outpatient medical and surgical services and specialty pharmacy drugs for many of our commercial members.    

Note: your RCR submissions will follow the same path through BlueApprovR as prior authorization requests.