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 Services requiring prior authorization through Blue Cross and Blue Shield of Montana:

Services requiring prior authorization through Carelon Medical Benefits Management:

Services requiring prior authorization through EviCore healthare:

Services requiring prior authorization for Healthy Montana Kids through BCBSMT:

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

Services requiring prior authorization for Federal Employee Program®:

  • Call toll-free 877-885-3751

Services requiring prior authorization for Medicare Advantage through BCBSMT:

  • Submit Prior Authorization request via Availity
  • Call toll-free 877-774-8592
  • Fax 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, name and date of birth
  • Place of treatment
  • Provider NPI, name and address
  • Diagnosis code(s)
  • Procedure code(s), (if applicable)

Step 4: Wait for review

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 for members of other Blue Plans (out-of-area members). This tool will route you directly to the other Plan's website to view specific prior authorization requirements for an out-of-area member. Visit our BlueCard page for more information. 

Recommended Clinical Review Requests

How to Submit a Request for Review via Availity:

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

How to Submit a Request for Review via Fax:

  1. To request a Recommended Clinical Review by fax or mail, complete the Recommended Clinical Review 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's group number, ID number, and date of birth cannot be completed and may be returned.)
  2. Fax information for each patient separately to 866-589-8256.
  3. Always place the Recommended Clinical Review 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 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.