Predetermination and Preauthorization
Predetermination is a process BCBSMT uses to make coverage decisions in accordance with medical policy and group or member contracts for a service, supply, drug, or device used to diagnose or treat an illness or condition.
BCBSMT recommends predetermination for services if a provider is uncertain about coverage or if BCBSMT might not consider the service medically necessary.
How to Submit a Request for Review
Predeterminations may be requested electronically via Availity® Provider Portal using the Attachments tool. Learn more by viewing the Electronic Predetermination of Benefits User Guide.
If you do not have online access, complete the Predetermination Request form and mail or fax it to BCBSMT.
- Do you need Predetermination Forms? Go to our Provider Forms page.
- Send predetermination requests to the address or fax on the form. For Outpatient Radiation Therapy, Molecular and Genomic Testing Pre-authorizations refer to the eviCore tab.
For Outpatient Radiation Therapy, Molecular and Genomic Testing Preauthorizations refer to the eviCore tab.
Radiation Oncology Predeterminations
- Phone: CareCore National at 866-668-7446
- Website: CareCore National
Our Medical and Behavioral reviewers partner with our members, providers, and hospitals to review all inpatient admission following national guidelines for all inpatient stays, except maternity admission for deliveries unless they stay longer than the federal mandate (2 days post normal delivery and 4 days for c-section).
Medical or surgical admissions: Notify Health Care Management by calling the Enterprise Intake Unit (EIU) at 855-313-8914 or via fax at 866-589-8256.
Behavioral Health inpatient, partial hospitalization, residential treatment admissions, or intensive outpatient treatment: Notify the Behavioral Health Call Center at 855-313-8909.
Do you need Predetermination Forms? Go to our Provider Forms page.
Pre-authorization Information for Federal Employee Program
For pre-authorization, call 877-885-3751.
Pre-authorization Information for Healthy Montana Kids (HMK)
For pre-authorization, call 855-699-9907.
HMK Intake Fax line 855-610-5684.
Pre-authorization Information for Medicare Advantage
For pre-authorization, call 877-774-8592 or fax to 855-874-4711.
Pre-authorization/Precertification Information for Out-of-Area Members
Use our Provider Router to obtain information about Pre-authorization/Precertification for out-of-area members. This tool will route you directly to the other Plan's website to view specific Pre-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 Pre-certification/Pre-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.
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 considered for compensation by BCBSMT prior to the service being performed. Through the AMN process, the member is able to understand the financial implications of receiving the service, and the participating provider is able to alter the financial liability of a service that would be denied as not medically necessary. The complete AMN policy is available on the Secure Provider Portal. The AMN form can be found on the Forms and Documents page.
Medical/Surgical Utilization Management Reference Guide for Precertification/Pre-authorization Changes
Utilization Management (UM) Program Description
The Utilization (UM) Management Program description defines the structure of the UM program for BCBSMT. Utilization management is part of our Wellbeing Management Program that supports a holistic approach to address members chronic or complex conditions and promotes member and provider satisfaction through coverage and access to affordable, quality healthcare. UM preauthorization and predetermination reviews are completed using evidenced based guidelines to deliver fair, impartial and consistent determinations that can be easily interpreted by members and providers with timely decisions to accommodate the clinical urgency of the member’s situation. Learn more about the UM Program .