Predetermination and Preauthorization

Predetermination

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.

Medical Policy

BCBSMT recommends predetermination for services if a provider is uncertain about coverage or if BCBSMT might not consider the service medically necessary.

Do you need Predetermination Forms? Go to our Provider Forms page.

Send predetermination requests to the address or fax on the form.

Radiation Oncology Predeterminations

Pre-authorization/Precertification

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.

View the Health Care Management Services Reference Guide PDF Document.

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 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.

Advance Member Notification

Advance Member Notification (AMN) PDF Document 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 AMN process only applies to professional services. This process does not apply to hospital-based services, skilled nursing facilities, or home health services.

Health Care Management Reference Guide

The Health Care Management department at BCBSMT created the attached reference guide to help providers navigate through some recent changes in the Health Care Management processes. The guide contains information regarding Medical/Surgical Pre-Authorization and Concurrent Review; Predetermination for Outpatient Services, Drugs and Devices; the Behavioral Health program; and the Appeals Process.

Medical/Surgical Utilization Management Reference Guide for Precertification/Pre-authorization Changes

View the Medical/Surgical Utilization Reference Guide for Precertification/Prior Authorization Changes PDF Document.