Predetermination is now Recommended Clinical Review

December 21, 2022

Effective Jan. 1, 2023, Blue Cross and Blue Shield of Montana (BCBSMT) is changing the name of its longstanding preservice review, previously called predetermination, to recommended clinical review (RCR).

Here are a few things to know:

  • Recommended clinical review is not a different process, and it will not generate a different result than a predetermination.
  • Recommended clinical reviews are optional medical necessity reviews conducted before services are provided. Submitting a request prior to rendering services informs you of situations where a service may not be covered.
  • There is no penalty if you do not submit a recommended clinical review, but the service will be subject to post-service review. 
  • Submitting a recommended clinical review evaluates the medical necessity of a service but does not guarantee the service will be covered under the members' benefit plans. The terms of the member's plan control the available benefits.

Download our recommended clinical review (predetermination) form

Use our recommended clinical review (predetermination) form after Jan. 1, 2023. The form is located here, under Forms and Documents in the Education and Reference area of our provider website.

For More Information

Learn more about our utilization management process, including prior authorization and recommended clinical review (predetermination) in the Utilization Management section of our provider website. Follow our News and Updates page for future updates.