Utilization Management: How to Avoid Delays and Denied Claims

December 19, 2023

Our utilization management program helps ensure our members get the right care, at the right time, in the right setting. Our preservice review process, including prior authorization or optional recommended clinical reviews use evidence-based clinical standards of care to help determine whether a benefit may be covered under the member’s health plan. 

Where to begin
Before rendering care or services, always check eligibility and benefits, 
via Availity® Essentials  or your preferred web vendor. In addition to verifying membership and coverage status, this step returns information on prior authorization requirements and utilization management vendors, if applicable.

Note: if you deliver care or services without a prior authorization, a post service medical necessity review will be conducted and you, not the member, may be responsible for denied charges.

Simplifying the complex
Member benefits and review requirements and recommendations may vary based on services rendered and individual/group policy elections.

Our utilization management website explains the various review types needed or suggested when providing care for Blue Cross and Blue Shield of Montana members. You can also find “how to” directions and vendor profiles as well as prior authorization and recommended clinical review code lists.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSMT. BCBSMT makes no endorsement, representations or warranties regarding any products or services provided by third party vendors.