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Prior Authorization

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What Is Prior Authorization?

Prior Authorization is also sometimes called prior authorization, preauthorization, pre-certification or prior approval. 

Sometimes you may need to get approval from Blue Cross and Blue Shield of Montana before we will cover certain inpatient, outpatient and home health care services and prescription drugs.

BCBSMT reviews the requested service or drug to find out if it’s medically necessary and appropriate for your needs. This review does not replace the advice of your provider.

BCBSMT contracts with outside vendors, including Carelon Medical Benefits Management® (Carelon), eviCore® healthcare and Magellan Healthcare for certain prior authorization services.

Who Requests Prior Authorization?

Usually, your health care providers will take care of prior authorization before they perform a service. But, it’s always a good idea to check if your providers have the needed approval.

If your providers aren’t in-network, you’ll be responsible for getting the prior authorization. If you don’t, we may not cover the cost. To make sure your provider is in-network, check our find care tool.

Check if Your Provider is In-Network

You or your provider can request a renewal of a prior authorization up to 60 days before it expires.

How You Can Request Prior Authorization

Check with us to find out if your provider has requested prior authorization before you get any services.

If your health care provider has not requested prior authorization, you can request it. Call the number listed on your BCBSMT member ID card. Our Customer Service will help you begin the process.

We will need the following information to complete a prior authorization request:

  • Your name, subscriber ID number and date of birth
  • Your provider’s name, address and National Provider Identifier (NPI)
  • Information about your medical or behavioral health condition
  • The proposed treatment plan, including any diagnostic or procedure codes (your provider can help you with these)
  • The date you’ll receive service and the estimated length of stay (if you are being admitted)
  • The place you’re being treated

Do You Need Prior Authorization?

You can use the resources below to look up a service or drug and check if it needs prior authorization.

Summary and Code Lists

To find the full list of services and drugs that require prior authorization, click below to download a copy of the spreadsheet. Except as otherwise noted, these prior authorization requirements are effective as of January 1, 2024.

For Fully Insured Members

Digital Lookup Tool

Use our digital lookup tool to find out if prior authorization is required for fully insured members.* Start your search by choosing one of the 3 categories shown below.

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Medical Procedures

Medical procedures such as surgeries, transplants, imaging and other tests.

Look Up Medical Procedures
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Medical Drugs

Medical drugs such as prescriptions that you may be taking.

Look Up Medical Drugs
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Behavioral Health Services

Behavioral services such as mental health, psychological testing and psychiatric care.

Look Up Behavioral Health
 

*Not sure if you’re fully insured? Check with your HR department or benefits administrator. If you aren’t fully insured, check your benefit booklet to learn your list of services that require prior authorization. If you still have questions, please call the Customer Service number listed on your BCBSMT member ID card.

 

Carelon Medical Benefits Management (Carelon) is an operating subsidiary of Anthem, Inc., an independent specialty medical benefits management company that provides utilization management services for BCBSMT.

eviCore® is a trademark of eviCore healthcare, LLC, formerly known as CareCore, an independent company that provides utilization review for select health care services on behalf of Blue Cross and Blue Shield of Montana.