Utilization management is at the heart of how we can help members continue to access the right care, at the right place and at the right time. In this section we will review the different types of reviews – Prior Authorization, Recommended Clinical Review (predetermination) and post-service review.
What is Utilization Management Review
A utilization management review determines whether a service is covered under the health plan using evidence-based clinical standards of care. Utilization Management includes:
- Prior authorization
- Recommended Clinical Review (Predetermination)
- Post-service review
What is Prior Authorization
Prior Authorization is a pre-service medical necessity review. A Prior Authorization is a required part of the Utilization Management process where we review the requested service or drug to see if it is medically necessary and covered under the member's health plan. Not all services and drugs need prior authorization.
A Prior Authorization is not a guarantee of benefits or payment. The terms of the member's plan control the available benefits. Go here to learn how to submit prior authorization requests.
Who Requests Prior Authorization
Participating Providers are responsible for obtaining Prior Authorization, in those circumstances where authorization may be required. If Prior Authorization is not obtained and the services are denied as not Medically Necessary, the Participating Provider will be held responsible and will not be able to bill the Member for the services.
Members are responsible for obtaining a Prior Authorization for out of network services. If the provider or member does not get Prior Authorization for out-of-network services, the claim may be denied, or the member may have to pay more out-of-pocket. Emergency services are an exception.
Why Obtain a Prior Authorization
If you do not get prior approval via the Prior Authorization process for services and drugs on our Prior Authorization lists:
- The service or drug may not be covered, and the in-network ordering or servicing provider or the member will be responsible.
- We may conduct a post-service utilization management review, which may include requesting medical records and review of claims for consistency with:
- Medical policies
- State and federal requirements
- Member's benefits
- Other clinical guidelines
- For Medicare members, if you don't get a Prior Authorization for a service or drug on our prior authorization list, we won't reimburse you, and you cannot bill our member for that service or drug.
What is 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 paid by BCBSMT before the service is performed. Through the AMN process:
- The member understands the financial implications of receiving the service.
- The participating provider can alter the financial liability of a service that would be denied as not medically necessary, experimental, investigational, or unproven.
The complete AMN policy is available in Availity® Payer Spaces. The AMN form can be found on the Forms and Documents page.
What is Recommended Clinical Review (Predetermination)
Recommended Clinical Reviews are:
BCBSMT is changing the name of its longstanding preservice review, called Predetermination, to Recommended Clinical Review, effective January 1, 2023.
Recommended Clinical Reviews are medical necessity reviews conducted before services are provided. Submitting the request prior to rendering the services is optional and informs the provider and member of situations where a service may not be covered.
- Recommended Clinical Review is not a different process and will not generate a different result than a predetermination.
- There is no penalty if a provider does not elect to use Recommended Clinical Review, but the service will be subject to post-service review.
- Submitting a Recommended Clinical Review does not guarantee services will be covered under the members' benefit plans. The terms of the member's plan control the available benefits
- You can find a list of services for which Recommended Clinical Review is available on the Recommended Clinical Review list.
Why Obtain a Recommended Clinical Review (Predetermination)
Providers have the option of submitting Recommended Clinical Review requests, which are reviews for medical necessity before services are provided. Submitting the request prior to rendering the services is optional and informs the provider and member of situations where a service may not be covered based upon medical necessity.
- BCBSMT will review Recommended Clinical Review requests to determine if the planned service meets approved medical policy, American Society of Addiction Medicine (ASAM) or MCG™ Care Guideline criteria before services are provided for medical and behavioral health services. Providers can access MCG™ Care Guidelines in the BCBSMT-branded Payer Spaces section in Availity® Essentials under the Resources tab. To locate specific criteria within the MCG Care Guidelines, use CTRL+F.
- Once a decision has been made on the services reviewed as part of the Recommended Clinical Review request, the same services will not be reviewed for Medical Necessity again on a retrospective basis.
- Submitted claims for services not included as part of a request for Recommended Clinical Review, may be reviewed retrospectively.
- Providers and members will be notified of the determination and will have the opportunity to appeal an adverse determination if the Recommended Clinical Review determines the proposed service does not meet medical necessity.
What is Post-Service Utilization Management Review
A post-service utilization management review occurs after the service is rendered. During a post-service utilization management review, we review clinical documentation to determine whether a service, drug, medical procedure, treatment or test was medically necessary and covered under the member's benefit plan. We may ask you for the information we do not have.
If the service required a prior authorization for a Medicare member, the claim will be denied with no post-service review.
Post-service reviews can include requesting medical records and reviewing claims for consistency with:
- Medical policies
- Other clinical guidelines
- The provider agreement
- Coding and Compensation policies
- Accuracy of payment
Utilization Management Program Description
The Utilization Management (UM) Program description defines the structure of the UM program for BCBSMT. Utilization Management is part of a holistic approach to address members' chronic or complex conditions. It promotes member and provider satisfaction through coverage and access to affordable, quality health care. UM Prior Authorization, Recommended Clinical Review (Predetermination), and post service reviews are completed using evidenced-based guidelines. This allows us to deliver fair, impartial and consistent determinations that can be easily interpreted by members and providers. We deliver timely decisions to accommodate the clinical urgency of the member's situation. Learn more about the UM Program