Utilization Management
Why Is Utilization Management Important?
It helps lower costs.
Utilization management helps Blue Cross and Blue Shield of Montana check the care given to you, to make sure it is needed and effective.
It improves patient care.
Utilization management can help check if a service or prescription drug is helping you. This information can help BCBSMT to approve of similar treatment plans in the future.
It reduces the denial of claims.
Utilization management reviews can gather data about which treatments are effective, and give providers information to support their treatment plans and claims.
How Does Utilization Management Work?
Blue Cross and Blue Shield of Montana evaluates each patient case to see if it’s necessary to perform medical procedures and services. Reviewers use evidence-based guidelines in their analysis.
To do this, your provider and BCBSMT will perform reviews and check the effectiveness of your treatments before, during and after you get care. These reviews can involve:
Before and During Treatment
- Prior Authorization
- Recommended Clinical Review (Predetermination)
After Treatment
- Post-Service Utilization Management Review
Before and During Treatment
What Is Prior Authorization?
Prior authorization is also sometimes called preauthorization, pre-certification or prior approval.
Sometimes you may need to get approval from BCBSMT before we will cover certain inpatient, outpatient and home health care services and prescription drugs.
BCBSMT contracts with outside vendors, including Carelon Medical Benefits Management® (Carelon), eviCore® healthcare and Magellan Healthcare for certain prior authorization services.*
Before and During Treatment
What Is Recommended Clinical Review (Predetermination)?
This is an optional review for utilization management you can ask for before getting care. You can ask for recommended clinical review for services that do not need prior authorization.
You may want to ask for this review if you are not sure about coverage or whether we may not consider it medically necessary. You will need to work with your provider to send a request for recommended clinical review.
To find out if this review is offered for a specific service, check the Recommended Clinical Review List (predetermination). BCBSMT updates this list when services are added or removed. You can also call BCBSMT Customer Service at the number on your member ID card.
Some services not requiring prior authorization may be reviewed for medical necessity before a claim is paid.
Recommended clinical review (predetermination) is not a guarantee of benefits. Actual availability of benefits is based on eligibility and the other terms, conditions, limitations, and exclusions under your benefit booklet.
After Treatment
What Is Post-Service Utilization Management Review?
A post-service utilization management review happens after you get care. During this review, we check whether a service or drug was medically necessary and covered under your health plan. We may ask your provider for more information.
We may also run a post-service utilization management review if you or your provider does not get a required prior authorization before you get care.
*Carelon Medical Benefits Management (Carelon) is an independent company that has contracted with BCBSMT to provide utilization management services for members with coverage through BCBSMT.
eviCore healthcare (eviCore) is an independent company that has contracted with BCBSMT to provide prior authorization for expanded outpatient and specialty utilization management for members with coverage through BCBSMT.