What to Know About Precertification

 Two women speaking with their healthcare provider to submit a precertification request.

Blue Cross Blue Shield of North Dakota (BCBSND) requires precertification for certain specific services and procedures. Here’s what you should know about precertification.

  • Why do I need to precertify?

Precertification is a process that validates the medical need for a service or procedure. Certain specific services and procedures require precertification to qualify for benefits. After a service or procedure is approved, it may be covered by benefits. However, approval of precertification does not guarantee payment.

  • Which services require precertification?

Click here to see a list of services and procedures that require precertification.

  • Who decides if my precertification is approved?

Precertification requests are reviewed by an RN. If the documentation provided meets established criteria, the nurse is able to approve the services. However, if the nurse does not feel that the criteria is met, the case is sent to a BCBSND medical director for review. At times, the medical director may request that the case be sent out for external review. Only the medical directors can deny services for medical necessity. The only time a nurse can issue a denial is if the service requested is not a covered benefit.

In addition, BCBSND partners with third parties for certain precertifications. For example, the world of molecular diagnostics and genetic testing is always changing. That’s why BCBSND partners with eviCore healthcare to review precertification for lab testing services. By working with eviCore, we can better manage our resources to provide the best solutions for our members.

If you are in need of a service or procedure that requires precertification, please speak with your provider to submit a precertification request.