What to Know About Prior Authorization (Insurance 101)

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

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

Why do I need prior authorization?

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

Which services require prior authorization?

See if you need prior authorization ›

Prior Authorization Updates Regarding PET Scans
As of December 15, 2023, PET scans will no longer require prior authorization from a health care provider. That way if your provider recommends a PET scan, you won’t have to wait for them to submit a request for approval from BCBSND. This change improves the experience between you and your providers, making it easier to receive the treatments to improve your well-being.

Who decides if my prior authorization is approved?

Prior authorization 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 prior authorization. For example, the world of molecular diagnostics and genetic testing is always changing. That’s why BCBSND partners with eviCore healthcare to review prior authorization 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 prior authorization, please speak with your provider to submit a prior authorization request.