Tips for Pre-Certification Requests

The Blue Cross Blue Shield of North Dakota (BCBSND) Availity Essentials portal is used to submit precertification requests for both inpatient and outpatient services. Below is additional information regarding precertification requests.

1.  The Availity Essentials portal does not give specific precertification benefits, but it will indicate if a member is active. Please contact the appropriate Provider Service department for verification of benefits.

2.  Since the Availity Essentials portal does not have the functionality to determine if a code requires precertification, utilize our BCBSND website to locate the applicable precertification list and search accordingly.

3.  Be sure to submit the required clinical documentation for any requests submitted via the Availity Essentials portal. Referencing BCBSND medical policies can assist in determining what clinical documentation is required for the review.

4.  You may receive a request for additional information or clarification, when necessary, via the Availity Essentials portal.

5.  If all required information is received:

• The determination will show in the Availity Essentials portal once it has been made.
• A fax will also be sent to the number which the request was submitted from.
• Determination letters will also be mailed to both the provider and member.

6.  As noted on the BCBSND Availity Essentials webpage, requests that do not require precertification and have a published BCBSND medical policy will be cancelled.

• Providers will be directed to contact Provider Service for benefits, or any questions related to the request.

7.  If you have questions regarding a submission, please contact Availity Essentials support at 1-800-282-4548.

Inpatient or Outpatient Fax Request

When submitting a request by fax, please complete the appropriate level of service precertification request form found on BCBSND.com.

1.  Please be sure to include the required clinical documentation, which is required for all medical necessity review requests.

2.  When submitting the request by fax, you will receive all responses, determinations and requests by fax at the number provided on the request form.

3.  Please note all approvals, denials and requests for additional information will display with the same fax format. If additional information is required, your request will remain pended until the requested information is received.

4.  In addition to your faxed response, you will also receive a determination letter which will contain clinical rationale.

Note: Precertification does not guarantee payment, this is determined based on member’s eligibility and benefits.