The Blue Cross Blue Shield of North Dakota (BCBSND) website contains information about which services require precertification. This information is available to providers 24/7 and eliminates the need to contact Provider Services to verify the requirements.
For Drugs, a list is available on the Rx Tools webpage (https://www.bcbsnd.com/web/guest/manage-my-benefits/pharmacy-listings). Towards the bottom of the page, under the “Restricted-Use Drugs” section, the listing can be found under the “Restricted-Use Prior Approval Drugs” link. When viewing the listing, pay attention to the far-righthand column. If the indicator is “MED” then the precertification request should be submitted to BCBSND. The Outpatient Authorization Request should be used. This form can be found at https://www.bcbsnd.com/web/providers/forms.
All other drugs on this list should be submitted to Prime Therapeutics for review. Providers are encouraged to go to the CoverMyMeds website or use the Prior Authorization link on the BCBSND retail pharmacy webpage (https://www.bcbsnd.com/web/providers/forms/retail-pharmacy). If using this option, after clicking on “Prior Authorization”, providers can continue without sign in and choose BCBS North Dakota as the health plan. Then select the appropriate form based on the drug or type of drug and follow the directions on the form to submit with the appropriate clinical documentation.
For any other service that may require precertification, a standard list can be found under the Policies & Approvals section of the provider website (https://www.bcbsnd.com/web/providers/precertification). If the procedure or admission requires precertification, the appropriate form is listed at the bottom of this page. There is also a hyperlink to the Medical Policy page which will connect providers to the appropriate medical criteria.
Please contact Provider Services at 1-800-368-2312 with any questions.