Out-of-Network Authorized Referral Requests through Availity Essentials

Blue Cross Blue Shield of North Dakota (BCBSND) is reminding providers of the Medicaid Expansion out-of-network authorized referral requirements. BCBSND requires authorize for all services outside of the Medicaid Expansion network. This is based on medical necessity and is reviewed to determine if an in-network provider can provide the service rather than going out of network. This request is initiated by submitting an authorization request through our Availity Essentials provider portal, the request will be reviewed by clinical review staff, and you will receive a response once the review is completed. 
 
To verify if the provider is within the network, select the Find a doctor link. Follow the prompts after selecting the link. 

Requests for out-of-network authorized referrals will need to be submitted as an authorization (not a referral) through the Availity provider portal. At this time, the referral function in Availity Essentials is only used for the commercial BCBSND line of business. Authorization referral required fields within Availity Essentials include:

• CPT Code
  • if the CPT is unknown, the CPT code 99199 can be used for these requests. 
• Diagnosis code
  • The provider should submit an applicable diagnosis code. 

• Date range
  • Enter appropriate start date. The date range will be reviewed by the Utilization Management area to establish the necessary amount of time.

• Allowed number of visits
  • Clinical review staff will review this, and you will receive a response once the review is completed.

• Documentation
  • Clinical documentation will need to be submitted with the request showing why an in-network provider cannot perform the services.

For additional questions, contact our ND Medicaid Expansion Customer Contact Center at 1-833-777-5779.