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Prior Authorization

Some services, procedures, and equipment require prior authorization before the service is performed. The ordering provider is typically responsible for obtaining prior authorization. Use the search tool below to verify if the service requires prior authorization.

Prior Authorization Instructions

  1. When a procedure, service or DME is ordered for a Commercial or Medicaid Expansion member, use the search function to check precertification requirements associated with the member's contract. For best results, search using a procedure code. This search function does not apply to the Federal Employee Program (FEP). 

  2. If the item indicates "precertification required," submit your request through Availity Essentials. You can use this resource guide to help. (No access to Availity Essentials? Complete and fax or mail the inpatient or outpatient authorization request form.)

  3. If you see no results for the code or search term entered, precertification is not required. Instead, refer to the medical necessity guidelines in the BCBSND medical policy.

NOTE:

  • Any service that is potentially cosmetic does require precertification.
  • Dental anesthesia and hospitalization for dental care, precertification is required for all Members age 9 and older.
  • Repair of a covered wheelchair does not require pre certification. Benefits are allowed for repairs of latest wheelchair that has been covered by insurance.

Nonparticipating providers:
Providers typically submit precertification requests on members' behalf. While not required for nonparticipating providers, it is appreciated by BCBSND members.

Admission Dates:
If a member’s admission date is moved to a future date, providers must notify the Utilization Management (UM) team of the new admission date.

This can be done by phone or fax, and the provider must include the:

  • Authorization approval number
  • New admission date

This ensures the prior authorization remains valid and accurately reflects the member’s care timeline.

Precertification is not required:

  • When BCBSND is secondary to other insurance, unless other insurance benefits have been exhausted
  • For maternity admissions that result in delivery
  • Medicare Supplement policies

Unable to submit through Availity Essentials?

Inpatient Authorization Request
Outpatient Authorization Request
ABA Form - For FEP use only


Want to know more about last year’s prior authorization activity?

The information found here shows prior authorization activity from the prior year for Qualified Health Plans (QHP) available through a Federally Facilitated Exchange and Medicaid Expansion plans. This information includes but is not limited to approval rates, denial rates, prior authorization appeal information.