Precertification

Some services, procedures, and equipment requires precertification before the service is performed. The ordering provider is typically responsible for obtaining precertification.

Precertification Instructions

  1. When a procedure, service or DME is ordered, use the search function below to check precertification requirements associated with the member's contract. For best results, double check the spelling or code you entered.
  2. If the item indicates "precertification required," submit your request through Availity.
    (No access to Availity? 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.

NOTE:  Dental anesthesia and hospitalization for dental care, precertification is required for all Members age 9 and older.

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

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

NOTE: The search results listed do not apply to the Federal Employee Program (FEP). Please refer to the FEP website or contact FEP Provider Services.

This code does not require a precertification. Medical policy may apply.

Any service that is potentially cosmetic does require precertification.

NOTE:  Dental anesthesia and hospitalization for dental care, precertification is required for all Members age 9 and older.

If this is a genomic code, BCBSND contracts with eviCore for its Laboratory Management Program. eviCore in an independent company providing specific medical policy and precertification services to BCBSND. Effective 1-1-2020, Lab Management (molecular and genomic testing) is delegated to eviCore.

Visit eviCore for Genomic Testing Policy

This keyword does not require a precertification. Medical policy may apply.

Any service that is potentially cosmetic does require precertification.

NOTE:  Dental anesthesia and hospitalization for dental care, precertification is required for all Members age 9 and older.

If this is a genomic code, BCBSND contracts with eviCore for its Laboratory Management Program. eviCore in an independent company providing specific medical policy and precertification services to BCBSND. Effective 1-1-2020, Lab Management (molecular and genomic testing) is delegated to eviCore.

Visit eviCore for Genomic Testing Policy

To view InterQual criteria, go to Authorizations and Referrals in Availity.

For more information visit InterQual.

Precertification required. Log into Availity.

Precertification required

Submit precertification requests

Unable to submit through Availity?
Inpatient Authorization Request
Outpatient Authorization Request
ABA Services for Autism Spectrum Disorder Supplement - This form is to accompany the appropriate authorization request