Important: This step, using our PA Checkpoint™ tool, is for Blue Cross Blue Shield of North Dakota (BCBSND) members only. Please skip this if you are submitting an authorization for any other Blues plan, including Federal Employee Program, (FEP), Medicare Supplement Plans or NextBlue of North Dakota Medicare Advantage plans.
This tool can be used to check if a prior authorization (also known as precertification) is required for health care services covered by BCBSND commercial and Medicaid Expansion health plans. To submit a prior authorization request for a member of another Blue Cross Blue Shield Plan, use the out-of-area prior authorization search to be routed to the appropriate Blues Plan.
Before using the tool to see if a service does require prior authorization, here are a few helpful things to know.
BCBSND requires authorization for inpatient admission, including but not limited to:
- All inpatient admissions to a health care provider not participating with BCBSND
- All inpatient hospitalizations for BCBSND Medicaid Expansion members, whether participating or not participating with BCBSND
- Residential treatment centers
- Skilled nursing facilities, transitional care units, swing beds, long-term acute care facilities
- All inpatient admissions to a rehabilitation facility
- All inpatient admissions for Dakotas Health Plan members require preauthorization unless the plan is secondary
This tool does not include information about formulary or step therapy requirements for prescription drugs covered by the pharmacy benefit.
It is important to always verify within the benefit plan if a service will be covered by BCBSND, regardless of whether a prior authorization is required. For more information on member benefits, call the number on the back of the member ID card. Providers can also refer to the Availity Essentials provider portal Eligibility and Benefits Inquiry screen for more benefit detail.
It is also important to verify that the provider rendering the service is in the member’s health plan network, regardless of whether prior authorization is required. Not all participating providers are in all networks. Some plans do not cover care from out-of-network providers. Some plans pay less for care from out-of-network providers. When care is received from a provider that is not participating with the BCBSND network, members may be responsible for paying the difference between the plan’s allowed amount and the out-of-network provider’s charges.
The ultimate decision on the member’s medical care must be made by the member and the member’s health care provider. BCBSND only has the authority to determine the extent of benefits available for covered services under the benefit plan. Procedures and services that do not require a prior authorization are still subject to all terms and conditions of a member’s applicable benefit plan, applicable medical policy exclusions and contract limitations that may result in denial of payment.
Receipt of prior authorization approval does not guarantee payment of benefits. All services provided are subject to further review by BCBSND to ensure the services are medically appropriate and necessary. Benefits will be denied if the member is not eligible for coverage under the benefit plan on the date services are provided or if services received are not medically appropriate and necessary as determined by BCBSND. Benefits for authorized services are subject to the definitions, conditions, limitations, and exclusion of the benefit plan.
