Precertification

Precertification is the process by which the member or the member's health care provider provides information to BCBSND to establish the medical appropriateness and necessity of specified services. 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.

Policy/Criteria
Members must consult their applicable benefit plans or contact Member Services for specific coverage information. Contact information is located on the back of the member's ID card.

Out-of-Area Search
To find precertification information for Blue Cross Blue Shield members outside of North Dakota, enter the member's three-character prefix in the box below.


     

 

Services/Procedures Requiring Precertification
The list below is a standard precertification list. Some benefit plans have variations to the list. You may verify if precertification is required for a service by contacting Provider Services at 800-368-2312.

  • Artificial intervertebral cervical disc;
  • Assisted reproductive technology for GIFT, ZIFT, ICSI and IVF;
  • Autologous chondrocyte implantation;
  • Bariatric surgery for morbid obesity;
  • Behavioral Modification Intervention for Autism Spectrum Disorder (Including Applied Behavior Analysis (ABA));
  • Bone growth stimulator (electrical or ultrasound);
  • Chronic pain management program;
  • Cochlear implant;
  • Deep brain stimulator;
  • Dental anesthesia and hospitalization for all Members age 9 and older;
  • Electric wheelchairs;
  • Gender reassignment surgery;
  • Growth hormone therapy/treatment;
  • Home Health Care;
  • Hospice;
  • Human organ and tissue transplants, except kidney and cornea transplants;
  • Inpatient Admission to a Rehabilitation Facility;
  • Inpatient Admissions to a Health Care Provider not participating with BCBSND;
  • Insulin infusion pump, patient owned continuous glucose monitoring systems and artificial pancreas device systems;
  • Long Term Acute Care Facility;
  • Negative pressure wound therapy in an outpatient setting;
  • Oral appliance for obstructive sleep apnea;
  • Oscillatory devices for respiratory conditions;
  • Osseointegrated dental implants;
  • Programmable lymphedema pumps;
  • Prosthetic Limbs controlled by microprocessors and any Prosthetic Limb replacement within 5 years;
  • Psychiatric and Substance Abuse Admissions, including Inpatient, Partial Hospitalization or Residential Treatment;
  • Restricted Use Drugs;
  • Sacral nerve stimulator (trial placement and permanent placement);
  • Services or procedures which could be considered Cosmetic Services;
  • Skilled Nursing Facility;
  • Spinal cord stimulator (trial placement and permanent placement);
  • Surgical treatment of obstructive sleep apnea;
  • Total ankle replacement;
  • Transitional Care Unit;
  • Vagus nerve stimulator;
  • Wearable cardioverter defibrillators; and
  • Wireless capsule endoscopy.

Note:

  • No precertification is required when BCBSND is secondary to other insurance, unless other insurance benefits have been exhausted.
  • No precertification is required for maternity admissions that result in delivery.
  • This list does not apply to the Federal Employee Program (FEP).

Precertification Request Forms & Supplemental Documentation
PDF iconInpatient Authorization Request
PDF iconOutpatient Authorization Request

PDF iconAPDS, CBM, Insulin Pump Supplement – This form is to accompany the appropriate authorization request
PDF iconABA Services for Autism Spectrum Disorder Supplement – This form is to accompany the appropriate authorization request

Medical Policy