What is Utilization Management Review?
A utilization management review helps determine the medical necessity and appropriateness of treatment for certain services.
Utilization management includes:
- Prior Authorization
- Recommended Clinical Review (Predetermination)
- Post-service reviews
What is Prior Authorization
Prior Authorization is the determination of the medical necessity and appropriateness of treatment as a required part of the Utilization Management process for certain covered services. Failure to obtain these proper permissions may affect claim payment, subject to the terms and conditions of a Coverage Plan. A Prior Authorization is not a guarantee of benefits or payment. Go here to learn how to submit prior authorization requests. (Link to Part B content below)
Who Requests Prior Authorization
The facility, treating physician or ancillary provider is responsible for obtaining prior authorization for Blue Cross and Blue Shield card carrying members, in accordance with the BCBSOK participating provider agreement. Please refer to the number on the member’s ID card for prior authorization requirements. Information for members is on our member site.
Most out-of-network services require utilization management review. If the provider or member does not get prior authorization for out-of-network services, the claim may be denied. Emergency services are an exception.
Why Obtain a Prior Authorization
If you do not get prior approval via the prior authorization process for services and drugs on our prior authorization lists:
- The service or drug may not be considered medically necessary, and the BCBSOK participating provider will be responsible.
- We may conduct a post-service utilization management review, which may include requesting medical records and review of claims for consistency with:
- Medical policies
- State and federal requirements
- Member’s benefits
- Other clinical guidelines
- Treating Medicare members, if you don’t get a prior authorization for a service or drug on our prior authorization list, we won’t reimburse you, and you cannot bill our member for that service or drug.
What is Recommended Clinical Review (Predetermination)
BCBSOK is changing the name of its longstanding preservice review, called Predetermination, to Recommended Clinical Review, effective Jan. 1, 2023.
Recommended Clinical Reviews (Predeterminations) are medical necessity reviews conducted before services are provided. Submitting the request prior to rendering the services is optional and informs the provider and member of situations where a service may not be covered based upon medical necessity. You can find a list of services for which Recommended Clinical Review is available on the Recommended Clinical Review list.
· Recommended Clinical Review is not a different process and will not generate a different result than a predetermination.
· The service will be subject to post-service review if a provider does not elect to use Recommended Clinical Review.
· Submitting a Recommended Clinical Review does not guarantee services will be covered under the members' benefit plans. The terms of the member's plan control the available benefits.
Why Obtain a Recommended Clinical Review (Predetermination)
· Submitting the request prior to the services is optional and informs the provider and member of situations where a service may not be covered based upon medical necessity.
· BCBSOK will review Recommended Clinical Review (Predetermination) requests to determine if the planned service meets approved medical policy, American Society of Addiction Medicine (ASAM) or MCG Care Guideline criteria before services are provided for medical and behavioral health services.
· Once a decision has been made on the services reviewed as part of the Recommended Clinical Review (Predetermination) request, the same services will not be reviewed for Medical Necessity again on a retrospective basis.
· Providers and members will be notified of the determination and will have the opportunity to appeal an adverse determination if the Recommended Clinical Review determines the proposed service does not meet medical necessity.
· Submitted claims for services not included as part of a request for Recommended Clinical Review (Predetermination), may be reviewed retrospectively.
What is Post-Service Utilization Management Review
A post-service utilization management review occurs after the service has been rendered. During a post-service utilization management review, we review clinical documentation to determine whether a service or drug was medically necessary and covered under the member’s benefit plan. We may ask you for the information we do not have.
We may also conduct a post-service utilization management review if you do not obtain a required prior authorization before the services were rendered. If the service required a prior authorization for a Medicare member, the claim will be denied with no post-service review.
The attached lists are for reference only and are not intended to be a substitute for benefit verification or BCBSOK's medical policies. All lists above apply only to members who have health insurance through a Blue Cross and Blue Shield of Oklahoma Plan or who are covered by a group plan administered by BCBSOK. If your patient is covered under a different Blue Cross and Blue Shield Plan, please refer to the Medical Policies of that Plan.