Utilization Management for BlueCard^® Members

Providers should remind patients that they are responsible for obtaining pre-certification/preauthorization for outpatient services from their Blue Plan. Participating providers are responsible for obtaining a pre-service review for inpatient facility services when the services are required by the account or member contract. In addition, members are held harmless when the pre-service review is required and not received for inpatient facility services (unless an account receives an approved exception). 

Providers must also follow specified timeframes for pre-service review notifications: 

• 48 hours to notify the member’s Plan of change in pre-service review; and 
• 72 hours for emergency/urgent pre-service review notification. 

General information on pre-certification/preauthorization information can be found on the out-of-area member Medical Policy and Preauthorization/Pre-certification Router at Find a member’s Blue Plan by Prefix using the three-letter prefix found on the member ID card. 

You may also contact the member’s Plan on the member’s behalf. You can do so by: 

• Calling the utilization management/precertification number on the back of the member’s ID card.
  
  
• If the utilization management number is not listed on the back of the member’s ID card, call 800-676-BLUE (2583) and ask to be transferred to the utilization management area.  
  • When precertification/preauthorization for a specific member is handled separately from eligibility verifications at the member’s Blue Cross and Blue Shield (BCBS) Plan, your call will be routed directly to the area that handles pre-certification/preauthorization. You will choose from four options depending on the type of service for which you are calling: 
    • Medical/Surgical 
    • Behavioral Health 
    • Diagnostic Imaging/Radiology 
    • Durable/Home Medical Equipment (D/HME) 
      
      
  If you are inquiring about eligibility and precertification/preauthorization, through 800-676-BLUE (2583), your eligibility inquiry will be addressed first. Then you will be transferred, as appropriate, to the pre-certification/preauthorization area.
  
  
• The member’s BCBS Plan may contact you directly regarding clinical information and medical records prior to treatment or for concurrent review or disease management for a specific member.  
  
  When obtaining pre-certification/preauthorization, please provide as much information as possible to minimize potential claims issues. Providers are encouraged to follow up immediately with a member’s BCBS Plan to communicate any changes in treatment or setting to ensure existing authorization is modified or a new one is obtained, if needed. Failure to obtain approval for the additional days may result in claims processing delays and potential payment denials. 

BlueCard^® - registered derivative