Name of Manual - Blue Cross and Blue Shield of Minnesota

Integrated Health Management
Pre-Certification/Authorization
Overview The purpose of pre-certification/authorization is to review services
prior to being rendered to determine if the services are
contractually eligible and medically necessary. Medical policy
criteria and member contract language is used to assist in
determining if benefits are available for the requested service.
Certification/Authorization for a service, device or drug does
not in itself guarantee coverage, but notifies you that as
described, the service, device or drug meets the criteria for medical
necessity and appropriateness. Payment for services and/or
supplies Blue Cross approves in advance is based on the following
requirements: if the policy is in force the date the member receives
care, premiums have been paid, lifetime or benefit maximums
have not been exceeded, the condition is not subject to a
preexisting condition limitation period, and the procedure that is
authorized is the service and/or supply that is billed by the
provider. Deductibles, coinsurance, allowed amount and copayments
will apply.
The “pre-certification/authorization” section identifies various
services, procedures, prescription drugs, and medical devices that
require pre-certification/pre-authorization. Please note, commercial
(including BlueLink TPA) and MN Government Programs have
different pre-certification/authorization lists and requirements.
These lists are not exclusive to medical policy services only; they
encompass other services that are subject to precertification/authorization
requirements. For your convenience,
links to the “Commercial Forms,” “BlueLink TPA Forms,” CMS
and DHS criteria websites have also been provided.
The Blue Cross clinical reviewer uses local and national medical
policy, Medicare guidelines, MHCP Guidelines, behavioral health
criteria and member contract language to assist in determining if
benefits are available for the request. Criteria are determined by
the type of plan in which the member is enrolled. Authorization for
a service, device, or drug does not in itself guarantee coverage but
notifies you if the request meets the criteria for medical necessity
and appropriateness. The provider should always check with
customer service to make sure the member, or patient has contract
benefits and that the coverage is up to date.
We will evaluate your request for pre-certification and will make a
determination once all the necessary medical information is
received. Review decisions will be made and communicated
within required time frames as defined by state and federal law.
4-14 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12)