BCBS Utilization Management Process Explained

Blue Cross Blue Shield (BCBS) has a utilization management process in place to ensure that healthcare services are necessary and provide the best possible outcomes for patients.

This process involves a team of healthcare professionals who review and authorize medical services, including hospitalizations, surgeries, and other treatments.

BCBS aims to reduce unnecessary healthcare costs and improve patient care through its utilization management process.

The goal is to help patients receive the right care at the right time, while also controlling costs and improving overall health outcomes.

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Utilization management is a process that happens after you receive a service. We check whether a service or drug was medically necessary and covered under your health plan.

A post-service utilization management review may be conducted if you or your provider didn't get a required prior authorization before receiving services. This review may involve asking your provider for more information.

Carelon Medical Benefits Management and eviCore healthcare are independent companies that have contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL.

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If your health care provider hasn't requested prior authorization, you can request it yourself. Call the number listed on your BCBSIL member ID card, and our Customer Service will help you begin the process.

You can use the digital lookup tool to find out if prior authorization is required for your specific needs. This tool is available for fully insured members and can be accessed by choosing one of three categories: medical procedures, medical drugs, or behavioral services.

If you're unsure about whether prior authorization is required, you can review the full list of services and drugs that require prior authorization. These lists are available for download, including the 2025 Commercial Prior Authorization Requirements Summary and the 2025 Commercial Outpatient Medical Surgical Prior Authorization Code List.

Pharmacy Prior Authorization is handled by Prime Therapeutics, which reviews prior authorization requests from physicians for BCBSIL members with prescription drug coverage. You can review their prior authorization/step therapy program list for more information.

You can also check the Prior Authorization Statistics page to see how many requests are received and approved each year.

If you're a Blue Cross Community Health Plans (BCCHP) member, review the BCCHP Prior Authorization page for details. If you're a Blue Cross Community MMAI (Medicare-Medicaid Plan) member, review the MMAI Medical Benefits page.

To request authorization, you can call the number listed on your BCBSIL member ID card or use the digital lookup tool to find out if prior authorization is required.

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The authorization process is a crucial part of BCBS utilization management. To initiate the process, your provider will need to submit a prior authorization request to BCBSIL, which includes your name, subscriber ID number, date of birth, and provider information.

The request will also require information about your medical or behavioral health condition, proposed treatment plan, and estimated length of stay. Your provider can help you with this information.

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BCBSIL reviews the request to determine if the service or drug is medically necessary and appropriate for your needs. This review does not replace the advice of your provider.

To complete a prior authorization request, you'll need to provide your name, subscriber ID number, and date of birth, as well as your provider's name, address, and National Provider Identifier (NPI).

Here are the required documents for a prior authorization request:

You can also use the digital lookup tool to find out if prior authorization is required for your service or drug. The tool categorizes services into three categories: medical procedures, medical drugs, and behavioral services.

Here are the categories and related links:

For a list of services and drugs that require prior authorization, you can download the following spreadsheets:

A post-service utilization management review happens after you receive a service, during which your health plan checks if the service or drug was medically necessary and covered.

This review may ask your provider for more information if needed. We may also conduct a review if you or your provider didn't get the required prior authorization before receiving services.

Carelon Medical Benefits Management and eviCore healthcare are independent companies that have contracted with BCBSIL and BCBSMT to provide utilization management services and prior authorization for expanded outpatient and specialty utilization management.

If you're not fully insured, check with your HR department or benefits administrator to confirm your coverage. You can also review your benefit booklet for a list of services that require prior authorization.

Utilization management helps lower costs by ensuring the care given is needed and effective.

It's a win-win for everyone involved: you get the best possible care, and your health insurance company saves money by avoiding unnecessary treatments.

Utilization management reviews can gather data about which treatments are effective, and provide providers with information to support their treatment plans and claims.

This helps reduce the denial of claims, making the process smoother for everyone.

Some services not requiring prior authorization may be reviewed for medical necessity before a claim is paid.

If you're unsure about coverage or whether a service is medically necessary, you can ask for a Recommended Clinical Review (Predetermination).

You'll need to work with your provider to submit a request for this review.

To find out if this review is available for a specific service, check the Recommended Clinical Review List (predetermination), or call your health insurance company's Customer Service number.

Recommended clinical review is not a guarantee of benefits, so be sure to check your benefit booklet for eligibility and other terms, conditions, and limitations.

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There are two types of reviews that BCBSMT uses to ensure medical necessity and coverage.

A recommended clinical review, also known as predetermination, is an optional request to inform the provider and member of potential coverage issues before rendering certain services.

This review happens before you get care, and it's a way to check if a service may not be covered based on medical necessity.

A post-service utilization management review, on the other hand, happens after you get care, and it's a check to see if a service or drug was medically necessary and covered under your health plan.

Carelon Medical Benefits Management and eviCore healthcare are independent companies that have contracted with BCBSMT to provide utilization management services and prior authorization for expanded outpatient and specialty utilization management.

During a post-service review, BCBSMT may ask your provider for more information, or they may run a review if you or your provider didn't get a required prior authorization before you got care.

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