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How Does Utilization Management Work?

Reviewers with BCBSMT evaluate each patient case to know if it’s necessary to perform the medical procedures and services a healthcare specialist recommends. These reviewers use evidence-based guidelines in their analysis. Together, your doctor and BCBSMT will perform reviews that help check how effective of your treatments are before, during and after care.

What is prior authorization?

Sometimes, we need to approve inpatient, health care services and prescriptions before they're covered by your plan. This is called prior authorization, also known preauthorization, pre-certification or prior approval. Prior authorization happens before or during care.

What is recommended clinical review?

You can ask for this optional review before getting care that doesn't require prior authorization.2 It's helpful if you're not sure about your coverage or if we'll consider the care medically necessary. Work with your provider to send a request for recommended clinical review. To find out if this review is offered for a service, check the Recommended Clinical Review List.

What is post-service review?

A post-service utilization management review happens after you get care. During this review, we check whether a service or drug was medically necessary and covered under your health plan. We may ask your provider for more information. We may also run a post-service utilization management review if you or your provider does not get a required prior authorization before you get care.