HealthCare News

Utilization Management (UM) Transition to InterQual

Issue: #402 JUL2018

Topic: Education


Blue Cross Blue Shield of North Dakota (BCBSND) has transitioned to InterQual Criteria, effective June 5, 2018, for medical and July 1, 2018, for behavioral health providers. InterQual Criteria is continuously updated with the most recent evidence and clinical standards, using a wide variety of medical specialists to manage and validate their medical criteria sets. Provider organizations may purchase access to provider criteria directly from InterQual. To gain more information on InterQual, please visit their website.

Medication Precertification Policy

BCBSND currently allows a five-year approval timeframe for medication precertification requests (also known as prior approval, prior authorization or preauthorization). Effective June 5, 2018, the current policy for medication precertification requests have been revised to allow a maximum one-year approval time frame.

Peer-to-Peer Conversation

The peer-to-peer process is an opportunity for the requesting/ordering provider to have a one-on-one conversation with a peer reviewer when a service has been denied as not medically necessary.

The purpose is to further explain the adverse determination – principle reason, clinical rationale, and components of specific medical policy. Effective June 5, 2018, the denial will not be overturned as a result of the peer-to-peer conversation. When the provider has received additional clarification, they may either accept the adverse determination or proceed with a formal appeal.

UM System-Generated Faxes

Effective June 5, 2018, as an enhanced functionality of the new UM tool, providers who have requested authorizations will begin receiving faxes indicating the determination of the request. This fax contains a brief summary of the determination. A mailed letter is also generated with complete details of the authorization request.

With this additional functionality, it is necessary for you to provide a fax number with your initial request for services.

Medical Records Submission

When submitting clinical information to BCBSND, please clearly state the reason for submission, member name, member ID and type of request (routine versus urgent) on the first page following the fax cover sheet. This information is necessary to deliver records to the appropriate area and to ensure timely responses.

In addition, authorization forms will be updated on the BCBSND Providers webpage. We recommend using the most recent forms to ensure your authorization request is delivered to the appropriate area.

We look forward to working with you and ensuring this transition is a success. As always, you may also reach out to the Provider Partnerships team with questions at prov.partners@bcbsnd.com.