Currentalacura_medical_transportation_managementPolicy N/A

Utilization Management Program Description (UM program)

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Defines the structure, staffing, clinical review criteria, and processes of Alacura's utilization management program as applied to members of Blue Cross and Blue Shield of Montana for specified commercial and individual products.

Policy Summary

Payeralacura_medical_transportation_management

PolicyUtilization Management Program Description (UM program)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionProviders must ensure member eligibility and submit required clinical documentation when requesting prior authorization or recommended clinical review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

ASAM & MCGPrimary clinical criteria referenced

BCBSMT membersTarget membership

Mar 1, 2026Effective date shown

Preservice/Concurrent/RetroReview types

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

Currentalacura_medical_transportation_managementPolicy N/A

Utilization Management Program Description (UM program)

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Policy Summary

Payeralacura_medical_transportation_management

PolicyUtilization Management Program Description (UM program)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionProviders must ensure member eligibility and submit required clinical documentation when requesting prior authorization or recommended clinical review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

ASAM & MCGPrimary clinical criteria referenced

BCBSMT membersTarget membership

Mar 1, 2026Effective date shown

Preservice/Concurrent/RetroReview types

24/7Automated web platform

RecommendedDental recommended review

Coverage and Medical Necessity Criteria

Medical necessity and review criteria

Covered when clinical review using specified criteria supports medical necessity and plan terms:

UM decision fundamentals: Request is reviewed by qualified UM clinical staff using ASAM (for substance-related conditions), MCG care guidelines, and BCBSMT medical policy; determination requires that the service meets the program's definition of medical necessity and is consistent with plan terms.

Preservice prior authorizations confer appeal rights; recommended clinical review is voluntary and processed similarly.

Authorization and review decision logic

Coverage and authorization decisions are made using the following sources and escalation logic.

Sources for medical necessity determinations: Decisions require application of ASAM Criteria, MCG care guidelines, and the payer's medical policy as applicable.

Clinical reviewers may approve requests that meet these criteria.

Escalation for non-conforming requests: Requests that do not meet the criteria or appear to be contract exclusions are referred to physician reviewers or behavioral health physician reviewers (or behavioral health psychologists when applicable).

Absolute contract exclusions are not processed further.

Emergency care: Emergency screening and stabilization do not require prior authorization.

Provider should proceed to emergency care without prior authorization.

Utilization review criteria and reviewer qualifications

Coverage and utilization review determinations use established clinical criteria and licensed dental consultant review.

Criteria sources: Utilization review uses MCG criteria for specified inpatient and observation levels of care, BCBSMT medical policy, ASAM Criteria for addiction disorders, and Dental Networks of America policies for dental reviews.

Entities delegated BCBSMT business must use the same criteria.

Reviewer qualifications: Dental necessity determinations are made with input from a dental consultant who holds an active and unrestricted license to practice dentistry and bases decisions on objective, valid standards consistent with accepted professional standards.

Recommended clinical review

Recommended clinical review process for some dental services

Recommended review impact: When recommended clinical review is obtained, coverage for medically necessary services is determined through that process; if not obtained, a retrospective review determines medical necessity and benefit applicability.

Providers should submit detailed supporting documentation (treatment plan, functional aspects, projected outcome, study models/photographs/x-rays, and appropriate CDT codes) when requested.

Services or determinations that fall outside a member's coverage eligibility at the time of service, or that are explicitly excluded by the member's plan terms, are not covered. The UM program focuses its reviews on determining whether requested services fall within the benefits described in the member's evidence of coverage and applicable plan documents, and will deny coverage for services outside those terms.

Absolute contract exclusions are handled as exclusions and are not advanced through physician or behavioral health reviewer workflows. Requests identified as absolute contract exclusions are not processed further for clinical review and are communicated to the member and provider as an exclusion under the plan.

A utilization review determination may conclude that a service is not a covered service or is subject to an exclusion and/or limitation as defined by the member's evidence of coverage. When a request is escalated for clinical review, adverse determinations (denials, reductions, or terminations) are made only by appropriately credentialed clinicians and are communicated in writing to the member (or authorized representative) and the requesting provider.

Services that are primarily for convenience, are not in accordance with generally accepted standards of practice, or are more costly than an equivalent alternative that is at least as likely to produce equivalent results are considered not medically necessary and are not covered.

During retrospective (post-service) review, UM clinicians evaluate clinical documentation to determine whether the service was medically necessary, not experimental or investigational, and covered under the member's benefit plan. If documentation does not support medical necessity, the service may be denied or payment reduced based on the retrospective determination.

A denial or rejection of a prior authorization or payment request frequently indicates that the service is not a covered service or is subject to an exclusion or limitation under the member's contract rather than an affirmative clinical finding that the service is medically required. All adverse determinations include written notice and appeal rights as required by policy.

Coding and Documentation Codes

Recommended coding for documentationmixed

Current Dental Terminology codes

Appropriate CDT codes required for documentation and recommended clinical review

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior authorization is required for certain services

Certain services require prior authorization as a preservice review that conditions receipt of benefits and includes appeal rights; prior authorizations and recommended clinical reviews are processed the same way but prior authorization is required for specific services.

Prior authorization is a preservice review.
Prior authorization reviews include appeal rights.
Prior authorization is required for certain services; recommended clinical review is voluntary.

Prior Authorization

Submit required prior authorizations via web platform or UM review

Prior authorization is required for select inpatient admissions and outpatient services submitted through the automated web platform or reviewed via the utilization review process; emergency screening and stabilization do not require prior authorization.

Requests for elective or emergent inpatient admissions, select outpatient services, coordinated home care/home infusion and transplants not completed via the automated web platform are reviewed through utilization review.

Program Background and Scope

The UM program uses nationally recognized, evidence-based clinical criteria to evaluate medical necessity and appropriateness of care. For behavioral health and substance-related disorders the program applies the ASAM Criteria, and for medical/surgical level-of-care and utilization decisions it uses MCG care guidelines, together with the payer's medical policy. These sources guide preservice, concurrent and retrospective reviews and are applied annually as part of program oversight.

Definitions

Utilization review — definition and scope

DefinitionUtilization review: formal techniques to monitor or evaluate the clinical necessity, appropriateness, efficacy or efficiency of health care services, including ambulatory review, prospective review, second opinions, certification, concurrent review, case management, discharge planning, and retrospective review.

PurposeTo monitor use of services and evaluate appropriateness of procedures or settings to ensure care aligns with clinical standards and program policy.

MethodsMay include preservice (prospective), concurrent, and retrospective review, second opinions, certification, case management and discharge planning.

Medical necessity — definition and requirements

DefinitionMedical necessity: health care services a prudent clinician would provide to prevent, evaluate, diagnose, treat, cure or relieve a condition, consistent with generally accepted standards of practice.

Policy Summary

Payeralacura_medical_transportation_management

PolicyUtilization Management Program Description (UM program)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMar 1, 2026

Next Review DateN/A

Key ActionProviders must ensure member eligibility and submit required clinical documentation when requesting prior authorization or recommended clinical review.

SourceLink

On This Page

The automated web platform accepts submissions 24/7 from physicians or facility personnel (including diagnosis/procedure codes and medical records).

Emergency screening and stabilization do not require prior authorization.

Note

Dentists: recommended clinical review for some services

Although dentists are not required to submit claims for prior authorization, recommended clinical review is advised for some dental services to help avoid unexpected expenses and to determine coverage for medically necessary services.

Utilization review for dental services occurs both prospectively and retrospectively.
Recommended clinical review determines coverage; if not obtained, retrospective review will assess medical necessity and benefit applicability.

Step Therapy

Use ASAM, MCG and medical policy to determine appropriateness

UM clinicians apply ASAM Criteria, MCG care guidelines and the payer's medical policy to determine medical necessity, appropriate level and site of care, length of stay, and duration of service; requests that do not meet these criteria are escalated to physician reviewers.

ASAM and MCG criteria and medical policy are used to evaluate appropriateness of treatment setting, length of stay, and duration of service.
UM clinicians may approve requests that meet established criteria; non-conforming requests are referred to physician reviewers.

Documentation Required

Verify member eligibility and match requested services to authorization

Providers must verify member eligibility and ensure that the services requested match the prior authorization or recommended clinical review request; benefits are conditioned on member eligibility, any changes in condition, rendered services matching the request, and the member's plan terms.

Confirm member coverage eligibility at time of service before relying on prior authorization.
Ensure the actual services rendered match what was authorized or reviewed; differences can affect benefit payment.

Documentation Required

Submit complete clinical documentation from reliable sources

UM clinicians document and accept clinical information from multiple reliable sources (verbal information from treating clinicians, medical office/facility personnel, and provider medical records); physicians or facility personnel may submit diagnosis and procedure codes and medical records via the automated web platform for prior authorization requests.

UM staff use verbal and medical record information to determine whether established criteria are met.
Providers may input diagnosis/procedure codes and upload medical records through the automated web platform.

Documentation Required

Provide detailed documentation for recommended clinical review

For recommended clinical review, providers must supply pertinent documentation including an explanation of proposed services, functional aspects, projected outcome, treatment plan, supporting materials (study models, photos, x-rays), and appropriate Current Dental Terminology codes.

Include treatment plan and projected outcome.
Provide supporting materials such as study models, photographs and x-rays.
List appropriate Current Dental Terminology (CDT) codes.

Denial Risk

Prior authorization reviews can lead to denials and affect benefits

Because prior authorization conditions receipt of benefits upon a preservice review, prior authorization reviews may result in denials; adverse determinations include appeal rights and are communicated in writing.

Prior authorization reviews include appeal rights.
Neither prior authorization nor recommended clinical review guarantee benefits or payments.

Denial Risk

Nonconforming requests may be denied or escalated to physician review

Requests that do not meet ASAM Criteria, MCG care guidelines, medical policy, or that appear to be potential contract exclusions are referred to physician reviewers and may result in adverse determinations (denial, reduction, or termination) communicated in writing.

Non-conforming requests are escalated to physician or behavioral health physician reviewers (or behavioral health psychologists when applicable).
Adverse determinations are communicated in writing and may be appealed.

Denial Risk

Denials and recommended review outcomes are adverse determinations with appeal rights

A decision to deny or partially deny a claim payment is an adverse benefit determination; failure to obtain a recommended clinical review may result in retrospective review and possible denial or reduced benefit, and adverse determinations are subject to appeal procedures.

Adverse determinations (denials/partial denials) are adverse benefit determinations.
If recommended clinical review is not obtained, a retrospective review determines medical necessity and benefit applicability.

Clinical appropriatenessServices must be clinically appropriate in type, frequency, extent, site and duration and effective for the patient's condition.

LimitationsServices must not be primarily for convenience and must not be more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results.

Authorized representative — who may act on behalf of a member

DefinitionAuthorized representative: a person to whom a covered person has given express written consent to represent them; a person authorized by law to provide substituted consent; a family member; or the treating health care provider if the covered person is unable to provide consent.

ScopeApplies with respect to benefits, claims, or appeals of adverse benefit determinations.

DocumentationExpress written consent is required when the representative is acting on behalf of the covered person unless other legal authorization exists.

ASAM Criteria — behavioral health screening and placement

DefinitionASAM Criteria: treatment criteria for addictive, substance‑related and co‑occurring conditions used as behavioral health clinical screening criteria across all levels of care.

FocusSupports multidimensional assessments and integrated care addressing mental and physical health disorders in patients with addictions.

Review frequencyEvaluated at least annually or sooner if new evidence or technologies become available; presented annually to the Behavioral Health Quality Improvement Committee.

MCG care guidelines — evidence‑based criteria for medical necessity

DefinitionMCG care guidelines: nationally recognized, evidence‑based clinical criteria used to screen and evaluate medical necessity and appropriateness of services in accordance with a member's health benefit plan.

ApplicationUsed by clinical review staff to evaluate medical, surgical and behavioral health procedures and inpatient admissions (preservice and concurrent) not completed through the automated web platform.

GovernanceMCG guidelines are evaluated annually or earlier as needed and approved by the chief medical officer or delegate; updates are communicated to Quality Improvement committees.

Dentally necessary — definition and reviewer standards

DefinitionDentally necessary: services that are medically necessary and appropriate for diagnosis or treatment of a member's dental condition according to accepted standards of dental practice and not provided only as a convenience.

Coverage contextUtilization decisions focus on whether services are covered under the member's plan; evidence of coverage lists covered dental services, exclusions, and limitations.

Reviewer qualificationsMedical/dental necessity decisions are made with input from a dental consultant who holds an active, unrestricted license to practice dentistry and bases decisions on objective, valid standards consistent with accepted professional dental standards.