This page provides a summary of pre-service requirements and recommendations for BCBSIL providers. Call the number on the back of the member's ID card if you have any questions.
Eligibility and Benefits Reminder: An eligibility and benefits inquiry should be completed first to confirm membership, verify coverage and determine whether or not pre-certification (also known as pre-notification or preauthorization) is required. This includes prior authorization for high-tech imaging services.
For additional information, refer to the Pre-Service Review for Out-of-Area Members tip sheet . You can also refer to the Electronic Provider Access (EPA) FAQs for additional information. Learn more about iExchange®.
Also known as preauthorization or pre-notification, pre-certification confirms that a physicians’ plan of treatment meets medical necessity criteria under the applicable health benefit plan.
- Most PPO benefit plans require the member or provider to pre-certify inpatient hospital admissions (acute care, inpatient rehab, etc.)
- Many PPO benefit plans also require pre-certification for coordinated health care (skilled nursing visits, home infusion therapy, etc.)
- Pre-certification also may be required for outpatient services for some employer groups.
Request, Verify or Obtain Pre-certifications
- Electronic Requests—Registered AvailityTM providers may submit online pre-certification and authorization requests and inquiries (ANSI 278 transaction)
- Telephone Inquiries—Call the pre-certification number on the back of the member’s ID card. Or, call our Provider Telecommunications Center (PTC) at (800) 972-8088—upon verification of eligibility and benefits, you will be advised how to proceed.
- Online Approvals—Sign up to use iExchange—an online tool that supports direct submissions and provides online approval of benefits for inpatient admissions and select outpatient services. Learn more about iExchange.
A Predetermination of Benefits is a written request for verification of benefits prior to rendering services.
- Recommended when the service may be considered experimental, investigational or cosmetic
- Approvals and denials often are based on approved BCBSIL Medical Policies
- Not a substitute for the eligibility and benefits verification process
How to Submit a Request for Review
- Complete the Predetermination Request Form and fax it to BCBSIL
- This form also may be used to request review of a previously denied Predetermination of Benefits
- You will be notified when a final outcome has been reached
Attention BCBS providers (outside of BCBSIL): Please see the BlueCard (Out-of-area) Reminder at the bottom of this page.
A Radiology Quality Initiative (RQI) number is required by BCBSIL prior to ordering CT/CTA scans, MRI/MRA scans, Nuclear Cardiology studies, and PET scans for most PPO members.*
- The RQI requirement applies when non-emergency high-tech imaging services are performed in a physician's office, the outpatient department of a hospital, or a freestanding imaging center.
- Obtaining an RQI is not a substitute for the eligibility and benefits verification process—providers must verify eligibility and benefits prior to rendering services.
- The RQI does not replace or override any pre-certification requirements specified by the member's benefit plan.
- The RQI number is valid for 30 days. (There is no grace period if the service is not performed.)
How do I obtain or verify an RQI?
AIM Specialty Health® (AIM) administers the RQI Program for BCBSIL (most groups). The ordering physician may obtain, and the rendering provider may verify, an RQI in either of the following ways:
- Log on to the AIM Provider Portal
- Contact the AIM Call Center at (866) 455-8415
AIM has developed a set of proprietary diagnostic imaging guidelines, based on a review of current medical literature and information obtained from major medical organizations. These clinical guidelines may be accessed via AIM's website.
BCBSIL sends updated provider and membership information to AIM.
- If you contact AIM and they do not have you on file as a BCBSIL provider, use our online form to Update Your Information.
- If you contact AIM and they have no record of a specific BCBSIL member, a Predetermination of Benefits may be needed.
BlueCard® (Out-of-area) Reminder
If you are providing service to out-of-area Blue Cross and Blue Shield (BCBS) members, please note:
- Some BCBS Plans have radiology management programs, other than AIM.
- These programs may be tied to member benefits, and therefore it is important to check benefits prior to service by calling the BlueCard Eligibility Hotline at (800) 676-BLUE(2583).
*Certain employer groups may require pre-certification for imaging services from other vendors. If you have any questions, please call the number on the back of the member's ID card.