Prior Authorization



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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 prenotification 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 Availity®  or RealMed®  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 ApprovalsSign 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 and BlueChoice Select 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 processproviders 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?

American Imaging Management (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:

Clinical Guidelines

AIM Specialty HealthSM (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.

 

Troubleshooting Tips

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).

Availity is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. Aerial, iExchange and Medecision® are trademarks of Medecision, Inc., a separate company that offers collaborative health care management solutions for payers and providers. BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by Availity or Medecision. The vendors are solely responsible for the products or services they offer. If you have any questions regarding any of the products or services they offer, you should contact the vendor(s) directly.

Please note that verification of eligibility and benefits information, and/or the fact that any pre-service review has been conducted, is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered.