March 31, 2023
Blue Cross and Blue Shield of Illinois (BCBSIL) is changing prior authorization requirements that may apply to some commercial non-HMO members. Changes are based on updates from Utilization Management prior authorization assessment, Current Procedural Terminology (CPT®) code changes released by the American Medical Association or Healthcare Common Procedure Coding System (HCPCS) code changes from the Centers for Medicaid & Medicare Services.
A summary of changes is as follows:
- July 1, 2023 – Addition of Medical Oncology drug codes to be reviewed by Carelon Medical Benefits Management (formerly known as AIM Specialty Health)
- July 1, 2023 – Replacement and removal of Musculoskeletal Joint and Spine codes reviewed by Carelon
- July 1, 2023 – Addition of Genetic Testing codes to be reviewed by Carelon
- July 1, 2023 – Replacement of an Infusion Site of Care drug code to be reviewed by BCBSIL
- July 1, 2023 – Addition of Advanced Imaging codes to be reviewed by Carelon
For more information, refer to the Utilization Management section for the updated procedure code lists. These are posted on the Support Materials (Commercial) page.
Also, effective May 14, 2023, enhancements to Carelon’s ProviderPortal will create an easier intake process for its Medical Oncology program. Register for a free training from Carelon below:
- Tuesday, May 16, noon CST Register for webinar at this link.
- Thursday, Aug. 10, 2 p.m. CST Register for webinar at this link.
- Tuesday, Nov. 14, 2 p.m. CST Register for webinar at this link.
Important Reminders
Effective April 1, 2023, the prior authorization list will include a link to the medical policy section for review of the specific medical policies associated with the procedure code rather than listing the medical policy number and title for each code. The list will continue to include information on whether prior authorization for the procedure code is managed by BCBSIL or by Carelon.
Always check eligibility and benefits first through Availity® Essentials or your preferred vendor portal, prior to rendering services. This step will confirm prior authorization requirements and utilization management vendors, if applicable.
Even if prior authorization isn’t required for a commercial non-HMO member, you still may want to submit a voluntary Recommended Clinical Review (Predetermination) request. This step can help avoid post-service medical necessity review. Checking eligibility and benefits can’t tell you when to request Recommended Clinical Review, since it’s optional. But there’s a 2023 Recommended Clinical Review, Post Service Review and Non-Covered Procedure Code List to help you decide.
Services performed without required prior authorization or that do not meet medical necessity criteria may be denied for payment and the rendering provider may not seek reimbursement from the member.
CPT copyright 2022 AMA. All rights reserved. CPT is a registered trademark of the AMA.
Checking eligibility and/or benefit information and/or obtaining prior authorization 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, including, but not limited to, exclusions and limitations applicable on the date services were rendered. If you have any questions, call the number on the member's ID card.
Carelon Medical Benefits Management (Carelon) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL. Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors.