November 16, 2023 (Updated December 6, 2023)
Blue Cross and Blue Shield of Illinois (BCBSIL) has postponed the relaunch of its laboratory management program, previously scheduled for January 1, 2024. Please watch News & Updates for future program announcements.
In October, we announced that, after pausing to review important aspects of our laboratory benefit management program earlier this year, Blue Cross and Blue Shield of Illinois will be relaunching the program with some changes, effective Jan. 1, 2024.
Program Overview
Mirroring the original launch in 2022, the laboratory benefit management program is a post-service review of claims for laboratory services provided to BCBSIL commercial non-HMO members in an outpatient setting (typically an office, outpatient hospital or independent laboratory setting). The program will help reduce over-testing (including fraud, waste, and abuse), lower cost variability, and help drive high quality care without creating barriers or delays to care.
Excluded from the program are laboratory services provided in an emergency room, hospital observation or hospital inpatient setting. Member coverage terms still apply. This program does not apply to government programs (Medicare Advantage or Illinois Medicaid) or any of our HMO members.
What is changing as part of the relaunch?
New BCBSIL Medical Policies (MED209) have been posted on our website since Oct. 2, 2023, on the Pending Policies page. Please note that this page is not searchable; however, users can sort the policies in numerical order by clicking on the arrows under the Policy Number column. On Jan. 1, 2024, these policies will be available on the Active Policies page. Each policy includes references to the specialized professional societies, scientific publications, national guidelines, and other standards of care relied upon to establish the criteria.
Claims Processing and Clinical Appeals
Effective with dates of service beginning Jan. 1, 2024, claims submitted for outpatient laboratory services (typically provided in an office, outpatient hospital or independent laboratory setting) may be denied if services do not meet the medical policy criteria. Claim summaries will include denial and ineligible reason codes. In the event a laboratory service is denied, the member and their provider will receive notification of the denial that includes instructions for filing a clinical appeal.
Webinars and Related Resources
BCBSIL’s Provider Network Consultant team remains dedicated to providing education and clarity to providers on all aspects of the laboratory benefit management program. Our PNCs are hosting free webinars to help you learn more and prepare for upcoming changes. Session dates and times are listed below. Use this link to register now for your preferred session. (Times listed are Central Time.)
- Dec. 7, 2023 – 10 to 11 a.m.
- Dec. 12, 2023 – 2 to 3 p.m.
- Dec. 14, 2023 – 10 to 11 a.m.
For more information, please refer to the updated Laboratory Benefit Management Program FAQs on our Claim Submission page, under Related Resources. Also continue to watch our Blue Review and News and Updates for future program announcements.
We appreciate the care and services you provide to our members, and we look forward to partnering with you.
Note: Pending Medical Policies are policies that will be effective on a future date. They are not to be used for current claims adjudication.