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A clinical review of benefits is a review by medical staff to determine if the service you are requesting is appropriate for your medical needs. Clinical reviews are done prior to services so that the patient will know in advance if the procedure is covered under their group benefit plan*. The clinical review of benefits is dependent upon information submitted before the services are rendered. Payment is dependent upon the information submitted after the services are rendered.
To begin the review process, your health care provider will need to forward all information requested.
The following is a list of services requiring clinical review. Note that this is not an all-inclusive list. Should you have questions about this list, please contact Blue Cross and Blue Shield of Illinois at 1-800-621-7336 (Bargained), 1-855-439-3641 (Management).
Physicians can download a Recommended Clinical Review Request Form, and return form with applicable information to:
Blue Cross and Blue Shield of Illinois
P.O. Box 660603
Dallas, TX 75266-0603
* Clinical review requests should be completed in 30 days or less, assuming all necessary information has been received. However, the review may take longer if additional information is requested. International Information: If translation is needed, time frame is two to three weeks. Quotations of benefits and/or the availability or extent of coverage are not a guarantee of payment. Payment is subject to actual information and charges submitted.