Prior Authorization

How It Works

Work with your provider. They know which services need to be approved and can make the request. Both BCCHP and your doctor will agree what treatments are medically necessary. “Medically necessary” refers to getting care that:

• Protects life
• Keeps you from getting seriously ill or disabled
• Finds out what’s wrong or treats a disease, illness, or injury
• Helps you do things like eating, dressing, and bathing

BCCHP won’t pay for service from a provider that isn’t part of our plan network if you don’t have approval. You can work with an out-of-network provider to get approval before you get care.

Your doctor may also request approval for inpatient days that extend beyond medical necessity. These days are known as administrative days. This is when BCCHP covers days in a hospital for members who are ready to be discharged to a lower level of care, but there is a problem finding an open bed in the facility where the member will be transferred.

Some services that do not need approval are:

• Primary care
• In-network specialist
• Family planning
• WHCP services (you must choose doctors in the network)
• Emergency care

Need to locate a provider? Search the Provider Finder^®.

How Does BCCHP Approve a Request?

Your doctors will use tools to check what treatments need approval. Tools used by PCPs (or other providers) include medical codes. Our doctors and staff make decisions about your care based on need and benefits. They use what is called clinical criteria. This helps to make sure you get the health care you need. Medical policies are also used to guide care decisions.

BCBSIL's Prior Authorization Code Lists

For Medical PA:

Your doctor will use the documents below to figure out what treatments or procedures need to be approved. For example, surgeries, organ transplants, or imaging must be approved before they will be covered by your plan. BCBSIL also keeps track for your doctor when a service or drug is added or removed from needing approval. This is done through a procedure code list change log. You can check these documents. They are lists of all the services and drugs that require approval.

• Service Authorization Program Summary  
• Prior Authorization Code List  
• Procedure Code List Change Log

For Prescription Drug PA:

Prime Therapeutics^® is the pharmacy benefit manager for BCBSIL. They review all PA requests from providers. To learn what drugs require PA, check the last column next to the drugs listed on the BCCHP Drug List. 

BCCHP wants to be sure you understand our PA program. Check our helpful glossary of terms.

Prior Authorization Statistics

The reports below give an overview of data related to the PA requests we received for Medicaid members. The data is from the last calendar year. BCBSIL reports both Federal and State data. These reports include the number of requests that were approved, denied, or appealed. Other data will vary with the reports.

Federal report: 

This PA Data Report  shows medical and behavioral health data aligned with metrics from Centers for Medicare and Medicaid Services (CMS).

State reports:

• Medical PA Data
• Behavioral Health PA Data
• Prescription Drug PA Data

Questions about PA? Call Member Services at 1-877-860-2837 (TTY: 711).