Prior Authorization and Claims

Prior authorization means approval is needed from your health plan for certain health tests or services. It’s important that approval is received before you get these services to help ensure your care is appropriate and avoid unexpected costs. If you visit in-network providers, they usually submit the approval request for you.

Services that may require prior authorization include:

• Inpatient admissions for hospital, rehabilitation, skilled nursing and long-term acute care/subacute care*
• Certain outpatient procedures and surgeries
• Some medications and drug therapies
• MRIs and CT scans

Check your benefit booklet or call Customer Service at 1-855-649-9624 for more information about services that may require prior authorization under the terms of your group plan.

Your doctor can download a Recommended Clinical Review Request Form and fax it with applicable information to 1-800-852-1360.

Mailing address:

Blue Cross and Blue Shield of Illinois
PO Box 660603
Dallas, TX 75266-0603

If you’re an active BCBSIL member, it’s easy to check the status of a prior authorization online:

• Log in to Blue Access for Members^SM, your online account.

or

• Use the BCBSIL App, tap Prior Authorizations and Referrals.

If you are a new member and have not yet received your ID card, you can call Customer Service at 1-855-649-9624 for help. Customer Service will ask for information to confirm your identity and eligibility. 

The prior authorization request from your doctor is reviewed using a set of clinical standards and proof-based guidelines. This helps make sure you get the care that is most useful to you. The service or prescription drug is reviewed during these steps to see if it is medically necessary following these basic standards:

• Must be needed to treat or manage a health issue or symptom.
• Must be the most helpful and low-cost care that can safely be given.
• Should follow broadly agreed-upon health care standards.
• Is not experimental, except those described under your plan that are allowed.
• Is not for the convenience of you or your doctor.

You can review the Medical Policy.

If you are notified of a denial, it is because the care or drug is not considered medically necessary. If you do not agree with this decision, there are steps you can take to appeal the decision.

Initial Review

Call Customer Service at 1-855-649-9624 and request a review of the denial. You can also make this request by sending a secure message through your online account.

Peer-to-Peer Review

If the prior authorization or claim is not approved after the Initial Review, your doctor can request a phone call with a doctor from BCBSIL prior to submitting a Level 1 Appeal. To schedule, your doctor should call 1-800-981-0591.

Level 1 Appeal

If BCBSIL continues to maintain a denial, you may appeal it. For all levels of appeals and reviews, you may give a written explanation about why you think BCBSIL should change the decision, and you may include documents to support this. You may also make a verbal statement about your case.

Both you and your provider may submit a Level 1 Appeal. (Note: Once an appeal has been initiated, your provider can no longer request a peer-to-peer review.)

If BCBSIL continues to maintain the denial based on any of the reasons below, you can request an external review.

• A decision is needed about the medical need for, or the experimental status of, a recommended treatment.
• A condition was considered pre-existing.
• Your health care coverage was rescinded (see your Benefit Booklet for details).
• Your claim was denied and involves services protected (or you believe to be protected) under the No Surprises Act.

External Review

If your case qualifies for External Review, an Independent Review Organization will look at it. You can include additional information at this time. This review is at no cost to you. To start an External Review, request a form from Customer Service at 1-855-649-9624. Complete the form and submit it to BCBSIL. You must file this request within four months from the date you received the Level 1 Appeal decision.

Expedited timing is available if you or your doctor believe that your health or life may be at risk. In this case, you will get a decision by phone within 72 hours. Standard timing is:

• Prior authorization appeals – written decision within 30 calendar days
• Post-service (claims) appeals – written decision within 60 calendar days
• External Review decisions – written decision within 45 calendar days