Utilization management review requirements and recommendations are in place to help ensure our members get the right care, at the right time, in the right setting. Types of utilization management review that may be conducted before services are rendered include prior authorization, recommended clinical review (predetermination), and pre-notification. Utilization management also may include post-service review. These reviews use evidence-based clinical standards of care to help determine whether a benefit may be covered under the member’s health plan.
We understand this topic can be complex: Member benefits and review requirements/recommendations may vary based on services rendered and individual/group policy elections. Also, utilization management and related review terminology can vary from plan to plan, carrier to carrier and vendor to vendor.
We’re here to help. This section outlines utilization management review definitions, requirements, guidelines and reminders to help assist you when you’re providing care and services for most Blue Cross and Blue Shield of Illinois (BCBSIL) members. Watch our Medical Director Video to learn more.*
*The information in this section does not apply to delegated commercial HMO and Medicare Advantage HMO.
Prior authorization is required for some members/services/drugs before services are rendered to confirm medical necessity as defined by the member’s health benefit plan. Learn more
Submitting a recommended clinical review request (previously called predetermination) prior to rendering certain services is optional to inform the provider and member of situations where a service may not be covered based upon medical necessity. Learn more
For some members/services, pre-notification (rather than prior authorization) may be required, before services are rendered. Learn more
View our summary, procedure code lists and related information for help navigating utilization management review requests for commercial, fully insured non-HMO members. Learn more
Check here for summary and procedure code lists and related information to help you navigate prior authorization requirements for our Illinois Medicaid and Medicare Advantage (MA) PPO and MA HMO non-delegated members.