What is pre-notification?
Generally, pre-notification is the process by which Blue Cross and Blue Shield of Illinois is typically alerted before a member undergoes a course of care such as a hospital admission or a complex diagnostic test.
Pre-notification may be required for some members/services, as specified by the member’s benefit plan. For example:
- Pre-notification through BCBSIL may be required for maternal delivery and some dialysis services,
- Pre-notification through a vendor may be required for advanced imaging, as outlined below.
- Pre-notification requirements specific members/services can be found by checking Eligibility and Benefits (see Step 1 below).
Radiology Quality Initiative (RQI) Pre-notification Program
Carelon Medical Benefits Management administers the RQI Program for BCBSIL. Obtaining an RQI number through Carelon is required, prior to ordering non-emergent advanced imaging services (CT/CTA scans, MRI/MRA scans, Nuclear Cardiology studies, PET scans) for some BCBSIL members.
Who requests the RQI pre-notification?
The ordering provider may obtain the RQI in either of the following ways:
- Online – Log on to the Carelon Provider Portal
- By phone – Call the Carelon Contact Center at 866-455-8415
Why obtain the RQI pre-notification?
- The RQI pre-notification process is required to help support member safety, accessibility/care coordination and cost effectiveness.
- Rendering providers use Carelon to confirm an RQI was obtained, if required, prior to rendering services.
- Failure to obtain an RQI number alone will not impact claims payment. However, if you don’t obtain an RQI number before providing advanced imaging services and the services are subsequently deemed not medically necessary, claims payment will be impacted.
When and how should RQI pre-notification requests be submitted?
In general, there are three steps providers should follow.
Step 1 – Confirm if Pre-notification is Required
Always check eligibility and benefits first, via the Availity® Provider Portal or your preferred web vendor, prior to rendering care and services. In addition to verifying membership/coverage status and other important details, this step returns information on prior authorization or pre-notification requirements and utilization management vendors, if applicable.
Step 2 – If an RQI pre-notification is required:
Gather the necessary information to support your request. (Note: Carelon has developed a set of proprietary diagnostic imaging guidelines, based on a review of current medical literature and information obtained from major medical organizations. These clinical guidelines may be accessed via Carelon's website.)
Step 3 – Submit Your RQI Pre-notification Request
The ordering provider may obtain an RQI in either of the following ways:
- Online – Log on to the Carelon Provider Portal
- By phone – Call Carelon Contact Center at 866-455-8415
What happens next?
You will be contacted if there are any questions or concerns related to your request. RQI order numbers are valid for 30 days. (There is no grace period if the service is not performed.) If you have any questions, contact Carelon at 866-455-8415.
Exceptions and Reminders
- The RQI pre-notification process does not apply for government programs (Illinois Medicaid and Medicare Advantage) or any of our commercial HMO members.
- Out-of-area (BlueCard® Program) members: In addition to BCBSIL, other Blue Cross and Blue Shield (BCBS) Plans may have radiology management programs that are tied to member benefits. Always check eligibility and benefits for all BCBS members prior to rendering services to confirm details, including utilization management vendors that must be used, if applicable. For more information, refer to the BlueCard Program Provider Manual .
Checking eligibility and benefits and/or obtaining prior authorization or pre-notification or an RQI for a service is not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations, and exclusions set forth in the member’s policy certificate and/or benefits booklet and or summary plan description. Certain employer groups may require prior authorization or pre-notification from other vendors for advanced imaging services. If you have any questions, call the number on the member's ID card. Regardless of any prior authorization, pre-notification or benefit determination, the final decision regarding any treatment or service is between the member and their health care provider.
Carelon Medical Benefits Management is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL. Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.