Claims and Eligibility

This section presents an introduction to doing business with Blue Cross and Blue Shield of Illinois, along with an overview of options and resources that may help you maximize administrative efficiencies in your office.

The pages in this section are designed to follow the claim cycle – from the moment a BCBSIL member walks into your office, through processing and payment for covered services you provide.

Electronic Commerce

The fastest way to conduct business with BCBSIL throughout the entire claims process is via Electronic Data Interchange (EDI) – the computer-to-computer transmission of standardized information. Learn more

Eligibility and Benefits

Patient eligibility and benefits should be verified prior to every scheduled appointment. Eligibility and benefit quotes include membership verification, coverage status and other important information, such as applicable copayment, coinsurance and deductible amounts. Learn more

Utilization Management

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 authorizationrecommended clinical review (predetermination), and pre-notification. Learn more

Pre-cert Router (out-of-area)

To view out-of-area Blue Plan's medical policy or general pre-certification/pre-authorization information. Learn more

Claim Submission

This section provides a quick introduction to filing claims with BCBSIL. Learn more

Claim Status and Adjudication

After submitting a claim, you can check the status online to verify if your claim has been received, pended or finalized. You can also verify the descriptions for any claim denials. Learn more

Claim Payment and Remittance

Electronic options are available including Electronic Funds Transfer (EFT), Electronic Remittance Advice (ERA) and Electronic Payment Summary (EPS). Learn more

Claim Review and Appeal

After adjudication, additional evaluation may be necessary (such as place of treatment, procedure/revenue code changes, or out-of-area claim processing issues). Learn more

Refund Management

You can use our electronic refund management tool to reconcile overpayments, which may be identified by BCBSIL and/or the provider. Learn more

Fee Schedule

Fee schedules—BCBSIL’s Schedule of Maximum Allowances—are a key component of your contractual relationship with BCBSIL, and we want to help ensure that you always have the most up-to-date information. Learn more