This page provides a summary of pre-service requirements and recommendations for BCBSIL providers. Call the number on the back of the member's ID card if you have any questions.
Eligibility and Benefits Reminder: An eligibility and benefits inquiry should be completed first to confirm membership, verify coverage and determine whether or not pre-certification (also known as pre-notification or preauthorization) is required. This includes prior authorization for high-tech imaging services.
For additional information, refer to the Pre-Service Review for Out-of-Area Members tip sheet . You can also refer to the Electronic Provider Access (EPA) FAQs for additional information.
Also known as preauthorization or pre-notification, pre-certification confirms that a physicians’ plan of treatment meets medical necessity criteria under the applicable health benefit plan.
- Most PPO benefit plans require the member or provider to pre-certify inpatient hospital admissions (acute care, inpatient rehab, etc.)
- Many PPO benefit plans also require pre-certification for coordinated health care (skilled nursing visits, home infusion therapy, etc.)
- Pre-certification also may be required for outpatient services for some employer groups.
- For information on benefit preauthorization requirements for BCBSIL members with health advocacy solutions, refer to the notice in the News and Updates.
Request, Verify or Obtain Pre-certifications
- Electronic Requests – Registered Availity® providers may submit online using Availity’s Authorizations tool (HIPAA-standard 278 transaction). This tool allows the electronic submission of inpatient admissions and select outpatient services handled by BCBSIL. Additionally, providers can check status on previously submitted requests and/or update applicable existing requests. For additional details, refer to the Availity Authorizations User Guide.
- Telephone Inquiries – Call the pre-certification number on the back of the member’s ID card. Or, call our Provider Services at 800-572-3089 – upon verification of eligibility and benefits, you will be advised how to proceed.
A Predetermination of Benefits is a written request for verification of benefits prior to rendering services.
- Recommended when the service may be considered experimental, investigational or cosmetic
- Approvals and denials often are based on approved BCBSIL Medical Policies
- Not a substitute for the eligibility and benefits verification process
How to Submit a Request for Review
- Complete the Predetermination Request Form and fax it to BCBSIL
- This form also may be used to request review of a previously denied Predetermination of Benefits
- You will be notified when a final outcome has been reached
Attention BCBS providers (outside of BCBSIL): Please see the BlueCard (Out-of-area) Reminder at the bottom of this page.
A Radiology Quality Initiative (RQI) number is required by BCBSIL prior to ordering CT/CTA scans, MRI/MRA scans, Nuclear Cardiology studies, and PET scans for most PPO members.*
- The RQI requirement applies when non-emergency high-tech imaging services are performed in a physician's office, the outpatient department of a hospital, or a freestanding imaging center.
- Obtaining an RQI is not a substitute for the eligibility and benefits verification process – providers must verify eligibility and benefits prior to rendering services.
- The RQI does not replace or override any pre-certification requirements specified by the member's benefit plan.
- The RQI number is valid for 30 days. (There is no grace period if the service is not performed.)
RQI requirements are for notification purposes only. Failure to obtain an RQI number alone will not impact claims payment. However, if you do not obtain an RQI number before providing Advanced Imaging services and the services are subsequently deemed not medically necessary, claims payment will be impacted.
How do I obtain or verify an RQI?
AIM Specialty Health® (AIM) administers the RQI Program for BCBSIL (most groups). The ordering physician may obtain, and the rendering provider may verify, an RQI in either of the following ways:
- Log on to the AIM Provider Portal
- Contact the AIM Call Center at 866-455-8415
AIM 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 AIM's website.
BCBSIL sends updated provider and membership information to AIM.
- If you contact AIM and they do not have you on file as a BCBSIL provider, use our online form to Update Your Information.
- If you contact AIM and they have no record of a specific BCBSIL member, a Predetermination of Benefits may be needed.
BlueCard® (Out-of-area) Reminder
If you are providing service to out-of-area Blue Cross and Blue Shield (BCBS) members, please note:
- Some BCBS Plans have radiology management programs, other than AIM.
- These programs may be tied to member benefits, and therefore it is important to check benefits prior to service by calling the BlueCard Eligibility Hotline at 800-676-BLUE(2583).
*Certain employer groups may require pre-certification for imaging services from other vendors. If you have any questions, please call the number on the member's ID card.
BCBSIL has contracted with eviCore healthcare (eviCore) to provide certain utilization management services for select outpatient procedures as noted below. eviCore is an independent company that provides specialty medical benefits management for BCBSIL.
Benefit Preauthorization Requirements
BCBSIL requires benefit preauthorization (for medical necessity)* through eviCore for outpatient molecular and genomic testing, radiation therapy, advanced imaging and musculoskeletal services for the following benefit plans:
- All retail plans
- All fully insured small and large commercial groups
Depending on account selection, benefit preauthorization through eviCore also may be required for select outpatient cardiology and sleep medicine services. For program-specific information, along with helpful worksheets and tutorials, visit the Provider Resource Page on the eviCore website.
This information does not apply to HMO members for whom benefit preauthorization (for medical necessity under the applicable benefit plan) is performed by the member’s medical group.
How to Obtain Benefit Preauthorization
There are two ways to submit benefit preauthorization requests to eviCore.
- Online – The eviCore Healthcare Web Portal is available 24x7. It is the quickest, most efficient way to obtain information. After a one-time registration, you may use this portal to initiate a case, check status, review guidelines, and more.
- Phone – Call eviCore toll-free at 855-252-1117 between 7 a.m. and 7 p.m. (local time), Monday through Friday.
Reminder: Always Check Eligibility and Benefits First
Benefits will vary based on the service being rendered and individual and group policy elections. It is critical to check eligibility and benefits for each patient to confirm coverage details. This step will also identify benefit preauthorization/pre-notification requirements and specify utilization management vendors that must be used, if applicable. Submit online eligibility and benefits requests (electronic 270 transactions) via the Availity® Provider Portal or your preferred web vendor portal.
*Preauthorization determines whether the proposed service or treatment meets the definition of medical necessity under the applicable benefit plan. Checking eligibility and benefits and/or obtaining preauthorization/pre-notification 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. Regardless of any preauthorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider. If you have any questions, call the number on the member's BCBSIL ID card.
eviCore is an independent specialty medical benefits management company that provides utilization management services for 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 any products or services provided by third party vendors such as eviCore or Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.
BCBSIL has contracted with eviCore healthcare (eviCore) to manage benefit preauthorization requests for specialized clinical services for BCBSIL members enrolled in any of the following plans:
- Blue Cross Community Health PlansSM
- Blue Cross Community MMAI (Medicare-Medicaid Plan)SM
- Blue Cross Medicare Advantage (PPO)SM
Additional information and training resources are available on the eviCore website. Call the eviCore Customer Service department at 800-575-4517 if you have any questions or need more information.
- 2020 Medicaid Benefit Preauthorization Summary List
- 2020 Medicaid Benefit Preauthorization Procedure Code List