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. Learn more about iExchange®.
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.
Request, Verify or Obtain Pre-certifications
- Electronic Requests—Registered AvailityTM providers may submit online pre-certification and authorization requests and inquiries (ANSI 278 transaction)
- Telephone Inquiries—Call the pre-certification number on the back of the member’s ID card. Or, call our Provider Telecommunications Center (PTC) at (800) 972-8088—upon verification of eligibility and benefits, you will be advised how to proceed.
- Online Approvals—Sign up to use iExchange—an online tool that supports direct submissions and provides online approval of benefits for inpatient admissions and select outpatient services. Learn more about iExchange.
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.)
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 back of the member's ID card.
Blue Cross and Blue Shield of Illinois (BCBSIL) has contracted with eviCore healthcare, LLC (eviCore)* to provide certain utilization management services for outpatient molecular and genomic testing and outpatient radiation therapy. eviCore is an independent company that provides specialty medical benefits management for BCBSIL.
BCBSIL requires preauthorization (for medical necessity)** through eviCore for outpatient molecular and genomic testing and outpatient radiation therapy for the following benefit plans:
- All retail plans
- All fully insured small and large commercial groups
- NOT included are HMO members in Illinois where preauthorization (for medical necessity under the applicable benefit plan) is performed by the member’s medical group.
Refer to the Lab Resources page to access the BCBSIL Lab Prior Authorization List and Lab Management Clinical Guidelines.
eviCore preauthorization’s for outpatient molecular and genomic testing and outpatient radiation therapy can be obtained using one of the following methods:
- The eviCore Healthcare Web Portal is available 24x7. After a one-time registration, you are able to initiate a case, check status, review guidelines, view authorizations/eligibility and more. The Web Portal is the quickest, most efficient way to obtain information.
- Providers can call toll-free at 855-252-1117 between 7 a.m. to 7 p.m. (local time) Monday through Friday.
- More specific program-related information can be found on the eviCore implementation site.
* eviCore is a trademark of eviCore healthcare, LLC, formerly known as CareCore, an independent company that provides utilization review for select health care services on behalf of BCBSIL.
** Preauthorization determines whether the proposed service or treatment meets the definition of medical necessity under the applicable benefit plan. Preauthorization of 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.
Effective June 1, 2017, eviCore healthcare (eviCore) will manage benefit preauthorization requests for specialized clinical services for BCBSIL members enrolled in any of the following plans:
- Blue Cross Community MMAI (Medicare-Medicaid Plan)SM
- Blue Cross Community Integrated Care Plan (ICP)SM
- Blue Cross Community Family Health PlanSM (FHP)
- Blue Cross Community Managed Long Term Supports and ServicesSM (MLTSS)
- Blue Cross Medicare Advantage (PPO)SM
Additional information and training resources are available on the eviCore website. Call the eviCore Customer Service department at 855-252-1117 if you have any questions or need more information.
eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSIL.
Please note that the fact that a service has been preauthorized/pre-certified is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered.