Billing for Medically Unnecessary and/or Medically Unproven Services

Posted February 19, 2014 (Updated May 8, 2014)

Under the terms of the health benefit plans that are offered or administered by Blue Cross and Blue Shield of Illinois (BCBSIL), benefits for health care services will be denied if it is determined that such items are deemed “medically unnecessary” or which are medically unproven, often referred to as “experimental and/or investigational." 

Effective for dates of service on or after July 14, 2014,* claims submitted to BCBSIL for services that are deemed to be medically unnecessary and/or medically unproven (experimental and investigational) will be denied with a message specifying that the member will not be financially responsible for charges associated with an inpatient hospital stay or any outpatient procedure or other service that is determined by utilization management to be medically unnecessary and/or medically unproven. 

If you and your patient are aware that a proposed service will be deemed medically unnecessary and/or medically unproven and you decide to proceed, you must obtain a written disclosure/ authorization from the member informing the member that services are not covered by BCBSIL and the patient is assuming all financial responsibility. The disclosure/authorization must state that the member has been informed prior to services being rendered that the services are not covered; it also must include the cost of the services and confirmation that the member accepts all financial responsibility. 

You may view the BCBSIL Medical Policies in the Standards and Requirements/Medical Policy section to help determine when services may be considered medically unproven.

*The implementation date announced previously was May 19, 2014. The revised implementation date is July 14, 2014.