Update: Sleep Studies/Testing, Sleep Therapy Services and Equipment, Advanced Imaging and Echocardiography Pre-service Review Requirements
Posted January 3, 2017 (Updated February 13, 2017)
Benefit preauthorization and medical necessity reviews for the services listed below will not be required beginning April 3, 2017, as previously stated. Please check back here for future News and Updates as well as the Blue Review for additional information.
At Blue Cross and Blue Shield of Illinois (BCBSIL), we use benefit preauthorization requirements to help make sure that the service or drug being requested is medically necessary, as defined in the member’s certificate of coverage. Benefit preauthorization is one of the many things we are doing to help make the health care system work better, by focusing on improving health care delivery.
Effective April 3, 2017, benefit preauthorization will be required prior to ordering diagnostic studies for obstructive sleep apnea (OSA) and home and in-lab sleep testing for most BCBSIL PPO members. These benefit preauthorization requests must be submitted via the AIM Specialty Health® (AIM) ProviderPortalSM, or by calling the AIM contact center at 866-455-8415. If benefit preauthorization is not obtained, as required, claims may be denied.
Additionally, effective April 3, 2017, providers are strongly advised to obtain medical necessity review through AIM prior to ordering services/equipment related to sleep therapy-related services and equipment, such as Positive Airway Pressure (PAP) sleep therapy, Durable Medical Equipment (DME) and supplies associated with sleep therapy, and oral appliances.
Effective April 3, 2017, the medical necessity review process also will apply to select advanced imaging studies – Computed Tomography (CT), Magnetic Resonance Imaging and Angiogram (MRI/MRA), Positron Emission Tomography (PET) – as well as Myocardial Perfusion Imaging (MPI) and Echocardiography.
Obtaining pre-service medical necessity review as noted above will be an important step, as effective April 3, 2017, claims for the above-mentioned services that have not received benefit preauthorization may be subject to post-claim medical necessity determination review.
If you already submit Radiology Quality Initiative (RQI) requests via the AIM ProviderPortal, the process for requesting benefit preauthorization and/or medical necessity reviews as noted above will be similar. Upon submitting a request through AIM for a particular member, your request will be routed to the appropriate path for review. In the coming months, BCBSIL and AIM will provide additional information and training that covers such topics as how to obtain benefit preauthorization, medical reviews, and more. Watch the Blue Review and News and Updates sections of our Provider website for details. Or, contact your assigned Provider Network Consultant for assistance.
AIM Specialty Health (AIM) is an independent company that provides medical necessity review for select health care services on behalf of BCBSIL. AIM is a wholly owned subsidiary of Anthem, Inc. and an independent third party vendor that is solely responsible for its products and services. BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by independent third party vendors. If you have any questions about the products or services offered by such vendors, you should contact the vendors directly. Certain employer groups may require preauthorization/pre-certification through other vendors. If you have any questions, please call the number on the back of the member's ID card.
Please note that verification of eligibility and benefits, and the fact that a service or treatment has been preauthorized or predetermined for benefits, 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. Regardless of any benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.