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Benefit Preauthorization Requirements for PPO Members with Health Advocacy Solutions

Posted September 29, 2017 [Updated Oct. 27, 2017]

This notice has been updated to include a reference to one additional care category (fertility).

Beginning Jan. 1, 2018, Blue Cross and Blue Shield of Illinois will provide Health Advocacy Solutions (HAS) for some PPO members. Members who may have HAS available to them include PPO (PPO network), Blue Choice PPOSM (BCS network), Blue Choice Preferred PPOSM (BCE network), Blue Options/Blue Choice OptionsSM (BCO network). There are dedicated HAS Health Advocates who will deliver personalized communication and educational resources, such as cutting-edge cost transparency tools, to help members make better-informed decisions concerning their health care. 

As part of HAS, there are additional care categories that will require benefit preauthorization. Information regarding HAS will appear on BCBSIL member ID cards. However, it is always important to check eligibility and benefits through AvailityTM or your preferred Web vendor prior to rendering services, as this step will also help you determine if benefit preauthorization is required for a particular member. For additional information, such as definitions and links to helpful resources, refer to the Eligibility and Benefits and Prior Authorization pages. 

The additional care categories for HAS that will require benefit preauthorization are listed below. Please note that some benefit preauthorizations must be requested through BCBSIL; others must be obtained through eviCore.

  • Molecular and Genomic Testing (eviCore)
  • Radiation Therapy (eviCore)
  • Advanced Radiology Imaging (eviCore) (Note: For some members, notification, rather than preauthorization, will apply.)
  • Sleep Studies and Sleep Durable Medical Equipment (DME) (eviCore)
  • Cardiology*
  • Ear, Nose and Throat*
  • Gastroenterology*
  • Musculoskeletal*
  • Neurology*
  • Non-Emergent Air Ambulance*
  • Outpatient Surgery (Orthognathic Surgery, Mastopexy, Reduction Mammaplasty, Bunionectomy, Cardiac Catheterization, Carpal Tunnel Repair, Inguinal Hernia Repair, Lithotripsy)*
  • Specialty Pharmacy (Administration)*
  • Wound Care*
  • Fertility (Note: Pre-service notification, rather than benefit preauthorization, may be required.)

To obtain benefit preauthorization through BCBSIL (such as for the services marked with an asterisk above), you will continue to use iExchange®. This online tool is accessible to physicians, professional providers and facilities contracted with BCBSIL. For more information or to set up a new account, refer to the iExchange page

To obtain benefit preauthorization through eviCore, go to evicore.com  or call 855-252-1117. See below for information on upcoming training sessions, hosted by eviCore. 

Services performed without benefit preauthorization may be denied for payment or may impose a greater financial liability on the member. You may not seek reimbursement from members. For any service not approved for payment, BCBSIL will provide, subject to the member or provider making an appeal, all appropriate rights for review or appeal. Please note that a member penalty may also apply based on the benefit plan. 

eviCore Web Orientation Schedule

eviCore will be hosting complimentary orientation sessions on how to obtain benefit preauthorization for the care categories listed below. During these training sessions, BCBSIL presenters will also provide a brief overview of Health Advocacy Solutions (HAS) and Availity’s role. Each training session will last approximately one hour. Advance registration is required.

Upcoming Training Sessions:

  • Radiation Therapy – Tues., Dec. 5, 2017, 11 a.m.
  • Molecular and Genomic Testing – Tues., Dec. 5, 2017, 1 p.m.
  • Advanced Radiology Imaging (CT/MR/PET) – Wed., Dec. 6, 2017, 1 p.m.
  • Sleep Studies – Thurs., Dec. 7, 2017, 10 a.m.
  • Sleep DME – Thurs., Dec. 7, 2017, 1 p.m.

How to Register:

Please read the following instructions carefully to register for and participate in a session:

  1. Once you have chosen a date and time, go to http://evicore.webex.com/
  2. Click on the “Training Center” tab at the top of the page.
  3. Find the date and time of the orientation session you wish to attend by clicking the “Upcoming” tab. All of the orientation sessions will be named “Blue Cross and Blue Shield of Illinois Provider [Program Name] Orientation Session.”   
  4. Click “Register.”
  5. Enter the registration information.

After you have registered, you will receive an email containing the following information:

  • The toll-free phone number and pass code you will need for the audio portion of the training.
  • A link to the online portion of the session.
  • The conference password.

Keep the registration email so you will have the audio and online information for the session in which you will be participating. If you are unable to participate in a session at any of the times listed, a copy of the presentation will be available on the implementation site at https://www.evicore.com/healthplan/bcbsil_c

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. 

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. iExchange is a trademark of Medecision, Inc., a separate company that provides collaborative health care management solutions for payers and providers. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity and Medecision. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly. 

eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSIL.