Additional Benefit Preauthorization Requirements for 2018
Posted September 29, 2017
Beginning Jan.1, 2018, benefit preauthorization through Blue Cross and Blue Shield of Illinois (BCBSIL) will be required for certain additional care categories, such as those listed below. These new benefit preauthorization requirements will apply for some PPO members with the following plans: PPO (PPO network), Blue Choice PPOSM (BCS network), Blue Choice Preferred PPOSM (BCE network), Blue Options/Blue Choice OptionsSM (BCO network). Additional requirements may apply, such as for PPO members with Health Advocacy Solutions (HAS). Benefit preauthorization through eviCore for additional care categories may be required as well.
For some PPO members, here is a summary listing of additional care categories that will require benefit preauthorization through BCBSIL, effective Jan. 1, 2018:
- Cardiology (Cardiac Services – Lipid Apheresis)
- Facility-based Sleep Studies
- Musculoskeletal (Interventional Pain Management, Orthopedic)
- Ear, Nose and Throat
- Outpatient Surgery (Orthognathic Surgery, Mastopexy, Reduction Mammaplasty)
- Wound Care
- Non-emergent Air Ambulance
To obtain benefit preauthorization through BCBSIL for the care categories noted above, you may 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.
Services performed without benefit preauthorization may be denied for payment and, in whole or in part, you may not seek reimbursement from members. Please note that a member penalty may also apply based on the benefit plan.
As a reminder, it is important to check member eligibility and benefits through AvailityTM or your preferred vendor Web portal prior to every scheduled appointment. Eligibility and benefit quotes include membership status, coverage status and other important information, such as applicable copayment, coinsurance and deductible amounts. Providers must also ask to see the member's ID card for current information and a photo ID to help guard against medical identity theft. When services may not be covered, members should be notified that they may be billed directly. Obtaining benefit preauthorization is not a substitute for checking member eligibility and benefits.
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.
eviCore healthcare (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. 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.