Updated Government Programs Benefit Preauthorization Code Lists Available Online
Posted April 11, 2018
We understand that keeping up with the number of new Medicaid and Medicare products, plans and requirements may be challenging. For an overview of benefit preauthorization requirements, you can find summary lists for Medicaid and Medicare Advantage on our Provider website. These summaries include links to the current lists of procedure codes that require benefit preauthorization. Specific codes may change or be removed throughout the year, so it is important for provides to ensure they are using the most up to date preauthorization information.
The Medicare Advantage PPO Benefit Preauthorization Requirements Summary List is available on our Provider website in the Standards and Requirements/Provider Manual section, under Blue Cross Medicare Advantage (PPO)SM Manual/Resources.
The Illinois Medicaid Benefit Preauthorization Requirements Summary List is located in the Network Participation section of our Provider website, in the Related Resources section. Medicaid includes Blue Cross Community MMAI (Medicare-Medicaid Plan)SM and Blue Cross Community Health PlansSM members.
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, as this step will help you determine if benefit preauthorization is required for a particular member. Obtaining benefit preauthorization is not a substitute for checking eligibility and benefits. If benefit preauthorization is required, services performed without benefit preauthorization or that do not meet medical necessity criteria may be denied for payment and the rendering provider may not seek reimbursement from the member.
Our goal is to support access to quality, affordable health care for our members. If you have any questions, contact your Provider Network Consultant (PNC) for assistance.
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.
The presence of codes on the list does not necessarily indicate coverage under the member benefits contract. Member contracts differ in their benefits. Consult the member benefit booklet, or contact a customer service representative to determine coverage for a specific medical service or supply.
eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSIL.
Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Medecision and Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.