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Guidance for BCCHP Benefit Preauthorizations

Posted April 25, 2018

Blue Cross and Blue Shield of Illinois (BCBSIL) has heard the requests of Blue Cross Community Health PlansSM (BCCHPSM) providers for clarification of our benefit preauthorization requirements during the 90-day Continuity of Care period as required by Healthcare and Family Services (HFS). We are issuing the following guidance.

  • All service categories that are on our 2018 Medicaid Benefit Preauthorization Summary List must be preauthorized by all providers or claims for these services will be denied (for participating or non-participating providers). The above Medicaid benefit preauthorization list can be found on the Network Participation/Medicaid page of our provider website.
  • For those services not included on our Medicaid benefit preauthorization requirements list, BCBSIL will waive the benefit preauthorization requirement for those providers who have submitted their signed contracts but have not yet been loaded in our system. This waiver will be effective through June 30, 2018.
  • With the exception of providers in the waiver period, as noted above, any provider who is non-participating in the BCCHP network and who sees a BCCHP member must still complete all necessary pre-service review requirements, including checking eligibility and benefits, and obtaining benefit preauthorization for all non-emergency services. If services are not preauthorized, the claim for these services will be denied.
  • Notification of emergency admissions must be provided within one business day.
  • If you are not contracted as a BCCHP network provider, you are considered out-of-network for these members.  If you see BCCHP members as an out-of-network provider, you must complete all necessary pre-service requirements -- including checking eligibility and benefits and obtaining benefit preauthorization in order for services to be considered for payment. Services performed without benefit preauthorization may be denied for payment. 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. 

Checking eligibility and/or benefit information 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. If you have any questions, please call the number on the member’s ID card.