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Utilization Management Decisions Are Not Financially Influenced

Posted May 31, 2018

Blue Cross and Blue Shield of Illinois (BCBSIL) is dedicated to serving our members* through the provision of health care coverage and related benefit services. Utilization management (UM) determinations are made by licensed clinical personnel based on the benefit policy (coverage) of a member’s health plan, evidence-based medical policies and medical necessity criteria, and the medical necessity of care and service. All utilization management decisions are based on appropriateness of care and service and existence of coverage. BCBSIL prohibits decisions based on financial incentives and does not specifically reward practitioners or clinicians for issuing denials of coverage. Financial incentives for utilization management decision makers do not encourage decisions that result in underutilization.

The criteria used for UM determinations are available upon request. Please call the Customer Service number on the member’s ID card.

*This does not include members with HMO Illinois®, Blue Advantage HMOSM, Blue Precision HMOSM, BlueCare DirectSM and Blue FocusCareSM, Blue Cross Medicare AdvantageSM (HMO and PPO) products.