Changes Coming to Benefit Preauthorization Requirements, Effective Jan. 1, 2019

Posted October 3, 2018

Blue Cross and Blue Shield of Illinois (BCBSIL) continues to refine our product options to help our customers find ways to better manage their health care investments. This includes customizable features, such as pre-service reviews, which support a more holistic approach to health care management. It is important for providers to be aware that patient benefit preauthorization requirements may change each year.

Effective Jan. 1, 2019, BCBSIL will expand the number of outpatient services requiring benefit preauthorization for some BCBSIL members with the commercial PPO products/networks listed below. This may include select advanced imaging, musculoskeletal and cardiology procedures. 

  • PPO (PPO)
  • Blue Choice Preferred PPOSM (BCE)
  • Blue Choice PPOSM (BCS)*
  • Blue OptionsSM/BlueChoice OptionsSM (BCO)*

Important! Always Check Eligibility and Benefits First

Benefits will vary based on the service being rendered and individual and group policy elections. It is imperative to always check eligibility and benefits for each patient to confirm benefits, benefit preauthorization/pre-notification requirements and utilization management vendors that must be used, if applicable. This step can be accomplished by using the Availity® Provider Portal or your preferred web vendor portal. Services performed without benefit preauthorization, if required, will be denied for payment and providers may not seek reimbursement from BCBSIL members. Obtaining benefit preauthorization/pre-notification is not a substitute for confirming eligibility and benefits.

For More Information…

While benefit preauthorization changes are necessary to better serve our members, we are also committed to working closely with providers to help smooth the transition to new processes. Please watch the News and Updates for more information in the coming weeks, including details on upcoming training opportunities and related resources. As always, our Provider Network Consultant team will be standing by to help you with any questions.

*These products are not currently offered in Central and Southern Illinois.

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. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly. 

Checking eligibility and benefits and/or obtaining preauthorization/pre-notification for a service is not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations, and exclusions set forth in the member’s policy certificate and/or benefits booklet and or summary plan description. Regardless of any preauthorization or benefit determination, the final decision regarding any treatment or service is between the patient and their health care provider. Certain employer groups may require preauthorization/pre-certification for imaging services through other vendors. If you have any questions, please call the number on the member's BCBSIL ID card.