Preauthorization Requirements Change Periodically: Remember to Always Check Eligibility and Benefits

Posted May 1, 2019

Blue Cross and Blue Shield of Illinois (BCBSIL) is committed to providing updates on changes that may affect how you do business with us.

As a reminder, BCBSIL member contracts differ in their benefits, and benefit changes may occur throughout the year. We encourage you to check eligibility and benefits via an electronic 270 transaction through the Availity® Provider Portal or your preferred vendor portal. It’s important to check eligibility and benefits for each patient at every visit to confirm coverage details. This step also helps you identify benefit preauthorization/pre-notification requirements.

Effective Aug. 1, 2019, benefit preauthorization requests for some BCBSIL members with three-character member ID prefixes PAS, BHP, SFZ and UAL must be obtained through eviCore healthcare (eviCore), an independent company that provides specialty medical benefits management, instead of BCBSIL. The medical policies being used for the pre-service medical necessity reviews will not change.

There are two ways to submit benefit preauthorization requests to eviCore:

  • Go online to initiate a case, check status, review guidelines and more. The eviCore web portal is the quickest, most efficient way to obtain information. 
  • Call eviCore at 855-252-1117 between 7 a.m. and 7 p.m. (CT), Monday through Friday. 

Note: Reviews of predetermination of benefits requests for these members also will be handled by eviCore.

Obtaining benefit preauthorization/pre-notification or submitting a predetermination of benefits request is not a substitute for checking eligibility and benefits. Services performed without benefit preauthorization, if required, will be denied for payment and providers may not seek reimbursement from BCBSIL members. Submitting a predetermination of benefits request may not be required; however, if health care services provided to a BCBSIL member are deemed not to be medically necessary, claim payment may be impacted. For more information refer to the Prior Authorization page.

If you have questions on benefits, contact the number on the member’s ID card. If you need help with other questions, email or contact your assigned BCBSIL Provider Network Consultant.

Checking eligibility and benefits and/or obtaining benefit preauthorization/pre-notification or predetermination of benefits is not a guarantee that benefits will be paid. Payment 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 your patient’s policy certificate and/or benefits booklet and/or summary plan description. Regardless of any benefit determination, the final decision regarding any treatment or service is between you and your patient. If you have any questions, please call the number on the member’s BCBSIL ID card.

eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services 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 offered by third party vendors such as eviCore or Availity. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly.