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Medicaid Providers: Benefit Preauthorization Tips and Peer-to-Peer Discussion Process

Posted May 22, 2019

Blue Cross and Blue Shield of Illinois (BCBSIL) would like to outline the below benefit preauthorization processes for our independently contracted providers treating Blue Cross Community Health PlansSM (BCCHPSM) and Blue Cross Community MMAI (Medicare-Medicaid Plan)SM members. As a reminder, it’s important to check eligibility and benefits eligibility and benefits first for each patient at every visit to confirm coverage details. This step also helps you identify benefit preauthorization/pre-notification requirements. For more information, refer to the Eligibility and Benefits page on our Provider website.

BCBSIL adheres to the standards for addressing all urgent concurrent requests, meeting or exceeding National Committee for Quality Assurance (NCQA) standards. These requests must be decided within 48 hours for BCCHP members, and 72 hours for MMAI members. Clear and timely submission of prior authorization requests and clinical documentation is very important to process requests within the required time frames.

Please fax clinical documents as soon as possible to help avoid unnecessary denial decisions. Our fax line, 312-233-4060, is open 24 hours a day, seven days a week. Our weekend staff is available to process documentation that is received over the weekend. When faxing benefit preauthorization requests, you must use the Benefit Preauthorization Form provided in the BCCHP provider manual. Provider manuals are available in the Standards and Requirements section.

To help ensure turnaround times are met and decisions are provided to requesting providers as quickly as possible, BCCHP and MMAI utilization management (UM) reviewers and medical directors are available seven days a week excluding BCBSIL identified holidays. During weekend hours, UM reviewers and medical directors continue to review requests and make decisions. 

If we don’t receive adequate clinical documentation, BCBSIL will reach out to your facility UM department. If a request does not meet medical necessity criteria for approval, the request will be assigned to a BCBSIL medical director for determination.

To support the decision process, we give providers the opportunity to discuss UM determinations with a peer physician prior to the decision completion. A provider may initiate a peer-to-peer discussion by calling 800-981-2795. The 2019 Medicaid Benefit Preauthorization Summary List and 2019 Medicaid Benefit Preauthorization Procedure Code List are available on the Medicaid page in the Related Resources column. The peer-to-peer discussion process is as follows:

  • MMAI providers will be notified by phone of potential adverse determinations and offered a date and time in which a pre-determination, peer-to-peer discussion is available. Once the turnaround time has passed and if adequate information still has not been received, the request will be sent to a BCBSIL medical director for review and final decision. Please be advised that in compliance with the Centers for Medicare & Medicaid Services (CMS), BCBSIL is not allowed to change a denial decision once it has been finalized by the BCBSIL medical director and the determination has been issued to the member. An appeal or grievance may be filed regarding the denial decision. For additional information regarding appeals and grievances refer to the MMAI provider manual or call 877-723-7702.

  • BCCHP providers will be notified by phone of potential adverse determinations and given a date and time in which a pre-determination, peer-to-peer discussion must be completed along with a contact number to schedule the peer-to-peer discussion with the UM clinician. Providers are allotted an additional seven calendar days from the notification of adverse determination to submit additional supporting documentation or schedule and complete a peer-to-peer discussion. The BCBSIL UM team will review one packet of additional supporting documentation after the adverse determination. If an appeal has been filed during this period, the peer-to-peer discussion is no longer available. Once the date given has passed and if adequate information still has not been received, the request will be sent to a BCBSIL medical director for review and final decision. An appeal or grievance may be filed regarding the denial decision. For additional information regarding appeals and grievances refer to the BCCHP provider manual or call 877-860-2837.

The peer-to-peer discussion is available as a courtesy to providers. The peer-to-peer discussion is not required, nor does it affect the providers’ dispute rights, or right to an appeal on behalf of a member. If an appeal has been filed, the peer-to-peer discussion is no longer available. Providers are allowed the opportunity to schedule one peer-to-peer discussion per adverse determination.

Peer-to-peer discussions are allowed for requests where clinical information was submitted with the original request. If no clinical information was submitted with a request, a peer-to-peer discussion is not permitted. It is the responsibility of the requesting provider to submit clinical documentation to substantiate a request for services.

To participate in a peer-to-peer discussion, a provider must be involved in the care and/or treatment of the member or have clinical knowledge of the member and request. The BCBSIL medical director may decline to conduct a peer-to-peer discussion if it is determined that the person requesting the discussion is not directly involved in the care or treatment of the member or does not have clinical knowledge of the case. 

Checking eligibility and/or benefit information and/or the fact that a service has been preauthorized 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.

The above material is for informational purposes only and is not intended to be a substitute for the independent medical judgment of a physician. Physicians and other health care providers are encouraged to use their own best medical judgment based upon all available information and the condition of the patient in determining the best course of treatment.