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Government Programs Update: Removal of Benefit Preauthorization Requirement for Cardiology and Specialty Therapy Services, Effective Sept. 1, 2019

Posted August 1, 2019

There are important changes to the benefit preauthorization requirements for your Blue Cross and Blue Shield of Illinois (BCBSIL) patients enrolled in any of the following government programs plans: Blue Cross Medicare Advantage (PPO)SM (MA PPO), Blue Cross Community MMAI (Medicare-Medicaid Plan)SM (MMAI) and Blue Cross Community Health PlansSM (BCCHP).

Beginning Sept. 1, 2019, benefit preauthorization through eviCore, an independent specialty medical management company, will no longer be required for the following services/BCBSIL members:

  • Cardiology services for MA PPO, MMAI and BCCHP members
  • Specialty therapy (chiropractic, physical, occupational and/or speech therapy) services for MA PPO members

As always, it is critical to check eligibility and benefits first, prior to rendering care and services, to confirm coverage, network status and other important details. When you check eligibility and benefits online by submitting an electronic 270 transaction through the Availity® Provider Portal or your preferred web vendor portal, you may determine if benefit preauthorization/pre-notification may be required based on the procedure code. Payment may be denied if you perform procedures without benefit preauthorization when benefit preauthorization is required. If this happens, you may not bill our members.

For more information, refer to the Eligibility and Benefits and Prior Authorization pages of our Provider website.

Please note that verification of eligibility and benefits, and/or the fact that a service or treatment has been preauthorized/pre-notified for benefits 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 questions, contact the number on the member’s ID card.

eviCore healthcare is an independent specialty medical benefits management company that provides utilization management services for BCBSIL. 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 eviCore or Availity. The vendors are solely responsible for the products or services they provide. If you have any questions regarding any of the products or services they provide, you should contact the vendor(s) directly.