Laboratory Benefit Level Change for Some Members

Posted September 30, 2019

Currently, Blue Cross and Blue Shield of Illinois (BCBSIL) covers many non-preventive lab services without any member cost sharing when billed with a preventive diagnosis.  

Beginning Jan. 1, 2020, or upon a member’s renewal date, non-preventive labs will no longer be covered at the no member cost-share level for some of our PPO and HMO members but will instead be treated as a standard medical benefit regardless of diagnosis code. Any applicable cost sharing (copay, coinsurance and deductible) may apply, based on the member’s health plan.

What does this mean for you?

  • You may have to seek payment from both BCBSIL and the member.
  • You may want to alert members that they could have to pay any applicable cost share (copayment, coinsurance, deductible) for laboratory services. 

Please refer to the Preventive Services Clinical Payment and Coding Policy, which contains the list of lab procedures that are considered preventive and will process at the no cost share benefit level when billed with a preventive diagnosis.

As a reminder, it is important to check member eligibility and benefits through Availity® Provider Portal or your preferred vendor web portal prior to every scheduled appointment. Eligibility and benefit quotes include membership status, coverage status and other important information, such as applicable copayment, coinsurance and deductible amounts. Checking eligibility and benefits also helps you confirm benefit preauthorization requirements. Also ask to see the member's ID card for current information and a photo ID to help guard against medical identity theft. When services may not be covered, members should be notified that they may be billed directly. Obtaining benefit preauthorization is not a substitute for checking member eligibility and benefits.

To confirm how a lab will process if it’s not identified on the Preventive Clinical Payment and Coding Policy, call the number on the member’s ID card and ask about the member’s non-ACA wellness benefit.

Note: This information does not apply to members who have Medicaid or Medicare plans.

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/or benefit information 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 a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. References to third party sources or organizations are not a representation, warranty or endorsement of such organizations. Any questions regarding those organizations should be addressed to them directly. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.