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Verify Procedure Code Prior Authorization Requirements and Submit Prior Authorization Requests via Availity®

Posted September 30, 2020

Providers can verify Current Procedural Terminology (CPT®) or Healthcare Common Procedure Coding System (HCPCS) code-specific prior authorization requirements and submit prior authorization requests handled by Blue Cross and Blue Shield of Illinois (BCBSIL), all within the Availity Provider Portal.

Checking patient eligibility and benefits is an imperative first step to confirm coverage and prior authorization requirements before rendering services. The Availity Eligibility and Benefits Inquiry allows you to quickly confirm prior authorization requirements by procedure code, along with contact information for the utilization management vendor, if applicable.  

If prior authorization through BCBSIL is required for the service or CPT/HCPCS code(s), you can easily submit the request online using the Availity Authorizations tool. As a reminder, the procedure code inquiry option is for prior authorization verification only and is not a code-specific quote of benefits.

How to Determine Code-specific Prior Authorization Requirements via Availity

  • Complete the eligibility and benefits inquiry entry (ANSI 270) by selecting a benefit/service type and/or enter the valid CPT/HCPCS code(s) and associated place of service. You may enter up to eight CPT/HCPCS codes in the inquiry.
  • The eligibility and benefit inquiry response (ANSI 271) displays specific prior authorization requirements in the Pre-Authorization Info tab for the benefit/service type and/or CPT/HCPCS codes entered in the inquiry.  

Note: If a benefit/service type is not selected, the place of service and at least one CPT/HCPCS code is required. If a CPT/HCPCS code is not entered, the place of service and benefit/service type is required. 
Exceptions

CPT/HCPCS code inquiry for prior authorization via Availity is not yet supported for the following lines of business:

  • Federal Employee Program® (FEP®)
  • Blue Cross Medicare Advantage (PPO)SM
  • Blue Cross Community MMAI (Medicare-Medicaid Plan)SM and Blue Cross Community Health PlansSM (BCCHPSM)

Also, as a reminder, the prior authorization information in this article does not apply for our HMO members. For these members, prior authorization is handled by the Medical Group/Independent Practice Association.

How to Submit Required Prior Authorization Requests Handled by BCBSIL via Availity*

  • Select the Patient Registration menu option, choose Authorizations & Referrals, then Authorizations
  • Select Payer BCBSIL, then select your organization
  • Select Inpatient Authorization or Outpatient Authorization
  • Enter prior authorization request
  • Review and submit

*The above information applies only to prior authorization requests handled by BCBSIL. The process of submitting benefit preauthorization requests through eviCore healthcare (eviCore) or other vendors has not changed.

For More Information
Refer to the educational Availity Eligibility and Benefits user guide and Availity Authorizations user guide. These resources and others are located in the Provider Tools section of our website. Also visit the Webinars and Workshops page to register for upcoming online training sessions.

Questions? Need customized training? Email our Provider Education Consultants for assistance.

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 or contract of coverage applicable on the date services were rendered. If you have any questions, please call the number on the member’s ID card.

CPT copyright 2019 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

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. eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity and eviCore. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.