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New Prior Authorization Requirements for Advocate Aurora Health Members Will Take Effect April 1, 2021

Posted December 30, 2020 (Updated December 31, 2020)

The phone number for prior authorization requests for inpatient, outpatient and specialty pharmacy service the members referenced below has been updated.

In the December News and Updates, we alerted you of a utilization management vendor change, effective Jan. 1, 2021, implemented by the Advocate Aurora Health Employee Benefit Plan for its employees and covered dependents with Blue Cross and Blue Shield of Illinois (BCBSIL) coverage. This change affects BCBSIL member ID prefix EAD and group numbers PI3844, PI3845 and PI3846

Effective April 1, 2021, the members referenced above may need prior authorization for the following procedures:

  • Advanced Imaging
  • Ambulance/Transportation
  • Ambulatory/Outpatient Surgery
  • Joint/Spine Surgery
  • Outpatient Services
  • Pain Management
  • Post-acute Care
  • Radiation Oncology
  • Sleep Medicine/Sleep Surgery
  • Elective Inpatient Medical/Surgical
  • Outpatient Rehab Services
  • Molecular and Genetic Lab
  • Durable Medical Equipment (DME)/Disposable Supplies
  • Orthotic/Prosthetic
  • Specialty Pharmacy
  • Behavioral Health Services       

Which members may be affected by this change?
This change applies only to BCBSIL members with the following three-character member ID prefix: EAD

How can prior authorization requests be submitted for these members?
As noted in previous communications,

  • Required prior authorization requests for inpatient, outpatient and specialty pharmacy services for these members must be submitted through Advocate Aurora Health. The phone number for prior authorization requests is 855-376-2386.
  • Required prior authorization requests for outpatient behavioral health disorders, behavioral illness and substance abuse services for these members must be submitted through AXCES Behavioral Health Advisor instead of BCBSIL. The phone number for outpatient behavioral health prior authorization requests is 800-454-6455.

Reminders and Resources
Prior authorization requirements are specific to the patient’s policy type and procedures(s) being rendered. Services performed with required prior authorization may be denied for payment and providers may not seek reimbursement form BCBSIL members. If you have any questions, call the number on the member’s ID card. 

It’s critical to check eligibility and benefits for each member prior to rendering services, through the Availity® Provider Portal  or your preferred web vendor. This step will confirm membership and other important details, such as prior authorization requirements and utilization management vendors, if applicable. 

Checking eligibility and benefits and/or obtaining prior authorization is not a guarantee of payment. 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, call the number on the member’s ID card.

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.