2020 Benefit Preauthorization Requirements, Reminders and Resources (PPO – Commercial and Government Programs)

January 3, 2020

Benefit preauthorization to confirm medical necessity is required for certain services and benefit plans as part of our commitment to help ensure all Blue Cross and Blue Shield of Illinois (BCBSIL) members get the right care, at the right time, in the right setting. It’s important to remember that benefit plans differ in their benefits, and details such as benefit preauthorization requirements, are subject to change. This article includes some general reminders and links to recent communications to provide you with an overview of some of the 2020 changes for PPO commercial and government programs.



Government Programs

  • 2020 Blue Cross Medicare Advantage (PPO)SM (MA PPO) Prior Authorization Requirements Summary – A link to this summary listing was posted in the News and Updates on Oct. 1, 2019. Only one change has been made for 2020: The hyperbaric oxygen service category was removed, as benefit preauthorization through BCBSIL will no longer be required. (Note: The procedure codes within some other service categories may be changing. An updated 2020 MA PPO procedure code list was posted Dec. 27, 2019, in the Prior Authorization section of our Provider website.)
  • 2020 Medicaid Prior Authorization Requirements Summary – A link to this summary listing was posted in the News and Updates on Oct. 1, 2019. It includes information that applies to our Blue Cross Community MMAI (Medicare-Medicaid Plan)SM and Blue Cross Community Health PlansSM (BCCHPSM) members. This summary list was last updated in September 2019; the categories will remain the same, with no additions or removals for January 2020. (Note: The procedure codes within some service categories may be changing. An updated 2020 Medicaid procedure code list was posted Dec. 27, 2019, on our Provider website.)

Check Eligibility and Benefits First
Benefit preauthorization requirements are specific to each patient’s policy type and the procedure(s) being rendered. It’s critical to check member eligibility and benefits through the Availity® Provider Portal or your preferred vendor portal prior to every scheduled appointment. This step will help you determine if benefit preauthorization is required for a particular member. Obtaining benefit preauthorization is not a substitute for checking eligibility and benefits. If benefit preauthorization is required, services performed without benefit preauthorization or that do not meet medical necessity criteria may be denied for payment and the rendering provider may not seek reimbursement from the member.

How to Obtain Benefit Preauthorization
As always, we encourage you to use electronic options. If benefit preauthorization through eviCore is required, you may submit your request online via the eviCore Web Portal. If benefit preauthorization through BCBSIL is required, you may continue to submit requests using our online tool iExchange®. A new online application for submission of electronic benefit preauthorization requests (278 transactions) will soon be available. See the News and Updates for details.

For More Information
We value your participation as an independently contracted network provider and we appreciate the quality care and services you provide to our members. We encourage you to visit us online often for the most up-to-date information.

Questions? Contact your BCBSIL Provider Network Consultant (PNC) team.

The information in this notice does not apply to requests for HMO members.

Checking eligibility and/or benefit information and/or the fact that a service has been preauthorized/pre-notified 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, call the number on the member’s ID card.

eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSIL. WINFertility is an independent company that provides fertility management solutions for BCBSIL. WINFertility is solely responsible for the products and services that it provides. iExchange is a trademark of Medecision, Inc., a separate company that provides collaborative health care management solutions for payers and providers. 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, WINFertility, Medecision or Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.

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 medic judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. 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.