Posted Aug. 28, 2020
This notice applies to providers who submit claims to Blue Cross and Blue Shield of Illinois (BCBSIL) for our Illinois Medicaid members. This includes our members with either of the following benefit plans: Blue Cross Community MMAI (Medicare-Medicaid)SM or Blue Cross Community Health PlansSM (BCCHPSM).
When prior authorization is required, it must be obtained before the service is performed. Prior authorization numbers are assigned by the payer or Utilization Management Organization (UMO) to confirm that necessary review has been completed and benefits have been approved for coverage.
Illinois Medicaid providers should include the assigned prior authorization number when submitting the claim for services rendered. Inclusion of this number will help ensure timely and accurate processing of the claim.
For electronic Professional and Institutional claims (837P and 837I transactions):
- If the prior authorization number is applicable for all services rendered on the claim, it should be included in the 2300 Loop, REF02 element with the G1 qualifier in REF01.
- If the prior authorization number is applicable to a single service line on the claim, it should be submitted in the 2400 Loop, REF02 element with the G1 qualifier in REF01.
For paper claims:
The prior authorization number should be submitted in Box 23 of the CMS-1500 Professional claim form and in Field 63 of the UB-04 Institutional claim form.
Please note that 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.
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.