December 28, 2020
To help ensure reviews for medical necessity and site of administration are being conducted according to member benefit plan details, 14 new procedure codes will be added to the Specialty Pharmacy Infusion Site of Care Prior Authorization Drug List, effective Jan. 1, 2021.
This list is located on the Support Materials (Commercial) page in the Utilization Management section of our Provider website. It includes specialty drugs (infusion site-of-care or provider administered drug therapies) that may require prior authorization through Blue Cross and Blue Shield of Illinois (BCBSIL) before administration of these drugs for some of our commercial, non-HMO members.
Codes being added effective Jan. 1, 2021, include: J0222, J0223, J0584, J0638, J0791, J1303, J1558, J1746, J3032, J3060, J3241, J3245, J3397 and Q5121. BCBSIL’s Specialty Medication Administration Site of Care Medical Policy (RX501.096) is available in the Medical Policy section of our website to help clarify when and how prior authorization requirements may apply.
Remember: Member benefit plans and requirements vary, so it’s critical to check eligibility and benefits first through the Availity Provider Portal® or your preferred web vendor, prior to rendering care and services, to confirm coverage and other important details.
Checking eligibility and benefits and/or obtaining prior authorization is not a guarantee of payment of benefits. Payment of benefits 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 the member’s policy certificate and/or benefits booklet and or summary plan description. Regardless of any prior authorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider. If you have any questions, call the number on the member's BCBSIL 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.