Posted Jan. 11, 2021
Prior authorization 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 prior authorization requirements – are subject to change. This article offers an overview of 2021 prior authorization support materials and related communications that may apply for some of our non-HMO commercial and government programs members, effective Jan. 1, 2021.
Commercial Prior Authorization Summary and Code Lists
The following summary and related prior authorization lists were posted on the Support Materials (Commercial) page the Utilization Management section of our Provider website as of Jan. 1, 2021:
- 2021 Commercial Prior Authorization Requirements Summary This one-page overview has been streamlined for 2021. It outlines general care categories with links to the three code lists below.
- 2021 Commercial Outpatient Medical Surgical Prior Authorization Code List Care categories did not change for 2021, but procedure codes within some categories were updated to reflect codes that were added or retired. An Update History column has been added to help identify what’s new.
- 2021 Commercial Specialty Pharmacy Prior Authorization Drug List This list was updated with 14 new codes effective Jan. 1, 2021.
- 2021 Commercial Outpatient Behavioral Health Prior Authorization Code List This list is a new addition on our website for 2021.
Here are links to some recent communications that were posted to notify you of important changes:
- Update: Utilization Management Change for Advocate Aurora Health Members, Effective Jan. 1, 2021 — This News and Updates was posted Dec.15, 2020, and updated Dec. 31, 2020 to reflect a corrected phone number. It clarifies a utilization management vendor change for specific members. (Note: For changes to come later this year, refer to this notice, posted Dec. 31, 2020: New Prior Authorization Requirements for Advocate Aurora Health Members Will Take Effect April 1, 2021.)
- Infusion Site of Care Prior Authorization Drug List: New Codes Will Be Added, Effective Jan. 1, 2021 — This notice was posted Dec. 28, 2020, to advise you of 14 new codes being added to our specialty pharmacy prior authorization drug list. The notice also refers to a medical policy for more information to help clarify when and how prior authorization requirements may apply.
- New Prior Authorization Requirements for Some Custom Account Members Will Take Effect Jan. 1, 2021 — This notice was posted Oct. 2, 2020, to notify you of care categories/services that may require prior authorization for some members with ID prefixes ACX, PAS, V2T, VXJ, VXL, VXR, VXV, VYD.
- Prior Authorization for Some Commercial Members Will Transition from eviCore to AIM, Effective Jan. 1, 2021 — This notice was posted Oct. 1, 2020, to alert you of a utilization management vendor change. A follow-up article with additional information on transition of member care was posted Dec. 4, 2020. (Note: For changes to come later this year, refer to this notice, posted Dec. 28, 2020: Commercial Prior Authorization Code Changes, Effective April 1, 2021.)
Government Programs Prior Authorization Summary and Code Lists
Summaries and code lists are posted as a reference to help you determine when prior authorization may be required for non-HMO government programs members. This includes our Medicaid – Blue Cross Community Health PlansSM (BCCHPSM) and Blue Cross Community MMAI (Medicare-Medicaid Plan)SM — and Blue Cross Medicare Advantage (PPO)SM(MA PPO) members.
For 2021, there were no changes to overall care categories, but some of the codes within certain categories may have been updated. The following summaries and related prior authorization lists were posted on the Support Materials (Government Programs) page as of Jan. 1, 2021:
- 2021 Medicaid Prior Authorization Requirements Summary
- 2021 Medicaid Prior Authorization Code List
- 2021 MA PPO Prior Authorization Requirements Summary
- 2021 MA PPO Prior Authorization Code List
Important Reminder: Check Eligibility and Benefits First
Prior authorization 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 prior authorization may be required for a specific member and service.
For More Information
- Visit the Prior Authorization page for details on how to submit electronic prior authorization requests. You’ll also find helpful related resources, such as our Utilization Management Process Overview documents — there’s one for Commercial and one for Government Programs.
- Continue to watch the News and Updates and upcoming issues of the Blue Review.
- If you have questions, contact the BCBSIL Provider Network Consultant (PNC) team.
The prior authorization 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 prior authorized 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. AIM Specialty Health (AIM) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL. 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, AIM 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 medical 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.