Posted Jan. 26, 2021
In November 2020, we launched a new Utilization Management section under the Claims and Eligibility tab of our Provider website.* As a reminder, this section includes a page for each type of pre-service medical necessity review: Prior Authorization, Predetermination and Pre-notification. Each page defines terminology and steps to assess if review is needed, and how to request it. Prior authorization code lists and other reference materials are posted on the Support Materials (Commercial) and Support Materials (Government Programs) pages.
It’s our goal to continue to enhance this section to help ensure the information is useful. Here are some recent updates:
- Medical Policy Reference List (Commercial) — This document is a new addition to the Related Resources on the Predetermination page. It includes Current Procedural Terminology (CPT®) and/or Healthcare Common Procedure Coding System (HCPCS) codes which, based on our medical policy, are subject to a medical necessity review and may be potential candidates to consider for predetermination requests for some commercial non-HMO members.
- Utilization Management Process Overview (Commercial) — This diagram is available in the Related Resources on multiple pages in the Utilization Management section. It outlines what type of review may be needed for commercial non-HMO members, as well as how to submit review requests. Posted originally in November 2020, this document was updated Jan. 1, 2021, to reflect the transition to AIM Specialty HealthSM for some commercial non-HMO prior authorization requests.
- Tips for Using AIM Specialty Health — For your quick reference purposes, we’ve also added this new flyer to the Support Materials (Commercial) page.
Is the information in the Utilization Management section clear and easy to navigate? Are the related resources we’ve added helpful? If you have feedback you’d like to share, please email us — we appreciate your input!
*The information in this section is not applicable to BCBSIL’s HMO members.
Checking eligibility and/or benefit information and/or obtaining prior authorization or pre-notification 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, including, but not limited to, exclusions and limitations applicable on the date services were rendered. If you have any questions, contact the number on the member’s ID card.
AIM Specialty Health (AIM) is an independent company that has contracted with Blue Cross and Blue Shield of Illinois (BCBSIL) to provide utilization management services for members with coverage through BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding third party vendors and the products and services offered by them.