February 1, 2021
Blue Cross and Blue Shield of Illinois (BCBSIL) would like to outline important updates, tips and reminders on prior authorization processes for independently contracted providers treating our Blue Cross Community Health PlansSM (BCCHPSM) and Blue Cross Community MMAI (Medicare-Medicaid Plan)SM members. For some services/members, prior authorization may be required through BCBSIL. For other services/members, BCBSIL has contracted with eviCore healthcare (eviCore) for utilization management and related services. Please note that, effective May 1, 2021, there will be a change to the BCCHP peer-to-peer discussion process, as specified below.
As a reminder, it’s important to check eligibility and benefits first for each patient at every visit to confirm coverage details. This step also helps you identify prior authorization requirements and utilization management vendors, if applicable. For more information, refer to the 2021 Medicaid Prior Authorization Requirements Summary and 2021 Medicaid Prior Authorization Code List available in the Medicaid section on the Support Materials (Government Programs) page.
BCBSIL adheres to the standards for addressing all urgent concurrent requests, meeting or exceeding National Committee for Quality Assurance (NCQA) standards. These requests must be decided within 48 hours for BCCHP members, and 72 hours for MMAI members. Clear and timely submission of prior authorization requests and clinical documentation is very important to process requests within the required time frames.
To help ensure turnaround times are met and decisions are provided to requesting providers as quickly as possible, BCCHP and MMAI utilization management (UM) reviewers and medical directors are available seven days a week, excluding BCBSIL identified holidays. During weekend hours, UM reviewers and medical directors continue to review requests and make decisions.
When faxing prior authorization requests, you must use the Medicaid Prior Authorization Request Form . If we do not receive adequate clinical documentation, BCBSIL will reach out to your facility UM department and provide a date and time in which clinical documentation is required to be received. If a request does not meet medical necessity criteria for approval, the request will be assigned to a BCBSIL medical director for determination.
To support the decision process, BCBSIL gives providers the opportunity to discuss UM determinations with a peer physician. Providers are allowed the opportunity to schedule one peer-to-peer discussion per adverse determination. A provider may initiate a peer-to-peer discussion by calling 800-981-2795. The peer-to-peer discussion process is as follows:
- MMAI providers will be notified by phone of potential adverse determinations and offered a date and time in which a pre-service, peer-to-peer discussion is available. Once the offered date and time has passed and if adequate information still has not been received, the request will be sent to a BCBSIL medical director for review and final decision. Please be advised that in compliance with the Centers for Medicare & Medicaid Services (CMS), BCBSIL is not allowed to change a denial decision once it has been finalized by the BCBSIL medical director and the determination has been issued to the member. An appeal or grievance may be filed regarding the denial decision. For additional information regarding appeals and grievances refer to the MMAI provider manual or call 877-723-7702.
- Updated: Effective May 1, 2021,* BCCHP providers will be notified by phone or fax of potential adverse determinations and given a date and time in which a pre-service peer-to-peer discussion is available. Once the date given has passed and if adequate information still has not been received, the request will be sent to a BCBSIL medical director for review and final decision. If the decision rendered by the BCBSIL medical director is an adverse determination, providers are allotted an additional seven calendar days from the notification of the adverse determination to schedule and complete a peer-to-peer discussion. If the provider wishes to forego the peer-to-peer discussion and wishes to submit an updated clinical packet for review, the BCBSIL Utilization Management team will review one packet of additional supporting documentation after the adverse determination. The clinical packet must be submitted within seven days of the adverse determination and the fax cover sheet must be clearly identified as the wish for a clinical re-review in lieu of a peer-to-peer discussion. If an appeal has been filed during this period, the peer-to-peer discussion and clinical review is no longer available. An appeal or grievance may be filed regarding the denial decision. For additional information regarding appeals and grievances, refer to the BCCHP provider manual or call 877-860-2837.
*Effective May 1, 2021, the only change is that providers can no longer submit clinical for BCCHP members IN ADDITION TO doing a peer-to-peer after the adverse determination. As of this date, providers may submit a new packet for clinical re-review OR do a peer-to-peer discussion.
For BCCHP and MMAI: Peer-to-peer discussions are allowed for requests where clinical information was submitted with the original request. If no clinical information was submitted with a request, a peer-to-peer discussion is not permitted. It is the responsibility of the requesting provider to submit clinical documentation to substantiate a request for services at the time of the service authorization request. Additional clinical information will not be reviewed by the utilization management team if the initial determination was an adverse determination due to failure to submit clinical information with the original request.
The peer-to-peer discussion is available as a courtesy to providers. The peer-to-peer discussion is not required, nor does it affect the providers’ right to an appeal on behalf of a member. If an appeal has been filed, the peer-to-peer discussion is no longer available. Additionally, the Provider Service Authorization Dispute process is available when an adverse service authorization has been rendered and the UM process has been followed. Failing to provide clinical information or timely notification of prior authorization requests may affect the outcome of a Service Authorization Dispute. Information on Service Authorization Disputes can be found on the Provider Service Authorization Dispute Resolution Request form.
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.
The above material is for informational purposes only and is not intended to be a substitute for the independent medical judgment of a physician. Physicians and other health care providers are encouraged to use their own best medical judgment based upon all available information and the condition of the patient in determining the best course of treatment.
eviCore is an independent specialty medical benefits management company that provides utilization management services for BCBSIL. eviCore is wholly responsible for its own products and services. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.