Posted March 30, 2021
It’s important to check eligibility and benefits first, before providing care and services. This step helps you determine if prior authorization or pre-notification may be required for our non-HMO members. Don’t forget, though, for commercial, non-HMO members, even if prior authorization and pre-notification aren’t required, you may want to submit a voluntary predetermination request. See the Utilization Management Process Overview (Commercial) for a high-level decision tree. This overview is located in the Utilization Management section of our Provider website.
The Utilization Management section also includes other resources to help you decide when to submit predetermination requests. Our Medical Policy Reference List is located in the Related Resources on the Predetermination page.
- This list shows procedure codes for services that are subject to medical necessity review, based on our medical policies.
- To help avoid post-service review for these codes/procedures, submit a voluntary predetermination request prior to rendering services.
- Quick tip: To go right to a specific code or description on the Medical Policy Reference List, press the “CTRL” and “F” keys at the same time – this will open a search field.
Remember, you can submit predetermination requests electronically, using the Attachments Tool on the Availity® Provider Portal. See the user guide for details.
The Medical Policy Reference List is not an exhaustive list of all codes. Codes may change, and this list may be updated throughout the year. The presence of codes on this list does not necessarily indicate coverage under the member benefits contract. Member contracts differ in their benefits. Consult the member benefit booklet or contact a customer service representative to determine coverage for a specific medical service or supply.
Checking eligibility and/or benefit information and/or obtaining prior authorization, pre-notification or predetermination 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.
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.