Government Programs Prior Authorization Update: Code Changes, Effective July 1, 2021

June 3, 2021

What’s Changing: Blue Cross and Blue Shield of Illinois (BCBSIL) is changing prior authorization (PA) requirements for Blue Cross Medicare Advantage (PPO)^SM (MA PPO), Blue Cross Community Health Plans^SM (BCCHP^SM) and Blue Cross Community MMAI (Medicare-Medicaid Plan)^SM members. A summary of changes (new procedure codes added) is included below. 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.

Important Reminders
Always check eligibility and benefits first through the Availity^® Provider Portal  or your preferred vendor portal, prior to rendering services. This step will confirm prior authorization requirements and utilization management vendors, if applicable.

If prior authorization is required, services performed without prior authorization or that do not meet medical necessity criteria may be denied for payment and the rendering provider may not seek reimbursement from the member. Avoid post-service medical necessity reviews and delays in claim processing by obtaining prior authorization before rendering services.

More Information:
Refer to the Utilization Management section of our Provider website. Updated MA PPO and Illinois Medicaid (BCCHP and MMAI) prior authorization summaries and procedure code lists are posted on the following page: Support Materials (Government Programs).

Checking eligibility and/or benefit information and/or obtaining prior authorization 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, 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. 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. The vendors are solely responsible for the products or services they offer. If you have any questions regarding any of the products or services they offer, you should contact the vendor(s) directly.