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

Posted June 30, 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.

As a reminder, 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.

A summary of changes, effective Oct. 1, 2021, is included below.

For More Information: Refer to the Utilization Management section. Updated MA PPO and Illinois Medicaid (BCCHP and MMAI) procedure code lists are posted on the Support Materials (Government Programs) page.

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.

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.

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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. eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSIL. 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.