October 1, 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 PlansSM (BCCHPSM) and Blue Cross Community MMAI (Medicare-Medicaid Plan)SM members.
A summary of changes (procedure codes being added or removed) 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.
- Jan. 1, 2022 – Removal of Radiation Therapy codes previously reviewed by eviCore
- Jan. 1, 2022 – Removal of Genetic Lab codes previously reviewed by eviCore
- Jan. 1, 2022 – Removal of Musculoskeletal codes previously reviewed by eviCore
- Jan. 1, 2022 – Removal of Radiology codes previously reviewed by eviCore
- Jan. 1, 2022 – Removal of Specialty Pharmacy codes previously reviewed by eviCore
- Jan. 1, 2022 – Removal of Medical Oncology codes previously reviewed by eviCore
- Jan. 1, 2022 – Addition of a Specialty Drug code to be reviewed by eviCore
- Jan. 1, 2022 – Removal of a Specialty Drug code previously reviewed by eviCore
- Jan. 1, 2022 – Addition of Radiology codes to be reviewed by eviCore
- Jan. 1, 2022 – Addition of Genetic Lab codes to be reviewed by eviCore
- Jan. 1, 2022 – Removal of Physical Health codes previously reviewed by BCBSIL
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).
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.
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 company that has contracted with BCBSIL to provide prior authorization for expanded outpatient and specialty utilization management for members with coverage through BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding third party vendors. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors.