June 28, 2022
What’s Changing: Blue Cross and Blue Shield of Illinois (BCBSIL) is changing prior authorization requirements that may apply to some commercial non-HMO fully insured members.
A summary of changes is as follows.
- Oct. 1, 2022 – Addition of one Musculoskeletal Joint and Spine Current Procedural Terminology (CPT®) code to be reviewed by AIM Specialty Health® (AIM)
- Oct. 1, 2022 – Addition of Molecular Genetic Lab Testing codes to be reviewed by AIM
- Oct. 1, 2022 – Addition and replacement of Medical Oncology drugs to be reviewed by AIM
- Oct. 1, 2022 – Removal of Musculoskeletal Joint and Spine and Pain codes previously reviewed by AIM
- Oct. 1, 2022 – Addition of Specialty Pharmacy codes to be reviewed by BCBSIL
For more information, refer to the Utilization Management section. Update procedure code lists are posted on the Prior Authorization Support Materials (Commercial) page.
Always check eligibility and benefits first through Availity® Essentials or your preferred vendor portal, prior to rendering services. This step will confirm prior authorization requirements and utilization management vendors, if applicable.
Even if prior authorization isn’t required for a commercial non-HMO member, you may still want to submit a voluntary predetermination request. This step can help avoid post-service medical necessity review. Checking eligibility and benefits can’t tell you when to request predetermination, since it’s optional. But there’s a Medical Policy Reference List on our Predetermination page to help you decide.
Services performed without required 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.
CPT copyright 2021 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
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. Regardless of any prior authorization or benefit determination, the final decision regarding any treatment or service is between the patient and their health care provider.
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. AIM Specialty Health (AIM) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL. BCBSIL makes no endorsement, representations, or warranties regarding third party vendors and the products and services offered by them.