September 30, 2022 (Updated Oct. 25, 2022)
The summary of changes in the notice below has been updated to include code removal and replacement information.
Blue Cross and Blue Shield of Illinois (BCBSIL) is changing prior authorization requirements that may apply to some commercial non-HMO members. Changes are based on updates from Utilization Management prior authorization assessment, Current Procedural Terminology (CPT®) code changes released by the American Medical Association or Healthcare Common Procedure Coding System (HCPCS) code changes from the Centers for Medicaid & Medicare Services.
A summary of changes is as follows:
- Jan. 1, 2023 – Addition of Medical Oncology and Supportive Care drugs (reported with unlisted codes) and other additions to drug codes to be reviewed by AIM Specialty Health® (AIM)
- Jan. 1, 2023 – Medical Oncology and Supportive Care drug codes previously reviewed by BCBSIL to be reviewed by AIM
- Jan. 1, 2023 – Addition of a Radiation Oncology code to be reviewed by AIM
- Jan. 1, 2023 – Removal of Musculoskeletal – Joint and Spine codes previously reviewed by AIM
- Jan. 1, 2023 – Removal of a Molecular Genetic Lab code previously reviewed by AIM
- Jan. 1, 2023 – Removal of a Specialty Pharmacy code previously reviewed by BCBSIL, that will continue to be reviewed by AIM
- Jan. 1, 2023 – Replacement of a Specialty Pharmacy code reviewed by AIM
- Jan. 1, 2023 – Removal of Orthopedic Musculoskeletal codes previously reviewed by BCBSIL
For more information, refer to the Utilization Management section for the updated procedure code lists. These are posted on the 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 still may 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 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.
AIM Specialty Health (AIM) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through 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. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors.