November 30, 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 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 – Removal of Orthopedic Musculoskeletal codes previously reviewed by BCBSIL
Jan. 1, 2023 – Code list will be updated to include codes for the existing prior authorization Transplant category; there’s no change to BCBSIL’s prior authorization requirements
Jan. 1, 2023 – Replacement of a Specialty Pharmacy code reviewed by BCBSIL
Jan. 1, 2023 – Removal of Outpatient Surgery-Obesity codes previously reviewed by BCBSIL
Jan. 1, 2023 – Removal of Behavioral Health codes previously reviewed by BCBSIL
Jan. 1, 2023 – Replacement of Behavioral Health codes reviewed by BCBSIL
Jan. 1, 2023 – Removal of Molecular Genetic Testing codes previously reviewed by AIM Specialty Health® (AIM)
For more information, refer to the Utilization Management section for the updated procedure code lists. These 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. You can use our Medical Policy Reference List for help deciding how to proceed.
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 third party vendors and the products and services they offer.