December 23, 2022
Effective Jan. 1, 2023, Blue Cross and Blue Shield of Illinois (BCBSIL) is changing the name of its long-standing pre-service review, previously called predetermination, to recommended clinical review. This type of pre-service review is available for commercial non-HMO members.
Here are a few things to know:
- Recommended clinical review isn’t a different process, and it won’t generate a different result than a predetermination.
- Recommended clinical reviews are optional medical necessity reviews conducted before services are provided. Submitting a request prior to rendering services informs you of situations where a service may not be covered based upon medical necessity criteria.
- There’s no penalty if you don’t submit a request for recommended clinical review, but keep in mind that the service may be subject to post-service medical necessity review.
- The recommended clinical review process evaluates the medical necessity of a service but doesn’t guarantee the service will be covered under the member’s benefit plan. The terms of the member's plan control the available benefits.
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 request for recommended clinical review (predetermination) to help avoid post-service medical necessity review. Checking eligibility and benefits can’t tell you when to request recommended clinical review (predetermination), since it’s optional. You can use our Medical Policy Reference List for help deciding how to proceed.
For More Information
Refer to the Utilization Management section for more information, such as how to submit prior authorization and recommended clinical review (predetermination) requests. Also continue to watch the News and Updates and Blue Review for future announcements and related resources.
The prior authorization and recommended clinical review (predetermination) processes referenced above aren’t available for government programs (Illinois Medicaid and Medicare Advantage) or any of our commercial HMO members.
Checking eligibility and/or benefit information, obtaining prior authorization or the fact that a recommended clinical review (predetermination) decision has been issued 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. Regardless of any prior authorization or recommended clinical review (predetermination, the final decision regarding any treatment or service is between the patient and the 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. BCBSIL makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.