Utilization Management for Equity in Behavioral Health: Provider Education, Reminders and Resources

March 30, 2023

In August 2021, Governor JB Pritzker signed into law Illinois House Bill 2595 (Public Act 102-0579), the Generally Accepted Standards of Behavioral Health Care Act of 2021. IL HB 2595 requires that insurers cover all medically necessary behavioral health care services as essential, beginning Jan. 1, 2023, for all eligible members.* 

While there are no changes to our members’ benefits related to IL HB 2595, Blue Cross and Blue Shield of Illinois (BCBSIL) remains committed to increasing awareness and removing barriers to behavioral health care services for our members. 

Utilization Management Reminders
BCBSIL’s medical, pharmacy and behavioral health care utilization management programs are in place to help ensure our members receive the right care at the right time and in the right setting. Our utilization management programs are updated annually with the most recent available research, and they align with professional guidelines, such as the American Society of Addiction Medicine (ASAM). 

Utilization review criteria are developed based on current clinical principles and processes with involvement from appropriate practitioners with current knowledge relevant to the criteria under review. 

BCBSIL uses written clinical criteria based on clinical evidence to make utilization management decisions regarding the medical necessity of covered items and services. 

The clinical criteria consider individual circumstances and the local delivery system when making medical necessity determinations for medical and behavioral health care services. Approved lengths of stay and frequency of review are indicated in the criteria used and are specific to the conditions and requested treatment. 

BCBSIL provides training on clinical review criteria and related processes to applicable staff members and other stakeholders. Educational resources are available to providers in the Utilization Management section of our website. 

Learn More
Refer to our Commercial and Government Programs Prior Authorization Support Materials pages for: 

  • Links to view information on clinical review criteria for BCBSIL and utilization management vendors
  • Clinical review criteria provider education presentations (Commercial and Government Programs)
  • Prior authorization code lists and digital lookup tools
  • Utilization management process overview (when and how to submit requests for review)

What else can you do?
IL HB 2595 helps spotlight behavioral health care as something that should be business-as-usual. With that goal in mind, there’s nothing you need to do differently. Rather, continue to: 

  • Talk with our members about their behavioral health – make sure they’re aware of symptoms to watch for and available treatment options.
  • Prior to rendering care and services, check eligibility and benefits to confirm if prior authorization is required.
  • For commercial non-HMO members, if prior authorization isn’t required, consider submitting an optional request for recommended clinical review (predetermination).
  • Refer to clinical review criteria to understand what clinical documentation should accompany your request.


*BCBSIL plans in scope include the following: Commercial fully insured; Illinois Medicaid – Blue Cross Community Health PlansSM and Blue Cross Community MMAI (Medicare-Medicaid Plan)SM; Administrative Services Only (ASO) plans offered to state employees and by employers that are municipalities, counties or public schools.

The ASAM Criteria®, © 2021 American Society of Addiction Medicine. All rights reserved.

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.