September 11, 2023
Blue Cross and Blue Shield of Illinois (BCBSIL) continues to streamline the pre-service review process to reduce your workload with BlueApprovR. This tool, accessible in Availity® Essentials, now processes optional recommended clinical review (RCR) requests – formerly called predetermination requests – for some medical and surgical and specialty pharmacy drugs for many of our commercial, non-HMO members.
Here’s how to submit RCR and prior authorization requests with BlueApprovR:
- In Availity, select Payer Spaces from the navigation menu, then select BCBSIL.
- On the Payer Spaces page, under the Applications tab, select BlueApprovR.
- You’ll be redirected to BlueApprovR to complete requests online.
Note: Your RCR submissions will follow the same path through BlueApprovR as prior authorization requests.
Don’t forget! Member benefits vary based on the service being rendered and individual and group policy elections. Always check eligibility and benefits first through Availity or your preferred web vendor. This step will confirm coverage and other important details, such as prior authorization requirements and utilization management vendors, if applicable. If prior authorization isn’t required for a commercial non-HMO member, you still may want to submit a voluntary RCR request. This step can help avoid post-service medical necessity review. View our Recommended Clinical Review (Predetermination), Post-Service Review and Non-covered 2023 Benefit Procedure Code List for more information
BlueApprovR Offers End-to-End Efficiencies
Registered Availity Essentials users have free, 24/7 access to BlueApprovR to:
- Submit RCR and prior authorization requests for many services and specialty pharmacy drugs
- Secure real-time approvals for certain services and drugs
- Easily attach medical records
- Check approval status of your request
Join us this month for a free, instructor-led webinar to learn how to use BlueApprovR. To register, select your preferred date and time from the list below. Times listed are Central Time.
- Sept. 13, 2023 - 11 a.m. to 12:30 p.m.
- Sept. 14, 2023 - 1 to 2 p.m.
- Sept. 20, 2023 - 11 a.m. to 12:30 p.m.
- Sept. 21, 2023 - 1 to 2 p.m.
- Sept. 27, 2023 - 11 a.m. to 12:30 p.m.
- Sept. 28, 2023 - 1 to 2 p.m.
You can use BlueApprovR to request RCR and prior authorization for these types of care:
- Specialty Pharmacy Drugs
- Inpatient Acute Care
- Long-term Acute Care
- Inpatient Rehab
- Skilled Nursing Facility
- Outpatient Hospice
- Inpatient Hospice
- Home Health
- Outpatient Service
Other RCR Request Methods
Use the Availity Attachments tool to submit an RCR, or download, complete and fax the Recommended Clinical Review (Predetermination) Request form to BCBSIL.
This tool is currently not available for Federal Employee Program® (FEP®) or Medicare Advantage or Illinois Medicaid members. Please use your existing process for prior authorization requests for these 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.