September 28, 2023
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, 2024 – Expansion of the Musculoskeletal Joint & Spine category to include arthroscopy codes to be reviewed by Carelon Medical Benefits Management (Carelon)
Jan. 1, 2024 – Expansion of the Cardiology (echo) category reviewed by Carelon
Jan. 1, 2024 – Addition of Specialty Pharmacy codes to be reviewed by BCBSIL
Jan. 1, 2024 – Addition of Medical Oncology drug codes to be reviewed by Carelon
Jan. 1, 2024 – Addition of Genetic Testing lab codes to be reviewed by Carelon
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 Recommended Clinical Review request. This step can help avoid post-service medical necessity review. Checking eligibility and benefits can’t tell you when to request Recommended Clinical Review, since it’s optional. But there’s a Medical Policy Reference List on our Recommended Clinical Review 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 2022 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.
Carelon Medical Benefits Management (Carelon) 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.