Utilization Management: Avoid Delays and Denials

January 22, 2024

Our utilization management program helps ensure our members get the right care, at the right time, in the right setting. There are optional recommended clinical reviews and required prior authorization reviews that are conducted before services are rendered. These pre-service, utilization management reviews are not a guarantee of benefits or payment. The terms of the member’s plan control the available benefits.

Before rendering care or services, always check eligibility and benefits first, via Availity® Essentials or your preferred web vendor. In addition to verifying membership and coverage status, this step returns information on prior authorization requirements and utilization management vendors, if applicable.

Member benefits and review requirements and recommendations may vary based on services rendered and individual/group policy elections.

Our Utilization Management page explains the review types needed or suggested when you’re providing care for Blue Cross and Blue Shield of Illinois members. You can find “how to” direction and vendor profiles as well as prior authorization and recommended clinical review code lists.  

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. 

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. Certain employer groups may require prior authorization or pre-notification through other vendors. If you have any questions, call the number on the member's ID card. Regardless of any prior authorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.