March 16, 2026
Effective July 1, 2026, we’ll enhance our claims editing and review process for office, inpatient and outpatient evaluation and management services for our members with commercial plans. These editing enhancements for professional claims will help ensure accurate billing and proper reimbursement.
What’s changing: When we review your claim for dates of service beginning July 1, if services billed do not support the level of E&M services billed, your reimbursement will be for a lower level of service validated. We’ll follow the American Medical Association guidelines for level of service and medical decision-making.
What happens next: If you agree with the level of service reimbursed, no further action is needed. If you do not agree with the level of service reimbursed, you may submit medical records to support your claim.
Learn more: Review RP024 Evaluation and Management (E/M) coding – Professional Provider services.
This is for informational and educational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider, nor is the information presented intended to replace or supersede any requirements set forth in your contract with Blue Cross and Blue Shield of Illinois. Physicians and other health care providers should use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment.