Blue Cross Blue Shield of Illinois Updates Prior Authorization Requirements for Government Programs
Attention healthcare providers: Blue Cross and Blue Shield of Illinois (BCBSIL) is implementing changes to prior authorization requirements for specific services covered under Blue Cross Medicare Advantage (PPO)SM, Blue Cross Community Health PlansSM, and Blue Cross Community MMAI (Medicare-Medicaid Plan)SM plans.
Effective July 1, 2024, these changes affect:
- Lab Tests: Certain lab tests will require pre-approval review by eviCore healthcare, a contractor for BCBSIL. Additionally, some previously reviewed lab tests will no longer need eviCore’s approval.
- Sleep Studies: Prior authorization from eviCore will now be mandatory for certain sleep study procedures.
- Specialty Drugs: BCBSIL will require prior authorization for specific specialty drugs.
Staying Informed:
- Healthcare providers can find a detailed breakdown of the code changes on the BCBSIL website under “Support Materials (Government Programs)”.
- The “Utilization Management” section of the BCBSIL website offers further information on these updates.
Important Reminders for Providers:
- Always verify member eligibility and benefits through Availity® Essentials or your preferred vendor portal before providing services. This step confirms prior authorization requirements and the appropriate utilization management vendor (if applicable).
- Obtain prior authorization if necessary. Services rendered without prior approval or not meeting medical necessity criteria may be denied payment, leaving providers unable to collect reimbursement from the member.
- Obtaining prior authorization helps avoid claim processing delays and potential denials due to missing information.
This announcement is for informational purposes only. Verifying eligibility and benefits and/or obtaining prior authorization does not guarantee payment. Final determinations will be made when a claim is submitted and will be based on factors such as member eligibility, their plan’s details (including exclusions and limitations), and the date services were provided.
Sources
https://www.bcbsil.com/provider/education/education-reference/news/2024/03-28-2024
