Request a prior authorization | Blue Cross and Blue Shield of Illinois (2024)

What is prior authorization?

Prior authorization (sometimes called preauthorization or pre-certification) is apre-service utilization management review. Prior authorization isrequiredfor some members/services/drugsbefore services are rendered to confirm medical necessity as defined by the member’s health benefit plan. A prior authorization isnota guarantee of benefits or payment. The terms of the member’s plan control the available benefits.

Who requests prior authorization?

Usually, the provider is responsible for requesting prior authorization before performing a service if the member is seeing an in-network provider. Sometimes, a plan may require the member to request prior authorization for services. Information for Blue Cross and Blue Shield of Illinois members is found onour member site.

Note: Most out-of-network services require utilization management review. If the provider or member doesn’t get prior authorization for out-of-network services, the claim may be denied. Emergency services are an exception.

Why obtain a prior authorization?

If you donotget prior approval via the prior authorization process for services and drugs on our prior authorization lists:

  • Theservice or drug may not be covered,and the ordering or servicingprovider will be responsible.
  • We may conducta post-service utilization management review, which may include requesting medical records and reviewing claims for consistency with medical policies; clinical payment and coding policies; and accuracy of payment.
  • ForMedicareandMedicaidmembers, if you don’t get prior authorization for services or drugs on our prior authorization lists, we won’t reimburse you, and you cannot bill our members for those services or drugs.

When and how should prior authorization requests be submitted?

In general, there arethreestepsprovidersshould follow.

Step 1 – Confirm if Prior Authorization is Required

Remember, member benefits and review requirements will vary based on service/drug being rendered and individual/group policy elections.Always check eligibility and benefits first,via theAvaility®Essentialsor your preferred web vendor, prior to rendering care and services. In addition to verifying membership/coverage status and other important details,this step returns information on prior authorization requirements and utilization management vendors, if applicable.

Note: Checking eligibility and benefits is key, butwe also have other resources to help you prepare.To viewrequirements summaries andprocedure code lists, refer to theSupport Materials (Commercial)andSupport Materials (Government Programs)pages.

Step 2–If prior authorization is required, have the following information ready:

  • Patient ID, name and date of birth
  • Patient’s medical or behavioral health condition
  • Proposed treatment plan
  • Date of service, estimated length of stay (if the patient is being admitted)
  • Place of treatment
  • Provider name, address and National Provider Identifier (NPI)
  • Diagnosis code(s)
  • Procedure code(s), if applicable

Step 3 – Submit Your Prior Authorization Request

Some requests are handled by BCBSIL; others are handled by utilization management vendors. As noted above, when you check eligibility and benefits, in addition to confirming if prior authorization is required, you’ll also be directed to the appropriate vendor, if applicable.

For prior authorization requests handled by BCBSIL:

There are different ways to initiate your request.

  • Online – Use BlueApprovRSM to request prior authorization for some services. For instructions, refer to theBlueApprovR UserGuide.
  • Online –RegisteredAvailityusers may useAvaility’s Authorizations tool(HIPAA-standard 278 transaction). For instructions, refer to theAvaility Authorizations User Guide.
  • By phone –Call the prior authorization number on the member’s ID card.

For commercialprior authorization requests handled by Carelon Medical Benefits Management:

Commercial non-HMO prior authorization requests can be submitted to Carelon intwo ways.

  • OnlineThe Carelon Provider Portalis available 24x7.
  • PhoneCall the Carelon Contact Center at 866-455-8415, Monday through Friday, 6 a.m. to 6 p.m., CT; and 9 a.m. to noon, CT on weekends and holidays.

For government programs prior authorization requests handled by eviCore healthcare (eviCore):
Prior authorization requests for our Blue Cross Medicare Advantage (PPO)SM(MA PPO), Blue Cross Community Health PlansSM(BCCHPSM) and Blue Cross Community MMAI (Medicare-Medicaid Plan)SMmembers can be submitted to eviCore in two ways.

  • Online– TheeviCore Web Portalis available 24x7.
  • Phone–Call eviCore toll-free at855-252-1117, Monday through Friday, 7 a.m. to 7 p.m., CT, except holidays.

What happens next?

Once a prior authorization request is received and processed, the decision is communicated to the provider. If you have questions on a request handled by Carelon or eviCore, call the appropriate vendor, as noted above. If you have questions on a request handled by BCBSIL, contact our Medical Management department.

BCBSIL Medical Management

  • Commercial (non-HMO) – 800-572-3089
  • Government Programs – 877-774-8592 (MA PPO); 877-860-2837 (BCCHP); 877-723-7702 (MMAI)

Exceptions and Reminders

  • Performance and Exception Based UM Program (Gold Carding Program) – BCBSIL is waiving certain medical necessity review prior authorization requirements for select inpatient services for those acute care facilities that have consistently exceeded prior authorization performance and quality criteria. The criteria evaluate facility providers on certain UM metrics against national benchmark and other key indicators which are updated yearly. These high-performing acute care facility providers may be eligible to receive automatic approval of up to 3 days for select prior authorization requests. This program excludes Government and Administrative Service contracts.
  • The prior authorization information in this section does not apply to services for our HMO members.For these members, prior authorization is handled by the Medical Group/Independent Practice Association.
  • For behavioral health services, there may be special instructions, forms orsteps to consider.SeetheBehavioral Health Program sectionfor details.
  • If pharmacy prior authorization (PA) program review through Prime Therapeutics is required,physicians maysubmit the uniform PA form. For more information, refer to thePharmacy Programs section.
  • For out-of-area (BlueCard®program) members,if prior authorization is required, use theonline router tool. It will redirect you to pre-service review information on the member’s Home Plan website. For Electronic Provider Access (EPA) details, refer to theBlueCard Program Provider Manual.

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.

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.Carelon Medical Benefits Management is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL.eviCore healthcare (eviCore) is an independent company that has contracted with BCBSIL to provide prior authorization for expanded outpatient and specialty utilization management for members with coverage through BCBSIL. Prime Therapeutics LLC (Prime) is a pharmacy benefit management company. BCBSIL contracts with Prime to provide pharmacy benefit management and other related services. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. BCBSIL makes no endorsement, representations or warrantiesregarding third party vendors and the products or services they offer.

Related Resources

  • Behavioral Health IP PA - IVR Caller Guide
  • Behavioral Health OP PA - IVR Caller Guide
  • Inpatient Preauthorization - IVR Caller Guide
  • Outpatient Preauthorization - IVR Caller Guide
  • Preauthorization: Check Request Status - IVR Caller Guide
Request a prior authorization  |  Blue Cross and Blue Shield of Illinois (2024)

FAQs

How to get prior authorization BCBSIL? ›

There are different ways to initiate your request.
  1. Online – Use BlueApprovRSM to request prior authorization for some services. ...
  2. Online – Registered Availity users may use Availity's Authorizations tool (HIPAA-standard 278 transaction). ...
  3. By phone – Call the prior authorization number on the member's ID card.

What is the phone number for BCBS of Illinois provider authorization? ›

800-972-8088

Do I need a referral to see a specialist with Blue Cross Blue Shield Illinois? ›

A PPO may be a good choice for you because: You don't need a primary care physician (PCP) to coordinate your care. You don't need a referral to see a specialist. You can get care from in-network or out-of-network providers.

How do I contact Availity for prior authorization? ›

How to access and use Availity Authorizations:
  1. Log in to Availity.
  2. Select Patient Registration menu option, choose Authorizations & Referrals, then Authorizations*
  3. Select Payer BCBSOK, then choose your organization.
  4. Select a Request Type and start request.
  5. Review and submit your request.

How can I speed up my prior authorization? ›

16 Tips That Speed Up The Prior Authorization Process
  1. Create a master list of procedures that require authorizations.
  2. Document denial reasons.
  3. Sign up for payor newsletters.
  4. Stay informed of changing industry standards.
  5. Designate prior authorization responsibilities to the same staff member(s).

Why is my insurance asking for a prior authorization? ›

Why does my health insurance company need a prior authorization? The prior authorization process gives your health insurance company a chance to review how necessary a medical treatment or medication may be in treating your condition. For example, some brand-name medications are very costly.

How to speak to someone at Blue Cross Blue Shield of Illinois? ›

Contact Us
  1. 888-802-8776 (inside the U.S.)
  2. 888-206-0244 (outside the U.S.)

Is the blue shield of Illinois the same as the blue cross blue shield? ›

About Blue Cross and Blue Shield of Illinois

BCBSIL is a division of Health Care Service Corporation, a Mutual Legal Reserve Company and an Independent Licensee of the Blue Cross and Blue Shield Association.

What is the phone number for BCBS of Illinois eligibility? ›

For most BCBSIL members, if you cannot submit your eligibility and benefit inquiries online, this information can also be easily obtained through our Interactive Voice Response (IVR) automated phone system at 800-972-8088, available Monday through Friday, 6 a.m. to 11:30 p.m., CT, and Saturday, 6 a.m. to 6 p.m., CT.

How much does Blue Cross Blue Shield cost per month in Illinois? ›

TierCheapest planMonthly cost
BronzeBCBS of IL Blue FocusCare Bronze$290
SilverBCBS of IL Blue FocusCare Silver$379
GoldAetna Gold S$436
PlatinumHealth Alliance Elite Platinum$840
1 more row
Jun 12, 2024

What is the grace period for Blue Cross Blue Shield of Illinois? ›

During the grace period, BCBSIL will: Process claims for services received during the 1st month of the grace period and pend and not process claims for covered services received in the 2nd and 3rd months of the grace period. This means that no payments will be made to your provider until you pay your premium in full.

Does Blue Cross Blue Shield of Illinois cover chiropractic? ›

If a PCP or WPHCP determines medical necessity for the services, the services are covered. Blue Precision HMOSM, BlueCare DirectSM and Blue FocusCareSM members – Chiropractic and Osteopathic manipulations have a 25-visit limit per calendar year.

Why do prior authorizations get denied? ›

Prior authorization requests can be denied or delayed because of seemingly mundane mistakes. A simple mistake could be having the request submitted for a patient named John Appleseed when the health plan member's health insurance card lists the member's name as Jonathan Q.

Can prior authorizations be automated? ›

Automated prior authorizations offer a promising solution to the challenges faced by traditional manual processes. By leveraging technology to streamline workflows and improve efficiency, healthcare providers can enhance patient care and optimize resource utilization.

What does preauthorization request mean? ›

A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary.

How to get an authorization in Availity? ›

Requesting authorizations on Availity* is a simple two-step process. Here's how it works: Submit your initial request on Availity using the Authorization (Precertification) Add transaction. Complete a short questionnaire, if asked, to give us more clinical information.

Is insurance approval the same as prior authorization? ›

A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification.

What is the difference between prior authorization and prescription? ›

Prior authorization is an approval of coverage from your insurance company, not your doctor. It's a restriction put in place to determine whether or not they will pay for certain medicines. It doesn't affect cash payment for prescriptions. Plus it's only required on those prescriptions when billed through insurance.

What is the difference between prior authorization and step therapy? ›

Prior authorization is a requirement by the insurance company to approve certain medications or procedures before they can be covered by insurance, while step therapy is a protocol that requires patients to try a less expensive or lower-risk medication before moving on to more expensive or risky treatments.

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