Prior Authorization

What is prior authorization?

Prior authorization (sometimes called preauthorization or pre-certification) is a pre-service utilization management review. Prior authorization is required for some members/services/drugs before services are rendered to confirm medical necessity as defined by the member’s health benefit plan. A prior authorization is not a 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 on our 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 do not get prior approval via the prior authorization process for services and drugs on our prior authorization lists:

  • The service or drug may not be covered, and the ordering or servicing provider will be responsible.
  • We may conduct a 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.
  • For Medicare and Medicaid members, 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 are three steps providers should 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 the Availity® Essentials or 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, but we also have other resources to help you prepare. To view requirements summaries and procedure code lists, refer to the Support Materials (Commercial) and Support 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.

For commercial prior authorization requests handled by Carelon Medical Benefits Management:

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

  • Online – The Carelon Provider Portal is available 24x7.
  • Phone – Call 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)SM members can be submitted to eviCore in two ways.

  • Online – The eviCore Web Portal is available 24x7.
  • Phone – Call eviCore toll-free at 855-252-1117, 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 or steps to consider. See the Behavioral Health Program section for details.
  • If pharmacy prior authorization (PA) program review through Prime Therapeutics is required, physicians may submit the uniform PA form . For more information, refer to the Pharmacy Programs section.
  • For out-of-area (BlueCard® program) members, if prior authorization is required, use the online 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 the BlueCard 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 warranties regarding third party vendors and the products or services they offer.

 

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