Prior AuthorizationSome services require prior authorization (preauthorization) before they are performed. Obtaining a prior authorization helps us pay claims faster with no denied charges, or unexpected costs to our members. Show
Urgent/emergency admissions do not require prior authorization. Once notified of admission, medical information is applied against InterQual® criteria for level of care review. Please follow these steps for Commercial and Medicare Advantage members. Important to note:
How Does it Work?1. Find out if a code needs prior authorization. Check whether a service requires preauthorization by consulting our online Code and Commenttool. You will need to log in. Using Code and Comment:
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Submit a prior authorization Reviewed by our partners Prior authorization requests for the following services are reviewed by our partners. This includes: 3. Review your request status/decision online Once a request is submitted, you can visit HealtheNet to check the status of a prior authorization. For pharmacy, call customer service for pharmacy benefit drugs. Call Provider Services for medical benefit drugs (customer service representatives can also transfer to the correct department for member-friendly experience if needed). You and your patient will be notified once your request has been reviewed and a decision has been made.
Time frames and NotificationsNon-urgent care
Urgent care
Concurrent Care (not applicable for Pharmacy)
Post-Service
*Please note, Medicare Part D post-service decisions will be made within 14 calendar days (delegated to ESI); Medicare Part B within 60 calendar days. BlueCross BlueShield of Illinois’s Preferred Method for Prior Authorization RequestsOur electronic prior authorization (ePA) solution provides a safety net to ensure the right information needed for a determination gets to patients' health plans as fast as possible. Improving efficiencies without sacrificing the essentials
How it worksThree Easy steps to completing requests electronically
Want to learn more? Join a webinar. “ No hold times. We know PA requests are complex. That's why we have a team of experts and a variety of help resources to make requests faster and easier. LET’s GET STARTED
1 - CoverMyMeds Provider Survey, 2019 2 - Express Scripts data on file, 2019 Does Illinois Medicaid require prior authorization?Some prescriptions and over-the-counter medicines require prior authorization for Medicaid reimbursement. Depending upon the drug, either the prescribing physician or the dispensing pharmacist may submit the request.
Does BCBS of Illinois require prior authorization?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.
Is Blue Cross of Illinois Medicaid?The Centers for Medicare & Medicaid Services (CMS) and the State of Illinois have contracted with Blue Cross and Blue Shield of Illinois (BCBSIL) along with other Managed Care Organizations (MCO) to implement Medicaid to all counties in Illinois.
How do I submit a prior authorization to availity?How to access and use Availity Authorizations:. Log in to Availity.. Select Patient Registration menu option, choose Authorizations & Referrals, then Authorizations*. Select Payer BCBSOK, then choose your organization.. Select a Request Type and start request.. Review and submit your request.. |