Blue Review
A newsletter for contracting institutional and professional providers

September 2019

Reminder: Verify Procedure Code Benefit Preauthorization Requirements Online

In a December 2018 News and Updates notice, we announced a new online capability that allows providers to verify benefit preauthorization requirements for specific Current Procedural Terminology (CPT®) or Healthcare Common Procedure Coding System (HCPCS) codes via an eligibility and benefits inquiry in the Availity® Provider Portal. Since implementation, many updates have been made to improve articulation.

How to Receive Accurate Results
To ensure code-specific benefit preauthorization requirements are returned online, valid CPT/HCPCS code(s)* and associated place of service must be submitted in the electronic eligibility and benefits inquiry (270). If a CPT/HCPCS code is not entered, then the place of service and benefit/service type are required. If a benefit/service type is not selected, the place of service and at least one CPT/HCPCS code are required. Additionally, no benefit or benefit preauthorization information will return for the benefit/service type if one is not selected.

The eligibility and benefit inquiry response (271) displays benefit preauthorization requirements in the Pre-Authorization Info tab. In some instances, providers may receive a “Auth Info Unknown” response for the requested benefit/service type. If benefit preauthorization is required or unknown, contact information for completing the request and other important details are included.

As a reminder, the CPT/HCPCS code inquiry option is for benefit preauthorization determination only and is not a code-specific quote of benefits.

Exceptions
Online code-specific benefit preauthorization information is not yet available for the following Blue Cross and Blue Shield of Illinois (BCBSIL) members:

  • Federal Employee Program® (FEP®)
  • Blue Cross Medicare Advantage (HMO)SM and Blue Cross Medicare Advantage (PPO)SM
  • Blue Cross Community MMAI (Medicare-Medicaid Plan)SM and Blue Cross Community Health PlansSM

Resources
Learn how to successfully verify benefit preauthorization requirements for benefits and procedure online by referencing the General Eligibility and Benefits Expanded Tip Sheet. For additional assistance, contact the Provider Education Consultants at PECS@bcbsil.com.