Blue Review
A Provider Publication

August 2021

Government Programs Prior Authorization Update: Code Changes, Effective Oct. 1, 2021

What’s Changing: Blue Cross and Blue Shield of Illinois (BCBSIL) is changing prior authorization (PA) requirements for Blue Cross Medicare Advantage (PPO)SM (MA PPO), Blue Cross Community Health PlansSM (BCCHPSM) and Blue Cross Community MMAI (Medicare-Medicaid Plan)SM members. 

 As a reminder, for some services/members, prior authorization may be required through BCBSIL. For other services/members, BCBSIL has contracted with eviCore healthcare (eviCore) for utilization management and related services.

A summary of Current Procedural Terminology (CPT®) changes, effective Oct. 1, 2021, is included below. 

MA PPO, BCCHP and MMAI

Code

Change

Effective Date

Send PA requests to:

0250U Added 

Oct. 1, 2021 eviCore
0252U Added  Oct. 1, 2021 eviCore
0253U Added 

Oct. 1, 2021 eviCore
0254U Added  Oct. 1, 2021 eviCore
J1427 Added 

Oct. 1, 2021 eviCore
J9037 Added  Oct. 1, 2021 eviCore
J9144 Added 

Oct. 1, 2021 eviCore
J9223 Added  Oct. 1, 2021 eviCore
J9281 Added 

Oct. 1, 2021 eviCore
J9316 Added  Oct. 1, 2021 eviCore
J9317 Added 

Oct. 1, 2021 eviCore
J9349 Added  Oct. 1, 2021 eviCore
Q5122 Added 

Oct. 1, 2021 eviCore
J7352 Added  Oct. 1, 2021 eviCore
S0013 Added 

Oct. 1, 2021 eviCore
J1554 Added  Oct. 1, 2021 eviCore
J1823 Added 

Oct. 1, 2021 eviCore

For More Information:  For More Information: Refer to the Utilization Management section. Updated MA PPO and Illinois Medicaid (BCCHP and MMAI) procedure code lists are posted on the Support Materials (Government Programs) page.

Important Reminders
Always check eligibility and benefits first through the Availity® Provider Portal or your preferred vendor portal, prior to rendering services. This step will confirm prior authorization requirements and utilization management vendors, if applicable.

If prior authorization is required, services performed without prior authorization or that do not meet medical necessity criteria may be denied for payment and the rendering provider may not seek reimbursement and or balance bill the member. Avoid post-service medical necessity reviews and delays in claim processing by obtaining prior authorization before rendering services.