Blue Review
A Provider Publication

August 2021

Prior Authorization Code Updates for Some Commercial Members, Effective Oct. 1, 2021

What’s changing?
Blue Cross and Blue Shield of Illinois (BCBSIL) is changing prior authorization requirements that may apply to some commercial, non-HMO members. Here’s a summary of changes:

  • Oct. 1, 2021 – Adding Genetic Testing Current Procedural Terminology (CPT®) codes to be reviewed by AIM Specialty Health® (AIM)
  • Oct. 1, 2021 – Removing Nasal and Sinus Surgery codes previously reviewed by BCBSIL
  • Oct. 1, 2021 – Removing a Specialty Pharmacy code previously reviewed by BCBSIL 
  • Oct. 1, 2021 – Removing an Orthopedic Musculoskeletal code previously reviewed by BCBSIL  

More Information
Refer to the Utilization Management section of our Provider website. Updated procedure code lists are posted on the Support Materials (Commercial) 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.

Even if prior authorization isn’t required for a commercial non-HMO member, you may still want to submit a voluntary predetermination request. This step can help avoid post-service medical necessity review. Checking eligibility and benefits can’t tell you when to request predetermination since it’s optional, but there’s a Medical Policy Reference List on our Predetermination page to help you decide. 

Note: Services performed without required 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.