December 2021

Prior Authorization Reform Act (Applies to Fully Insured Non-HMO and Illinois Medicaid Plans Only)

The Prior Authorization Reform Act (House Bill 711) was signed into Illinois law on Aug. 19, 2021. The new law takes effect as of Jan. 1, 2022. It applies to Illinois-regulated fully insured health insurance plans, including Medicaid. It does not apply to federally regulated ERISA* self-funded Administrative Services Only (ASO) plans or Medicare.

Brief Summary: 2021 Illinois House Bill 711 establishes prior authorization standards that health insurers must follow when requiring prior authorization for coverage of health care services, including, but not limited to, notification requirements for non-urgent circumstances, urgent health care services and emergency health care services; the timeframes in which to review prior authorization requests; the qualifications of health care professionals who can review prior authorization requests, issue adverse benefit determinations and review appeals; and length of time an approved prior authorization is valid. The legislation also applies the emergency services coverage provisions and the post-stabilization coverage provisions currently applicable to PPO plans; and makes other technical changes.

Applicable Plans: Blue Cross and Blue Shield of Illinois (BCBSIL) is making necessary changes for adherence with all Illinois state-mandated requirements. These changes will only affect the prior authorization review process for services for our fully insured non-HMO members, including Illinois Medicaid [Blue Cross Community Health Plans^SM (BCCHP^SM) and Blue Cross Community MMAI (Medicare-Medicaid Plan)^SM]. Changes will not apply to prior authorizations for any of our commercial HMO members, Medicare Advantage members, or members with self-funded ASO employer groups.

What’s not changing?

There are no changes to prior authorization review processes for BCBSIL members with any of our commercial HMO, Medicare Advantage or self-funded ASO plans. All prior authorization review processes currently in place for these members will remain the same.
The process for submitting initial prior authorization requests isn’t changing for any of our members. For all BCBSIL members, always check eligibility and benefits first via the Availity^® Provider Portal or your preferred web vendor before rendering care and services. This step helps you confirm prior authorization requirements and utilization management vendors, if applicable.

Quick Tip: How to Identify ASO Members
Providers can view, download and print most members’ electronic BCBSIL ID cards by completing an eligibility and benefits inquiry through Availity. The BCBSIL ID card for ASO group members includes a note on the back to specify that, for these members, BCBSIL provides claims processing only and assumes no financial risk for claims. This wording does not appear on fully insured member ID cards.

BCBSIL is continuing to review all requirements to ensure ongoing compliance. We’re also assessing ways we can help clarify further for providers, such as within the Utilization Management section of the BCBSIL website. Watch the News and Updates and Blue Review for more information as it becomes available.

*Self-funded health plans are governed by the Employee Retirement Income Security Act of 1974 (ERISA).

The information provided above is only intended to be a brief summary of legislation that has been proposed or laws that have been enacted and is not an exhaustive description of the law or a legal opinion of such law. This material is for informational purposes only and is not legal advice. If you have any questions regarding this legislation, you should consult with your legal advisor.

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. 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. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity.