Blue Review
A newsletter for contracting institutional and professional providers

June 2021

Current Procedural Terminology (CPT®) Code Updates for Prior Authorization for Some Commercial Members

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.

A summary of changes is as follows:

  • April 16, 2021 – Removed Sleep Medicine/Durable Medical Equipment (DME) CPT code previously reviewed by AIM Specialty Health® (AIM)
  • July 1, 2021 – Adding Select Outpatient Services code to be reviewed by BCBSIL
  • July 1, 2021 – Removing Advanced Imaging code previously reviewed by AIM
  • July 1, 2021 – Removing Advanced Imaging code previously reviewed by AIM
  • July 1, 2021 – Removing Genetic Testing codes previously reviewed by AIM

More Information
Refer to the Utilization Management section of our Provider website for the updated Commercial Outpatient Medical Surgical Prior Authorization Code List. It’s available 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.

Services performed without required prior authorization or that don’t meet medical necessity criteria may be denied for payment and the rendering provider may not seek reimbursement from the member.

CPT copyright 2020 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

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. If you have any questions, call the number on the member's ID card.

AIM Specialty Health (AIM) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL. 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. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.