Blue Review
A Provider Publication

January 2022

Use Our New Digital Lookup Tool to View Prior Authorization Requirements for Commercial Fully Insured Members

It’s important to check eligibility and benefits prior to providing care and services to Blue Cross and Blue Shield of Illinois (BCBSIL) members. This step helps you confirm coverage and other important information, like prior authorization requirements and utilization management vendors.

In addition to checking eligibility and benefits, you can also use other resources on our Provider website for reference purposes, such as our prior authorization summary and procedure code lists. Recently, we added a new resource to offer a different view of prior authorization requirements that may apply to commercial fully insured non-HMO BCBSIL members.

Using our new digital lookup tool, you can conduct a search by entering a 5-digit procedure code, service description or drug name. The tool returns information for procedures that may require prior authorization through BCBSIL or AIM Specialty Health® (AIM) for commercial fully insured non-HMO members.

To access the digital lookup tool, refer to the Prior Authorization Support Materials (Commercial) page in the Utilization Management section of our Provider website. There are three separate links so you can conduct a search according to the following procedure categories:

  • Medical Procedures (such as surgeries, imaging and other tests)
  • Medical Drugs (drugs under the member’s medical benefit)
  • Behavioral Health Services (psychological testing, counseling, psychiatric care, etc.)

Searches must be conducted according to the appropriate category. Using the tool to search in the Medical Procedures category will not reflect prior authorization information for Medical Drugs or Behavioral Health Services.

While not included in the digital lookup tool, some services always require prior authorization, such as inpatient facility admissions. Refer to our commercial prior authorization summary for more details.

The digital lookup tool is intended for reference purposes only. Information provided is not exhaustive and is subject to change. Always check eligibility and benefits through the Availity® Provider Portal or your preferred web vendor before rendering services. This step will help you confirm prior authorization requirements and utilization management vendor information, if applicable.

Don’t forget: For commercial non-HMO members, if prior authorization isn’t required, you may still want to submit a voluntary predetermination request. See our Predetermination page for more information on when and how to submit predetermination requests. This page also includes helpful resources, like our Medical Policy Reference List.

Checking eligibility and benefits and/or obtaining prior authorization is not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations, and exclusions set forth in the member’s policy certificate and/or benefits booklet and or summary plan description. 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. If you have any questions, call the number on the member's BCBSIL ID card.

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. 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 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 or AIM.