June 2022
Prior Authorization Reform: New Resources on Our Website
In December 2021, we published an introductory article about the Prior Authorization Reform Act (House Bill 711). We included a summary of the bill and alerted you we’d be making necessary changes to some prior authorization (PA) review processes for services provided to our fully insured commercial non-HMO and Illinois Medicaid [Blue Cross Community Health PlansSM (BCCHPSM) and Blue Cross Community MMAI (Medicare-Medicaid)SM] members.
In our December article, we also emphasized what’s not changing related to HB 711, like the PA review process for members with commercial HMO, Medicare Advantage or self-funded Administrative Services Only (ASO) plans* and the process for submitting PA requests, which remains the same.
What’s new?
Necessary changes related to HB 711 were implemented as of Jan. 1, 2022; we've made additional updates to ensure adherence with all Illinois-state mandated requirements. These changes are reflected in new resources on two pages in the Utilization Management section of our Provider website.
Commercial PA Support Materials
You’ll still find PA summaries and code lists on our Prior Authorization Support Materials (Commercial) page. In January 2022, we updated this page with links to our new PA digital lookup tool for fully insured members. More recently, we added these features:
- Clinical Review Criteria – View BCBSIL and vendor guidelines that may apply.
- PA Statistical Data – View approval and denials stats associated with PA requests for the previous calendar year. There are reports in four categories: medical, medical drugs, behavioral health, and pharmaceutical drugs.
Government Programs PA Support Materials
The PA summaries on our Prior Authorization Support Materials (Government Programs) page will look familiar, but, when you view our updated Medicaid code lists, you’ll notice some new details, like medical policy information and effective dates. We've also added Clinical Review Criteria so you can view BCBSIL and vendor guidelines that may apply.
Need more information?
Our Utilization Management section has resources to help you navigate the PA process from start to finish. Go to the Prior Authorization page for an introduction, with links to process overview maps for commercial and government programs. This page also gives you step-by-step instructions that spotlight online options, like the Availity® Authorizations tool.
We want to make it easier for you to work with us. Continue to watch the Blue Review and News and Updates for announcements and related resources. If you have comments, feedback, or questions, contact your assigned Provider Network Consultant (PNC). We’re here to help!
The information in the Utilization Management section doesn’t apply to any of our HMO members.
*Self-funded health plans are governed by the Employee Retirement Income Security Act of 1974 (ERISA).
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. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors.