August 2023

Marking Non-Urgent Prior Authorization Requests as ‘Urgent’ Only Causes More Delays

We’ve seen an increase in prior authorization requests marked by submitters as urgent or expedited. Some of these “urgent” requests are for non-urgent situations.

When is it appropriate to mark requests urgent or expedited?
An urgent or expedited prior authorization request, for Blue Cross and Blue Shield of Illinois (BCBSIL) members, is appropriate only for a situation that, when delayed:

• Could seriously jeopardize the life and health of the member or the member’s ability to regain maximum function.
• Would subject the member to severe pain that cannot be adequately managed without the requested care or treatment.
• Would subject the member to adverse health consequences without the care or treatment that is the subject of the request.

What happens when non-urgent requests are marked urgent?
When non-urgent requests are marked urgent, they can overburden the review process by taking precedence over standard requests. The resulting backlog can affect response times, causing potential delays for truly urgent requests.

How To Help Prevent Delays
Always check eligibility and benefits first through Availity^® Essentials or your preferred vendor. This step helps you confirm prior authorization requirements and utilization management vendors, if applicable. When submitting prior authorization requests for BCBSIL members, include the appropriate documentation and level of urgency.

For more information on prior authorization, including code lists and a digital lookup tool, refer to our Utilization Management section.

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.

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 third party vendors and the products or services they offer.