January 2023
Check Eligibility and Benefits: Don’t skip this important first step!
Is your patient’s membership with Blue Cross and Blue Shield of Illinois (BCBSIL) still active? Are you or your practice/medical group in- or out-of-network for a specific patient? Is prior authorization required for a particular member/service?
Get Answers Up Front
Benefits will vary based on the service being rendered and individual and group policy elections. It’s critical to check eligibility and benefits for each patient before every scheduled appointment. Eligibility and benefit quotes include important information about the patients’ benefits, such as membership verification, coverage status and applicable copayment, coinsurance and deductible amounts. Also, the benefit quote may include information on applicable prior authorization or pre-notification requirements.* When services may not be covered, you should notify members that they may be billed directly.
Don’t Take Chances
Ask to see the member’s BCBSIL ID card for current information. Also ask for a driver’s license or other photo ID to help guard against medical identity theft. Remind your patients to call the number on their BCBSIL card if they have questions about their benefits.
Use Online Options
We encourage you to check eligibility and benefits via an electronic 270 transaction through Availity® Essentials or your preferred vendor portal. You can conduct electronic eligibility and benefits inquiries for local BCBSIL member, and out-of-area Blue Plan and Federal Employee Program® (FEP®) members.
Learn More
For more information, such as an Availity user guide, refer to the Eligibility and Benefits page on our Provider website. BCBSIL also offers educational webinars with an emphasis on electronic transactions, including eligibility and benefits inquiries. Refer to the Webinars and Workshops page for upcoming dates, times and registration links to sign up now.
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*Note: For commercial non-HMO members, even if prior authorization isn’t required, you still may want to submit an optional request for recommended clinical review (predetermination). This step can help avoid post-service medical necessity review. Checking eligibility and benefits can’t tell you when to request recommended clinical review (predetermination), since it’s optional. But there’s a Medical Policy Reference List on our Recommended Clinical Review (Predetermination) page to help you decide. |
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 and services they offer.
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 their health care provider.