September 2023
Medical Policy Updates
Approved, new or revised Blue Cross and Blue Shield of Illinois (BCBSIL) Medical Policies and their effective dates are usually posted on our Provider website. Medical policies, both new and revised, are used as guidelines for benefit determinations in health care benefit programs for most BCBSIL members, unless otherwise indicated. These policies may affect your reimbursement and your patients’ benefits.
Although medical policies can be used as a guide, providers serving HMO members should refer to the HMO Scope of Benefits in the BCBSIL Provider Manual, located in the Standards and Requirements section.
You may view active, new, and revised policies, along with policies pending implementation, by visiting the BCBSIL Medical Policy page. Select “View all Active and Pending Medical Policies.” After confirming your agreement with the Medical Policies disclaimer, you will be directed to the Medical Policies homepage.
You also may view draft medical policies that are under development or are in the process of being revised by selecting “View and comment on Draft Medical Policies.” After confirming your agreement with the Medical Policies disclaimer, you will be directed to the Draft Medical Policies page. Click on the title of the draft policy you wish to review, and then select “Comments” to submit your feedback to us.
Visit the Standards and Requirements section of our website for access to the most complete and up-to-date BCBSIL Medical Policy information. You’ll find a Recommended Clinical Review (Predetermination) Code List in the Related Resources on our Recommended Clinical Review (Predetermination) page – this list is updated on a monthly basis. In addition to medical policies, other policies and information regarding payment can be found on the Clinical Payment and Coding Policies page.
The BCBSIL Medical Policies are for informational purposes only and are not a substitute for the independent medical judgment of health care providers. Providers are instructed to exercise their own clinical judgment based on each individual patient’s health care needs. The fact that a service or treatment is described in a medical policy is not a guarantee that the service or treatment is a covered benefit under a health benefit plan. Some benefit plans administered by BCBSIL, such as some self-funded employer plans or governmental plans, may not utilize BCBSIL Medical Policies. Members should contact the customer service number on their member ID card for more specific coverage information.