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for Providers

May 2024

Use Our New Form for Anti-VEGF Intravitreal Injection Therapy Verification

Blue Cross and Blue Shield of Illinois reviews voluntary requests for pre-service recommended clinical review (previously, predetermination) of anti-VEGF (vascular endothelial growth factor) intravitreal injections for certain conditions of the eye when services are proposed for our commercial non-HMO and Federal Employee Program® members. BCBSIL offers the RCR process as a voluntary pre-service option that can help you avoid unexpected claim denials.

For the services referenced above, RCR determinations are made based on medical necessity criteria outlined in the following medical policies:*

To help ensure we receive all necessary information to support your voluntary RCR request, a new Anti-VEGF Intravitreal Injection Therapy Verification Form is available on our Provider website. The purpose of this form is to help you prepare, prior to submitting a voluntary RCR request to BCBSIL.

Our therapy verification form includes detailed instructions and a Provider Questionnaire. Think of it as a worksheet to help clarify your request and expedite the RCR process.

Please refer to the applicable medical policy for specific coverage criteria.

Reminders and Related Resources
Submitting a voluntary RCR request doesn’t replace checking eligibility and benefits.

If there’s an adverse RCR determination (pre-service), you’ll receive a letter from BCBSIL with more information. You’ll have the option to request a peer-to-peer discussion or file an appeal. The member also will receive a letter. If a claim is denied (post-service), the notification process and options are the same.

For more information, refer to the Recommended Clinical Review page in our Utilization Management section.

The RCR process isn’t available for government programs (Illinois Medicaid and Medicare Advantage) or any of our commercial HMO members.

*The above list of medical policies may change. Check the website for any other policies that may apply.

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Checking eligibility and/or benefit information, obtaining prior authorization or the fact that a recommended clinical review (predetermination) decision has been issued 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. Regardless of any prior authorization or recommended clinical review (predetermination), the final decision regarding any treatment or service is between the patient and the health care provider.

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.  

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.