May 2024
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.