Pre-service Requirements: Precertification and Predetermination of Benefits

Precertification, (also referred to as: pre-notification) is the process of determining medical necessity and appropriateness of the physician’s plan of treatment. Most BCBSIL PPO and POS contracts require that either the member or provider notify the plan and receive prior approval from our Medical Services Advisory (MSA) Department for inpatient hospital admissions, including the following services:

• Acute, inpatient rehabilitation
• Skilled nursing
• Long-term acute care
• Inpatient hospice (some groups)
• Many groups also require pre-notification for Coordinated Health Care, i.e., skilled nursing visits, IV medication, etc.

Note: For mental health admissions and chemical dependency services, the member should contact the telephone number that is usually listed on the back of their ID card.

Although most employer groups do not require pre-notification for outpatient services, there may be some who do. Contact our Provider Telecommunications Center at (800) 972-8088 to determine if pre-notification is required. If it is, call our MSA Department to make the request. Contact information and time frames for notification are listed on the back of the member’s BCBSIL ID card.

You may pre-notify BCBSIL on behalf of PPO and POS members, but you are responsible for pre-notification for the following products:

• Community Participating Option (CPO)
• Blue Advantage/Blue Advantage Entrepreneur (BAE) PPO
• Blue Print
• BlueChoice Select
• FEP (Federal Employees Program)

For HMO members, it is the responsibility of the member’s physician to notify their Medical Group/IPA for inpatient hospital admissions.

iExchange for Providers 
BCBSIL also offers iExchange, an online pre-notification and case management tool for facility and professional providers. To schedule a demonstration, please contact your Network Consultant.

Predetermination of Benefits
Predetermination of benefits is a written request for verification of benefits prior to services being rendered. Predetermination approvals and denials are based on medical policy provisions. A predetermination approval does not guarantee payment for services, since benefits are also subject to eligibility and coverage limitations at the time services are rendered. A predetermination of benefits is recommended when the service could be considered experimental, investigational, or cosmetic. Medical policies located on BCBSIL’s Web site may also be used as a guideline.

Fax all predetermination of benefit requests to BCBSIL at (800) 852-1360, with the exception of high-tech imaging services.

Predeterminations for High Tech Imaging Services
When high-tech imaging services are performed in an office, an outpatient department of a hospital or a free-standing imaging center, the ordering physician must contact American Imaging Management (AIM) to obtain a Radiology Quality Initiative (RQI) number. AIM should be contacted prior to scheduling an imaging exam for BCBSIL PPO and BlueChoice Select members who need the following services:

• CT and CTA scans
• MRI and MRA scans
• Nuclear cardiology studies
• Pet scans – Enhancement to the program: If an RQI number is issued by AIM, no further predetermination will be necessary. However, if AIM cannot issue the RQI, they will direct you back to BCBSIL for the normal predetermination process.

You should always verify eligibility and benefits prior to rendering services. To request an RQI number, the ordering physician can use AIM’s interactive Web site by registering at www.americanimaging.net.  You can also contact AIM’s Call Center toll-free at (866) 455-8415, Monday through Friday, 8:30 a.m. to 6 p.m. (CST).

Note: The RQI program is not a substitute for the pre-notification/precertification process.