Prior Authorization

Blue Cross and Blue Shield of Illinois Medical Policies are based on scientific and medical research. They are often used as a guide to decide what is covered by a health plan. These policies can relate to topics such as:

• Medical procedures
• Treatments
• Drugs
• Devices

BCBSIL puts these policies online. Medical Policies are not medical advice or care. They do not promise any results. BCBSIL does not give medical advice. BCBSIL does not provide health care. Independent health care providers are responsible for:

• Diagnosis
• Treatment
• Medical advice

Members may talk about Medical Policies with their health care providers. You should always talk to your providers about any health questions or concerns. Review Medical Policies.

BCCHP has strict rules about how decisions are made about your care. Our doctors and staff make decisions about your care based only on need and benefits. There are no rewards to deny or promote care. BCCHP does not encourage doctors to give less care than you need. Doctors are not paid to deny care.

You can talk with BCCHP about our utilization management (UM) process. UM means we look at medical records, claims, and prior authorization requests. This is to make sure that treatments are medically necessary. We check that services are provided in the right setting. We also look to make sure the treatment is consistent with the condition reported. If you want to know more about this process or how decisions are made about your care, contact us. Call Member Services at 1-877-860-2837 (TTY/TDD: 711).

BCCHP wants to be sure you understand our prior authorization program. Check our helpful glossary of terms.

Your doctor will use the documents below to figure out what treatments need to be approved. BCCHP also keeps track for your doctor when a service is added or removed from needing an approval. This is done through a procedure code list change log. You can check documents used by your doctor below.

• Service Authorization Program Summary
• Prior Authorization Code List
• Procedure Code List Change Log

You will get an “Adverse Benefit Determination” letter from us if: 

• We decide that a requested service or item cannot be approved, or 
• A service is reduced or stopped. 

An adverse benefit determination is when a newly requested benefit or benefit currently being provided to a member is denied, reduced, has limited approval, suspended, or ended. These include decisions based on:

• Type or level of service
• Medical necessity criteria or requirements
• Appropriateness of setting
• Effectiveness of a service

You can file an appeal if BCBSIL decides that a service cannot be approved, or if a service is reduced, stopped or ended. Learn more about our appeal process.