Utilization Management

Utilization management is at the heart of how you access the right care, at the right place and at the right time. It includes:

• Prior Authorization
• Recommended Clinical Review (Predetermination)
• Post-service reviews

We use evidence-based clinical standards of care to make sure you get the health care you need.

What Is Prior Authorization?

Sometimes you may need to get approval from Blue Cross and Blue Shield of Illinois before we will cover certain inpatient, outpatient and home health care services and prescription drugs. This is called prior authorization, preauthorization, pre-certification or prior approval. These terms all refer to the requirements that you may need to meet before treatment may begin.

Who Requests Prior Authorization?

Usually, your health care providers will take care of prior authorization before they perform a service. But, it’s always a good idea to check if your providers have the needed approval.

If your providers aren’t in-network, you’ll be responsible for getting the prior authorization. If you don’t, we may not cover the cost. To make sure your provider is in-network, check our find care tool.

You or your provider can request a renewal of a prior authorization up to 60 days before it expires.

BCBSIL contracts with outside vendors, including Carelon Medical Benefits Management® (Carelon), eviCore® healthcare and Magellan Healthcare for certain prior authorization services.

How You Can Request Prior Authorization

Check with us to find out if your provider has requested prior authorization before you get any services.

If your health care provider has not requested prior authorization, you can request it. Call the number listed on your BCBSIL member ID card. Our Customer Service will help you begin the process.

What Happens During the Prior Authorization Process?

BCBSIL reviews the requested service or drug to find out if it’s medically necessary and appropriate for your needs. This review does not replace the advice of your provider.

We need the following information to complete a prior authorization request:

• Your name, subscriber ID number and date of birth
• Your provider’s name, address and National Provider Identifier (NPI)
• Information about your medical or behavioral health condition
• The proposed treatment plan, including any diagnostic or procedure codes (your provider can help you with these)
• The date you’ll receive service and the estimated length of stay (if you are being admitted)
• The place you’re being treated

Do You Need Prior Authorization?

Digital Lookup Tool: Use our digital lookup tool to find out if prior authorization is required for fully insured members.* Start your search by choosing one of the 3 categories shown below.

Summary and Code Lists: Use the links below to review the full list of services and drugs that require prior authorization, click below to download a copy of the spreadsheet.

• 2024 Commercial Prior Authorization Requirements Summary
• 2023 Commercial Prior Authorization Requirements Summary
• 2024 Commercial Outpatient Medical Surgical Prior Authorization Code List
  
• 2023 Commercial Outpatient Medical Surgical Prior Authorization Code List
• 2024 Commercial Specialty Pharmacy Prior Authorization Drug List
• 2023 Commercial Specialty Pharmacy Prior Authorization Drug List  
• 2024 Commercial Outpatient Behavioral Health Prior Authorization Code List
• 2023 Commercial Outpatient Behavioral Health Prior Authorization Code List
• Summary/Code List Archive

Pharmacy Prior Authorization: Prime Therapeutics reviews prior authorization requests from physicians for BCBSIL members with prescription drug coverage. For requirements and related information, review our prior authorization/step therapy program list. 

Clinical Review Criteria: Utilization management reviews use evidence-based clinical standards of care to help determine whether a benefit may be covered under the member’s health plan. Use the links below to view BCBSIL and vendor guidelines that may apply.

• BCBSIL – Medical Policies
  
• BCBSIL – Clinical Payment and Coding Policies
• Carelon Clinical Appropriateness Guidelines
• MCG^TM Care Guidelines (members can read the guidelines by logging in to Blue Access for Members^SM)
• Prime Therapeutics

Prior Authorization Statistics: We keep track of how many requests for prior authorization we receive each year. This includes how many requests we approve and deny. 

Use the links below for an overview of prior authorization statistics for previous calendar year(s).

Medical Data History

• Medical Prior Authorization Data (Excel file)

Medical Drug Data History

• Medical Drug Prior Authorization Data (Excel file)

Behavioral Health Data History

• Behavioral Health Prior Authorization Data (Excel file)

Pharmaceutical Drug Data History

• Pharmaceutical Drug Prior Authorization Data (Excel file)

Government Programs: The prior authorization requirements and clinical review criteria above are specific to commercial fully insured members. Separate information is available for our government programs members.

Illinois Medicaid members: If you’re a Blue Cross Community Health Plans^SM (BCCHP) member, review the BCCHP Prior Authorization page for details. If you’re a Blue Cross Community MMAI (Medicare-Medicaid Plan)^SM member, review the MMAI Medical Benefits page.

What Is Recommended Clinical Review (Predetermination)?

• This is an option for utilization management review before having services.  
• Some services not requiring prior authorization may be reviewed for medical necessity before a claim is paid. 
• This review may be used if you are not sure about coverage or whether we may not consider it medically necessary.
• You will work with your provider to submit a request for recommended clinical review (predetermination). 

To find out if this review is available for a specific service, check the Recommended Clinical Review List (predetermination).  BCBSIL updates this list when services are added or removed.  You can also call BCBSIL Customer Service at the number on your member ID card.      

Recommended clinical review (predetermination) is not a guarantee of benefits.  Actual availability of benefits is subject to eligibility and the other terms, conditions, limitations, and exclusions under your benefit booklet.

What Is Post-Service Utilization Management Review?

A post-service utilization management review happens after you receive a service. During this review, we check whether a service or drug was medically necessary and covered under your health plan. We may ask your provider for more information.

We may also conduct a post-service utilization management review if you or your provider does not get a required prior authorization before you receive services.

*Not sure if you’re fully insured? Check with your HR department or benefits administrator. If you aren’t fully insured, check your benefit booklet to review your list of services that require prior authorization. If you still have questions, call the Customer Service number listed on your BCBSIL member ID card.

Carelon Medical Benefits Management (Carelon) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL.

eviCore healthcare (eviCore) is an independent company that has contracted with BCBSIL to provide prior authorization for expanded outpatient and specialty utilization management for members with coverage through BCBSIL. 

Prime Therapeutics LLC (Prime) is a pharmacy benefit management company. BCBSIL contracts with Prime to provide pharmacy benefit management and other related services. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime.

The ASAM Criteria^®, ©2021 American Society of Addiction Medicine. All rights reserved.

MCG (formerly Milliman Care Guidelines) is a trademark of MCG Health, LLC (part of the Hearst Health network), an independent third party vendor.

BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors.