What is pre-notification?
Generally, pre-notification is the process by which Blue Cross and Blue Shield of Illinois is typically alerted before a member undergoes a course of care such as a hospital admission or a complex diagnostic test.
Pre-notification may be required for some members/services, as specified by the member’s benefit plan. For example:
- Pre-notification through BCBSIL may be required for maternal delivery and some dialysis services,
- Pre-notification requirements specific members/services can be found by checking Eligibility and Benefits (see Step 1 below).
Step 1 – Confirm if Pre-notification is Required
Always check eligibility and benefits first, via Availity® Essentials or your preferred web vendor, prior to rendering care and services. In addition to verifying membership/coverage status and other important details, this step returns information on prior authorization or pre-notification requirements and utilization management vendors, if applicable.
Exceptions and Reminders
- Out-of-area (BlueCard® Program) members: In addition to BCBSIL, other Blue Cross and Blue Shield (BCBS) Plans may have radiology management programs that are tied to member benefits. Always check eligibility and benefits for all BCBS members prior to rendering services to confirm details, including utilization management vendors that must be used, if applicable. For more information, refer to the BlueCard Program Provider Manual.
Checking eligibility and benefits and/or obtaining prior authorization or pre-notification for a service is not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations, and exclusions set forth in the member’s policy certificate and/or benefits booklet and or summary plan description. Certain employer groups may require prior authorization or pre-notification from other vendors for advanced imaging services. If you have any questions, call the number on the member's ID card. Regardless of any prior authorization, pre-notification or benefit determination, the final decision regarding any treatment or service is between the member and their health care provider.
Carelon Medical Benefits Management is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL. 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.