What is recommended clinical review (predetermination)?
A recommended clinical review (formerly called predetermination) is a medical necessity review conducted before services are provided.
Submitting the request prior to rendering the services is optional and informs the provider and member of situations where a service may not be covered based upon medical necessity. You can find a list of services for which recommended clinical review is available on our Recommended Clinical Review (Predetermination) Code List.
- Recommended clinical review isn’t a different process and won’t generate a different result than a predetermination.
- There’s no penalty if a provider doesn’t elect to use the recommended clinical review process, but the service will be subject to post-service review.
- Submitting a recommended clinical review (predetermination) doesn’t guarantee services will be covered under the member’s benefit plan. The terms of the member's plan control the available benefits.
The recommended clinical review (predetermination) process isn’t available for government programs (Illinois Medicaid and Medicare Advantage) or any of our commercial HMO members.
*Note: A request for recommended clinical review (predetermination) doesn’t replace checking eligibility and benefits. See Step 1 below for details.
Who requests a recommended clinical review (predetermination)?
Recommended clinical review (predetermination) requests may only be submitted by providers.
Why obtain recommended clinical review (predetermination)?
The recommended clinical review (predetermination) process is a service Blue Cross and Blue Shield of Illinois offers so you can submit your claims with confidence. This review process helps confirm that the proposed services are in alignment with BCBSIL Medical Policy, American Society of Addiction Medicine (ASAM) or MCGTM Care Guidelines criteria medical and behavioral health before services are provided.
Once a decision has been made on the services reviewed as part of the recommended clinical review (predetermination) request, the same services will not be reviewed again for medical necessity on a retrospective basis.
Submitted claims for services not included as part of a request for recommended clinical review (predetermination) may be reviewed retrospectively.
Providers and members will be notified of the outcome and will have the opportunity to appeal an adverse determination if the recommended clinical review determines the proposed service doesn’t meet medical necessity.
When and how should recommended clinical review (predetermination) requests be submitted?
In general, there are three steps providers should follow.
Step 1 – Check Eligibility and Benefits
Remember, member benefits and review requirements/recommendations can vary based on service rendered and individual/group policy elections. Always check eligibility and benefits first through Availity® Essentials or your preferred vendor portal for each patient at every visit.
- Checking eligibility and benefits doesn’t provide a recommendation on when to submit a recommended clinical review (predetermination) request. But it helps you identify prior authorization requirements and utilization management vendors, if applicable.
- If prior authorization is required for a service/drug, recommended clinical review (predetermination) isn’t necessary.
Step 2 – Decide if You Want To Request Recommended Clinical Review (Predetermination)
If you’ve checked eligibility and benefits and prior authorization isn’t required, your next step is to assess if submitting a recommended clinical review (predetermination) request may be a good idea.
- You can find a list of services for which recommended clinical review (predetermination) is available on our Recommended Clinical Review (Predetermination) Code List.
- The Recommended Clinical Review (Predetermination) Code List helps identify recommended clinical review (predetermination) candidates – it includes codes/services that are subject to medical necessity review, based on our medical policies. (Note: This list isn’t an exhaustive list of all codes. Codes may change and this list may be updated throughout the year.)
- Quick Tip: Check the Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU) policy, which is one of our Clinical Payment and Coding Policies (CPCPs). Codes listed in the EIU CPCP aren’t covered for most members. (If you have benefit questions, call the number on the member’s BCBSIL ID card.)
Step 3 – Submit Your Recommended Clinical Review (Predetermination) Request
If you’ve decided you’d like to obtain recommended clinical review (predetermination), there are three ways to submit your request:
- Online – Use BlueApprovRSM to submit requests for recommended clinical review to BSBSIL for some inpatient and/or outpatient, medical and surgical services and specialty pharmacy drugs. Electronic options are preferred to help expedite your request.
- Online – Use the Availity Attachments tool to quickly submit recommended clinical review (predetermination) requests to BCBSIL via the Availity Portal. Electronic options are preferred to help expedite your request.
- By Fax – If you don’t have online access, you may download, complete and fax the Recommended Clinical Review (Predetermination) Request Form to BCBSIL, along with necessary supporting documentation. Please note that faxed documents do not enter our system immediately.
What happens next?
A medical necessity review is conducted according to details of the member’s benefit plan and for consistency with BCBSIL Medical Policy and Clinical Payment and Coding Policies, the provider agreement, and other nationally recognized peer reviewed medically necessary criteria/guidelines. You will be notified when a final outcome is reached. Your notification will include instructions on how to proceed if further action is needed.
Exceptions and Reminders
The recommended clinical review (predetermination) process isn’t available for government programs (Illinois Medicaid and Medicare Advantage) or any of our commercial HMO members.
Post-service utilization management reviews may include requesting medical records and reviewing claims for consistency with:
- Medical policies
- The provider agreement
- Clinical payment and coding policies
- Accuracy of payment
A post-service utilization management review occurs after the service occurs. During a post-service utilization management review, BCBSIL reviews clinical documentation to determine whether a service or drug was medically necessary and covered under the member’s benefit plan. BCBSIL may ask you for the information BCBSIL doesn't have.
Checking eligibility and/or benefit information, obtaining prior authorization or the fact that a recommended clinical review (predetermination) decision has been issued is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage, including, but not limited to, exclusions and limitations applicable on the date services were rendered. Regardless of any prior authorization or recommended clinical review (predetermination), the final decision regarding any treatment or service is between the patient and the health care provider.
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