The resources on this page are intended to help you navigate prior authorization requirements for Blue Cross and Blue Shield of Illinois commercial non-HMO fully insured members.
Always check eligibility and benefits first through the Availity® Essentials or your preferred web vendor portal to confirm coverage and other important details, including prior authorization requirements and vendors, if applicable. For some services/members, prior authorization may be required through BCBSIL. For other services/members, BCBSIL has contracted with Carelon Medical Benefits Management for utilization management and related services.
Quick Tip: How to Identify Administrative Services Only (ASO) Members
You can view, download and print most members’ electronic BCBSIL ID cards by completing an eligibility and benefits inquiry through Availity. The BCBSIL ID card for self-funded ASO group members includes a note on the back to specify that, for these members, BCBSIL provides claims processing only and assumes no financial risk for claims. This wording does not appear on fully insured member ID cards.
Commercial Prior Authorization Summary and Code Lists
The Requirements Summary below offers an overview with reminders and helpful links. Procedure code lists are included for reference purposes. Note: These resources reflect general information for some commercial non-HMO fully insured members only.
- 2024 Commercial Prior Authorization Requirements Summary
- 2024 Commercial Outpatient Medical Surgical Prior Authorization Code List
- 2024 Commercial Specialty Pharmacy Prior Authorization Drug List
- 2024 Commercial Outpatient Behavioral Health Prior Authorization Code List
- Summary/Code List Archive
Digital Lookup Tool for Prior Authorization Requirements
For a different view of prior authorization requirements that may apply to some of our commercial non-HMO fully insured members, you can use our digital lookup tool. Select the link for the procedure category below to begin your search. Note: This digital lookup tool is intended for reference purposes only. Information provided is not exhaustive and is subject to change.
Pharmacy Benefit Prior Authorization Requirements – Prime Therapeutics, our pharmacy benefit manager, conducts all reviews of prior authorization requests from physicians for BCBSIL members with prescription drug coverage. For a listing of programs included in our standard utilization management package, refer to the 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
- American Society of Addiction Medicine (ASAM)*
- MCG Care Guidelines (Accessible to providers through the BCBSIL-branded Payer Spaces section in Availity under the Resources tab – use CTRL+F to locate specific criteria within the MCG Care Guidelines. BCBSIL members can view guidelines through Blue Access for MembersSM.)
- Prime Therapeutics
Learn more about clinical review criteria that are used in prior authorization decision-making for our Commercial members.
Prior Authorization Statistical Data
The reports below provide an overview of prior authorization data for the previous calendar year for commercial, fully insured members. Each report includes statistical information associated with total number of prior authorization requests received (e.g., approvals, denials, and top five reasons for denial).
- Medical Prior Authorization Data
- Medical Drug Prior Authorization Data
- Behavioral Health Prior Authorization Data
- Pharmaceutical Drug Prior Authorization Data
*Licensee's use and interpretation of the American Society of Addiction Medicine’s ASAM Criteria for Addictive, Substance-Related, and Co-Occurring Conditions does not imply that the American Society of Addiction Medicine has either participated in or concurs with the disposition of a claim for benefits.
Checking eligibility and benefits and/or obtaining prior authorization 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. Regardless of any prior authorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider. If you have any questions, call the number on the member's BCBSIL ID card.
The BCBSIL Medical Policies are for informational purposes only and are not a substitute for the independent medical judgment of health care providers. Providers are instructed to exercise their own clinical judgment based on each individual patient’s health care needs. The fact that a service or treatment is described in a medical policy is not a guarantee that the service or treatment is a covered benefit under a health benefit plan. Some benefit plans administered by BCBSIL, such as some self-funded employer plans or governmental plans, may not utilize BCBSIL Medical Policies. Members should contact the customer service number on their member ID card for more specific coverage information.
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. Carelon Medical Benefits Management (formerly AIM Specialty Health) is an independent company that has contracted with BCBSIL to provide utilization management services 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. BCBSIL makes no endorsement, representations or warranties regarding third party vendors and the products and services they offer.
The ASAM Criteria®, ©2021 American Society of Addiction Medicine. All rights reserved.
MCG Care Guidelines are administered and provided by MCG Health, an independent company that has contracted with BCBSIL to provide care and disease management for members with coverage through BCBSIL.
The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the conditions of the patient in determining the appropriate course of treatment. References to other third party sources or organizations are not a representation, warranty or endorsement of such organizations. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.