October 3, 2023 (Updated October 4, 2023)
The content below has been updated to include clarification on how to view the new policies on our website.
In November 2022, Blue Cross and Blue Shield of Illinois (BCBSIL) launched a laboratory benefit management program for certain outpatient laboratory services provided to our commercial non-HMO members. We are grateful for the feedback we received from providers, which helped us determine opportunities to refine the program as described below.
| After pausing to review important aspects of the program earlier this year, BCBSIL will be relaunching it with changes as outlined below. Our new review program for laboratory services provided to BCBSIL commercial non-HMO members in an outpatient setting (typically an office, outpatient hospital or independent laboratory setting) will be effective for claims with dates of service beginning Jan. 1, 2024. |
What is staying the same?
The laboratory benefit management program is a post-service medical necessity review of claims for laboratory services provided to BCBSIL commercial non-HMO members in an outpatient setting (typically an office, outpatient hospital or independent laboratory setting). The program will help reduce over-testing (including fraud, waste, and abuse), lower cost variability, and help drive high quality care without creating barriers or delays to care.
Excluded from the program are laboratory services provided in an emergency room, hospital observation or hospital inpatient setting. Member coverage terms still apply.
This program does not apply to government programs (Medicare Advantage or Illinois Medicaid) or any of our HMO members.
What is different?
New BCBSIL Medical Policies (MED209) have been posted on our website since Oct. 2, 2023, on the Pending Policies page. Please note that this page is not searchable; however, users can sort the policies in numerical order by clicking on the arrows under the Policy Number column. On Jan. 1, 2024, these policies will be available on the Active Policies page. Each policy includes references to the specialized professional societies, scientific publications, national guidelines, and other standards of care relied upon to establish the criteria.
Effective with dates of service beginning Jan. 1, 2024, claims submitted for outpatient laboratory services (typically provided in an office, outpatient hospital or independent laboratory setting) may be denied if services do not meet the medical policy criteria. Claim summaries will include denial and ineligible reason codes. In the event a laboratory service is denied, the member and their provider will receive notification of the denial that includes instructions for filing a clinical appeal.
For More Information
Our Provider Network Consultant team remains dedicated to providing education and clarity to providers about this program. Please continue to watch the News and Updates for program announcements and related resources. We appreciate the care and services you provide to our members, and we look forward to partnering with you.
Note: Pending Medical Policies are policies that will be effective on a future date. They are not to be used for current claims adjudication.