March 2017
New Medicaid and Medicare Benefit Preauthorization Requirements through eviCore
Blue Cross and Blue Shield of Illinois (BCBSIL) has contracted with eviCore healthcare (eviCore), an independent specialty medical benefits management company, to provide utilization management services for benefit preauthorization requirements outlined below.
Effective April 3, 2017, BCBSIL members enrolled in any of the government programs listed below will be subject to the new benefit preauthorization requirements set forth in this notice:
- Blue Cross Community MMAI (Medicare-Medicaid Plan)SM
- Blue Cross Community Integrated Care Plan (ICP)SM
- Blue Cross Community Family Health PlanSM (FHP)
- Blue Cross Community Managed Long Term Supports and ServicesSM (MLTSS)
- Blue Cross Medicare Advantage (PPO)SM
eviCore will manage benefit preauthorization requests for the following specialized clinical services effective for dates of service on or after April 3, 2017:
- Outpatient Molecular Genetics
- Outpatient Radiation Therapy
- Musculoskeletal services
- Chiropractic
- Physical and Occupational Therapy
- Speech Therapy
- Spine Surgery (Outpatient/Inpatient)
- Spine Lumbar Fusion (Outpatient/Inpatient)
- Interventional Pain
- Outpatient Cardiology & Radiology imaging services
- Pediatric Abdomen Imaging
- Pediatric Cardiac Imaging
- Pediatric Chest Imaging
- Pediatric Head Imaging
- Pediatric Musculoskeletal Imaging
- Pediatric Neck Imaging
- Pediatric Oncology Imaging
- Pediatric Pelvis Imaging
- Pediatric Peripheral Nerve Disorders (Pnd) Imaging
- Pediatric Peripheral Vascular Disease (Pvd) Imaging
- Pediatric Spine Imaging
- Abdomen Imaging
- Cardiac Imaging
- Chest Imaging
- Cardiac Rhythm Implantable Device (Crid)
- Head Imaging
- Musculoskeletal
- Neck Imaging
- Obstetrical Ultrasound Imaging
- Oncology Imaging
- Pelvis Imaging
- Peripheral Nerve Disorders (Pnd) Imaging
- Peripheral Vascular Disease (Pvd) Imaging
- Spine Imaging
- Outpatient Medical Oncology
- Outpatient Sleep
- Post-Acute Care
- Outpatient Specialty Drug
Services performed without benefit preauthorization or that do not meet medical necessity criteria may be denied for payment, and the rendering provider may not seek reimbursement from the member.
Providers may continue to use iExchange® for all other services that require benefit preauthorization.
BCBSIL and eviCore will be providing additional information, including training opportunities, in the coming months on the Provider website at bcbsil.com/provider and in Blue Review.
Our goal is to support access to quality, affordable health care for our members. If you have any questions, please contact your assigned Provider Network Consultant (PNC).
Please note that the fact that a service has been preauthorized/pre-certified 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 applicable on the date services were rendered.
eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSIL.
iExchange is a trademark of Medecision, Inc., a separate company that offers collaborative health care management solutions for payers and providers. BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by third party vendors such as Medecision. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly.
Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.