BCBSIL Issues 2019 Medicaid and Medicare Advantage Benefit Pre and Prior Authorization Lists and Requirements

October 2018 ~

Blue Cross and Blue Shield of Illinois (BCBSIL) has published updated priorauthorization requirements for certain services provided to Medicaid and Medicare Advantage (PPO) members, scheduled to take effect January 1, 2019.

Medicaid Benefit Preauthorization Requirements

Limitations of Covered Benefits by Member Contract

The table below includes information on benefit preauthorization requirements for non-emergency services provided to BCBSIL’s Medicaid (MMAI and BCCHP) members. Medical necessity, as defined in the Member Handbook, must be determined before a benefit preauthorization number will be issued. Claims received that do not have a benefit preauthorization number may be denied. Independently contracted providers may not seek payment from the MMAI or BCCHP member when services are deemed not to meet the medical necessity definition in the Member Handbook and the claim is denied.

Network Participation

Out-of-network providers must seek prior authorization for all services.

Notification Requirements

In cases of an emergency, notification is required within one business day of admission.

Medical Necessity

Medical necessity, as defined in the Member’s handbook, must be met for all services regardless if prior authorization is required. All services are subject to retrospective review and recoupment in accordance with State and Federal rules and regulations.

Inpatient Facility Admission Summary

  • All planned (elective) inpatient hospital care (surgical, non-surgical, behavioral health and/or substance abuse). Elective admissions must have prior authorization before the admission occurs.
  • All unplanned inpatient hospital care (surgical, non-surgical, behavioral health and/or substance abuse). Notification must be made within one business day of admission to the facility.
  • Admission to a skilled nursing facility, a long term acute care hospital (LTACH) or a rehabilitation facility
  • All residential treatment program admissions

Prior Authorization Rules – Medicaid Medical/Surgical (Non-Behavioral Health)

BENEFIT PREAUTHORIZATION REQUIREMENTS THROUGH EVICORE HEALTHCARE *Including Network Exceptions [out-of-plan or out-ofnetwork (due to network adequacy) for managed programs]

  • Outpatient Molecular Genetics
  • Outpatient Radiation Therapy
  • Musculoskeletal Services
    • Chiropractic
    • Physical/Occupational/Speech Therapy
    • Spine, Joint, Pain
  • Outpatient Cardiology and Radiology Imaging Services
  • Outpatient Medical Oncology
  • Outpatient Sleep
  • Post-Acute Care
  • Outpatient Specialty Drug

Prior Authorization Rules Medicaid Medical/Surgical (Non-Behavioral Health)

BENEFIT PREAUTHORIZATION REQUIREMENTS THROUGH BCBSIL

Prior Authorization Rules – Medicaid Behavioral Health

2018 Blue Cross Medicare Advantage (PPO) SM Benefit Preauthorization List

BENEFIT PREAUTHORIZATION REQUIREMENTS* THROUGH EVICORE HEALTHCARE *Including Network Exceptions [out-of-plan or out-of-network (due to network adequacy) for managed programs]

  • Outpatient Molecular Genetics
  • Outpatient Radiation Therapy
  • Musculoskeletal Services
    • Chiropractic
    • Physical/Occupational/Speech Therapy
    • Spine, Joint, Pain
  • Outpatient Cardiology and Radiology Imaging Services
  • Outpatient Medical Oncology
  • Outpatient Sleep
  • Post-Acute Care
  • Outpatient Specialty Drug

BENEFIT PREAUTHORIZATION REQUIREMENTS THROUGH BCBSIL

Behavioral Health

 

 

Source(s): Blue Cross and Blue Shield of Illinois News and Updates;

 

 

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