Changes Coming to the BCBSIL Predetermination Request Form

Posted June 28, 2018

In an effort to streamline the predetermination of benefits process, Blue Cross and Blue Shield of Illinois (BCBSIL) is updating the Medical and Surgical Predetermination Request Form. Beginning in October 2018, the Member Data and Documentation sections of the form will include two new fields for drug name and dosing information. In addition, the procedure code fields will also capture units.

These additional fields will help make the predetermination process more efficient by collecting required information that is currently captured from within the clinical notes, if it is included by the provider’s office. By capturing this information on the form, the volume of outbound calls to provider offices to collect missing information if it is not added to the clinical notes may be reduced and the time required for review may be expedited.

The new fields will also be added to iExchange®, our online benefit preauthorization/determination of benefits tool. You may access iExchange directly or through the Availity® Provider Portal. Until the updates are made, please add the following information in the Additional Notes section on iExchange or in the supporting documents of the paper predetermination form to help expedite the review process:

  • Drug Name(s)
  • Dose/Frequency/Duration
  • Procedure Code(s)/Units

As a reminder, predeterminations typically are not required. A predetermination is a voluntary, written request by a provider to determine if a proposed treatment or service is covered under a patient’s health benefit plan. Predetermination approvals and denials are usually based on our medical policies. The provider and member will be notified when the final outcome has been reached.

For more information, refer to the Prior Authorization page.

This information does not apply to HMO Illinois®, Blue Advantage HMOSM, Blue Precision HMOSM, BlueCare DirectSM, Blue FocusCareSM, Blue Cross Community Health PlansSM (BCCHPSM), Blue Cross Community MMAI (Medicare-Medicaid Plan)SM, Blue Cross Medicare Advantage HMOSM and Blue Cross Medicare Advantage PPOSM.

Checking eligibility and/or benefit information and/or the fact that a service has been preauthorized or predetermined 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. Exceptions may apply. Regardless of any 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 ID card.

iExchange is a trademark of Medecision, Inc., a separate company that provides collaborative health care management solutions for payers and providers. 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. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Medecision and Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.