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Reminder of Change to the Pre-service Appeals Process for Government Programs Effective Nov. 1, 2019

Posted December 11, 2019

This is a reminder that important changes to the pre-service appeals process recently occurred for your Blue Cross and Blue Shield of Illinois (BCBSIL) patients enrolled in the following government programs plans: Blue Cross Medicare Advantage (PPO)SM (MA PPO) and Blue Cross Community MMAI (Medicare-Medicaid)SM (MMAI), as previously communicated on Aug. 12, 2019. These changes are designed to help streamline workflows and lead to an improved member and provider experience.

As of Nov. 1, 2019, eviCore® healthcare (eviCore), an independent medical benefits management company, is no longer administering the pre-service appeals process for denied or partially denied benefit preauthorizations. Instead, BCBSIL is administering the pre-service appeals process for these members, from pre-service appeal intake to appeal determination.

eviCore has, however, continued its role administering the initial determination of preauthorization requests.

Note: The medical policies being used for these pre-service appeal reviews have not changed. Remember, when submitting a pre-service appeal, always follow the directions included within the denial letter.

As always, it is critical to check eligibility and benefits first, prior to rendering care and services to confirm coverage, network status and other important details. When you check eligibility and benefits online by submitting an electronic 270 transaction through the Availity® Provider Portal or your preferred web vendor portal, you may determine if benefit preauthorization/pre-notification may be required for the service type.

Payment may be denied if you perform procedures without obtaining benefit preauthorization when benefit preauthorization is required. If this happens, you may not bill our members. For more information, refer to the Eligibility and Benefits and Prior Authorization pages of our Provider website.

Please note that verification of eligibility and benefits, and/or the fact that a service or treatment has been preauthorized/pre-notified for benefits 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. If you have questions, contact the number on the member’s ID card.

eviCore healthcare is an independent specialty medical benefits management company that provides utilization management services for BCBSIL. 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 offered by third party vendors such as eviCore or Availity or eviCore. The vendors are solely responsible for the products or services they offer. If you have any questions regarding any of the products or services they offer, you should contact the vendor(s) directly.