When do I need approval from BCBSIL for a medical procedure?

Sometimes, to receive benefits for certain services or prescription drugs, you or your provider must call BCBSIL before you receive treatment. This is known as prior benefit authorization. It is also sometimes called pre-certification or pre-approval. Note that this is different than getting a referral to see a specialist. Sometimes, you may need to get a referral to see a specialist and prior benefit authorization to receive benefits for a service from that specialist. You can work with your doctor on determining when you need each.

When you or your provider contact BCBSIL with a prior benefit authorization request, we will ask for some information regarding the care or treatment that is proposed. This may include the following:

• Information about your medical condition
• The proposed treatment plan
• The estimated length of stay (if you are being admitted)

During the prior benefit authorization process, BCBSIL reviews the requested service or medication to see if the service or medication is medically necessary.

"Medically Necessary" is defined in your benefit booklet and generally refers to health care services that:

1. are required to treat or manage a medical condition or symptom;
2. are the most efficient and economical services that can safely be provided;
3. follow generally accepted medical standards;
4. are not considered experimental or investigational, except those described under your policy; and
5. are not primarily for the convenience of you or your doctor.

The service or treatment must meet your plan's definition of medical necessity in order to be eligible for benefits under your plan. The prior benefit authorization process is not a substitute for the medical advice of your health care provider. The final decision to receive any medical service or treatment is between you and your health care provider.

For more information on medical necessity, see your benefit booklet.

If you are unsure which health care services or medications need prior benefit authorization, you can call the Customer Service number on the back of your BCBSIL member ID card.

Remember, even if a service or medication is authorized, if the provider is out of network you will likely pay more out of pocket. Check Provider Finder to ensure the provider is in your plan's network. Also, a determination that a service is authorized or medically necessary is not a guarantee of coverage. The applicable terms of your plan will control the benefits that you will receive.

For PPO members: Most PPO benefit plans require you or your provider to obtain benefit preapproval for inpatient hospital admissions (acute care, inpatient rehab, etc.). In addition, many PPO benefit plans require prior benefit authorization for services such as skilled nursing visits and home infusion therapy. Make sure to consult the terms of your plan.

For HMO members: Contact your primary care physician (PCP) to coordinate your care. If you are seeking care from a specialist, ask your PCP to ensure that you have received any needed prior benefit authorization.

For all members: If your or your doctor's request for prior benefit authorization is denied, you have the right to appeal the decision. However, you may be responsible for the cost of that service or drug. You can learn more about the appeals process in the Why Was Payment for the Service I Received Denied? section. You can also refer to your benefits documents or call the Customer Service number on the back of your BCBSIL member ID card.