Remember, member benefits and review requirements will vary based on service/drug being rendered and individual/group policy elections. Step 1 – Confirm if Prior Authorization is Required In general, there are three steps providers should follow. When and how should prior authorization requests be submitted? For Medicare and Medicaid members, if you don’t get prior authorization for services or drugs on our prior authorization lists, we won’t reimburse you, and you cannot bill our members for those services or drugs.We may conduct a post-service utilization management review, which may include requesting medical records and reviewing claims for consistency with medical policies clinical payment and coding policies and accuracy of payment.The service or drug may not be covered, and the ordering or servicing provider will be responsible. If you do not get prior approval via the prior authorization process for services and drugs on our prior authorization lists: If the provider or member doesn’t get prior authorization for out-of-network services, the claim may be denied. Note: Most out-of-network services require utilization management review. Information for Blue Cross and Blue Shield of Illinois members is found on our member site. Sometimes, a plan may require the member to request prior authorization for services. Usually, the provider is responsible for requesting prior authorization before performing a service if the member is seeing an in-network provider. The terms of the member’s plan control the available benefits. A prior authorization is not a guarantee of benefits or payment. Prior authorization is required for some members/services/drugs before services are rendered to confirm medical necessity as defined by the member’s health benefit plan. Prior authorization (sometimes called preauthorization or pre-certification) is a pre-service utilization management review.
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