Blue cross blue shield of illinois predetermination form

WASHINGTON – The Blue Cross and Blue Shield Federal Employee Program® (FEP®) announced today that it will waive cost-sharing for coronavirus diagnostic testing, waive prior authorization requirements for treatment and take other steps to enhance access to care for those needing treatment for COVID-19 to ensure its members can swiftly access the right care in the right setting during the outbreak.

These changes, which have been approved by the Office of Personnel Management, will ensure that nearly 6 million federal employees, retirees and their families have comprehensive, accessible care. They include:

FEP will waive prior authorizations for diagnostic tests and for covered services that are medically necessary and consistent with Centers for Disease Control and Prevention (CDC) guidance if diagnosed with COVID-19.
Similarly, FEP will waive any copays or deductibles for diagnostic tests or treatment that are medically necessary and consistent with CDC guidance if diagnosed with COVID-19.
FEP will increase access to prescription medications by waiving early medication refill limits on 30-day prescription maintenance medications. FEP will also encourage members to use 90-day mail order benefit.
FEP will also eliminate any cost share for prescriptions for up to a 14-day supply.
FEP will waive copays for telehealth services related to COVID-19.

“As Americans continue to monitor the coronavirus outbreak, one thing they should not be concerned with is whether Blue Cross and Blue Shield will be there for them,” said William A. Breskin, senior vice president of government programs for the Blue Cross Blue Shield Association. “We take our members’ health very seriously and want to make sure there are no barriers to their seeking appropriate care if they become sick.”

FEP and Blue Cross and Blue Shield (BCBS) companies are following CDC prevention guidelines and other federal recommendations and will continue to support and protect the health and well-being of its members, their families and the community. These actions will apply to all FEP members of the 36 U.S. and Puerto Rico-based BCBS companies, including those members located overseas, when applicable.

For more information on FEP’s policy changes, please visit www.fepblue.org for details on the expansion of benefits and services. Members can also call the National Information Center at 1-800-411-BLUE (2583). If you are not an FEP member and have questions about your health plan, please contact your local BCBS Company: bcbs.com/memberservices.

About Blue Cross Blue Shield Association

The Blue Cross and Blue Shield Association is a national federation of 34 independent, community-based and locally operated Blue Cross and Blue Shield companies that collectively provide health care coverage for one in three Americans.

The Blue Cross Blue Shield Association is an association of 35 independent, locally operated Blue Cross and/or Blue Shield companies.

April 2017

Effective for dates of service on or after Jan. 1, 2017, predetermination of benefits is required for sleep studies (polysomnography) conducted in settings other than the home (including but not limited to hospitals, skilled nursing facilities, clinics and sleep labs) for Federal Employee Program (FEP) members. Predetermination of benefits requests for sleep study services for FEP members are processed through a Blue Cross and Blue Shield of Illinois (BCBSIL) Clinical Health Medical Management review.

Predetermination of benefits requests and electronic medical record attachments may be submitted online through iExchange®, or by faxing a predetermination of benefits request form and clinical information to 888-368-3406. Additional information on iExchange is available in the Education and Reference Center/Provider Tools section of our website at bcbsil.com/provider. The predetermination of benefits request fax form can be found in the same section of our Provider website on the Forms page. Clinical information submitted should include clinical data as to why a home sleep study is contraindicated.

Additional Reminders for FEP Members:

Sleep studies performed in the home do not require a predetermination of benefits.
Obtaining a predetermination of benefits through BCBSIL is waived when traditional Medicare or other insurance is primary.
The sleep study service provider must have the appropriate licenses and credentials necessary to conduct sleep study services.
The sleep study services must meet the medical necessity guidelines.

Check Eligibility and Benefits for All Members
Member eligibility and benefits should be checked prior to every scheduled appointment. Eligibility and benefit quotes include membership status, coverage status and other important information, such as applicable copayment, coinsurance and deductible amounts. Also ask to see the member’s BCBSIL ID card for current information as well as a photo ID to help guard against medical identity theft. When services might not be covered, members should be notified that they might be billed directly.

If you have questions or need additional information, contact your assigned BCBSIL Provider Network Consultant (PNC) for assistance.

Checking eligibility and/or benefit information 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 any questions, please call the number on the member’s ID card.

Health care providers are instructed to use their own best medical judgment based upon all available information and the condition of the patient in determining a course of treatment. Regardless of any benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.

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

Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.