Our clinical guidelines and pathways, supported by our cloud-based technology, are the foundation of our clinical appropriateness review process. In the complex arena of health care, rapid advances in medicine make it hard for physicians to keep up with the latest evidence-based guidelines and variation from established best practices compromises efficiency, effectiveness, quality, and safety in care.Ĭarelon Medical Benefits Management (MBM) helps ensure clinically appropriate care is adopted across today’s most complex, costly, and specialized clinical areas. The costs associated with care that is not appropriate create a burden on our entire health system and can leave patients without the means to pay. New tests, treatments, and medications hold the promise of improving or even saving lives.īut not all innovations create meaningful benefits, and not all care that is administered follows accepted standards for care. Aligning care with best practices: clinical appropriateness review We promote the most appropriate use of specialty care services through the application of widely accepted clinical guidelines delivered via an innovative platform of technologies and services. Our mission is to help ensure delivery of health care services are more clinically appropriate, safer, and more affordable. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.About Carelon Medical Benefits ManagementĬarelon is a leading specialty benefits management company with more than 30 years of experience. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity or AIM. Availity provides administrative services to BCBSILAIM Specialty Health (AIM) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL. If you have any questions, call the number on the member's ID card.Īvaility is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. 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, including, but not limited to, exclusions and limitations applicable on the date services were rendered. CPT is a registered trademark of the AMA.Ĭhecking eligibility and/or benefit information and/or obtaining prior authorization is not a guarantee of payment. This step will confirm prior authorization requirements and utilization management vendors, if applicable.ĬPT copyright 2020 American Medical Association (AMA). Important Reminder: Always check eligibility and benefits first through the Availity ® Provider Portal or your preferred vendor portal, prior to rendering services. The above codes are designated “Removed from update release. More Information: Refer to the updated Commercial Outpatient Medical Surgical Prior Authorization Code List in the Utilization Management section. RPR 1 TORN LIGM&/CAPSL KNE COLTRL&CRUCIATE REPAIR PRIMARY TORN LIGM&/CAPSULE KNEE CRUCIAT RPR PRIMARY TORN LIGM&/CAPSULE KNEE COLLATERAL MANJ W/ANES SHOULDER JOINT W/FIXATION APPARATUS What’s Changing: Blue Cross and Blue Shield of Illinois (BCBSIL) is removing the prior authorization requirement through AIM effective April 1, 2021, for six “Musculoskeletal” codes for commercial non-HMO members.Ĭurrent Procedural Terminology (CPT ®) CodeĪRTHRS AID RPR LES/TALAR DOME FX/TIBL PLAFOND FX
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