Reminder: eviCore to Manage Commercial Prior Authorization Appeals Process through April 2021 for 2020 Adverse Determinations

Posted March 18, 2021

As a reminder, for dates of service on or after Jan. 1, 2021, AIM Specialty Health^® (AIM) is the utilization management vendor for Blue Cross and Blue Shield of Illinois (BCBSIL) commercial non-HMO prior authorization requests that were formerly handled by eviCore Healthcare (eviCore). To assist providers with this transition, in December 2020, a notice appeared on the eviCore website to alert providers of the appeals run-out process, which will continue through April 2021.

If you submitted a prior authorization (pre-service) request through eviCore and that request was denied, or if eviCore conducted a post-service (post-claim) medical necessity review resulting in an adverse determination, your letter will instruct that peer-to-peer discussions and appeals must be requested through eviCore. Please note that, for these pre- and post-service adverse determinations, eviCore will continue to process peer-to-peer and appeal requests through April 30, 2021, only. After April 30, 2021, eviCore will redirect any peer-to-peer and appeal requests to BCBSIL.

The vendor that issued the pre- or post-service adverse determination will process any related peer-to-peer or appeals requests through April 30, 2021. For any adverse determination after Jan. 1, 2021, follow the instructions in the letter you receive from BCBSIL.

Other Reminders and Resources
Refer to our Utilization Management section for more information on prior authorization and related processes at BCBSIL. Also visit the AIM Provider Resources microsite  for training and other resources.

Always check eligibility and benefits first through the Availity^® Provider Portal  or your preferred vendor, prior to rendering care and services to our members. This step will confirm:

• Membership and benefit coverage
• Prior authorization or pre-notification requirements
• Utilization management vendors to use, if applicable

For government programs, eviCore will continue to be the utilization management vendor for prior authorization requests for certain services for our Blue Cross Medicare Advantage (PPO)^SM, Blue Cross Community MMAI (Medicare-Medicaid)^SM and Blue Cross Community Health Plans^SM (BCCHP^SM) members.

This information does not apply for any of our HMO members.

Checking eligibility and/or benefit information and/or obtaining prior authorization or pre-notification 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, including, but not limited to, exclusions and limitations applicable on the date services were rendered. Certain employer groups may require prior authorization or pre-notification through other vendors. If you have any questions, call the number on the member's ID card. Regardless of any prior authorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.

eviCore healthcare (eviCore) is an independent company that has contracted with Blue Cross and Blue Shield of Illinois to provide prior authorization for expanded outpatient and specialty utilization management for members with coverage through BCBSIL. 

AIM Specialty Health (AIM) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through 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 third party vendors. Members should contact the vendor(s) directly with questions about the products or services offered by third parties.