*Licensee's use and interpretation of the American Society of Addiction Medicines ASAM Criteria for Addictive, Substance-Related, and Co-Occurring Conditions does not imply that the American Society of Addiction Medicine has either participated in or concurs with the disposition of a claim for benefits. At Blue Cross Community MMAI (Medicare-Medicaid Plan) SM, we take great pride in ensuring that you receive the care you need. Its a great chance to work with faith leaders, advocacy groups and other community-based organizations that support our members health and well-being. Choose the best payment option for your Blue Cross and Blue Shield of Illinois (BCBSIL) monthly bill. These tools used by PCPs (or specialists) include medical codes. Home and Community-Based Services & Waivers, Grievances, Appeals and Coverage Decisions, Language Assistance and Non-Discrimination Notice. Blue Cross and Blue Shield of Illinois, aDivision of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association, PDF File is in portable document format (PDF). Contact Us | Blue Cross and Blue Shield of Illinois Contact Us AIM Specialty Health (AIM) is an operating subsidiary of Anthem and an independent third party vendor that is solely responsible for its products and services. Availity provides administrative services to BCBSIL. You pay nothing ($0) when you go to a doctor or health care provider in the plan's network. Blue Cross Community MMAI (Medicare-Medicaid Plan) SM includes coverage for selected prescription and over-the-counter (OTC) drugs, and selected medical supplies. File is in portable document format (PDF). Blue Cross and Blue Shield of Illinois is proud to be the states only statewide, customer-owned health insurer. Members should contact the vendor(s) directly with questions about the products or services offered by third parties. }&ji[@_{dsTchsqD7bL+x3AXG>z>(y{+/en6=V/e{.t&>jFj750hS) !yppH7edMUFA{u38_tZ'oKAlr, @qiD `9wL Stay informed about BCBSIL programs, products, initiatives, and more. ALLTRAILS and the AllTrails Mountain Design are registered trademarks of AllTrails, LLC in the United States as well as certain other jurisdictions. Join us as we build the next generation of health insurance. To view this file, you may need to install a PDF reader program. The tool returns a list of services that may require prior authorization through BCBSIL or eviCore healthcare (eviCore) for BCCHP and MMAI members. They use what is called clinical criteria to make sure you get the health care you need. For more information, refer to the 2021 Medicaid Prior Authorization Requirements Summary and 2021 Medicaid Prior Authorization Code List available in the Medicaid section on the Support Materials (Government Programs) page. Blue Cross and Blue Shield of Illinois (BCBSIL) would like to outline some important updates, tips and reminders on prior authorization processes for independently contracted providers treating our Blue Cross Community Health Plans SM (BCCHP SM) and Blue Cross Community MMAI (Medicare-Medicaid Plan) SM members. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. Log In to the Shopping Cart, Need to Make a Payment? Sometimes you may need to get approval from Blue Cross and Blue Shield of Illinois (BCBSIL) before we will cover certain inpatient, outpatient and home health care services and prescription drugs. External link You are leaving this website/app (site). 0 The peer-to-peer discussion is not required, nor does it affect the providers right to an appeal on behalf of a member. Copyright 2021 Health Care Service Corporation. File is in portable document format (PDF). Search your plan's drug list, find a pharmacy, and more. Blue Cross and Blue Shield of Illinois, aDivision of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association, PDF File is in portable document format (PDF). 373 0 obj <> endobj There are some exceptions when care you receive from an out-of-network provider will be covered. GDChv0O{Q~ $W0!&~(c~;=1^!GD=q2z5OR%AG.)H&lz'9|^f!(@.ib These include prior authorization code lists with effective dates and related information for Blue Cross Community Health Plans SM (BCCHP SM) and Blue Cross Community MMAI (Medicare-Medicaid Plan) SM members. R'sYI D@ zmG@5msm!T%FN3_z. You can find out if your drug has any added conditions or limits by looking at the Drug List. But we know its nice to have other ways to view prior authorization information, too. Luckily, your health insurance can change with you. How Does Blue Cross Community MMAI (Medicare-Medicaid Plan)SMMake Decisions for Prior Authorizations? Health Equity and Social Determinants of Health (SDoH), Over the Counter Equivalent Exclusion Program, Prior Authorization and Step Therapy Programs, Consolidated Appropriations Act & Transparency in Coverage, Medical Policy/Pre-certification: Out-of-area Members. February 1, 2021 Blue Cross and Blue Shield of Illinois (BCBSIL) would like to outline important updates, tips and reminders on prior authorization processes for independently contracted providers treating our Blue Cross Community Health Plans SM (BCCHP SM) and Blue Cross Community MMAI (Medicare-Medicaid Plan) SM members. Non-Discrimination Notice. For more than 85 years, weve provided our members with comprehensive, affordable health plans, making Illinois a healthier place to live, work and play. % Government Programs Prior Authorization Summary and Code ListsRefer to the Summary documents below for an overview of prior authorization requirements, reminders and helpful links. One option is Adobe Reader which has a built-in screen reader. Prime Therapeutics LLC (Prime) is a pharmacy benefit management company. Related Resources Clinical Review Criteria Utilization management reviews use evidence-based clinical standards of care to help determine whether a benefit may be covered under the members health plan. YDLmW~/Pi_7wRwN]_RwMFrg~ w BJA9V)F:C5F7\(]U{8-KBC T.~mj mBlw~ C5?eja3\p0FooS"_iNQq9;H`76 97hQsD0O8IL*]"w}mP2H#^mHqMD[kn>iE7T" + {pxk4(uN7Lmgw5oCOa1 This link will take you to a new site not affiliated with BCBSIL. One option is Adobe Reader which has a built-in screen reader. Checking eligibility and benefits through Availity Essential or your preferred web vendor is always the best place to start, before you provide care and services to any of our members. The site may also contain non-Medicare related information. Those exceptions are: Emergency care or urgently needed care. For other services/members, BCBSIL has contracted witheviCore healthcare (eviCore)for utilization management and related services. <>/Metadata 528 0 R/ViewerPreferences 529 0 R>> Out-of-Network Coverage. Blue Cross Community MMAI (Medicare-Medicaid Plan)SM includes coverage for selected prescription and over-the-counter (OTC) drugs, and selected medical supplies. During weekend hours, UM reviewers and medical directors continue to review requests and make decisions. If you have any questions, call the number on the members ID card. Some benefit plans administered by BCBSIL, such as some self-funded employer plans or governmental plans, may not utilize BCBSIL Medical Policies. Welcome. eviCore healthcare (eviCore) is an independent company that has contracted with BCBSIL to provide prior authorization for expanded outpatient and specialty utilization management for members with coverage through BCBSIL. Whens the meeting for the next quarter? When faxing prior authorization requests, you must use the Medicaid Prior Authorization Request Form. BCBSIL adheres to the standards for addressing all urgent concurrent requests, meeting or exceeding National Committee for Quality Assurance (NCQA) standards. endstream endobj startxref Request a new replacement member ID card, or download a temporary copy. Its important to check eligibility and benefits first for each patient at every visit to confirm coverage details. Medical policies are also used to guide care decisions. 2 0 obj Whats on the agenda? Home and Community-Based Services & Waivers, Grievances, Appeals and Coverage Decisions, Language Assistance and Non-Discrimination Notice, Have a prescription from your doctor for them, Fill the prescription at a network pharmacy. Benefits will be determined once a claim is received and will be based upon, among other things, the members eligibility and the terms of the members certificate of coverage applicable on the date services were rendered. This list includes generic and brand drugs and medical supplies. Checking eligibility and benefits and/or obtaining prior authorization is not a guarantee of payment of benefits. All Rights Reserved. Stage 3 of the long-distance hiking trail WestfalenWanderWeg, North Rhine-Westphalia. Your feedback is vital to improving the care and services these members receive. 3 0 obj When: Thursday, May 18, 2023, from 1 to 2:30 p.m. CST Why participate? Members should contact the customer service number on their member ID card for more specific coverage information. New User? 101 S. River Street In addition, some sites may require you to agree to their terms of use and privacy policy. Recently, we added a digital lookup tool that gives you a different way to view prior authorization requirements that may apply to our BCCHP and MMAI members. The resources on this page are intended to help you navigate prior authorization requirements for Blue Cross and Blue Shield of Illinois (BCBSIL) government programs members enrolled in any of the following plans: Always check eligibility and benefits first through Availity or your preferred web vendor portal to confirm coverage and other important details, including prior authorization requirements and vendors, if applicable. x=r8?Qi xJI&JfIl3D:#SfAw $nb"n q~+|Vz?p~Q{vrle{{_F^gEx6,>/?e=kOws/nTgO~S>)ga0)D>Mx,lN}=v,QPD>j" Blue Cross Community MMAI (Medicare-Medicaid Plan)SM includes: Medical benefits such as coverage for preventive care services, emergency and urgent care coverage, diagnostic tests and more Behavioral Health benefits Prescription coverage Transportation Services to help you get to and from your appointments Dental care, eye care, and more If you want to know more about the utilization management process or how decisions are made about your care, Contact Us. <> hb```) ea&pd:Se Learn about the many ways we are contributing to the well-being of our local Illinois communities in the latest Corporate Social Responsibility Report. URGENT (If checked, please provide anticipated date of service below) k+:6@1)^]WNQj sGG& hFa`@,%LFPBA7Xmxt$.=e0ne}#IoE 20iF 6Xg8Sf;+-P > Information on Service Authorization Disputes can be found on the Provider Service Authorization Dispute Resolution Request Form. Please see Drug Information for more information. Wetter: With an ascent of 703 m, WestfalenWanderWeg Etappe 3: Wetter - Schwerte has the most elevation gain of all of the historic site trails in the area. hbbd```b``6O L %,"&*u`0;L:`5 ; As you transition to Medicare, we hope you'll Stay with Blue and get Medicare coverage from a company you trust. You are leaving this website/app (site). For some services/members, prior authorization may be required through BCBSIL. %PDF-1.6 % Use the links below to view BCBSIL and vendor guidelines that may apply. The most popular and difficult historic site trail in Wetter is Von Wetter zum Nacken with a 3.6-star rating from 2 reviews. Who is responsible for getting the prior authorization? Please note that, effective May 1, 2021, there will be a change to the BCCHP peer-to-peer discussion process, as specified below. Renew Illinois Individual, Family & Medicaid Health Insurance, Blue Cross Community MMAI (Medicare-Medicaid Plan), Illinois Health Plan Tiered Prescription Drug Lists, Making Your Health Insurance Work For You, Prescription Drug Changes and Pharmacy Information, Machine Readable Files for Transparency in Coverage. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations, and exclusions set forth in the members policy certificate and/or benefits booklet and or summary plan description. Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. BCBSIL contracts with Prime to provide pharmacy benefit management and other related services. This step helps you confirm membership, coverage and other details, including prior authorization requirements and utilization management vendors. We are also the largest provider of health benefits in Illinois, serving more than 8.9 million members in all 102 counties across the state. Out of area dialysis services. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. Medical Policies are based on scientific and medical research. References to other third party sources or organizations are not a representation, warranty or endorsement of such organizations. MCG (formerly Milliman Care Guidelines) is a trademark of MCG Health, LLC (part of the Hearst Health network), an independent third party vendor. You are leaving this website/app ("site"). @SssUJ- =`~4*>_faS A$wa8|9NN4 d>!XHDhf\~%r'7m|oHF~D#R X(b(uQu (pd)8MA/> ?&ME.@.$O4>!Mwiw%c:IlAc:4U&SUDaE:?{Or-RaX%,(( You also have the right to ask for a coverage decision. Sara will be discussing Mental Health Awareness Month and cultural competency. (Accessible to providers through the BCBSIL-branded Payer Spaces section in, 2022 MA PPO and MA HMO Non-Delegated Prior Authorization Requirements Summary, 2022 MA PPO and MA HMO Non-Delegated Prior Authorization Code List, 2022 Medicaid Prior Authorization Requirements Summary, 2022 Medicaid Prior Authorization Code List, American Society of Addiction Medicine (ASAM), Illinois Department of Human Services/Division of Mental Health, Illinois Department of Health and Family Services Medicaid Provider Handbooks, Utilization Management Process Overview (Gov Programs), Blue Cross Medicare Advantage HMO Non-Delegated Model, Blue Cross Community MMAI (Medicare-Medicaid Plan). Updated February 2021 1 Medicaid Prior Authorization Requirements Summary, Effective Jan. 1, 2021 (Updated February 2021) This information applies to Blue Cross Community MMAI (Medicare-Medicaid)SM and Blue Cross Community Health PlansSM (BCCHPSM) members. According to AllTrails.com, the longest historic site trail in Wetter is. Talk with your doctor about your medication. The site may also contain non-Medicare related information. The fact that a service or treatment is described in a medical policy is not a guarantee that the service or treatment is a covered benefit under a health benefit plan. In most cases, you must receive your care from a Blue Cross Community MMAI (Medicare-Medicaid Plan) SM in-network plan provider. BCBSIL makes no endorsement, representations or warranties regarding third-party vendors. Subscribe now to receive the monthly Blue Review via email. endobj Registration is required. 3oDiCBG\{?xyH Pharmacy Benefit Prior Authorization Requirements Prime Therapeutics, our pharmacy benefit manager, conducts all reviews of prior authorization requests from physicians for BCBSIL members with prescription drug coverage. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider. Blue Cross Community MMAI (Medicare-Medicaid Plan) SM Always check eligibility and benefits first through Availity or your preferred web vendor portal to confirm coverage and other important details, including prior authorization requirements and vendors, if applicable. The Drug List (sometimes called a formulary) is a list showing the drugs that can be covered by the plan. To support the decision process, BCBSIL gives providers the opportunity to discuss UM determinations with a peer physician. The peer-to-peer discussion process is as follows: *Effective May 1, 2021, the only change is that providers can no longer submit clinicals for BCCHP members IN ADDITION TO doing a peer-to-peer call after the adverse determination. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors. Step-by-Step Guide for Provider Finder. Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. In addition, some sites may require you to agree to their terms of use and privacy policy. According to AllTrails.com, the longest historic site trail in Wetter is RuhrtalRadweg Etappe 4: Wetter (Ruhr) - Essen. If your doctor wants you to have a drug that is not on the list, he or she can request approval for that drug. hb``0b`0 36 fah@t#(f`XU1U B)xPB2@+4s\ X:EolHd]1ofxF/120i7@ZN 4`SBa@3P]8D5/@ F& endstream endobj 13 0 obj <>]/Pages 10 0 R/Perms/Filter<>/PubSec<>>>/Reference[<>/Type/SigRef>>]/SubFilter/adbe.pkcs7.detached/Type/Sig>>>>/Type/Catalog/ViewerPreferences<>>> endobj 14 0 obj <. You may be familiar with some of the Medicaid prior authorization resources on our Provider website. New to Blue Access for Members? Sign up for theLifeTimes newsletterto get health and benefits articles delivered to your inbox every month. Your doctor will need to request approval before these drugs can be prescribed. Your PCP will handle the prior authorization process. Doctors are not paid to deny care. Santori Library To view this file, you may need to install a PDF reader program. Topics include everything from improving your well-being to explaining health coverage. Blue Cross Community MMAI has strict rules about how decisions are made about your care. The site may also contain non-Medicare Aurora, IL 60506. To view this file, you may need to install a PDF reader program. This new site may be offered by a vendor or an independent third party. Your doctor should know which services need approval and can help with the details. Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. All Rights Reserved. endstream endobj 374 0 obj <. It also includes the drugs covered by Medicare Part D. As a member, you have no copay for covered items on the Drug List. For Medicaid (BCCHP and MMAI) members, prior authorization requirements are found in the last column of the BCCHP drug list and MMAI drug list. Copyright document.write(new Date().getFullYear()); Health Care Service Corporation. Our doctors and staff make decisions about your care based on need and benefits. Lunch will be provided. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com From Siegen with the beautiful day ticket (33 euros for 5 people) to Wetter / Ruhr. One option is Adobe Reader which has a built-in reader. Create an account. 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. Prior Authorization Doctors and Hospitals When choosing a doctor, make sure the doctor is part of the Blue Cross Community MMAI (Medicare-Medicaid Plan) SM network. Were hosting quarterly Community Stakeholder Committee meetings to find ways to better serve our Blue Cross Community MMAI (Medicare-Medicaid Plan)SM and Blue Cross Community Health PlansSM(BCCHP) members. hbbd```b``nF`+d'lO0{d&WEV"8EVU9`"DaDa@6`4r lf|pwOIF@W; v#30^0 !X endstream endobj startxref 0 %%EOF 107 0 obj <>stream For some drugs, the plan limits the amount that will be covered. Search for doctors, dentists, hospitals and other health care providers. Blue Access for MembersSM is a powerful tool for managing all your health plan benefits. 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. Your Summary of Benefits has information about which services require prior authorization. Medicaid Prior Authorization Request Form, Provider Service Authorization Dispute Resolution Request Form. R{O *L%U}r?:B22Rj=]p ($c j `-g [W}]blE&rT}TmPi]`8*I/,%,((56eA lLlkFy_&df4]`)`m9lrSQHp*:Y0T"NEAu:",@vR8za7nn7I,Iz-rSroq@T#}MW *7I :=C;hEQQq_1d"A B M$ }u$z Customer Service: File the dispute by calling Customer Service at 1-877-860-2837. The BCBSIL Provider Manuals are comprehensive guides for Blue Cross Community Health Plans SM, Blue Cross Community MMAI (Medicare-Medicaid Plan) SM, Blue Cross Medicare Advantage (HMO) SM, Blue Cross Medicare Advantage (PPO) SM, Blue Choice PPO SM, HMO, PPO and Blue High Performance Network (Blue HPN ) EPO professional and facility providers. What: Q2 2023 MMAI and BCCHP Community Stakeholder Committee Meeting Limitations of Covered Benefits by Member Contract Prior Authorization Support Materials (Government Programs). For BCCHP and MMAI: Peer-to-peer discussions are allowed for requests where clinical information was submitted with the original request. 396 0 obj <>/Filter/FlateDecode/ID[<0A7FBF13C253BF478050EB5B54DA8A47><3D37E1700F053247902B206B607ACED5>]/Index[373 43]/Info 372 0 R/Length 112/Prev 171011/Root 374 0 R/Size 416/Type/XRef/W[1 3 1]>>stream #5 - RuhrtalRadweg Etappe 4: Wetter (Ruhr) - Essen, #6 - WestfalenWanderWeg Etappe 3: Wetter - Schwerte. This trail is estimated to be 42.6 km long. Additional clinical information will not be reviewed by the utilization management team if the initial determination was an adverse determination due to failure to submit clinical information with the original request. Your plan does not encourage doctors to give less care than you need. The next highest ascent for historic site trails is Von Wetter zum Nacken with 664 m of elevation gain. To view this file, you may need to install a PDF reader program. April 24, 2023. Clear and timely submission of prior authorization requests and clinical documentation is very important to process requests within the required timeframes. For some services/members, prior authorization may be required through BCBSIL. Your doctors will use other tools to check prior authorization needs. Failing to provide clinical information or timely notification of prior authorization requests may affect the outcome of a Service Authorization Dispute. If a request does not meet medical necessity criteria for approval, the request will be assigned to a BCBSIL medical director for determination. External link You are leaving this website/app (site). How to request prior authorization: Prior authorization requests may be made by phone (call 877-860-2837 for BCCHP members, call 877-723-7702 for MMAI members) or by fax to 312-233-4060 (same fax number for BCCHP and MMAI). Explore the most popular historic site trails near Wetter with hand-curated trail maps and driving directions as well as detailed reviews and photos from hikers, campers and nature lovers like you. All rights reserved. See Chapter 4 of theMember Handbookon the Forms & Documents page for more details. The health of your eyes and teeth can affect your overall health. Physicians and other health care providers are encouraged to use their own best medical judgment based upon all available information and the condition of the patient in determining the best course of treatment. These include prior authorization code lists with effective dates and related information for Blue Cross Community Health PlansSM (BCCHPSM) and Blue Cross Community MMAI (Medicare-Medicaid Plan)SM members. The digital lookup tool is intended for reference purposes only. Home The Customer Service representative will provide you a reference number, which can be used to track the dispute. Most PDF readers are a free download. Drug Coverage. All Rights Reserved. We also feature guest speakers and allow time for a general Q&A. Our doctors and staff make decisions about your care based only on need and benefits. Davis Vision is an independent company that has contracted with BCBSIL to provide vision benefits administration for government programs members with coverage through BCBSIL. The peer-to-peer discussion is available as a courtesy to providers. Want to be part of our amazing team? stream Always check eligibility and benefits through Availity or your preferred web vendor before rendering services. This step also helps you identify prior authorization requirements and utilization management vendors, if applicable. There are no rewards to deny or promote care. To see if you are eligible, Contact:Blue Cross and Blue Shield of Illinois' OTC vendor,Convey Health Solutions, at: 1-855-891-5274. What is the longest historic site trail in Wetter? Procedure code lists are provided for reference purposes. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/Annots[ 27 0 R 28 0 R 29 0 R 30 0 R] /MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> 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. Certain drugs on the list need prior authorization. endobj Returning Shopper? Prior authorization requests for administrative days (ADs) may not be submitted online at this time. %%EOF Refer to our Medicaid prior authorization summary for more details. If you have a complaint about how we handle any services provided to you, you can file a grievance or an appeal. related information. What is the most popular and difficult historic site trail in Wetter? 6C("=L,`YF'0 d Blue Cross Community Health Plans and Blue Cross Community MMAI plans are provided by Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC), an Independent Licensee of the Blue Cross and Blue Shield Association. File is in portable document format (PDF). However, you can order these items once every three months. To return to our website, simply close the new window. You can: Pay a bill online or sign up for auto bill pay. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. Checking eligibility and benefits and/or obtaining prior authorization is not a guarantee of payment of benefits. DV. Whats new on the web? The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Blue Cross Community MMAI (Medicare-Medicaid Plan) SM The Centers for Medicare & Medicaid Services (CMS) and the State of Illinois have contracted with Blue Cross and Blue Shield of Illinois (BCBSIL) along with other Managed Care Organizations (MCO) to implement MMAI. Personal health-related items (such as a toothbrush and toothpaste) are not included on this list. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors. One option is Adobe Reader which has a built-in reader. This new site may be offered by a vendor or an independent third party. Regardless of any prior authorization or benefit determination, the final decision regarding any treatment or service is between the patient and their health care provider. This new site may be offered by a vendor or an independent third party. Check out our Corporate Social Responsibility Reportto learn the ways we're serving our community.

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