Whats new on the web? The site may also contain non-Medicare related information. At every meeting, we share updates for MMAI and BCCHP providers, such as new programs and resources to share with your patients. All Rights Reserved. It is the responsibility of the requesting provider to submit clinical documentation to substantiate a request for services at the time of the service authorization request. 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. At Blue Cross Community MMAI (Medicare-Medicaid Plan) SM, we take great pride in ensuring that you receive the care you need. These requests must be decided within 48 hours for BCCHP members, and 72 hours for MMAI members. Availity provides administrative services to BCBSIL. 396 0 obj
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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. Out-of-Network Coverage. 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).
These tools used by PCPs (or specialists) include medical codes. All Rights Reserved. For some services/members, prior authorization may be required through BCBSIL. These tools used by PCPs (or specialists) include medical codes. x=r8?Qi xJI&JfIl3D:#SfAw
$nb"n q~+|Vz?p~Q{vrle{{_F^gEx6,>/?e=kOws/nTgO~S>)ga0)D>Mx,lN}=v,QPD>j" The tool returns a list of services that may require prior authorization through BCBSIL or eviCore healthcare (eviCore) for BCCHP and MMAI members. 1 0 obj
Related Resources
Some benefit plans administered by BCBSIL, such as some self-funded employer plans or governmental plans, may not utilize BCBSIL Medical Policies. 373 0 obj
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Some services need approval from your health plan before you get treated. New to Blue Access for Members? What is the most popular and difficult historic site trail in Wetter? Our doctors and staff make decisions about your care based on need and benefits. The next highest ascent for historic site trails is. option is Adobe Reader which has a built-in reader. Convey Health Solutions, Inc. is an independent company that provides administrative services for over-the-counter supplemental benefits for Blue Cross and Blue Shield of Illinois. R{O *L%U}r?:B22Rj=]p
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M$ }u$z 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. Information provided is not exhaustive and is subject to change. See below for details, including the Zoom registration link. 0
You can: Pay a bill online or sign up for auto bill pay. Life changes happen at any time. Medical policies are also used to guide care decisions. Luckily, your health insurance can change with you. Certain drugs on the list need prior authorization. Medicaid Prior Authorization Request Form Please fax completed form to 312-233-4060 This information applies to Blue Cross Community Health PlansSM (BCCHPSM) and Blue Cross Community MMAI (Medicare-Medicaid Plan)SM members. BCBSIL adheres to the standards for addressing all urgent concurrent requests, meeting or exceeding National Committee for Quality Assurance (NCQA) standards. FIND YOUR WAY OUTSIDE is a trademark of AllTrails, LLC. 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. Step-by-Step Guide for Provider Finder. MCG (formerly Milliman Care Guidelines) is a trademark of MCG Health, LLC (part of the Hearst Health network), an independent third party vendor. Rather than viewing all codes on a running list in a static document, you can use our interactive digital lookup tool to perform a faster, more targeted search. But we know its nice to have other ways to view prior authorization information, too. 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. Frequently asked questions about historic site trails in Wetter. Information on Service Authorization Disputes can be found on the Provider Service Authorization Dispute Resolution Request Form. Medical Policies are based on scientific and medical research. stream
If you have any questions, call the number on the members ID card. Create an account. For some drugs, the plan limits the amount that will be covered. This is called prior authorization, preauthorization, pre-certification or prior approval. Stage 3 of the long-distance hiking trail WestfalenWanderWeg, North Rhine-Westphalia. 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. Please see Drug Information for more information. 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. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com
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It also includes the drugs covered by Medicare Part D. As a member, you have no copay for covered items on the Drug List. While not included in the digital lookup tool, some services always require prior authorization, such as inpatient facility admissions. 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. Doctors are not paid to deny care. Explore Out-of-Network Coverage for more information about your network. hb```) ea&pd:Se New User? Whens the meeting for the next quarter? 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. Once additional meetings are confirmed, well alert you via the News and Updates. This approval is called "prior authorization." Sign up! Welcome. To view this file, you may need to install a PDF reader program.
Prior Authorization Support Materials (Government Programs). To view this file, you may need to install a PDF reader program. Talk with your doctor about your medication. 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. 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. Those exceptions are: Emergency care or urgently needed care. 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. 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. Your PCP will handle the prior authorization process. Failing to provide clinical information or timely notification of prior authorization requests may affect the outcome of a Service Authorization Dispute. Learn about the many ways we are contributing to the well-being of our local Illinois communities in the latest Corporate Social Responsibility Report. Sara will be discussing Mental Health Awareness Month and cultural competency. 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. 415 0 obj
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Topics include everything from improving your well-being to explaining health coverage. Log in to your account to get the most accurate, personalized search results based on your plan. In addition, some sites may require you to agree to their terms of use and privacy policy. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. All rights reserved. ALLTRAILS and the AllTrails Mountain Design are registered trademarks of AllTrails, LLC in the United States as well as certain other jurisdictions. Davis Vision is an independent company that has contracted with BCBSIL to provide vision benefits administration for government programs members with coverage through BCBSIL. A provider may initiate a peer-to-peer discussion by calling 800-981-2795. Your doctor will choose which drug is best for you. In addition, some sites may require you to agree to their terms of use and privacy policy. *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. Use the links below to view BCBSIL and vendor guidelines that may apply. File is in portable document format (PDF). If you have a complaint about how we handle any services provided to you, you can file a grievance or an appeal. 4 0 obj
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. 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. 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 @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%,(( For some services/members, prior authorization may be required through BCBSIL. If we do not receive adequate clinical documentation, BCBSIL will reach out to your facility UM department and provide a date and time in which clinical documentation is required to be received. We also feature guest speakers and allow time for a general Q&A. Most PDF readers are a free download. Providers are allowed the opportunity to schedule one peer-to-peer discussion per adverse determination. }&ji[@_{dsTchsqD7bL+x3AXG>z>(y{+/en6=V/e{.t&>jFj750hS)
!yppH7edMUFA{u38_tZ'oKAlr, @qiD 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. Want to be part of our amazing team? The peer-to-peer discussion is not required, nor does it affect the providers right to an appeal on behalf of a member. BCBSIL contracts with Prime to provide pharmacy benefit management and other related services. Most PDF readers are a free download. To access the BCCHP and MMAI digital lookup tool, refer to the Prior Authorization Support Materials (Government Programs) page in our Utilization Management section. 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. 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. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors. If your doctor wants you to have a drug that is not on the list, he or she can request approval for that drug. Who is responsible for getting the prior authorization? 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. To protect your health and keep you safe, make sure your doctor and pharmacist know what medicines you are taking, including OTC drugs. Copyright document.write(new Date().getFullYear()) Health Care Service Corporation. If you have any questions, call the number on the member's BCBSIL ID card. Your plan covers the items in the Drug List as long as you: To see your plan's Drug List, go toForms & Documents. According to AllTrails.com, the longest historic site trail in Wetter is RuhrtalRadweg Etappe 4: Wetter (Ruhr) - Essen. The site may also contain non-Medicare related information. 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. This link will take you to a new site not affiliated with BCBSIL. Request a new replacement member ID card, or download a temporary copy. Access Your Payment Options. The site may also contain non-Medicare
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In addition, some sites may require you to agree to their terms of use and privacy policy. How to File a Claims Dispute using Enterprise Appeals Application (EAA) Tracking ID 1. endstream
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<. Medical Benefits Blue Cross Community MMAI (Medicare-Medicaid Plan) SM covers many of your health care needs. The code lists are posted as PDFs so you can scroll through pages manually or enter
to search, highlight and advance to all instances of a particular word or number. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. Join us as we build the next generation of health insurance. Its important to check eligibility and benefits first for each patient at every visit to confirm coverage details. Please note that, effective May 1, 2021, there will be a change to the BCCHP peer-to-peer discussion process, as specified below. 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. Click here to see prior authorization tools, clinical review criteria and MMAI Medical Policies used by your doctor to make a decision. For other services/members, BCBSIL has contracted witheviCore healthcare (eviCore)for utilization management and related services. The most popular and difficult historic site trail in Wetter is Von Wetter zum Nacken with a 3.6-star rating from 2 reviews. %PDF-1.6
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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. 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. File is in portable document format (PDF). #5 - RuhrtalRadweg Etappe 4: Wetter (Ruhr) - Essen, #6 - WestfalenWanderWeg Etappe 3: Wetter - Schwerte. The next highest ascent for historic site trails is Von Wetter zum Nacken with 664 m of elevation gain. You are leaving this website/app (site). Blue Cross Community MMAI (Medicare-Medicaid Plan) SM includes coverage for selected prescription and over-the-counter (OTC) drugs, and selected medical supplies. What: Q2 2023 MMAI and BCCHP Community Stakeholder Committee Meeting End along the Ruhr meadows over Lake Kemader to Lake Baldeney in Essen. For some services/members, prior authorization may be required through BCBSIL. Your doctors will use other tools to check prior authorization needs. 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. To return to our website, simply close the new window. 101 S. River Street This new site may be offered by a vendor or an independent third party. Procedure code lists are provided for reference purposes. To support the decision process, BCBSIL gives providers the opportunity to discuss UM determinations with a peer physician. Copyright document.write(new Date().getFullYear()); Health Care Service Corporation. A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
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We're 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 Plans SM (BCCHP) members. Well also include reminders in the Blue Review. This list includes generic and brand drugs and medical supplies. This new site may be offered by a vendor or an independent third party. This list includes generic and brand drugs and medical supplies. Your Summary of Benefits has information about which services require prior authorization. endobj
During weekend hours, UM reviewers and medical directors continue to review requests and make decisions. For BCCHP and MMAI: Peer-to-peer discussions are allowed for requests where clinical information was submitted with the original request. Highlights: Our guest speaker is Sara Gray, Executive Director of National Alliance on Mental Illness, Kane-south, DeKalb and Kendall Counties. You must indicate that you want to file a claims dispute. 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. 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 PlansSM (BCCHPSM) and Blue Cross Community MMAI (Medicare-Medicaid Plan)SM members. Which historic site trail has the most elevation gain in Wetter? To view this file, you may need to install a PDF reader program. Returning Shopper? This new site may be offered by a vendor or an independent third party. Registration is required. This trail is estimated to be 42.6 km long. Members should contact the vendor(s) directly with questions about the products or services offered by third parties. hbbd```b``6O L %,"&*u`0;L:`5 ; Lunch will be provided. Its a great chance to work with faith leaders, advocacy groups and other community-based organizations that support our members health and well-being. Providers are instructed to exercise their own clinical judgment based on each individual patients health care needs. 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. Search articles and watch videos; ask questions and get answers. They use what is called clinical criteria to make sure you get the health care you need. One option is Adobe Reader which has a built-in screen reader. For more than 85 years, weve provided our members with comprehensive, affordable health plans, making Illinois a healthier place to live, work and play. This step also helps you identify prior authorization requirements and utilization management vendors, if applicable. The peer-to-peer discussion is available as a courtesy to providers. {0c8Lp~#g.wS,#.z
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sDH- rst !-`*M68G#gYmw/|O|)- One option is Adobe Reader which has a built-in reader. Checking eligibility and benefits and/or obtaining prior authorization is not a guarantee of payment of benefits. 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. Without approval, the drug won't be covered. Also, some services need approval before treatment or services are received. Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. R'sYI D@
zmG@5msm!T%FN3_z. From Siegen with the beautiful day ticket (33 euros for 5 people) to Wetter / Ruhr. Copyright 2021 Health Care Service Corporation. Register Now. How Does Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Make Decisions for Prior Authorizations? The digital lookup tool is intended for reference purposes only. URGENT (If checked, please provide anticipated date of service below) Where: Hybrid, Join us in person: It will open in a new window. To help ensure turnaround times are met and decisions are provided to requesting providers as quickly as possible, BCCHP and MMAI utilization management (UM) reviewers and medical directors are available seven days a week, excluding BCBSIL identified holidays. The Customer Service representative will provide you a reference number, which can be used to track the dispute. For Medicaid (BCCHP and MMAI) members, prior authorization requirements are found in the last column of the BCCHP drug list and MMAI drug list. Limitations of Covered Benefits by Member Contract 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. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider. Personal health-related items (such as a toothbrush and toothpaste) are not included on this list. To see if you are eligible, Contact:Blue Cross and Blue Shield of Illinois' OTC vendor,Convey Health Solutions, at: 1-855-891-5274. Members should contact the customer service number on their member ID card for more specific coverage information. Stay informed about BCBSIL programs, products, initiatives, and more. If no clinical information was submitted with a request, a peer-to-peer discussion is not permitted. DentaQuest is an independent company that provides dental benefits for BCBSILs Medicaid plans. 2 0 obj
The BCBSIL Medical Policies are for informational purposes only and are not a substitute for the independent medical judgment of health care providers. You are leaving this website/app ("site"). You also have the right to ask for a coverage decision. The Drug List (sometimes called a formulary) is a list showing the drugs that can be covered by the plan. Prime Therapeutics LLC (Prime) is a pharmacy benefit management company. Most PDF readers are a free download. <>/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>>
How do I know if I need a prior authorization? 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. We'd like to invite you to join us for our next committee meeting on May 18, 2023. Your doctor should know which services need approval and can help with the details. 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.
In addition, some sites may require you to agree to their terms of use and privacy policy. All Rights Reserved. You also can call the MMAI plan's pharmacy help-line. In most cases, you must receive your care from a Blue Cross Community MMAI (Medicare-Medicaid Plan) SM in-network plan provider. Most PDF readers are a free download. 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). The most popular and difficult historic site trail in Wetter is, RuhrtalRadweg Etappe 4: Wetter (Ruhr) - Essen, WestfalenWanderWeg Etappe 3: Wetter - Schwerte. Blue Cross Community MMAI (Medicare-Medicaid Plan)SM includes coverage for selected prescription and over-the-counter (OTC) drugs, and selected medical supplies. Choose the best payment option for your Blue Cross and Blue Shield of Illinois (BCBSIL) monthly bill. Get the most from your BCBSIL pharmacy benefits. (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). %
Check out our Corporate Social Responsibility Reportto learn the ways we're serving our community. One
If a request does not meet medical necessity criteria for approval, the request will be assigned to a BCBSIL medical director for determination. DV. If you do not use the $30, it does not roll over into the next three months. <>
Your doctors will use other tools to check prior authorization needs. What is the longest historic site trail in Wetter? How Does Blue Cross Community MMAI (Medicare-Medicaid Plan)SMMake Decisions for Prior Authorizations? hb``0b`0 36 fah@t#(f`XU1U B)xPB2@+4s\
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GDChv0O{Q~ $W0!&~(c~;=1^!GD=q2z5OR%AG.)H&lz'9|^f!(@.ib Most PDF readers are a free download. New User? Prior authorization to confirm medical necessity is required for certain services and benefit plans as part of our commitment to help ensure all Blue Cross and Blue Shield of Illinois (BCBSIL) members get the right care, at the right time, in the right setting. Non-Discrimination Notice.
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