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. 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. Customer Service: File the dispute by calling Customer Service at 1-877-860-2837. Log in to your account to get the most accurate, personalized search results based on your plan. 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. 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. The tool returns a list of services that may require prior authorization through BCBSIL or eviCore healthcare (eviCore) for BCCHP and MMAI members. 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. In most cases, you must receive your care from a Blue Cross Community MMAI (Medicare-Medicaid Plan) SM in-network plan provider. Where: Hybrid, Join us in person: endstream endobj startxref GDChv0O{Q~ $W0!&~(c~;=1^!GD=q2z5OR%AG.)H&lz'9|^f!(@.ib BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. 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. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the conditions of the patient in determining the appropriate course of treatment. The site may also contain non-Medicare For BCCHP and MMAI: Peer-to-peer discussions are allowed for requests where clinical information was submitted with the original request. (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). Use the links below to view BCBSIL and vendor guidelines that may apply. 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. You pay nothing ($0) when you go to a doctor or health care provider in the plan's network. Members should contact the customer service number on their member ID card for more specific coverage information. hb```) ea&pd:Se 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. Stay informed about BCBSIL programs, products, initiatives, and more. We know you like to plan ahead. 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. 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. ALLTRAILS and the AllTrails Mountain Design are registered trademarks of AllTrails, LLC in the United States as well as certain other jurisdictions. The above material is for informational purposes only and is not intended to be a substitute for the independent medical judgment of a physician. One option is Adobe Reader which has a built-in screen reader. The Customer Service representative will provide you a reference number, which can be used to track the dispute. The digital lookup tool is intended for reference purposes only. 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. stream For some drugs, the plan limits the amount that will be covered. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. To access the BCCHP and MMAI digital lookup tool, refer to the Prior Authorization Support Materials (Government Programs) page in our Utilization Management section. File is in portable document format (PDF). If your doctor wants you to have a drug that is not on the list, he or she can request approval for that drug. Most PDF readers are a free download. Our trusted community experts can give you the one-on-one help you need to shop for health insurance. 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. 1 0 obj This new site may be offered by a vendor or an independent third party. Providers are allowed the opportunity to schedule one peer-to-peer discussion per adverse determination. The peer-to-peer discussion is not required, nor does it affect the providers right to an appeal on behalf of a member. Choose the best payment option for your Blue Cross and Blue Shield of Illinois (BCBSIL) monthly bill. If you want to know more about the utilization management process or how decisions are made about your care, Contact Us. Get the most from your BCBSIL pharmacy benefits. The Drug List (sometimes called a formulary) is a list showing the drugs that can be covered by the plan. Qf#yQ>u(KpRE{UIQp[)5T:p:jBFp*WWhwIA36YwNG)!G/!Yr6v7e|12 rUp3?R1H-6Kre vh) yj?O&y]\x,$aU7Mm'a 5a1owahiT@IC+ But we know its nice to have other ways to view prior authorization information, too. The peer-to-peer discussion is available as a courtesy to providers. hbbd```b``6O L %,"&*u`0;L:`5 ; Certain drugs on the list need prior authorization. If an appeal has been filed, the peer-to-peer discussion is no longer available. It will open in a new window. All rights reserved. This new site may be offered by a vendor or an independent third party. Those exceptions are: Emergency care or urgently needed care. Refer to important information for our linking policy. A provider may initiate a peer-to-peer discussion by calling 800-981-2795. Without approval, the drug won't be covered. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com Information on Service Authorization Disputes can be found on the Provider Service Authorization Dispute Resolution Request Form. 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 reader. 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. At every meeting, we share updates for MMAI and BCCHP providers, such as new programs and resources to share with your patients. This step also helps you identify prior authorization requirements and utilization management vendors, if applicable. To view this file, you may need to install a PDF reader program. Always check eligibility and benefits through Availity or your preferred web vendor before rendering services. For some services/members, prior authorization may be required through BCBSIL. #5 - RuhrtalRadweg Etappe 4: Wetter (Ruhr) - Essen, #6 - WestfalenWanderWeg Etappe 3: Wetter - Schwerte. Provider Finder. Luckily, your health insurance can change with you. 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. In addition, some sites may require you to agree to their terms of use and privacy policy. Check out our Corporate Social Responsibility Reportto learn the ways we're serving our community. Highlights: Our guest speaker is Sara Gray, Executive Director of National Alliance on Mental Illness, Kane-south, DeKalb and Kendall Counties. Grievance (Complaint) Appeals This approval is called "prior authorization." 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. 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. 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. This list includes generic and brand drugs and medical supplies. Sign up! Out of area dialysis services. Blue Cross Community MMAI (Medicare-Medicaid Plan) SM includes coverage for selected prescription and over-the-counter (OTC) drugs, and selected medical supplies. 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. 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. Frequently asked questions about historic site trails in Wetter. New User? 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 3oDiCBG\{?xyH 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. 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. 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. Its a great chance to work with faith leaders, advocacy groups and other community-based organizations that support our members health and well-being. From Essen-Kupferdreh back with the S-Bahn to the main station and from there without changing with the RE 16 back to Siegerland. 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. Most PDF readers are a free download. 0 Our doctors and staff make decisions about your care based only on need and benefits. 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. This trail is estimated to be 42.6 km long. This is the third stage of the varied WestfalenWanderWeg, which leads 216 km from Hattingen through the southern Ruhr area, the Paderborn region and the foothills of the Sauerland to Altenbeken in the Teutoburg Forest / Eggegebirge nature park. <>/Metadata 528 0 R/ViewerPreferences 529 0 R>> Stage 3 of the long-distance hiking trail WestfalenWanderWeg, North Rhine-Westphalia. You must indicate that you want to file a claims dispute. The most popular and difficult historic site trail in Wetter is, RuhrtalRadweg Etappe 4: Wetter (Ruhr) - Essen, WestfalenWanderWeg Etappe 3: Wetter - Schwerte. DentaQuest is an independent company that provides dental benefits for BCBSILs Medicaid plans. 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 Please see Drug Information for more information. ( Note: See Medicaid page for BCCHP and MMAI Provider Finder links.) How Does Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Make Decisions for Prior Authorizations? 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. The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. Blue Cross Community MMAI has strict rules about how decisions are made about your care. If you do not use the $30, it does not roll over into the next three months. The site may also contain non-Medicare related information. 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. 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 next highest ascent for historic site trails is. Medical policies are also used to guide care decisions. Simply enter a 5-digit code, service description or drug name in the search field. Some benefit plans administered by BCBSIL, such as some self-funded employer plans or governmental plans, may not utilize BCBSIL Medical Policies. This link will take you to a new site not affiliated with BCBSIL. If no clinical information was submitted with a request, a peer-to-peer discussion is not permitted. Limitations of Covered Benefits by Member Contract Welcome. Government Programs Prior Authorization Summary and Code ListsRefer to the Summary documents below for an overview of prior authorization requirements, reminders and helpful links. Aurora, IL 60506. To ask for instructions on how to appeal, call the Member Services line for the MMAI plan or call the Senior HelpLine and ask for the MMAI Ombudsman at 1-800-252-8966 (TTY users should call 1-888-206-1327) Monday-Friday 8:30 am-5pm. 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. Copyright document.write(new Date().getFullYear()) Health Care Service Corporation. Your doctors will use other tools to check prior authorization needs. `9wL Register Now. A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association If you have any questions, call the number on the members ID card. *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. Lunch will be provided.
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