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" For other services/members, BCBSIL has contracted witheviCore healthcare (eviCore)for utilization management and related services. Medical policies are also used to guide care decisions. GDChv0O{Q~ $W0!&~(c~;=1^!GD=q2z5OR%AG.)H&lz'9|^f!(@.ib It also includes the drugs covered by Medicare Part D. As a member, you have no copay for covered items on the Drug List. To support the decision process, BCBSIL gives providers the opportunity to discuss UM determinations with a peer physician. Grievance (Complaint) Appeals End along the Ruhr meadows over Lake Kemader to Lake Baldeney in Essen. Your doctor should know which services need approval and can help with the details. All rights reserved. Utilization Management | Blue Cross and Blue Shield of Illinois - BCBSIL Simply enter a 5-digit code, service description or drug name in the search field. Limitations of Covered Benefits by Member Contract Out of area dialysis services. 4 0 obj Your doctors will use other tools to check prior authorization needs. 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. Life changes happen at any time. Contact Us | Blue Cross and Blue Shield of Illinois - BCBSIL This step will help you confirm prior authorization requirements and utilization management vendor information, if applicable. For Medicaid (BCCHP and MMAI) members, prior authorization requirements are found in the last column of the BCCHP drug list and MMAI drug list. 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. Join us as we build the next generation of health insurance. The most popular and difficult historic site trail in Wetter is, RuhrtalRadweg Etappe 4: Wetter (Ruhr) - Essen, WestfalenWanderWeg Etappe 3: Wetter - Schwerte. This step also helps you identify prior authorization requirements and utilization management vendors, if applicable. It will open in a new window. See below for details, including the Zoom registration link. Also, some services need approval before treatment or services are received. New to Blue Access for Members? Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. {0c8Lp~#g.wS,#.z (c PT+ ~"%V3xCh`q'cgI$i%0!J"Cd"$| wFx&U K>txE |3Z$IJri]d(I,14)ze49E]'o|E1F |o%BIwF=";v=sN&./"G0'89)JuJ.v@FiS_$.xpP*GMG"g'K;KmVGA?7nW/pJ'3P.u'7y*6#E!LbC?hhCp6 4y%CS"R;%j)`y31pc`{%w)/*5hKE7:KRnQ&C+grc-pG`3P8+C~J7X 3o'YBa@sOz0zRlA_>]B]]#@W)o)|CNogbC;, jXw8w;![@0\bBJh1e8M'Z9owf;CYP[Hk`|8 (d/v_59=_O~o=pn[3f5+@tn0M|!ev"]"A!^A cc=zZf` sDH- rst !-`*M68G#gYmw/|O|)- endobj Use Our New Prior Authorization Digital Lookup Tool for Medicaid Member All Rights Reserved. Home and Community-Based Services & Waivers, Grievances, Appeals and Coverage Decisions, Language Assistance and Non-Discrimination Notice, Have a prescription from your doctor for them, Fill the prescription at a network pharmacy. % Santori Library To return to our website, simply close the new window. Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. Providers are instructed to exercise their own clinical judgment based on each individual patients health care needs. k+:6@1)^]WNQj sGG& hFa`@,%LFPBA7Xmxt$.=e0ne}#IoE 20iF 6Xg8Sf;+-P > Blue Cross and Blue Shield of Illinois is proud to be the states only statewide, customer-owned health insurer. 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. Check out our Corporate Social Responsibility Reportto learn the ways we're serving our community. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. eviCore healthcare manages all Inpatient Post-Acute Care (PAC) preauthorization requests for Blue Cross and Blue Shield of Illinois (BCBSIL) members enrolled in the following programs: Medicare Blue Cross Medicare Advantage (PPO)SM Medicaid Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Subscribe now to receive the monthly Blue Review via email. Get the most from your BCBSIL pharmacy benefits. To view this file, you may need to install a PDF reader program. Choose the best payment option for your Blue Cross and Blue Shield of Illinois (BCBSIL) monthly bill. 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. 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. hb```) ea&pd:Se At every meeting, we share updates for MMAI and BCCHP providers, such as new programs and resources to share with your patients. 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. You must indicate that you want to file a claims dispute. MMAI Prior Authorization | Blue Cross and Blue Shield of Illinois - BCBSIL BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors. There are no rewards to deny or promote care. To view this file, you may need to install a PDF reader program. Your doctor will choose which drug is best for you. %PDF-1.6 % How Does Blue Cross Community MMAI (Medicare-Medicaid Plan)SMMake Decisions for Prior Authorizations? The site may also contain non-Medicare related information. To access the BCCHP and MMAI digital lookup tool, refer to the Prior Authorization Support Materials (Government Programs) page in our Utilization Management section. <> Aurora, IL 60506. 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. 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. Its important to check eligibility and benefits first for each patient at every visit to confirm coverage details. One option is Adobe Reader which has a built-in screen reader. You can find out if your drug has any added conditions or limits by looking at the Drug List. 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. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. You'll see details that may help lower health care costs. Register Now. If no clinical information was submitted with a request, a peer-to-peer discussion is not permitted. Medical Benefits Blue Cross Community MMAI (Medicare-Medicaid Plan) SM covers many of your health care needs. If an appeal has been filed, the peer-to-peer discussion is no longer available. Log In to the Shopping Cart, Need to Make a Payment? Why participate? MCG (formerly Milliman Care Guidelines) is a trademark of MCG Health, LLC (part of the Hearst Health network), an independent third party vendor. Returning Shopper? 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. 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. The code lists are posted as PDFs so you can scroll through pages manually or enter <CTRL F> to search, highlight and advance to all . This list includes generic and brand drugs and medical supplies. 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). This trail is estimated to be 42.6 km long. BCBSIL contracts with Prime to provide pharmacy benefit management and other related services. There are some exceptions when care you receive from an out-of-network provider will be covered. Government Programs Prior Authorization Summary and Code ListsRefer to the Summary documents below for an overview of prior authorization requirements, reminders and helpful links. 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. MMAI Plan Details | Blue Cross and Blue Shield of Illinois - BCBSIL From Siegen with the beautiful day ticket (33 euros for 5 people) to Wetter / Ruhr. Most PDF readers are a free download. Log in to your account to get the most accurate, personalized search results based on your plan. Please note that, effective May 1, 2021, there will be a change to the BCCHP peer-to-peer discussion process, as specified below. If you have any questions, call the number on the members ID card. When faxing prior authorization requests, you must use the Medicaid Prior Authorization Request Form. 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. Grievances, Appeals and Coverage Decisions | Blue Cross and Blue Shield `9wL 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. Where: Hybrid, Join us in person: The next highest ascent for historic site trails is. Some benefit plans administered by BCBSIL, such as some self-funded employer plans or governmental plans, may not utilize BCBSIL Medical Policies. Provider | Blue Cross and Blue Shield of Illinois - BCBSIL 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. 1 0 obj 12 0 obj <> endobj 64 0 obj <>/Filter/FlateDecode/ID[<377B542E37144E99AA8D3C27588EFAA9><9D42E3C64D6B4195AB6A428BC62E2046>]/Index[12 96]/Info 11 0 R/Length 151/Prev 468246/Root 13 0 R/Size 108/Type/XRef/W[1 3 1]>>stream FIND YOUR WAY OUTSIDE is a trademark of AllTrails, LLC. The site may also contain non-Medicare related information. The site may also contain non-Medicare related information. Availity provides administrative services to BCBSIL. See Chapter 4 of theMember Handbookon the Forms & Documents page for more details. April 24, 2023. Copyright document.write(new Date().getFullYear()) Health Care Service Corporation. Request a new replacement member ID card, or download a temporary copy. You pay nothing ($0) when you go to a doctor or health care provider in the plan's network. Welcome. If you do not use the $30, it does not roll over into the next three months. Prior Authorization Support Materials (Government Programs) - BCBSIL 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. Providers are allowed the opportunity to schedule one peer-to-peer discussion per adverse determination. Medicaid Providers: Updated Prior Authorization Tips and Peer - BCBSIL This list includes generic and brand drugs and medical supplies. 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. If you have any questions, call the number on the member's BCBSIL ID card. Sara will be discussing Mental Health Awareness Month and cultural competency. Learn about the many ways we are contributing to the well-being of our local Illinois communities in the latest Corporate Social Responsibility Report. Wetter - Kupferdreh Ruhrradweg | Map, Guide - North Rhine-Westphalia For some services/members, prior authorization may be required through BCBSIL. 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. Search for doctors, dentists, hospitals and other health care providers. The site may also contain non-Medicare The next highest ascent for historic site trails is Von Wetter zum Nacken with 664 m of elevation gain. File is in portable document format (PDF). BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors. endobj Sign up! Out-of-Network Coverage. ( Note: See Medicaid page for BCCHP and MMAI Provider Finder links.) As you transition to Medicare, we hope you'll Stay with Blue and get Medicare coverage from a company you trust. Sign up for theLifeTimes newsletterto get health and benefits articles delivered to your inbox every month. hbbd```b``6O L %,"&*u`0;L:`5 ; To view this file, you may need to install a PDF reader program. All Rights Reserved. Your plan does not encourage doctors to give less care than you need. Additionally, the Provider Service Authorization Dispute process is available when an adverse service authorization has been rendered and the UM process has been followed. Topics include everything from improving your well-being to explaining health coverage. 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. Search articles and watch videos; ask questions and get answers. Drug Coverage. <> This new site may be offered by a vendor or an independent third party. Medicaid Prior Authorization Request Form, Provider Service Authorization Dispute Resolution Request Form. PDF Medicaid Prior Authorization Request Form - BCBSIL Prior authorization requests for administrative days (ADs) may not be submitted online at this time. Without approval, the drug won't be covered. Personal health-related items (such as a toothbrush and toothpaste) are not included on this list. endobj Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. You are leaving this website/app ("site"). 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. 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 BCBSIL Medical Policies are for informational purposes only and are not a substitute for the independent medical judgment of health care providers. For some services/members, prior authorization may be required through BCBSIL. Most PDF readers are a free download. 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. 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 <. 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. If you have a complaint about how we handle any services provided to you, you can file a grievance or an appeal. To view this file, you may need to install a PDF reader program. Your PCP will handle the prior authorization process. Your Summary of Benefits has information about which services require prior authorization. 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. Medicaid | Blue Cross and Blue Shield of Illinois - BCBSIL This new site may be offered by a vendor or an independent third party. 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. Our trusted community experts can give you the one-on-one help you need to shop for health insurance. For more than 85 years, weve provided our members with comprehensive, affordable health plans, making Illinois a healthier place to live, work and play. #5 - RuhrtalRadweg Etappe 4: Wetter (Ruhr) - Essen, #6 - WestfalenWanderWeg Etappe 3: Wetter - Schwerte. Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. 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. For some drugs, the plan limits the amount that will be covered. Blue Cross Community MMAI (Medicare-Medicaid Plan)SM includes coverage for selected prescription and over-the-counter (OTC) drugs, and selected medical supplies. You also can call the MMAI plan's pharmacy help-line. You also have the right to ask for a coverage decision. 3oDiCBG\{?xyH PDF Medicare-Medicaid Alignment Initiative (MMAI) Demonstration Frequently To protect your health and keep you safe, make sure your doctor and pharmacist know what medicines you are taking, including OTC drugs. BCBSIL adheres to the standards for addressing all urgent concurrent requests, meeting or exceeding National Committee for Quality Assurance (NCQA) standards. Once additional meetings are confirmed, well alert you via the News and Updates. 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. What is the most popular and difficult historic site trail in Wetter? Create an account. If a request does not meet medical necessity criteria for approval, the request will be assigned to a BCBSIL medical director for determination. Our doctors and staff make decisions about your care based on need and benefits. External link You are leaving this website/app (site). The tool returns a list of services that may require prior authorization through BCBSIL or eviCore healthcare (eviCore) for BCCHP and MMAI members. DentaQuest is an independent company that provides dental benefits for BCBSILs Medicaid plans. For some services/members, prior authorization may be required through BCBSIL. You are leaving this website/app ("site"). 3 0 obj Step-by-Step Guide for Provider Finder. Some services need approval from your health plan before you get treated. endstream endobj 374 0 obj <. New User? During weekend hours, UM reviewers and medical directors continue to review requests and make decisions. Availity provides administrative services to BCBSIL. Blue Cross Community MMAI has strict rules about how decisions are made about your care. 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. MMAI Drug Coverage | Blue Cross and Blue Shield of Illinois. - BCBSIL Legal and Privacy 2. 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. 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. Customer Service: File the dispute by calling Customer Service at 1-877-860-2837. 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. The Drug List (sometimes called a formulary) is a list showing the drugs that can be covered by the plan. 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. Medical Policies are based on scientific and medical research. File is in portable document format (PDF). Its a great chance to work with faith leaders, advocacy groups and other community-based organizations that support our members health and well-being. 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. Failing to provide clinical information or timely notification of prior authorization requests may affect the outcome of a Service Authorization Dispute. 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. MMAI and BCCHP Providers: Join Our Community Stakeholder Committee Blue Cross Community MMAI (Medicare-Medicaid Plan) SM includes coverage for selected prescription and over-the-counter (OTC) drugs, and selected medical supplies. If you want to know more about the utilization management process or how decisions are made about your care, Contact Us. related information. 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. You are leaving this website/app (site). Access Your Payment Options. We also feature guest speakers and allow time for a general Q&A. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider. Search your plan's drug list, find a pharmacy, and more. Information provided is not exhaustive and is subject to change. Reminder: Hospital 30-day Readmission Review Process for BCCHP and MMAI As of this date, providers may submit a new packet for clinical re-review OR do a peer-to-peer discussion. In addition, some sites may require you to agree to their terms of use and privacy policy. These requests must be decided within 48 hours for BCCHP members, and 72 hours for MMAI members. One 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 PDF Medicaid Prior Authorization Requirements Summary, Effective Jan. 1 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. The above material is for informational purposes only and is not intended to be a substitute for the independent medical judgment of a physician. Provider Finder. The health of your eyes and teeth can affect your overall health. <>/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>> This approval is called "prior authorization." One option is Adobe Reader which has a built-in reader. 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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