Your doctor should know which services need approval and can help with the details. Also, some services need approval before treatment or services are received. To support the decision process, BCBSIL gives providers the opportunity to discuss UM determinations with a peer physician. This trail is estimated to be 42.6 km long. 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. endstream endobj startxref 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. While not included in the digital lookup tool, some services always require prior authorization, such as inpatient facility admissions. File is in portable document format (PDF). At Blue Cross Community MMAI (Medicare-Medicaid Plan) SM, we take great pride in ensuring that you receive the care you need. You'll see details that may help lower health care costs. But we know its nice to have other ways to view prior authorization information, too. Whats on the agenda? Availity provides administrative services to BCBSIL. Information on Service Authorization Disputes can be found on the Provider Service Authorization Dispute Resolution Request Form. {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|)- The BCBSIL Medical Policies are for informational purposes only and are not a substitute for the independent medical judgment of health care providers. 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. This approval is called "prior authorization." During weekend hours, UM reviewers and medical directors continue to review requests and make decisions. How Does Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Make Decisions for Prior Authorizations? 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. All Rights Reserved. From Essen-Kupferdreh back with the S-Bahn to the main station and from there without changing with the RE 16 back to Siegerland. Which historic site trail has the most elevation gain in Wetter? Most PDF readers are a free download. Providers are allowed the opportunity to schedule one peer-to-peer discussion per adverse determination. Your doctor will choose which drug is best for you. Grievance (Complaint) Appeals Luckily, your health insurance can change with you. This new site may be offered by a vendor or an independent third party. 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. For more than 85 years, weve provided our members with comprehensive, affordable health plans, making Illinois a healthier place to live, work and play. Blue Cross and Blue Shield of Illinois is proud to be the states only statewide, customer-owned health insurer. Related Resources Life changes happen at any time. If you want to know more about the utilization management process or how decisions are made about your care, Contact Us. For some services/members, prior authorization may be required through BCBSIL. If no clinical information was submitted with a request, a peer-to-peer discussion is not permitted. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors. Our doctors and staff make decisions about your care based on need and benefits. Checking eligibility and benefits and/or obtaining prior authorization is not a guarantee of payment of benefits. Members should contact the customer service number on their member ID card for more specific coverage information. Medical Policies are based on scientific and medical research. 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 <. To return to our website, simply close the new window. 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. All Rights Reserved. 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. GDChv0O{Q~ $W0!&~(c~;=1^!GD=q2z5OR%AG.)H&lz'9|^f!(@.ib Your doctor will need to request approval before these drugs can be prescribed. 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. 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 You are leaving this website/app ("site"). Lunch will be provided. Most PDF readers are a free download. 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. Prime Therapeutics LLC (Prime) is a pharmacy benefit management company. These requests must be decided within 48 hours for BCCHP members, and 72 hours for MMAI members. Most PDF readers are a free download. For other services/members, BCBSIL has contracted with eviCore healthcare (eviCore) for utilization management and related services. Copyright 2021 Health Care Service Corporation. 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. Please note that, effective May 1, 2021, there will be a change to the BCCHP peer-to-peer discussion process, as specified below. End along the Ruhr meadows over Lake Kemader to Lake Baldeney in Essen. 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. External link You are leaving this website/app (site). 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 This new site may be offered by a vendor or an independent third party. Join us as we build the next generation of health insurance. If you do not use the $30, it does not roll over into the next three months. Register Now. We are also the largest provider of health benefits in Illinois, serving more than 8.9 million members in all 102 counties across the state. Our doctors and staff make decisions about your care based on need and benefits. Home Some services need approval from your health plan before you get treated. For some services/members, prior authorization may be required through BCBSIL. DV. One option is Adobe Reader which has a built-in reader. New User? Personal health-related items (such as a toothbrush and toothpaste) are not included on this list. option is Adobe Reader which has a built-in reader. These tools used by PCPs (or specialists) include medical codes. endobj Step-by-Step Guide for Provider Finder. Limitations of Covered Benefits by Member Contract Legal and Privacy Checking eligibility and benefits and/or obtaining prior authorization is not a guarantee of payment of benefits. It is the responsibility of the requesting provider to submit clinical documentation to substantiate a request for services at the time of the service authorization request. hbbd```b``6O L %,"&*u`0;L:`5 ; When faxing prior authorization requests, you must use the Medicaid Prior Authorization Request Form. @SssUJ- =`~4*>_faS A$wa8|9NN4 d>!XHDhf\~%r'7m|oHF~D#R X(b(uQu (pd)8MA/> ?&ME.@.$O4>!Mwiw%c:IlAc:4U&SUDaE:?{Or-RaX%,(( Davis Vision is an independent company that has contracted with BCBSIL to provide vision benefits administration for government programs members with coverage through BCBSIL. 4 0 obj Your feedback is vital to improving the care and services these members receive. Our doctors and staff make decisions about your care based only on need and benefits. Blue Cross Community MMAI (Medicare-Medicaid Plan) SM includes coverage for selected prescription and over-the-counter (OTC) drugs, and selected medical supplies. Whats new on the web? x=r8?Qi xJI&JfIl3D:#SfAw $nb"n q~+|Vz?p~Q{vrle{{_F^gEx6,>/?e=kOws/nTgO~S>)ga0)D>Mx,lN}=v,QPD>j" You can find out if your drug has any added conditions or limits by looking at the Drug List. k+:6@1)^]WNQj sGG& hFa`@,%LFPBA7Xmxt$.=e0ne}#IoE 20iF 6Xg8Sf;+-P > You pay nothing ($0) when you go to a doctor or health care provider in the plan's network. 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. Register Now. Most PDF readers are a free download. What: Q2 2023 MMAI and BCCHP Community Stakeholder Committee Meeting If an appeal has been filed, the peer-to-peer discussion is no longer available. Doctors are not paid to deny care. Its important to check eligibility and benefits first for each patient at every visit to confirm coverage details. External link You are leaving this website/app (site). We also feature guest speakers and allow time for a general Q&A. 3oDiCBG\{?xyH You can get one shipment every three months. 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 Drug List (sometimes called a formulary) is a list showing the drugs that can be covered by the plan. A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Learn about the many ways we are contributing to the well-being of our local Illinois communities in the latest Corporate Social Responsibility Report. If you have any questions, call the number on the members ID card. <> This list includes generic and brand drugs and medical supplies. 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 ASAM Criteria, 2021 American Society of Addiction Medicine. Certain drugs on the list need prior authorization. You also have the right to ask for a coverage decision. To view this file, you may need to install a PDF reader program. %PDF-1.6 % ( Note: See Medicaid page for BCCHP and MMAI Provider Finder links.) Government Programs Prior Authorization Summary and Code ListsRefer to the Summary documents below for an overview of prior authorization requirements, reminders and helpful links. This step also helps you identify prior authorization requirements and utilization management vendors, if applicable. We'd like to invite you to join us for our next committee meeting on May 18, 2023. Copyright document.write(new Date().getFullYear()) Health Care Service Corporation. endstream endobj 374 0 obj <. New User? Sara will be discussing Mental Health Awareness Month and cultural competency. There are some exceptions when care you receive from an out-of-network provider will be covered. Medicaid Prior Authorization Request Form, Provider Service Authorization Dispute Resolution Request Form. 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. What is the most popular and difficult historic site trail in Wetter? Whens the meeting for the next quarter? What is the longest historic site trail in Wetter? The most popular and difficult historic site trail in Wetter is, RuhrtalRadweg Etappe 4: Wetter (Ruhr) - Essen, WestfalenWanderWeg Etappe 3: Wetter - Schwerte. 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. Create an account. 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. 1 0 obj The tool returns a list of services that may require prior authorization through BCBSIL or eviCore healthcare (eviCore) for BCCHP and MMAI members. Your Summary of Benefits has information about which services require prior authorization. Medical policies are also used to guide care decisions. Prior authorization requests for administrative days (ADs) may not be submitted online at this time. Welcome. Once additional meetings are confirmed, well alert you via the News and Updates. Click here to see prior authorization tools, clinical review criteria and MMAI Medical Policies used by your doctor to make a decision. *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. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. % If a request does not meet medical necessity criteria for approval, the request will be assigned to a BCBSIL medical director for determination. The plan will pay up to $30 (plus $5 for shipping) for each order. A provider may initiate a peer-to-peer discussion by calling 800-981-2795. It also includes the drugs covered by Medicare Part D. As a member, you have no copay for covered items on the Drug List. Aurora, IL 60506. Want to be part of our amazing team? The Drug List (sometimes called a formulary) is a list showing the drugs that can be covered by the plan. Pharmacy Benefit Prior Authorization Requirements Prime Therapeutics, our pharmacy benefit manager, conducts all reviews of prior authorization requests from physicians for BCBSIL members with prescription drug coverage. Qf#yQ>u(KpRE{UIQp[)5T:p:jBFp*WWhwIA36YwNG)!G/!Yr6v7e|12 rUp3?R1H-6Kre vh) yj?O&y]\x,$aU7Mm'a 5a1owahiT@IC+ Use the links below to view BCBSIL and vendor guidelines that may apply. 101 S. River Street Those exceptions are: Emergency care or urgently needed care. 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. endobj 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. These tools used by PCPs (or specialists) include medical codes. If your doctor wants you to have a drug that is not on the list, he or she can request approval for that drug. Providers are instructed to exercise their own clinical judgment based on each individual patients health care needs. How to File a Claims Dispute using Enterprise Appeals Application (EAA) Tracking ID 1. References to other third party sources or organizations are not a representation, warranty or endorsement of such organizations. Simply enter a 5-digit code, service description or drug name in the search field. For Medicaid (BCCHP and MMAI) members, prior authorization requirements are found in the last column of the BCCHP drug list and MMAI drug list. For some drugs, the plan limits the amount that will be covered. endobj Frequently asked questions about historic site trails in Wetter. 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. Choose the best payment option for your Blue Cross and Blue Shield of Illinois (BCBSIL) monthly bill. 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 know you like to plan ahead. 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. Talk with your doctor about your medication. The next highest ascent for historic site trails is. Sign up for theLifeTimes newsletterto get health and benefits articles delivered to your inbox every month. Subscribe now to receive the monthly Blue Review via email. Our trusted community experts can give you the one-on-one help you need to shop for health insurance. BCBSIL contracts with Prime to provide pharmacy benefit management and other related services. The site may also contain non-Medicare related information. Prior Authorization Support Materials (Government Programs). You may be familiar with some of the Medicaid prior authorization resources on our Provider website. The site may also contain non-Medicare Search articles and watch videos; ask questions and get answers. One 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 access the BCCHP and MMAI digital lookup tool, refer to the Prior Authorization Support Materials (Government Programs) page in our Utilization Management section. All Rights Reserved. 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). Your doctors will use other tools to check prior authorization needs. Clear and timely submission of prior authorization requests and clinical documentation is very important to process requests within the required timeframes. You are leaving this website/app (site). All Rights Reserved. In addition, some sites may require you to agree to their terms of use and privacy policy. They use what is called clinical criteria to make sure you get the health care you need. hb```) ea&pd:Se <>/Metadata 528 0 R/ViewerPreferences 529 0 R>> Check out our Corporate Social Responsibility Reportto learn the ways we're serving our community. Blue Access for MembersSM is a powerful tool for managing all your health plan benefits. Always check eligibility and benefits through Availity or your preferred web vendor before rendering services. Some benefit plans administered by BCBSIL, such as some self-funded employer plans or governmental plans, may not utilize BCBSIL Medical Policies. Refer to important information for our linking policy. ALLTRAILS and the AllTrails Mountain Design are registered trademarks of AllTrails, LLC in the United States as well as certain other jurisdictions. You are leaving this website/app ("site"). 415 0 obj <>stream From Siegen with the beautiful day ticket (33 euros for 5 people) to Wetter / Ruhr. MCG (formerly Milliman Care Guidelines) is a trademark of MCG Health, LLC (part of the Hearst Health network), an independent third party vendor. FIND YOUR WAY OUTSIDE is a trademark of AllTrails, LLC. Non-Discrimination Notice. }&ji[@_{dsTchsqD7bL+x3AXG>z>(y{+/en6=V/e{.t&>jFj750hS) !yppH7edMUFA{u38_tZ'oKAlr, @qiD If you have any questions, call the number on the member's BCBSIL ID card. For other services/members, BCBSIL has contracted witheviCore healthcare (eviCore)for utilization management and related services.
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