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 a request does not meet medical necessity criteria for approval, the request will be assigned to a BCBSIL medical director for determination. The Drug List (sometimes called a formulary) is a list showing the drugs that can be covered by the plan. Whats new on the web? Well also include reminders in the Blue Review. BCBSIL adheres to the standards for addressing all urgent concurrent requests, meeting or exceeding National Committee for Quality Assurance (NCQA) standards. One Medical Benefits Blue Cross Community MMAI (Medicare-Medicaid Plan) SM covers many of your health care needs. You must indicate that you want to file a claims dispute. Most PDF readers are a free download. End along the Ruhr meadows over Lake Kemader to Lake Baldeney in Essen. File is in portable document format (PDF). Use the links below to view BCBSIL and vendor guidelines that may apply. Get the most from your BCBSIL pharmacy benefits. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider. External link You are leaving this website/app (site). The health of your eyes and teeth can affect your overall health. Procedure code lists are provided for reference purposes. Non-Discrimination Notice. 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. 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. *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. Subscribe now to receive the monthly Blue Review via email. You also have the right to ask for a coverage decision. Step-by-Step Guide for Provider Finder. This list includes generic and brand drugs and medical supplies. The next highest ascent for historic site trails is. We'd like to invite you to join us for our next committee meeting on May 18, 2023. To protect your health and keep you safe, make sure your doctor and pharmacist know what medicines you are taking, including OTC drugs. Our trusted community experts can give you the one-on-one help you need to shop for health insurance. It also includes the drugs covered by Medicare Part D. As a member, you have no copay for covered items on the Drug List. 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. The above material is for informational purposes only and is not intended to be a substitute for the independent medical judgment of a physician. Also, some services need approval before treatment or services are received. Click here to see prior authorization tools, clinical review criteria and MMAI Medical Policies used by your doctor to make a decision. Blue Cross Community MMAI has strict rules about how decisions are made about your care. 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. From Siegen with the beautiful day ticket (33 euros for 5 people) to Wetter / Ruhr. Once additional meetings are confirmed, well alert you via the News and Updates. The tool returns a list of services that may require prior authorization through BCBSIL or eviCore healthcare (eviCore) for BCCHP and MMAI members. The ASAM Criteria, 2021 American Society of Addiction Medicine. If an appeal has been filed, the peer-to-peer discussion is no longer available. Providers are instructed to exercise their own clinical judgment based on each individual patients health care needs. We also feature guest speakers and allow time for a general Q&A. All rights reserved. If you have any questions, call the number on the members ID card. Refer to important information for our linking policy. From the train station through the underpass, it goes straight across the street to the Ruhr cycle path. Certain drugs on the list need prior authorization. To view this file, you may need to install a PDF reader program. 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. Your doctors will use other tools to check prior authorization needs. endstream endobj startxref In addition, some sites may require you to agree to their terms of use and privacy policy. To view this file, you may need to install a PDF reader program. YDLmW~/Pi_7wRwN]_RwMFrg~ w BJA9V)F:C5F7\(]U{8-KBC T.~mj mBlw~ C5?eja3\p0FooS"_iNQq9;H`76 97hQsD0O8IL*]"w}mP2H#^mHqMD[kn>iE7T" + {pxk4(uN7Lmgw5oCOa1 Home Related Resources The site may also contain non-Medicare related information. Blue Access for MembersSM is a powerful tool for managing all your health plan benefits. For Medicaid (BCCHP and MMAI) members, prior authorization requirements are found in the last column of the BCCHP drug list and MMAI drug list. Highlights: Our guest speaker is Sara Gray, Executive Director of National Alliance on Mental Illness, Kane-south, DeKalb and Kendall Counties. 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. How to File a Claims Dispute using Enterprise Appeals Application (EAA) Tracking ID 1. Sign up for theLifeTimes newsletterto get health and benefits articles delivered to your inbox every month. ( Note: See Medicaid page for BCCHP and MMAI Provider Finder links.) If you want to know more about the utilization management process or how decisions are made about your care, Contact Us. 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. Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. This approval is called "prior authorization." Medical policies are also used to guide care decisions. 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. #5 - RuhrtalRadweg Etappe 4: Wetter (Ruhr) - Essen, #6 - WestfalenWanderWeg Etappe 3: Wetter - Schwerte. Out-of-Network Coverage. A provider may initiate a peer-to-peer discussion by calling 800-981-2795. You are leaving this website/app (site). `9wL Your PCP will handle the prior authorization process. Some benefit plans administered by BCBSIL, such as some self-funded employer plans or governmental plans, may not utilize BCBSIL Medical Policies. At Blue Cross Community MMAI (Medicare-Medicaid Plan) SM, we take great pride in ensuring that you receive the care you need. New to Blue Access for Members? There are no rewards to deny or promote care. (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). You are leaving this website/app ("site"). Your PCP will handle the prior authorization process. All Rights Reserved. One option is Adobe Reader which has a built-in screen reader. 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. 373 0 obj <> endobj BCBSIL contracts with Prime to provide pharmacy benefit management and other related services. File is in portable document format (PDF). One option is Adobe Reader which has a built-in reader. Personal health-related items (such as a toothbrush and toothpaste) are not included on this list. See Chapter 4 of theMember Handbookon the Forms & Documents page for more details. To see if you are eligible, Contact:Blue Cross and Blue Shield of Illinois' OTC vendor,Convey Health Solutions, at: 1-855-891-5274. Availity provides administrative services to BCBSIL. For more than 85 years, weve provided our members with comprehensive, affordable health plans, making Illinois a healthier place to live, work and play. Provider Finder. If no clinical information was submitted with a request, a peer-to-peer discussion is not permitted. Prior authorization requests for administrative days (ADs) may not be submitted online at this time. 415 0 obj <>stream The table below contains some of the services covered under your plan. 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. To return to our website, simply close the new window. Your Summary of Benefits has information about which services require prior authorization. You also can call the MMAI plan's pharmacy help-line. Medical Policies are based on scientific and medical research. This list includes generic and brand drugs and medical supplies. endstream endobj 374 0 obj <. 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. Most PDF readers are a free download. This new site may be offered by a vendor or an independent third party. Luckily, your health insurance can change with you. Copyright document.write(new Date().getFullYear()); Health Care Service Corporation. Sara will be discussing Mental Health Awareness Month and cultural competency. As you transition to Medicare, we hope you'll Stay with Blue and get Medicare coverage from a company you trust. Create an account. Limitations of Covered Benefits by Member Contract Wed like to invite you to join us for our next committee meeting on May 18, 2023. When faxing prior authorization requests, you must use the Medicaid Prior Authorization Request Form. 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. For some services/members, prior authorization may be required through BCBSIL. Talk with your doctor about your medication. endobj Log in to your account to get the most accurate, personalized search results based on your plan. Customer Service: File the dispute by calling Customer Service at 1-877-860-2837. This link will take you to a new site not affiliated with BCBSIL. 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 Always check eligibility and benefits through Availity or your preferred web vendor before rendering services. 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. As of this date, providers may submit a new packet for clinical re-review OR do a peer-to-peer discussion. 101 S. River Street Our doctors and staff make decisions about your care based on need and benefits. The site may also contain non-Medicare related information. This new site may be offered by a vendor or an independent third party. To view this file, you may need to install a PDF reader program. 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. Please note that, effective May 1, 2021, there will be a change to the BCCHP peer-to-peer discussion process, as specified below. Topics include everything from improving your well-being to explaining health coverage. 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. }&ji[@_{dsTchsqD7bL+x3AXG>z>(y{+/en6=V/e{.t&>jFj750hS) !yppH7edMUFA{u38_tZ'oKAlr, @qiD Medicaid Prior Authorization Request Form, Provider Service Authorization Dispute Resolution Request Form. Learn about the many ways we are contributing to the well-being of our local Illinois communities in the latest Corporate Social Responsibility Report. Copyright 2021 Health Care Service Corporation. 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. 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. <> One option is Adobe Reader which has a built-in reader. Join us as we build the next generation of health insurance. MCG (formerly Milliman Care Guidelines) is a trademark of MCG Health, LLC (part of the Hearst Health network), an independent third party vendor. This step also helps you identify prior authorization requirements and utilization management vendors, if applicable. Qf#yQ>u(KpRE{UIQp[)5T:p:jBFp*WWhwIA36YwNG)!G/!Yr6v7e|12 rUp3?R1H-6Kre vh) yj?O&y]\x,$aU7Mm'a 5a1owahiT@IC+ 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. 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). You can get one shipment every three months. Your doctor will choose which drug is best for you. The site may also contain non-Medicare related information. For other services/members, BCBSIL has contracted witheviCore healthcare (eviCore)for utilization management and related services. %%EOF 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 URGENT (If checked, please provide anticipated date of service below) Checking eligibility and benefits and/or obtaining prior authorization is not a guarantee of payment of benefits. This step helps you confirm membership, coverage and other details, including prior authorization requirements and utilization management vendors. FIND YOUR WAY OUTSIDE is a trademark of AllTrails, LLC. DV. 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. 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. Copyright document.write(new Date().getFullYear()) Health Care Service Corporation. k+:6@1)^]WNQj sGG& hFa`@,%LFPBA7Xmxt$.=e0ne}#IoE 20iF 6Xg8Sf;+-P > You'll see details that may help lower health care costs. In addition, some sites may require you to agree to their terms of use and privacy policy. Davis Vision is an independent company that has contracted with BCBSIL to provide vision benefits administration for government programs members with coverage through BCBSIL. %PDF-1.7 Copyright document.write(new Date().getFullYear()) Health Care Service Corporation. Our doctors and staff make decisions about your care based only on need and benefits. hbbd```b``6O L %,"&*u`0;L:`5 ; This new site may be offered by a vendor or an independent third party. All Rights Reserved. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors. Clear and timely submission of prior authorization requests and clinical documentation is very important to process requests within the required timeframes. You can: Pay a bill online or sign up for auto bill pay. Copyright document.write(new Date().getFullYear()) Health Care Service Corporation. At every meeting, we share updates for MMAI and BCCHP providers, such as new programs and resources to share with your patients. <>/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>> stream 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. 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 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. Access Your Payment Options. 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. DentaQuest is an independent company that provides dental benefits for BCBSILs Medicaid plans. The peer-to-peer discussion process is as follows: *Effective May 1, 2021, the only change is that providers can no longer submit clinicals for BCCHP members IN ADDITION TO doing a peer-to-peer call after the adverse determination. The BCBSIL Medical Policies are for informational purposes only and are not a substitute for the independent medical judgment of health care providers. You may be familiar with some of the Medicaid prior authorization resources on our Provider website. Without approval, the drug won't be covered. % 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. Registration is required. 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. Your doctor should know which services need approval and can help with the details. In most cases, you must receive your care from a Blue Cross Community MMAI (Medicare-Medicaid Plan) SM in-network plan provider. 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. How Does Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Make Decisions for Prior Authorizations? Want to be part of our amazing team? In addition, some sites may require you to agree to their terms of use and privacy policy. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com Log In to the Shopping Cart, Need to Make a Payment? What: Q2 2023 MMAI and BCCHP Community Stakeholder Committee Meeting 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. 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. This new site may be offered by a vendor or an independent third party. A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 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. Your plan does not encourage doctors to give less care than you need. 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. External link You are leaving this website/app (site). @SssUJ- =`~4*>_faS A$wa8|9NN4 d>!XHDhf\~%r'7m|oHF~D#R X(b(uQu (pd)8MA/> ?&ME.@.$O4>!Mwiw%c:IlAc:4U&SUDaE:?{Or-RaX%,(( Request a new replacement member ID card, or download a temporary copy. ALLTRAILS and the AllTrails Mountain Design are registered trademarks of AllTrails, LLC in the United States as well as certain other jurisdictions. R'sYI D@ zmG@5msm!T%FN3_z. How do I know if I need a prior authorization? One option is Adobe Reader which has a built-in screen reader. However, you can order these items once every three months. 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. Availity provides administrative services to BCBSIL. Explore Out-of-Network Coverage for more information about your network. The most popular and difficult historic site trail in Wetter is Von Wetter zum Nacken with a 3.6-star rating from 2 reviews. All Rights Reserved. Your doctor will need to request approval before these drugs can be prescribed. From Essen-Kupferdreh back with the S-Bahn to the main station and from there without changing with the RE 16 back to Siegerland. 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 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.
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