endstream endobj startxref Our doctors and staff make decisions about your care based on need and benefits. Your doctor should know which services need approval and can help with the details. One Search your plan's drug list, find a pharmacy, and more. For Medicaid (BCCHP and MMAI) members, prior authorization requirements are found in the last column of the BCCHP drug list and MMAI drug list. Prior authorization requests for administrative days (ADs) may not be submitted online at this time. External link You are leaving this website/app (site). 0 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. This step also helps you identify prior authorization requirements and utilization management vendors, if applicable. If your doctor wants you to have a drug that is not on the list, he or she can request approval for that drug. Your doctor will need to request approval before these drugs can be prescribed. The Customer Service representative will provide you a reference number, which can be used to track the dispute. Clear and timely submission of prior authorization requests and clinical documentation is very important to process requests within the required timeframes. From the train station through the underpass, it goes straight across the street to the Ruhr cycle path. Prior Authorization Support Materials (Government Programs) - BCBSIL Blue Access for MembersSM is a powerful tool for managing all your health plan benefits. 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. The table below contains some of the services covered under your plan. 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. If a request does not meet medical necessity criteria for approval, the request will be assigned to a BCBSIL medical director for determination. Log In to the Shopping Cart, Need to Make a Payment? Learn about the many ways we are contributing to the well-being of our local Illinois communities in the latest Corporate Social Responsibility Report. Well also include reminders in the Blue Review. To view this file, you may need to install a PDF reader program. Check out our Corporate Social Responsibility Reportto learn the ways we're serving our community. %PDF-1.6 % Also, some services need approval before treatment or services are received. Prior Authorization Support Materials (Government Programs) - BCBSIL Get the most from your BCBSIL pharmacy benefits. File is in portable document format (PDF). Reminder: Hospital 30-day Readmission Review Process for BCCHP and MMAI 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. Copyright 2021 Health Care Service Corporation. You are leaving this website/app ("site"). For some services/members, prior authorization may be required through BCBSIL. You also can call the MMAI plan's pharmacy help-line. Santori Library Choose the best payment option for your Blue Cross and Blue Shield of Illinois (BCBSIL) monthly bill. 4 0 obj There are no rewards to deny or promote care. Certain drugs on the list need prior authorization. This is called prior authorization, preauthorization, pre-certification or prior approval. 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. From Essen-Kupferdreh back with the S-Bahn to the main station and from there without changing with the RE 16 back to Siegerland. Home During weekend hours, UM reviewers and medical directors continue to review requests and make decisions. option is Adobe Reader which has a built-in reader. ALLTRAILS and the AllTrails Mountain Design are registered trademarks of AllTrails, LLC in the United States as well as certain other jurisdictions. Some benefit plans administered by BCBSIL, such as some self-funded employer plans or governmental plans, may not utilize BCBSIL Medical Policies. Refer to our Medicaid prior authorization summary for more details. Its important to check eligibility and benefits first for each patient at every visit to confirm coverage details. 2. If you have any questions, call the number on the members ID card. Use Our New Prior Authorization Digital Lookup Tool for Medicaid Member Home and Community-Based Services & Waivers, Grievances, Appeals and Coverage Decisions, Language Assistance and Non-Discrimination Notice. All Rights Reserved. References to other third party sources or organizations are not a representation, warranty or endorsement of such organizations. Our doctors and staff make decisions about your care based only on need and benefits. For some services/members, prior authorization may be required through BCBSIL. Personal health-related items (such as a toothbrush and toothpaste) are not included on this list. This new site may be offered by a vendor or an independent third party. related information. Which historic site trail has the most elevation gain in Wetter? 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. All Rights Reserved. FIND YOUR WAY OUTSIDE is a trademark of AllTrails, LLC. The peer-to-peer discussion is available as a courtesy to providers. 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. Information on Service Authorization Disputes can be found on the Provider Service Authorization Dispute Resolution Request Form. Subscribe now to receive the monthly Blue Review via email. Blue Cross and Blue Shield of Illinois is proud to be the states only statewide, customer-owned health insurer. Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. Use the links below to view BCBSIL and vendor guidelines that may apply. How to File a Claims Dispute using Enterprise Appeals Application (EAA) Tracking ID 1. In addition, some sites may require you to agree to their terms of use and privacy policy. PDF Medicaid Prior Authorization Request Form - BCBSIL BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. One option is Adobe Reader which has a built-in reader. Frequently asked questions about historic site trails in Wetter. The health of your eyes and teeth can affect your overall health. Copyright document.write(new Date().getFullYear()) Health Care Service Corporation. R'sYI D@ zmG@5msm!T%FN3_z. 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. 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. 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. 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. 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 Availity provides administrative services to BCBSIL. Copyright document.write(new Date().getFullYear()) Health Care Service Corporation. For some services/members, prior authorization may be required through BCBSIL. 2 0 obj Want to be part of our amazing team? What is the most popular and difficult historic site trail in Wetter? These requests must be decided within 48 hours for BCCHP members, and 72 hours for MMAI members. Qf#yQ>u(KpRE{UIQp[)5T:p:jBFp*WWhwIA36YwNG)!G/!Yr6v7e|12 rUp3?R1H-6Kre vh) yj?O&y]\x,$aU7Mm'a 5a1owahiT@IC+ There are some exceptions when care you receive from an out-of-network provider will be covered. 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. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com See below for details, including the Zoom registration link. All Rights Reserved. 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. DentaQuest is an independent company that provides dental benefits for BCBSILs Medicaid plans. Grievances, Appeals and Coverage Decisions | Blue Cross and Blue Shield Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. To protect your health and keep you safe, make sure your doctor and pharmacist know what medicines you are taking, including OTC drugs. Medical Policies are based on scientific and medical research. 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. Doctors are not paid to deny care. From Siegen with the beautiful day ticket (33 euros for 5 people) to Wetter / Ruhr. 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. Availity provides administrative services to BCBSIL. For BCCHP and MMAI: Peer-to-peer discussions are allowed for requests where clinical information was submitted with the original request. <>/Metadata 528 0 R/ViewerPreferences 529 0 R>> 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. Blue Cross Community MMAI (Medicare-Medicaid Plan) SM - BCBSIL 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. Most PDF readers are a free download. Step-by-Step Guide for Provider Finder. ( Note: See Medicaid page for BCCHP and MMAI Provider Finder links.) Lunch will be provided. The Drug List (sometimes called a formulary) is a list showing the drugs that can be covered by the plan. Whats on the agenda? Most PDF readers are a free download. 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. Legal and Privacy Additionally, the Provider Service Authorization Dispute process is available when an adverse service authorization has been rendered and the UM process has been followed. 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). 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 > Aurora, IL 60506. Sign up for theLifeTimes newsletterto get health and benefits articles delivered to your inbox every month. As of this date, providers may submit a new packet for clinical re-review OR do a peer-to-peer discussion. 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. Out-of-Network Coverage. %PDF-1.7 It will open in a new window. To see if you are eligible, Contact:Blue Cross and Blue Shield of Illinois' OTC vendor,Convey Health Solutions, at: 1-855-891-5274. 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. You can: Pay a bill online or sign up for auto bill pay. Whats new on the web? 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. Drug Coverage. <> Simply enter a 5-digit code, service description or drug name in the search field. Create an account. Our trusted community experts can give you the one-on-one help you need to shop for health insurance. Join us as we build the next generation of health insurance. Providers are instructed to exercise their own clinical judgment based on each individual patients health care needs. For some services/members, prior authorization may be required through BCBSIL. 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. A provider may initiate a peer-to-peer discussion by calling 800-981-2795. Explore Out-of-Network Coverage for more information about your network. The next highest ascent for historic site trails is. At Blue Cross Community MMAI (Medicare-Medicaid Plan) SM, we take great pride in ensuring that you receive the care you need. The BCBSIL Medical Policies are for informational purposes only and are not a substitute for the independent medical judgment of health care providers. 3oDiCBG\{?xyH In addition, some sites may require you to agree to their terms of use and privacy policy. 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 Copyright document.write(new Date().getFullYear()); Health Care Service Corporation. %PDF-1.6 % 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. At every meeting, we share updates for MMAI and BCCHP providers, such as new programs and resources to share with your patients. For other services/members, BCBSIL has contracted with eviCore healthcare (eviCore) for utilization management and related services. In most cases, you must receive your care from a Blue Cross Community MMAI (Medicare-Medicaid Plan) SM in-network plan provider. One option is Adobe Reader which has a built-in reader. Prior Authorization Requirement Summaries, Code Lists and - BCBSIL Luckily, your health insurance can change with you. Its a great chance to work with faith leaders, advocacy groups and other community-based organizations that support our members health and well-being. 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. All Rights Reserved. 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. 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. The site may also contain non-Medicare related information. April 24, 2023. File is in portable document format (PDF). If you have any questions, call the number on the member's BCBSIL ID card. Blue Cross Community MMAI has strict rules about how decisions are made about your care. Wed like to invite you to join us for our next committee meeting on May 18, 2023. The site may also contain non-Medicare related information. Welcome. Limitations of Covered Benefits by Member Contract Stay informed about BCBSIL programs, products, initiatives, and more. This step helps you confirm membership, coverage and other details, including prior authorization requirements and utilization management vendors. To view this file, you may need to install a PDF reader program. Without approval, the drug won't be covered. How Does Blue Cross Community MMAI (Medicare-Medicaid Plan)SMMake Decisions for Prior Authorizations? `9wL MMAI Plan Details | Blue Cross and Blue Shield of Illinois - BCBSIL }&ji[@_{dsTchsqD7bL+x3AXG>z>(y{+/en6=V/e{.t&>jFj750hS) !yppH7edMUFA{u38_tZ'oKAlr, @qiD <> The ASAM Criteria, 2021 American Society of Addiction Medicine. This link will take you to a new site not affiliated with BCBSIL. URGENT (If checked, please provide anticipated date of service below) Please note that, effective May 1, 2021, there will be a change to the BCCHP peer-to-peer discussion process, as specified below. These tools used by PCPs (or specialists) include medical codes. Highlights: Our guest speaker is Sara Gray, Executive Director of National Alliance on Mental Illness, Kane-south, DeKalb and Kendall Counties. File is in portable document format (PDF). 101 S. River Street Non-Discrimination Notice. 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. Related Resources You can get one shipment every three months. If no clinical information was submitted with a request, a peer-to-peer discussion is not permitted. Always check eligibility and benefits through Availity or your preferred web vendor before rendering services. Davis Vision is an independent company that has contracted with BCBSIL to provide vision benefits administration for government programs members with coverage through BCBSIL. The Drug List (sometimes called a formulary) is a list showing the drugs that can be covered by the plan. Out-of-Network Coverage | Blue Cross and Blue Shield of Illinois - 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. New User? 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. 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. 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 <. This approval is called "prior authorization." The tool returns a list of services that may require prior authorization through BCBSIL or eviCore healthcare (eviCore) for BCCHP and MMAI members. Register Now. hb```) ea&pd:Se See Chapter 4 of theMember Handbookon the Forms & Documents page for more details. 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. BCBSIL Provider Manual | Blue Cross and Blue Shield of Illinois Your plan covers the items in the Drug List as long as you: To see your plan's Drug List, go toForms & Documents. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. It also includes the drugs covered by Medicare Part D. As a member, you have no copay for covered items on the Drug List. PDF Post-Acute Care Utilization Management Program for Blue Cross and Blue To return to our website, simply close the new window. Grievance (Complaint) Appeals Your Summary of Benefits has information about which services require prior authorization. Wetter - Kupferdreh Ruhrradweg | Map, Guide - North Rhine-Westphalia In addition, some sites may require you to agree to their terms of use and privacy policy. According to AllTrails.com, the longest historic site trail in Wetter is RuhrtalRadweg Etappe 4: Wetter (Ruhr) - Essen. The digital lookup tool is intended for reference purposes only. 2023 Best Historic Site Trails in Wetter | AllTrails The site may also contain non-Medicare related information. The above material is for informational purposes only and is not intended to be a substitute for the independent medical judgment of a physician. Providers are allowed the opportunity to schedule one peer-to-peer discussion per adverse determination. 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. Provider | Blue Cross and Blue Shield of Illinois - BCBSIL 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. The code lists are posted as PDFs so you can scroll through pages manually or enter