Medical Policies are based on scientific and medical research. To see if you are eligible, Contact:Blue Cross and Blue Shield of Illinois' OTC vendor,Convey Health Solutions, at: 1-855-891-5274. Our doctors and staff make decisions about your care based on need and benefits. While not included in the digital lookup tool, some services always require prior authorization, such as inpatient facility admissions. Log In to the Shopping Cart, Need to Make a Payment? The most popular and difficult historic site trail in Wetter is, RuhrtalRadweg Etappe 4: Wetter (Ruhr) - Essen, WestfalenWanderWeg Etappe 3: Wetter - Schwerte. Topics include everything from improving your well-being to explaining health coverage. To view this file, you may need to install a PDF reader program. Lunch will be provided. 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. To view this file, you may need to install a PDF reader program. One option is Adobe Reader which has a built-in screen reader. Those exceptions are: Emergency care or urgently needed care. endstream endobj startxref For some services/members, prior authorization may be required through BCBSIL. This list includes generic and brand drugs and medical supplies. 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. All rights reserved. These include prior authorization code lists with effective dates and related information for Blue Cross Community Health PlansSM (BCCHPSM) and Blue Cross Community MMAI (Medicare-Medicaid Plan)SM members. Its important to check eligibility and benefits first for each patient at every visit to confirm coverage details. When: Thursday, May 18, 2023, from 1 to 2:30 p.m. CST Providers are instructed to exercise their own clinical judgment based on each individual patients health care needs. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors. You are leaving this website/app ("site"). In most cases, you must receive your care from a Blue Cross Community MMAI (Medicare-Medicaid Plan) SM in-network plan provider. 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 . For some services/members, prior authorization may be required through BCBSIL. Search for doctors, dentists, hospitals and other health care providers. Step-by-Step Guide for Provider Finder. 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. Blue Cross Community MMAI (Medicare-Medicaid Plan) SM includes coverage for selected prescription and over-the-counter (OTC) drugs, and selected medical supplies. 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. 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. Also, some services need approval before treatment or services are received. From Essen-Kupferdreh back with the S-Bahn to the main station and from there without changing with the RE 16 back to Siegerland. Blue Cross and Blue Shield of Illinois, 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). Aurora, IL 60506. Click here to see prior authorization tools, clinical review criteria and MMAI Medical Policies used by your doctor to make a decision. Request a new replacement member ID card, or download a temporary copy. Copyright 2021 Health Care Service Corporation. FIND YOUR WAY OUTSIDE is a trademark of AllTrails, LLC. Personal health-related items (such as a toothbrush and toothpaste) are not included on this list. Medical Benefits Blue Cross Community MMAI (Medicare-Medicaid Plan) SM covers many of your health care needs. Clear and timely submission of prior authorization requests and clinical documentation is very important to process requests within the required timeframes. GDChv0O{Q~ $W0!&~(c~;=1^!GD=q2z5OR%AG.)H&lz'9|^f!(@.ib 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. 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. How do I know if I need a prior authorization? Search your plan's drug list, find a pharmacy, and more. % In addition, some sites may require you to agree to their terms of use and privacy policy. Blue Cross and Blue Shield of Illinois (BCBSIL) would like to outline some important updates, tips and reminders on prior authorization processes for independently contracted providers treating our Blue Cross Community Health Plans SM (BCCHP SM) and Blue Cross Community MMAI (Medicare-Medicaid Plan) SM members. See below for details, including the Zoom registration link. URGENT (If checked, please provide anticipated date of service below) Our doctors and staff make decisions about your care based only on need and benefits. 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. External link You are leaving this website/app (site). Home and Community-Based Services & Waivers, Grievances, Appeals and Coverage Decisions, Language Assistance and Non-Discrimination Notice, Have a prescription from your doctor for them, Fill the prescription at a network pharmacy. This list includes generic and brand drugs and medical supplies. 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. At every meeting, we share updates for MMAI and BCCHP providers, such as new programs and resources to share with your patients. April 24, 2023. During weekend hours, UM reviewers and medical directors continue to review requests and make decisions. Search articles and watch videos; ask questions and get answers. 1 0 obj 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. If you have any questions, call the number on the member's BCBSIL ID card. Prime Therapeutics LLC (Prime) is a pharmacy benefit management company. 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. Limitations of Covered Benefits by Member Contract The next highest ascent for historic site trails is. Health Equity and Social Determinants of Health (SDoH), Over the Counter Equivalent Exclusion Program, Prior Authorization and Step Therapy Programs, Consolidated Appropriations Act & Transparency in Coverage, Medical Policy/Pre-certification: Out-of-area Members. Medical policies are also used to guide care decisions. 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 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. Join us as we build the next generation of health insurance. Medicaid Prior Authorization Request Form, Provider Service Authorization Dispute Resolution Request Form. 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. Sign up for theLifeTimes newsletterto get health and benefits articles delivered to your inbox every month. Sara will be discussing Mental Health Awareness Month and cultural competency. hbbd```b``6O L %,"&*u`0;L:`5 ; <> Learn about the many ways we are contributing to the well-being of our local Illinois communities in the latest Corporate Social Responsibility Report. 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 peer-to-peer discussion is available as a courtesy to providers. From Siegen with the beautiful day ticket (33 euros for 5 people) to Wetter / Ruhr. How to File a Claims Dispute using Enterprise Appeals Application (EAA) Tracking ID 1. Provider Finder. DentaQuest is an independent company that provides dental benefits for BCBSILs Medicaid plans. Whats on the agenda? Most PDF readers are a free download. You can get one shipment every three months. Copyright document.write(new Date().getFullYear()) Health Care Service Corporation. The digital lookup tool is intended for reference purposes only. Our trusted community experts can give you the one-on-one help you need to shop for health insurance. This link will take you to a new site not affiliated with BCBSIL. How Does Blue Cross Community MMAI (Medicare-Medicaid Plan)SMMake Decisions for Prior Authorizations? (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). The BCBSIL Medical Policies are for informational purposes only and are not a substitute for the independent medical judgment of health care providers. Members should contact the customer service number on their member ID card for more specific coverage information. Refer to important information for our linking policy. %PDF-1.6 % See Chapter 4 of theMember Handbookon the Forms & Documents page for more details. All Rights Reserved. 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 Once additional meetings are confirmed, well alert you via the News and Updates. 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 new site may be offered by a vendor or an independent third party. Home and Community-Based Services & Waivers, Grievances, Appeals and Coverage Decisions, Language Assistance and Non-Discrimination Notice. 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. #5 - RuhrtalRadweg Etappe 4: Wetter (Ruhr) - Essen, #6 - WestfalenWanderWeg Etappe 3: Wetter - Schwerte. 415 0 obj <>stream 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. Register Now. Highlights: Our guest speaker is Sara Gray, Executive Director of National Alliance on Mental Illness, Kane-south, DeKalb and Kendall Counties. To view this file, you may need to install a PDF reader program. 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. 2. %PDF-1.7 Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com Whens the meeting for the next quarter? Your feedback is vital to improving the care and services these members receive. 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. The most popular and difficult historic site trail in Wetter is Von Wetter zum Nacken with a 3.6-star rating from 2 reviews. This new site may be offered by a vendor or an independent third party. Your doctor will choose which drug is best for you. 3 0 obj All Rights Reserved. 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. For some services/members, prior authorization may be required through BCBSIL. One option is Adobe Reader which has a built-in reader. stream Santori Library If your doctor wants you to have a drug that is not on the list, he or she can request approval for that drug. @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%,(( 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. End along the Ruhr meadows over Lake Kemader to Lake Baldeney in Essen. There are some exceptions when care you receive from an out-of-network provider will be covered. Choose the best payment option for your Blue Cross and Blue Shield of Illinois (BCBSIL) monthly bill. 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. 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. 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. 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. 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. Legal and Privacy 0 Your PCP will handle the prior authorization process. If you want to know more about the utilization management process or how decisions are made about your care, Contact Us. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors. For more than 85 years, weve provided our members with comprehensive, affordable health plans, making Illinois a healthier place to live, work and play. For some services/members, prior authorization may be required through BCBSIL. External link You are leaving this website/app (site). 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). DV. Blue Access for MembersSM is a powerful tool for managing all your health plan benefits. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. You may be familiar with some of the Medicaid prior authorization resources on our Provider website. 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. All Rights Reserved. As of this date, providers may submit a new packet for clinical re-review OR do a peer-to-peer discussion. ( Note: See Medicaid page for BCCHP and MMAI Provider Finder links.) BCBSIL adheres to the standards for addressing all urgent concurrent requests, meeting or exceeding National Committee for Quality Assurance (NCQA) standards. Life changes happen at any time. Use the links below to view BCBSIL and vendor guidelines that may apply. To access the BCCHP and MMAI digital lookup tool, refer to the Prior Authorization Support Materials (Government Programs) page in our Utilization Management section. 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. Whats new on the web? The health of your eyes and teeth can affect your overall health. A provider may initiate a peer-to-peer discussion by calling 800-981-2795. If you do not use the $30, it does not roll over into the next three months. References to other third party sources or organizations are not a representation, warranty or endorsement of such organizations. These tools used by PCPs (or specialists) include medical codes. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. Check out our Corporate Social Responsibility Reportto learn the ways we're serving our community. Non-Discrimination Notice. Your Summary of Benefits has information about which services require prior authorization. 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. We know you like to plan ahead. 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. 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. This new site may be offered by a vendor or an independent third party. The Customer Service representative will provide you a reference number, which can be used to track the dispute. 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. %PDF-1.6 % For other services/members, BCBSIL has contracted with eviCore healthcare (eviCore) for utilization management and related services. The tool returns a list of services that may require prior authorization through BCBSIL or eviCore healthcare (eviCore) for BCCHP and MMAI members. Blue Cross Community MMAI (Medicare-Medicaid Plan)SM includes coverage for selected prescription and over-the-counter (OTC) drugs, and selected medical supplies. 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. The site may also contain non-Medicare related information. The next highest ascent for historic site trails is Von Wetter zum Nacken with 664 m of elevation gain. Certain drugs on the list need prior authorization. {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|)- Out-of-Network Coverage. Prior Authorization Support Materials (Government Programs). All Rights Reserved. You also can call the MMAI plan's pharmacy help-line. Additionally, the Provider Service Authorization Dispute process is available when an adverse service authorization has been rendered and the UM process has been followed. One option is Adobe Reader which has a built-in screen reader. Welcome. To view this file, you may need to install a PDF reader program. If you have a complaint about how we handle any services provided to you, you can file a grievance or an appeal. For BCCHP and MMAI: Peer-to-peer discussions are allowed for requests where clinical information was submitted with the original request. February 1, 2021 Blue Cross and Blue Shield of Illinois (BCBSIL) would like to outline important updates, tips and reminders on prior authorization processes for independently contracted providers treating our Blue Cross Community Health Plans SM (BCCHP SM) and Blue Cross Community MMAI (Medicare-Medicaid Plan) SM members. 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. To support the decision process, BCBSIL gives providers the opportunity to discuss UM determinations with a peer physician. The table below contains some of the services covered under your plan. If no clinical information was submitted with a request, a peer-to-peer discussion is not permitted. The peer-to-peer discussion is not required, nor does it affect the providers right to an appeal on behalf of a member. endstream endobj 374 0 obj <. Our doctors and staff make decisions about your care based on need and benefits. Talk with your doctor about your medication. Most PDF readers are a free download. 373 0 obj <> endobj 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. The Drug List (sometimes called a formulary) is a list showing the drugs that can be covered by the plan. From the train station through the underpass, it goes straight across the street to the Ruhr cycle path. Government Programs Prior Authorization Summary and Code ListsRefer to the Summary documents below for an overview of prior authorization requirements, reminders and helpful links. 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. Get the most from your BCBSIL pharmacy benefits. Customer Service: File the dispute by calling Customer Service at 1-877-860-2837. File is in portable document format (PDF). Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. For Medicaid (BCCHP and MMAI) members, prior authorization requirements are found in the last column of the BCCHP drug list and MMAI drug list. 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. Most PDF readers are a free download. 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). 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. 3oDiCBG\{?xyH The site may also contain non-Medicare related information. This approval is called "prior authorization." Blue Cross and Blue Shield of Illinois is proud to be the states only statewide, customer-owned health insurer. Your PCP will handle the prior authorization process. MCG (formerly Milliman Care Guidelines) is a trademark of MCG Health, LLC (part of the Hearst Health network), an independent third party vendor. 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. If a request does not meet medical necessity criteria for approval, the request will be assigned to a BCBSIL medical director for determination. You can: Pay a bill online or sign up for auto bill pay. You'll see details that may help lower health care costs. endobj But we know its nice to have other ways to view prior authorization information, too. In addition, some sites may require you to agree to their terms of use and privacy policy. 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. `9wL Where: Hybrid, Join us in person: 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. In addition, some sites may require you to agree to their terms of use and privacy policy. Members should contact the vendor(s) directly with questions about the products or services offered by third parties. Providers are allowed the opportunity to schedule one peer-to-peer discussion per adverse determination. Doctors are not paid to deny care. 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 Procedure code lists are provided for reference purposes. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. All Rights Reserved. What: Q2 2023 MMAI and BCCHP Community Stakeholder Committee Meeting To return to our website, simply close the new window. Well also include reminders in the Blue Review. endobj Grievance (Complaint) Appeals Information provided is not exhaustive and is subject to change. Related Resources Availity provides administrative services to BCBSIL. endobj The site may also contain non-Medicare For some drugs, the plan limits the amount that will be covered. Copyright document.write(new Date().getFullYear()) Health Care Service Corporation. 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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