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. Its important to check eligibility and benefits first for each patient at every visit to confirm coverage details. One option is Adobe Reader which has a built-in screen reader. Blue Cross Community MMAI has strict rules about how decisions are made about your care. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors. Non-Discrimination Notice. 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. 2 0 obj 1 0 obj Your doctors will use other tools to check prior authorization needs. Who is responsible for getting the prior authorization? Personal health-related items (such as a toothbrush and toothpaste) are not included on this list. 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. Prior Authorization Support Materials (Government Programs). 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 most popular and difficult historic site trail in Wetter is Von Wetter zum Nacken with a 3.6-star rating from 2 reviews. Medical policies are also used to guide care decisions. The BCBSIL Medical Policies are for informational purposes only and are not a substitute for the independent medical judgment of health care providers. How Does Blue Cross Community MMAI (Medicare-Medicaid Plan)SMMake Decisions for Prior Authorizations? Without approval, the drug won't be covered. Most PDF readers are a free download. The above material is for informational purposes only and is not intended to be a substitute for the independent medical judgment of a physician. This approval is called "prior authorization." Sign up for theLifeTimes newsletterto get health and benefits articles delivered to your inbox every month. You are leaving this website/app ("site"). End along the Ruhr meadows over Lake Kemader to Lake Baldeney in Essen. Blue Cross and Blue Shield of Illinois is proud to be the states only statewide, customer-owned health insurer. 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. 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. Home and Community-Based Services & Waivers, Grievances, Appeals and Coverage Decisions, Language Assistance and Non-Discrimination Notice. Search articles and watch videos; ask questions and get answers. Topics include everything from improving your well-being to explaining health coverage. Prior authorization requests for administrative days (ADs) may not be submitted online at this time. Some services need approval from your health plan before you get treated. The site may also contain non-Medicare This step helps you confirm membership, coverage and other details, including prior authorization requirements and utilization management vendors. 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. Your doctor will choose which drug is best for you. It also includes the drugs covered by Medicare Part D. As a member, you have no copay for covered items on the Drug List. Which historic site trail has the most elevation gain in Wetter? 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. A provider may initiate a peer-to-peer discussion by calling 800-981-2795. To support the decision process, BCBSIL gives providers the opportunity to discuss UM determinations with a peer physician. Grievance (Complaint) Appeals Registration is required. You are leaving this website/app (site). For some drugs, the plan limits the amount that will be covered. Failing to provide clinical information or timely notification of prior authorization requests may affect the outcome of a Service Authorization Dispute. Search your plan's drug list, find a pharmacy, and more. @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%,(( Lunch will be provided. To access the BCCHP and MMAI digital lookup tool, refer to the Prior Authorization Support Materials (Government Programs) page in our Utilization Management section. GDChv0O{Q~ $W0!&~(c~;=1^!GD=q2z5OR%AG.)H&lz'9|^f!(@.ib We also feature guest speakers and allow time for a general Q&A. Medical Policies are based on scientific and medical research. Certain drugs on the list need prior authorization. *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. You pay nothing ($0) when you go to a doctor or health care provider in the plan's network. FIND YOUR WAY OUTSIDE is a trademark of AllTrails, LLC. Home 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. 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. Your doctor should know which services need approval and can help with the details. Learn about the many ways we are contributing to the well-being of our local Illinois communities in the latest Corporate Social Responsibility Report. Providers are allowed the opportunity to schedule one peer-to-peer discussion per adverse determination. option is Adobe Reader which has a built-in reader. All Rights Reserved. related information. The site may also contain non-Medicare related information. DentaQuest is an independent company that provides dental benefits for BCBSILs Medicaid plans. 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. The most popular and difficult historic site trail in Wetter is, RuhrtalRadweg Etappe 4: Wetter (Ruhr) - Essen, WestfalenWanderWeg Etappe 3: Wetter - Schwerte. Your PCP will handle the prior authorization process. Availity provides administrative services to BCBSIL. If you have any questions, call the number on the member's BCBSIL ID card. <> stream The peer-to-peer discussion is not required, nor does it affect the providers right to an appeal on behalf of a member. (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 plan will pay up to $30 (plus $5 for shipping) for each order. In addition, some sites may require you to agree to their terms of use and privacy policy. External link You are leaving this website/app (site). The site may also contain non-Medicare related information. The Drug List (sometimes called a formulary) is a list showing the drugs that can be covered by the plan. In addition, some sites may require you to agree to their terms of use and privacy policy. 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. For some services/members, prior authorization may be required through BCBSIL. In addition, some sites may require you to agree to their terms of use and privacy policy. There are some exceptions when care you receive from an out-of-network provider will be covered. Talk with your doctor about your medication. If no clinical information was submitted with a request, a peer-to-peer discussion is not permitted. For some services/members, prior authorization may be required through BCBSIL. References to other third party sources or organizations are not a representation, warranty or endorsement of such organizations. If a request does not meet medical necessity criteria for approval, the request will be assigned to a BCBSIL medical director for determination. 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. Some benefit plans administered by BCBSIL, such as some self-funded employer plans or governmental plans, may not utilize BCBSIL Medical Policies. All Rights Reserved. The tool returns a list of services that may require prior authorization through BCBSIL or eviCore healthcare (eviCore) for BCCHP and MMAI members. Most PDF readers are a free download. #5 - RuhrtalRadweg Etappe 4: Wetter (Ruhr) - Essen, #6 - WestfalenWanderWeg Etappe 3: Wetter - Schwerte. ALLTRAILS and the AllTrails Mountain Design are registered trademarks of AllTrails, LLC in the United States as well as certain other jurisdictions. At Blue Cross Community MMAI (Medicare-Medicaid Plan) SM, we take great pride in ensuring that you receive the care you need. The site may also contain non-Medicare related information. If you do not use the $30, it does not roll over into the next three months. You also can call the MMAI plan's pharmacy help-line. Our trusted community experts can give you the one-on-one help you need to shop for health insurance. However, you can order these items once every three months. In addition, some sites may require you to agree to their terms of use and privacy policy. What: Q2 2023 MMAI and BCCHP Community Stakeholder Committee Meeting Stay informed about BCBSIL programs, products, initiatives, and more. Most PDF readers are a free download. 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. 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 %PDF-1.6 % Provider Finder. 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. To view this file, you may need to install a PDF reader program. 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 BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors. 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. Government Programs Prior Authorization Summary and Code ListsRefer to the Summary documents below for an overview of prior authorization requirements, reminders and helpful links. What is the most popular and difficult historic site trail in Wetter? Medicaid Prior Authorization Request Form, Provider Service Authorization Dispute Resolution Request Form. Out-of-Network Coverage. 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. All Rights Reserved. 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. We know you like to plan ahead. One Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. The Drug List (sometimes called a formulary) is a list showing the drugs that can be covered by the plan. endobj {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|)- Use the links below to view BCBSIL and vendor guidelines that may apply. Want to be part of our amazing team? 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. Choose the best payment option for your Blue Cross and Blue Shield of Illinois (BCBSIL) monthly bill. endobj How to File a Claims Dispute using Enterprise Appeals Application (EAA) Tracking ID 1. 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 . File is in portable document format (PDF). You can get one shipment every three months. The site may also contain non-Medicare related information. BCBSIL contracts with Prime to provide pharmacy benefit management and other related services. One option is Adobe Reader which has a built-in screen reader. Your doctor will need to request approval before these drugs can be prescribed. Get the most from your BCBSIL pharmacy benefits. Your feedback is vital to improving the care and services these members receive. %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. If an appeal has been filed, the peer-to-peer discussion is no longer available. One option is Adobe Reader which has a built-in reader. 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. 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. According to AllTrails.com, the longest historic site trail in Wetter is. Clear and timely submission of prior authorization requests and clinical documentation is very important to process requests within the required timeframes. Returning Shopper? 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. 373 0 obj <> endobj This new site may be offered by a vendor or an independent third party. Wed like to invite you to join us for our next committee meeting on May 18, 2023. Providers are instructed to exercise their own clinical judgment based on each individual patients health care needs. 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 Members should contact the vendor(s) directly with questions about the products or services offered by third parties. 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. This new site may be offered by a vendor or an independent third party. Refer to our Medicaid prior authorization summary for more details. 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. Life changes happen at any time. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. 101 S. River Street While not included in the digital lookup tool, some services always require prior authorization, such as inpatient facility admissions. You'll see details that may help lower health care costs. To view this file, you may need to install a PDF reader program. As you transition to Medicare, we hope you'll Stay with Blue and get Medicare coverage from a company you trust. 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. 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. Aurora, IL 60506. These tools used by PCPs (or specialists) include medical codes. 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. Highlights: Our guest speaker is Sara Gray, Executive Director of National Alliance on Mental Illness, Kane-south, DeKalb and Kendall Counties. 396 0 obj <>/Filter/FlateDecode/ID[<0A7FBF13C253BF478050EB5B54DA8A47><3D37E1700F053247902B206B607ACED5>]/Index[373 43]/Info 372 0 R/Length 112/Prev 171011/Root 374 0 R/Size 416/Type/XRef/W[1 3 1]>>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. }&ji[@_{dsTchsqD7bL+x3AXG>z>(y{+/en6=V/e{.t&>jFj750hS) !yppH7edMUFA{u38_tZ'oKAlr, @qiD You must indicate that you want to file a claims dispute. This step will help you confirm prior authorization requirements and utilization management vendor information, if applicable. % %PDF-1.7 Where: Hybrid, Join us in person: Santori Library endstream endobj 374 0 obj <. Those exceptions are: Emergency care or urgently needed care. Most PDF readers are a free download. April 24, 2023. Register Now. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider. Customer Service: File the dispute by calling Customer Service at 1-877-860-2837. 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). 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. To ask for instructions on how to appeal, call the Member Services line for the MMAI plan or call the Senior HelpLine and ask for the MMAI Ombudsman at 1-800-252-8966 (TTY users should call 1-888-206-1327) Monday-Friday 8:30 am-5pm. 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. File is in portable document format (PDF). Copyright document.write(new Date().getFullYear()); Health Care Service Corporation. 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. 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. Register Now. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. Checking eligibility and benefits and/or obtaining prior authorization is not a guarantee of payment of benefits. The peer-to-peer discussion is available as a courtesy to providers. 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. BCBSIL adheres to the standards for addressing all urgent concurrent requests, meeting or exceeding National Committee for Quality Assurance (NCQA) standards.
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