To access the BCCHP and MMAI digital lookup tool, refer to the Prior Authorization Support Materials (Government Programs) page in our Utilization Management section. 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. stream The Drug List (sometimes called a formulary) is a list showing the drugs that can be covered by the plan. Your PCP will handle the prior authorization process. %PDF-1.7 Your feedback is vital to improving the care and services these members receive. endobj Personal health-related items (such as a toothbrush and toothpaste) are not included on this list. Some services need approval from your health plan before you get treated. Stage 3 of the long-distance hiking trail WestfalenWanderWeg, North Rhine-Westphalia. 3oDiCBG\{?xyH Out of area dialysis services. How to File a Claims Dispute using Enterprise Appeals Application (EAA) Tracking ID 1. Blue Cross and Blue Shield of Illinois is proud to be the states only statewide, customer-owned health insurer. Log in to your account to get the most accurate, personalized search results based on your plan. 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. If your doctor wants you to have a drug that is not on the list, he or she can request approval for that drug. 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. Welcome. Lunch will be provided. 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. 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. 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. These include prior authorization code lists with effective dates and related information for Blue Cross Community Health Plans SM (BCCHP SM) and Blue Cross Community MMAI (Medicare-Medicaid Plan) SM members. endobj DV. 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. Your doctors will use other tools to check prior authorization needs. The Drug List (sometimes called a formulary) is a list showing the drugs that can be covered by the plan. Your doctors will use other tools to check prior authorization needs. Returning Shopper? When faxing prior authorization requests, you must use the Medicaid Prior Authorization Request Form. Its important to check eligibility and benefits first for each patient at every visit to confirm coverage details. 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. New User? The table below contains some of the services covered under your plan. To protect your health and keep you safe, make sure your doctor and pharmacist know what medicines you are taking, including OTC drugs. During weekend hours, UM reviewers and medical directors continue to review requests and make decisions. All Rights Reserved. Updated February 2021 1 Medicaid Prior Authorization Requirements Summary, Effective Jan. 1, 2021 (Updated February 2021) This information applies to Blue Cross Community MMAI (Medicare-Medicaid)SM and Blue Cross Community Health PlansSM (BCCHPSM) members. 3 0 obj It also includes the drugs covered by Medicare Part D. As a member, you have no copay for covered items on the Drug List. Your plan covers the items in the Drug List as long as you: To see your plan's Drug List, go toForms & Documents. endobj 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. Limitations of Covered Benefits by Member Contract Your Summary of Benefits has information about which services require prior authorization. This new site may be offered by a vendor or an independent third party. Medical Benefits Blue Cross Community MMAI (Medicare-Medicaid Plan) SM covers many of your health care needs. Choose the best payment option for your Blue Cross and Blue Shield of Illinois (BCBSIL) monthly bill. The Customer Service representative will provide you a reference number, which can be used to track the dispute. 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. x=r8?Qi xJI&JfIl3D:#SfAw $nb"n q~+|Vz?p~Q{vrle{{_F^gEx6,>/?e=kOws/nTgO~S>)ga0)D>Mx,lN}=v,QPD>j" 4 0 obj Search for doctors, dentists, hospitals and other health care providers. In addition, some sites may require you to agree to their terms of use and privacy policy. Prior authorization requests for administrative days (ADs) may not be submitted online at this time. 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. 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. From Essen-Kupferdreh back with the S-Bahn to the main station and from there without changing with the RE 16 back to Siegerland. There are some exceptions when care you receive from an out-of-network provider will be covered. Home 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. Without approval, the drug won't be covered. }&ji[@_{dsTchsqD7bL+x3AXG>z>(y{+/en6=V/e{.t&>jFj750hS) !yppH7edMUFA{u38_tZ'oKAlr, @qiD This is called prior authorization, preauthorization, pre-certification or prior approval. Members should contact the customer service number on their member ID card for more specific coverage information. Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. The peer-to-peer discussion is not required, nor does it affect the providers right to an appeal on behalf of a member. Copyright document.write(new Date().getFullYear()) Health Care Service Corporation. 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. Blue Access for MembersSM is a powerful tool for managing all your health plan benefits. 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 Luckily, your health insurance can change with you. We'd like to invite you to join us for our next committee meeting on May 18, 2023. 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. <> The next highest ascent for historic site trails is. <>/Metadata 528 0 R/ViewerPreferences 529 0 R>> Doctors are not paid to deny care. Learn about the many ways we are contributing to the well-being of our local Illinois communities in the latest Corporate Social Responsibility Report. For more than 85 years, weve provided our members with comprehensive, affordable health plans, making Illinois a healthier place to live, work and play. From Siegen with the beautiful day ticket (33 euros for 5 people) to Wetter / Ruhr. These requests must be decided within 48 hours for BCCHP members, and 72 hours for MMAI 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. Checking eligibility and benefits and/or obtaining prior authorization is not a guarantee of payment of benefits. Blue Cross Community MMAI has strict rules about how decisions are made about your care. Grievance (Complaint) Appeals File is in portable document format (PDF). 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. Davis Vision is an independent company that has contracted with BCBSIL to provide vision benefits administration for government programs members with coverage through BCBSIL. For Medicaid (BCCHP and MMAI) members, prior authorization requirements are found in the last column of the BCCHP drug list and MMAI drug list. To return to our website, simply close the new window. 6C("=L,`YF'0 d BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors. How do I know if I need a prior authorization? When: Thursday, May 18, 2023, from 1 to 2:30 p.m. CST Refer to our Medicaid prior authorization summary for more details. Whats on the agenda? Wed like to invite you to join us for our next committee meeting on May 18, 2023. 2 0 obj They use what is called clinical criteria to make sure you get the health care you need. A provider may initiate a peer-to-peer discussion by calling 800-981-2795. 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). One option is Adobe Reader which has a built-in screen reader. Subscribe now to receive the monthly Blue Review via email. 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 There are no rewards to deny or promote care. BCBSIL makes no endorsement, representations or warranties regarding third-party vendors. Our doctors and staff make decisions about your care based on need and benefits. 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 an appeal has been filed, the peer-to-peer discussion is no longer available.
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