To protect your health and keep you safe, make sure your doctor and pharmacist know what medicines you are taking, including OTC drugs. 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. 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. If an appeal has been filed, the peer-to-peer discussion is no longer available. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors. Provider | Blue Cross and Blue Shield of Illinois - BCBSIL 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. Clear and timely submission of prior authorization requests and clinical documentation is very important to process requests within the required timeframes. 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. 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. You must indicate that you want to file a claims dispute. endobj Always check eligibility and benefits through Availity or your preferred web vendor before rendering services. To view this file, you may need to install a PDF reader program. These tools used by PCPs (or specialists) include medical codes. option is Adobe Reader which has a built-in reader. PDF Medicaid Prior Authorization Requirements Summary, Effective Jan. 1 Failing to provide clinical information or timely notification of prior authorization requests may affect the outcome of a Service Authorization Dispute. 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. 2 0 obj Log In to the Shopping Cart, Need to Make a Payment? The table below contains some of the services covered under your plan. You pay nothing ($0) when you go to a doctor or health care provider in the plan's network. 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. 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. 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. 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 return to our website, simply close the new window. Check out our Corporate Social Responsibility Reportto learn the ways we're serving our community. All rights reserved. Our doctors and staff make decisions about your care based only on need and benefits. 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. This step also helps you identify prior authorization requirements and utilization management vendors, if applicable. The tool returns a list of services that may require prior authorization through BCBSIL or eviCore healthcare (eviCore) for BCCHP and MMAI members. Wetter - Kupferdreh Ruhrradweg | Map, Guide - North Rhine-Westphalia Checking eligibility and benefits and/or obtaining prior authorization is not a guarantee of payment of benefits. Your plan covers the items in the Drug List as long as you: To see your plan's Drug List, go toForms & Documents. We know you like to plan ahead. Your PCP will handle the prior authorization process. Blue Cross Community MMAI has strict rules about how decisions are made about your care. BCBSIL contracts with Prime to provide pharmacy benefit management and other related services. 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. 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. Talk with your doctor about your medication. Copyright 2021 Health Care Service Corporation. Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. 2023 Best Historic Site Trails in Wetter | AllTrails If you have any questions, call the number on the member's BCBSIL ID card. This new site may be offered by a vendor or an independent third party. For other services/members, BCBSIL has contracted with eviCore healthcare (eviCore) for utilization management and related services. Register Now. Copyright document.write(new Date().getFullYear()) Health Care Service Corporation. From Essen-Kupferdreh back with the S-Bahn to the main station and from there without changing with the RE 16 back to Siegerland. In addition, some sites may require you to agree to their terms of use and privacy policy. %%EOF One option is Adobe Reader which has a built-in screen reader. Get the most from your BCBSIL pharmacy benefits. Stage 3 of the long-distance hiking trail WestfalenWanderWeg, North Rhine-Westphalia. ALLTRAILS and the AllTrails Mountain Design are registered trademarks of AllTrails, LLC in the United States as well as certain other jurisdictions. Our trusted community experts can give you the one-on-one help you need to shop for health insurance. Members should contact the vendor(s) directly with questions about the products or services offered by third parties. DV. This new site may be offered by a vendor or an independent third party. Medical policies are also used to guide care decisions. According to AllTrails.com, the longest historic site trail in Wetter is. Our doctors and staff make decisions about your care based on need and benefits. Topics include everything from improving your well-being to explaining health coverage. 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. 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. 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. From Siegen with the beautiful day ticket (33 euros for 5 people) to Wetter / Ruhr. All Rights Reserved. All Rights Reserved. Government Programs Prior Authorization Summary and Code ListsRefer to the Summary documents below for an overview of prior authorization requirements, reminders and helpful links. New to Blue Access for Members? For some services/members, prior authorization may be required through BCBSIL. 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. You can get one shipment every three months. 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. 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. ( Note: See Medicaid page for BCCHP and MMAI Provider Finder links.) This step will help you confirm prior authorization requirements and utilization management vendor information, if applicable. To support the decision process, BCBSIL gives providers the opportunity to discuss UM determinations with a peer physician. Choose the best payment option for your Blue Cross and Blue Shield of Illinois (BCBSIL) monthly bill. 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. The peer-to-peer discussion is not required, nor does it affect the providers right to an appeal on behalf of a member. 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). Some benefit plans administered by BCBSIL, such as some self-funded employer plans or governmental plans, may not utilize BCBSIL Medical Policies. You can find out if your drug has any added conditions or limits by looking at the Drug List. In most cases, you must receive your care from a Blue Cross Community MMAI (Medicare-Medicaid Plan) SM in-network plan provider. This approval is called "prior authorization." These tools used by PCPs (or specialists) include medical codes. Prior Authorization Support Materials (Government Programs). The next highest ascent for historic site trails is Von Wetter zum Nacken with 664 m of elevation gain. How to File a Claims Dispute using Enterprise Appeals Application (EAA) Tracking ID 1. The site may also contain non-Medicare related information. Registration is required. There are no rewards to deny or promote care. 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. 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" Without approval, the drug won't be covered. To access the BCCHP and MMAI digital lookup tool, refer to the Prior Authorization Support Materials (Government Programs) page in our Utilization Management section. If you do not use the $30, it does not roll over into the next three months. Subscribe now to receive the monthly Blue Review via email. Search for doctors, dentists, hospitals and other health care providers. 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. One option is Adobe Reader which has a built-in screen reader. To see if you are eligible, Contact:Blue Cross and Blue Shield of Illinois' OTC vendor,Convey Health Solutions, at: 1-855-891-5274. One option is Adobe Reader which has a built-in reader. Most PDF readers are a free download. You are leaving this website/app (site). Personal health-related items (such as a toothbrush and toothpaste) are not included on this list. This list includes generic and brand drugs and medical supplies. Reminder: Hospital 30-day Readmission Review Process for BCCHP and MMAI Information provided is not exhaustive and is subject to change. BCBSIL adheres to the standards for addressing all urgent concurrent requests, meeting or exceeding National Committee for Quality Assurance (NCQA) standards. Out-of-Network Coverage | Blue Cross and Blue Shield of Illinois - BCBSIL Welcome. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. As you transition to Medicare, we hope you'll Stay with Blue and get Medicare coverage from a company you trust. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider. However, you can order these items once every three months. 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. The site may also contain non-Medicare related information. If a request does not meet medical necessity criteria for approval, the request will be assigned to a BCBSIL medical director for determination. Provider Finder. This new site may be offered by a vendor or an independent third party. Whats on the agenda? All Rights Reserved. Our doctors and staff make decisions about your care based on need and benefits. For some drugs, the plan limits the amount that will be covered. File is in portable document format (PDF). In addition, some sites may require you to agree to their terms of use and privacy policy. At Blue Cross Community MMAI (Medicare-Medicaid Plan) SM, we take great pride in ensuring that you receive the care you need. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. Highlights: Our guest speaker is Sara Gray, Executive Director of National Alliance on Mental Illness, Kane-south, DeKalb and Kendall Counties. k+:6@1)^]WNQj sGG& hFa`@,%LFPBA7Xmxt$.=e0ne}#IoE 20iF 6Xg8Sf;+-P > In addition, some sites may require you to agree to their terms of use and privacy policy. Medicaid Providers: Updated Prior Authorization Tips and Peer - BCBSIL 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. Stay informed about BCBSIL programs, products, initiatives, and more. 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. One hbbd```b``6O L %,"&*u`0;L:`5 ; If you have a complaint about how we handle any services provided to you, you can file a grievance or an appeal. Please note that, effective May 1, 2021, there will be a change to the BCCHP peer-to-peer discussion process, as specified below. Create an account. 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. Home and Community-Based Services & Waivers, Grievances, Appeals and Coverage Decisions, Language Assistance and Non-Discrimination Notice. File is in portable document format (PDF). How Does Blue Cross Community MMAI (Medicare-Medicaid Plan)SMMake Decisions for Prior Authorizations? This new site may be offered by a vendor or an independent third party. Luckily, your health insurance can change with you. Contact Us | Blue Cross and Blue Shield of Illinois - BCBSIL Qf#yQ>u(KpRE{UIQp[)5T:p:jBFp*WWhwIA36YwNG)!G/!Yr6v7e|12 rUp3?R1H-6Kre vh) yj?O&y]\x,$aU7Mm'a 5a1owahiT@IC+ Blue Cross Community MMAI (Medicare-Medicaid Plan) SM includes coverage for selected prescription and over-the-counter (OTC) drugs, and selected medical supplies. 3oDiCBG\{?xyH Blue Cross Community MMAI (Medicare-Medicaid Plan) SM - BCBSIL If you have any questions, call the number on the members ID card. According to AllTrails.com, the longest historic site trail in Wetter is RuhrtalRadweg Etappe 4: Wetter (Ruhr) - Essen. These requests must be decided within 48 hours for BCCHP members, and 72 hours for MMAI members. One option is Adobe Reader which has a built-in reader. Your doctor will need to request approval before these drugs can be prescribed. A provider may initiate a peer-to-peer discussion by calling 800-981-2795. Prior Authorization Requirement Summaries, Code Lists and - BCBSIL PDF Medicare-Medicaid Alignment Initiative (MMAI) Demonstration Frequently Blue Cross Community MMAI (Medicare-Medicaid Plan)SM includes coverage for selected prescription and over-the-counter (OTC) drugs, and selected medical supplies. File is in portable document format (PDF). It also includes the drugs covered by Medicare Part D. As a member, you have no copay for covered items on the Drug List. 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. Providers are allowed the opportunity to schedule one peer-to-peer discussion per adverse determination. They use what is called clinical criteria to make sure you get the health care you need. 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. A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors. For some services/members, prior authorization may be required through BCBSIL. Prior Authorization Support Materials (Government Programs) - BCBSIL Its important to check eligibility and benefits first for each patient at every visit to confirm coverage details. Availity provides administrative services to BCBSIL. But we know its nice to have other ways to view prior authorization information, too. 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. Some services need approval from your health plan before you get treated. 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. }&ji[@_{dsTchsqD7bL+x3AXG>z>(y{+/en6=V/e{.t&>jFj750hS) !yppH7edMUFA{u38_tZ'oKAlr, @qiD Where: Hybrid, Join us in person: 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). Also, some services need approval before treatment or services are received. For some services/members, prior authorization may be required through BCBSIL. Grievances, Appeals and Coverage Decisions | Blue Cross and Blue Shield Copyright document.write(new Date().getFullYear()); Health Care Service Corporation. If your doctor wants you to have a drug that is not on the list, he or she can request approval for that drug. Availity provides administrative services to BCBSIL. Providers are instructed to exercise their own clinical judgment based on each individual patients health care needs. How do I know if I need a prior authorization? Your Summary of Benefits has information about which services require prior authorization. At every meeting, we share updates for MMAI and BCCHP providers, such as new programs and resources to share with your patients. BCBSIL makes no endorsement, representations or warranties regarding third-party vendors. External link You are leaving this website/app (site). The site may also contain non-Medicare related information. We'd like to invite you to join us for our next committee meeting on May 18, 2023. Medical Benefits Blue Cross Community MMAI (Medicare-Medicaid Plan) SM covers many of your health care needs. This list includes generic and brand drugs and medical supplies. References to other third party sources or organizations are not a representation, warranty or endorsement of such organizations. @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%,(( Related Resources Aurora, IL 60506. Most PDF readers are a free download. Frequently asked questions about historic site trails in Wetter. Sign up! Santori Library <> Checking eligibility and benefits and/or obtaining prior authorization is not a guarantee of payment of benefits. endobj Life changes happen at any time. Your doctors will use other tools to check prior authorization needs. If no clinical information was submitted with a request, a peer-to-peer discussion is not permitted. The next highest ascent for historic site trails is. The BCBSIL Medical Policies are for informational purposes only and are not a substitute for the independent medical judgment of health care providers. New User? 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. %PDF-1.6 % While not included in the digital lookup tool, some services always require prior authorization, such as inpatient facility admissions. MMAI Drug Coverage | Blue Cross and Blue Shield of Illinois. - BCBSIL 3 0 obj URGENT (If checked, please provide anticipated date of service below) Information on Service Authorization Disputes can be found on the Provider Service Authorization Dispute Resolution Request Form. Join us as we build the next generation of health insurance. 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. It will open in a new window. To view this file, you may need to install a PDF reader program. This is called prior authorization, preauthorization, pre-certification or prior approval. *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. 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. Why participate? 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. For other services/members, BCBSIL has contracted witheviCore healthcare (eviCore)for utilization management and related services.