Where: Hybrid, Join us in person: Copyright document.write(new Date().getFullYear()) Health Care Service Corporation. Refer to important information for our linking policy. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. Failing to provide clinical information or timely notification of prior authorization requests may affect the outcome of a Service Authorization Dispute. At every meeting, we share updates for MMAI and BCCHP providers, such as new programs and resources to share with your patients. Without approval, the drug won't be covered. Prior Authorization Support Materials (Government Programs) - BCBSIL %
To return to our website, simply close the new window. The site may also contain non-Medicare related information. Prior authorization requests for administrative days (ADs) may not be submitted online at this time. Most PDF readers are a free download. The Drug List (sometimes called a formulary) is a list showing the drugs that can be covered by the plan. If you have any questions, call the number on the member's BCBSIL ID card. File is in portable document format (PDF). Search your plan's drug list, find a pharmacy, and more. One
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BJA9V)F:C5F7\(]U{8-KBC T.~mj mBlw~ C5?eja3\p0FooS"_iNQq9;H`76 97hQsD0O8IL*]"w}mP2H#^mHqMD[kn>iE7T" + {pxk4(uN7Lmgw5oCOa1 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. Wetter - Kupferdreh Ruhrradweg | Map, Guide - North Rhine-Westphalia 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. Drug Coverage. 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. 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. Search articles and watch videos; ask questions and get answers. (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). Prior Authorization Support Materials (Government Programs). The most popular and difficult historic site trail in Wetter is, RuhrtalRadweg Etappe 4: Wetter (Ruhr) - Essen, WestfalenWanderWeg Etappe 3: Wetter - Schwerte. For some services/members, prior authorization may be required through BCBSIL. You are leaving this website/app ("site"). Stay informed about BCBSIL programs, products, initiatives, and more. The Customer Service representative will provide you a reference number, which can be used to track the dispute. Its important to check eligibility and benefits first for each patient at every visit to confirm coverage details. You must indicate that you want to file a claims dispute. Talk with your doctor about your medication. A provider may initiate a peer-to-peer discussion by calling 800-981-2795. Log In to the Shopping Cart, Need to Make a Payment? Want to be part of our amazing team? For BCCHP and MMAI: Peer-to-peer discussions are allowed for requests where clinical information was submitted with the original request. option is Adobe Reader which has a built-in reader. 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. This new site may be offered by a vendor or an independent third party. If no clinical information was submitted with a request, a peer-to-peer discussion is not permitted. endstream
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Out-of-Network Coverage. To protect your health and keep you safe, make sure your doctor and pharmacist know what medicines you are taking, including OTC drugs. Copyright 2021 Health Care Service Corporation. One option is Adobe Reader which has a built-in screen reader. The resources on this page are intended to help you navigate prior authorization requirements for Blue Cross and Blue Shield of Illinois (BCBSIL) government programs members enrolled in any of the following plans: 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 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. All rights reserved. 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. For some services/members, prior authorization may be required through BCBSIL. There are some exceptions when care you receive from an out-of-network provider will be covered. 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 new site may be offered by a vendor or an independent third party. Who is responsible for getting the prior authorization? endstream
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<. To view this file, you may need to install a PDF reader program. Your doctors will use other tools to check prior authorization needs. Qf#yQ>u(KpRE{UIQp[)5T:p:jBFp*WWhwIA36YwNG)!G/!Yr6v7e|12
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$nb"n q~+|Vz?p~Q{vrle{{_F^gEx6,>/?e=kOws/nTgO~S>)ga0)D>Mx,lN}=v,QPD>j" You pay nothing ($0) when you go to a doctor or health care provider in the plan's network. To see if you are eligible, Contact:Blue Cross and Blue Shield of Illinois' OTC vendor,Convey Health Solutions, at: 1-855-891-5274. 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. This step will help you confirm prior authorization requirements and utilization management vendor information, if applicable. Legal and Privacy
The site may also contain non-Medicare related information. See below for details, including the Zoom registration link. 4 0 obj
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). Aurora, IL 60506. 373 0 obj
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Procedure code lists are provided for reference purposes. This step helps you confirm membership, coverage and other details, including prior authorization requirements and utilization management vendors. Checking eligibility and benefits and/or obtaining prior authorization is not a guarantee of payment of benefits. MMAI Plan Details | Blue Cross and Blue Shield of Illinois - BCBSIL DentaQuest is an independent company that provides dental benefits for BCBSILs Medicaid plans. Your plan does not encourage doctors to give less care than you need. These tools used by PCPs (or specialists) include medical codes. 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. hbbd```b``6O L %,"&*u`0;L:`5 ;
From Essen-Kupferdreh back with the S-Bahn to the main station and from there without changing with the RE 16 back to Siegerland. The next highest ascent for historic site trails is. Request a new replacement member ID card, or download a temporary copy. While not included in the digital lookup tool, some services always require prior authorization, such as inpatient facility admissions. You are leaving this website/app ("site"). 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. Which historic site trail has the most elevation gain in Wetter? Explore Out-of-Network Coverage for more information about your network. #5 - RuhrtalRadweg Etappe 4: Wetter (Ruhr) - Essen, #6 - WestfalenWanderWeg Etappe 3: Wetter - Schwerte. New User? Blue Cross Community MMAI (Medicare-Medicaid Plan) SM includes coverage for selected prescription and over-the-counter (OTC) drugs, and selected medical supplies. If you want to know more about the utilization management process or how decisions are made about your care, Contact Us. Simply enter a 5-digit code, service description or drug name in the search field. Check out our Corporate Social Responsibility Reportto learn the ways we're serving our community. PDF Medicare-Medicaid Alignment Initiative (MMAI) Demonstration Frequently How Does Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Make Decisions for Prior Authorizations? Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. Information provided is not exhaustive and is subject to change. PDF Post-Acute Care Utilization Management Program for Blue Cross and Blue As you transition to Medicare, we hope you'll Stay with Blue and get Medicare coverage from a company you trust. The peer-to-peer discussion is available as a courtesy to providers. PDF Medicaid Prior Authorization Requirements Summary, Effective Jan. 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 . All Rights Reserved. 3oDiCBG\{?xyH 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. 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. Medicaid Providers: Updated Prior Authorization Tips and Peer-to-Peer To view this file, you may need to install a PDF reader program. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. Copyright document.write(new Date().getFullYear()) Health Care Service Corporation. In addition, some sites may require you to agree to their terms of use and privacy policy. k+:6@1)^]WNQj sGG&
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These requests must be decided within 48 hours for BCCHP members, and 72 hours for MMAI members. You also have the right to ask for a coverage decision. %PDF-1.6
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Providers are allowed the opportunity to schedule one peer-to-peer discussion per adverse determination. 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. When faxing prior authorization requests, you must use the Medicaid Prior Authorization Request Form. Use the links below to view BCBSIL and vendor guidelines that may apply. 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. Access Your Payment Options. Certain drugs on the list need prior authorization. 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. 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. Once additional meetings are confirmed, well alert you via the News and Updates.
The peer-to-peer discussion is not required, nor does it affect the providers right to an appeal on behalf of a member. Lunch will be provided. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors. Your PCP will handle the prior authorization process. Most PDF readers are a free download. April 24, 2023. You also can call the MMAI plan's pharmacy help-line. 12 0 obj
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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. }&ji[@_{dsTchsqD7bL+x3AXG>z>(y{+/en6=V/e{.t&>jFj750hS)
!yppH7edMUFA{u38_tZ'oKAlr, @qiD Your doctor should know which services need approval and can help with the details. Your feedback is vital to improving the care and services these members receive. If you do not use the $30, it does not roll over into the next three months. Also, some services need approval before treatment or services are received. 2023 Best Historic Site Trails in Wetter | AllTrails Refer to our Medicaid prior authorization summary for more details. For some services/members, prior authorization may be required through BCBSIL. This new site may be offered by a vendor or an independent third party. 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. <>
In addition, some sites may require you to agree to their terms of use and privacy policy. Information on Service Authorization Disputes can be found on the Provider Service Authorization Dispute Resolution Request Form. The health of your eyes and teeth can affect your overall health. 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. 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. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com
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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 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. BCBSIL contracts with Prime to provide pharmacy benefit management and other related services. Checking eligibility and benefits and/or obtaining prior authorization is not a guarantee of payment of benefits. Doctors are not paid to deny care. endobj
Register Now. related information. Your Summary of Benefits has information about which services require prior authorization. In addition, some sites may require you to agree to their terms of use and privacy policy. File is in portable document format (PDF). Utilization Management | Blue Cross and Blue Shield of Illinois - BCBSIL 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. Sign up for theLifeTimes newsletterto get health and benefits articles delivered to your inbox every month. Some benefit plans administered by BCBSIL, such as some self-funded employer plans or governmental plans, may not utilize BCBSIL Medical Policies. Create an account. Log in to your account to get the most accurate, personalized search results based on your plan. 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. You can find out if your drug has any added conditions or limits by looking at the Drug List. 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. Welcome. The next highest ascent for historic site trails is Von Wetter zum Nacken with 664 m of elevation gain. 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. Related Resources From the train station through the underpass, it goes straight across the street to the Ruhr cycle path. The site may also contain non-Medicare
At Blue Cross Community MMAI (Medicare-Medicaid Plan) SM, we take great pride in ensuring that you receive the care you need. Our doctors and staff make decisions about your care based on need and benefits. 2. The Drug List (sometimes called a formulary) is a list showing the drugs that can be covered by the plan. BCBSIL adheres to the standards for addressing all urgent concurrent requests, meeting or exceeding National Committee for Quality Assurance (NCQA) standards. 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. Personal health-related items (such as a toothbrush and toothpaste) are not included on this list. See Chapter 4 of theMember Handbookon the Forms & Documents page for more details. For other services/members, BCBSIL has contracted with eviCore healthcare (eviCore) for utilization management and related services. Wed like to invite you to join us for our next committee meeting on May 18, 2023. FIND YOUR WAY OUTSIDE is a trademark of AllTrails, LLC. The table below contains some of the services covered under your plan. New to Blue Access for Members? Availity provides administrative services to BCBSIL. Always check eligibility and benefits through Availity or your preferred web vendor before rendering services. 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. If you have any questions, call the number on the members ID card. What: Q2 2023 MMAI and BCCHP Community Stakeholder Committee Meeting Medical Policies are based on scientific and medical research. Clear and timely submission of prior authorization requests and clinical documentation is very important to process requests within the required timeframes. Out-of-Network Coverage | Blue Cross and Blue Shield of Illinois - BCBSIL R'sYI D@
zmG@5msm!T%FN3_z. Click here to see prior authorization tools, clinical review criteria and MMAI Medical Policies used by your doctor to make a decision. For some services/members, prior authorization may be required through BCBSIL. Stage 3 of the long-distance hiking trail WestfalenWanderWeg, North Rhine-Westphalia. `9wL Well also include reminders in the Blue Review. Why participate? For some drugs, the plan limits the amount that will be covered. 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. Use Our New Prior Authorization Digital Lookup Tool for Medicaid Member Government Programs Prior Authorization Summary and Code ListsRefer to the Summary documents below for an overview of prior authorization requirements, reminders and helpful links. To view this file, you may need to install a PDF reader program. hb```) ea&pd:Se
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