How Does Blue Cross Community MMAI (Medicare-Medicaid Plan)SMMake Decisions for Prior Authorizations? This is called prior authorization, preauthorization, pre-certification or prior approval. Qf#yQ>u(KpRE{UIQp[)5T:p:jBFp*WWhwIA36YwNG)!G/!Yr6v7e|12 rUp3?R1H-6Kre vh) yj?O&y]\x,$aU7Mm'a 5a1owahiT@IC+ External link You are leaving this website/app (site). Want to be part of our amazing team? Copyright document.write(new Date().getFullYear()) Health Care Service Corporation. 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. Copyright document.write(new Date().getFullYear()); Health Care Service Corporation. Simply enter a 5-digit code, service description or drug name in the search field. They use what is called clinical criteria to make sure you get the health care you need. Your Summary of Benefits has information about which services require prior authorization. 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. 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. You are leaving this website/app ("site"). Checking eligibility and benefits and/or obtaining prior authorization is not a guarantee of payment of benefits. A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Reminder: Hospital 30-day Readmission Review Process for BCCHP and MMAI 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. Some benefit plans administered by BCBSIL, such as some self-funded employer plans or governmental plans, may not utilize BCBSIL Medical Policies. If you have any questions, call the number on the members ID card. This step also helps you identify prior authorization requirements and utilization management vendors, if applicable. 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. Prior authorization requests for administrative days (ADs) may not be submitted online at this time. For more than 85 years, weve provided our members with comprehensive, affordable health plans, making Illinois a healthier place to live, work and play. PDF Medicaid Prior Authorization Request Form - BCBSIL Most PDF readers are a free download. Prior Authorization Support Materials (Government Programs) - BCBSIL You'll see details that may help lower health care costs. Customer Service: File the dispute by calling Customer Service at 1-877-860-2837. Your doctor will choose which drug is best for you. Stage 3 of the long-distance hiking trail WestfalenWanderWeg, North Rhine-Westphalia. New User? 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 In most cases, you must receive your care from a Blue Cross Community MMAI (Medicare-Medicaid Plan) SM in-network plan provider. See below for details, including the Zoom registration link. 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. 2023 Best Historic Site Trails in Wetter | AllTrails Failing to provide clinical information or timely notification of prior authorization requests may affect the outcome of a Service Authorization Dispute. 2 0 obj 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. 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 For other services/members, BCBSIL has contracted witheviCore healthcare (eviCore)for utilization management and related services. This step helps you confirm membership, coverage and other details, including prior authorization requirements and utilization management vendors. 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. Returning Shopper? 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. Once additional meetings are confirmed, well alert you via the News and Updates. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com This approval is called "prior authorization." 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. Check out our Corporate Social Responsibility Reportto learn the ways we're serving our community. Blue Cross and Blue Shield of Illinois is proud to be the states only statewide, customer-owned health insurer. Blue Cross Community MMAI has strict rules about how decisions are made about your care. The peer-to-peer discussion is not required, nor does it affect the providers right to an appeal on behalf of a member. To access the BCCHP and MMAI digital lookup tool, refer to the Prior Authorization Support Materials (Government Programs) page in our Utilization Management section. 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. File is in portable document format (PDF). All Rights Reserved. Stay informed about BCBSIL programs, products, initiatives, and more. One Most PDF readers are a free download. Availity provides administrative services to BCBSIL. Procedure code lists are provided for reference purposes. Wed like to invite you to join us for our next committee meeting on May 18, 2023. Well also include reminders in the Blue Review. Why participate? Personal health-related items (such as a toothbrush and toothpaste) are not included on this list. Your plan does not encourage doctors to give less care than you need. Providers are instructed to exercise their own clinical judgment based on each individual patients health care needs. ALLTRAILS and the AllTrails Mountain Design are registered trademarks of AllTrails, LLC in the United States as well as certain other jurisdictions. This list includes generic and brand drugs and medical supplies. Prior Authorization Support Materials (Government Programs) - BCBSIL To view this file, you may need to install a PDF reader program. Sign up! To support the decision process, BCBSIL gives providers the opportunity to discuss UM determinations with a peer physician. Topics include everything from improving your well-being to explaining health coverage. In addition, some sites may require you to agree to their terms of use and privacy policy. Refer to important information for our linking policy. 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. 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. Out of area dialysis services. Blue Cross Community MMAI (Medicare-Medicaid Plan) SM - BCBSIL 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. Please note that, effective May 1, 2021, there will be a change to the BCCHP peer-to-peer discussion process, as specified below. 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. Related Resources At every meeting, we share updates for MMAI and BCCHP providers, such as new programs and resources to share with your patients. MMAI Drug Coverage | Blue Cross and Blue Shield of Illinois. - BCBSIL At Blue Cross Community MMAI (Medicare-Medicaid Plan) SM, we take great pride in ensuring that you receive the care you need. Some services need approval from your health plan before you get treated. 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. In addition, some sites may require you to agree to their terms of use and privacy policy. 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. Our doctors and staff make decisions about your care based on need and benefits. The site may also contain non-Medicare 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. Medicaid Providers: Updated Prior Authorization Tips and Peer-to-Peer Drug Coverage. Most PDF readers are a free download. 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. Your PCP will handle the prior authorization process. 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. For other services/members, BCBSIL has contracted with eviCore healthcare (eviCore) for utilization management and related services. R'sYI D@ zmG@5msm!T%FN3_z. Your doctor should know which services need approval and can help with the details. Search articles and watch videos; ask questions and get answers. Utilization Management | Blue Cross and Blue Shield of Illinois - BCBSIL Request a new replacement member ID card, or download a temporary copy. This new site may be offered by a vendor or an independent third party. PDF Post-Acute Care Utilization Management Program for Blue Cross and Blue Home and Community-Based Services & Waivers, Grievances, Appeals and Coverage Decisions, Language Assistance and Non-Discrimination Notice. The tool returns a list of services that may require prior authorization through BCBSIL or eviCore healthcare (eviCore) for BCCHP and MMAI members. You may be familiar with some of the Medicaid prior authorization resources on our Provider website. BCBSIL Provider Manual | Blue Cross and Blue Shield of Illinois 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. Explore Out-of-Network Coverage for more information about your network. 6C("=L,`YF'0 d Copyright 2021 Health Care Service Corporation. 1 0 obj Most PDF readers are a free download. Please see Drug Information for more information. Whens the meeting for the next quarter? For BCCHP and MMAI: Peer-to-peer discussions are allowed for requests where clinical information was submitted with the original request. Luckily, your health insurance can change with you. 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. All Rights Reserved. Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. We'd like to invite you to join us for our next committee meeting on May 18, 2023. There are no rewards to deny or promote care. You are leaving this website/app ("site"). 415 0 obj <>stream 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. Certain drugs on the list need prior authorization. Blue Cross Community MMAI (Medicare-Medicaid Plan) SM includes coverage for selected prescription and over-the-counter (OTC) drugs, and selected medical supplies. What is the longest historic site trail in Wetter? If you do not use the $30, it does not roll over into the next three months. April 24, 2023. Those exceptions are: Emergency care or urgently needed care. 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. 373 0 obj <> endobj For some services/members, prior authorization may be required through BCBSIL. Click here to see prior authorization tools, clinical review criteria and MMAI Medical Policies used by your doctor to make a decision. Santori Library <> 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). %PDF-1.6 % 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. The next highest ascent for historic site trails is. Wetter - Kupferdreh Ruhrradweg | Map, Guide - North Rhine-Westphalia Create an account. During weekend hours, UM reviewers and medical directors continue to review requests and make decisions.
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