Blue Cross Community MMAI has strict rules about how decisions are made about your care. Clear and timely submission of prior authorization requests and clinical documentation is very important to process requests within the required timeframes. However, you can order these items once every three months. You are leaving this website/app (site). 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. 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. Wed like to invite you to join us for our next committee meeting on May 18, 2023. This list includes generic and brand drugs and medical supplies. Check out our Corporate Social Responsibility Reportto learn the ways we're serving our community. 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. Life changes happen at any time. 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. We'd like to invite you to join us for our next committee meeting on May 18, 2023. Information on Service Authorization Disputes can be found on the Provider Service Authorization Dispute Resolution Request Form. These requests must be decided within 48 hours for BCCHP members, and 72 hours for MMAI members. 373 0 obj <> endobj To view this file, you may need to install a PDF reader program. References to other third party sources or organizations are not a representation, warranty or endorsement of such organizations. Most PDF readers are a free download. Register Now. 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. Qf#yQ>u(KpRE{UIQp[)5T:p:jBFp*WWhwIA36YwNG)!G/!Yr6v7e|12 rUp3?R1H-6Kre vh) yj?O&y]\x,$aU7Mm'a 5a1owahiT@IC+ Benefits will be determined once a claim is received and will be based upon, among other things, the members eligibility and the terms of the members certificate of coverage applicable on the date services were rendered. {0c8Lp~#g.wS,#.z (c PT+ ~"%V3xCh`q'cgI$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_$.xpP*GMG"g'K;KmVGA?7nW/pJ'3P.u'7y*6#E!LbC?hhCp6 4y%CS"R;%j)`y31pc`{%w)/*5hKE7:KRnQ&C+grc-pG`3P8+C~J7X 3o'YBa@sOz0zRlA_>]B]]#@W)o)|CNogbC;, jXw8w;![@0\bBJh1e8M'Z9owf;CYP[Hk`|8 (d/v_59=_O~o=pn[3f5+@tn0M|!ev"]"A!^A cc=zZf` sDH- rst !-`*M68G#gYmw/|O|)- R{O *L%U}r?:B22Rj=]p ($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 Whats on the agenda? The ASAM Criteria, 2021 American Society of Addiction Medicine. Choose the best payment option for your Blue Cross and Blue Shield of Illinois (BCBSIL) monthly bill. Government Programs Prior Authorization Summary and Code ListsRefer to the Summary documents below for an overview of prior authorization requirements, reminders and helpful links. hb``0b`0 36 fah@t#(f`XU1U B)xPB2@+4s\ X:EolHd]1ofxF/120i7@ZN 4`SBa@3P]8D5/@ F& endstream endobj 13 0 obj <>]/Pages 10 0 R/Perms/Filter<>/PubSec<>>>/Reference[<>/Type/SigRef>>]/SubFilter/adbe.pkcs7.detached/Type/Sig>>>>/Type/Catalog/ViewerPreferences<>>> endobj 14 0 obj <. Information provided is not exhaustive and is subject to change. You can find out if your drug has any added conditions or limits by looking at the Drug List. Home and Community-Based Services & Waivers, Grievances, Appeals and Coverage Decisions, Language Assistance and Non-Discrimination Notice. If you do not use the $30, it does not roll over into the next three months. All Rights Reserved. }&ji[@_{dsTchsqD7bL+x3AXG>z>(y{+/en6=V/e{.t&>jFj750hS) !yppH7edMUFA{u38_tZ'oKAlr, @qiD What: Q2 2023 MMAI and BCCHP Community Stakeholder Committee Meeting The BCBSIL Medical Policies are for informational purposes only and are not a substitute for the independent medical judgment of health care providers. We also feature guest speakers and allow time for a general Q&A. There are no rewards to deny or promote care. *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. 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. The Drug List (sometimes called a formulary) is a list showing the drugs that can be covered by the plan. You may be familiar with some of the Medicaid prior authorization resources on our Provider website. BCBSIL makes no endorsement, representations or warranties regarding third-party vendors. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. 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. 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). This new site may be offered by a vendor or an independent third party. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. 1 0 obj You are leaving this website/app ("site"). In most cases, you must receive your care from a Blue Cross Community MMAI (Medicare-Medicaid Plan) SM in-network plan provider. 12 0 obj <> endobj 64 0 obj <>/Filter/FlateDecode/ID[<377B542E37144E99AA8D3C27588EFAA9><9D42E3C64D6B4195AB6A428BC62E2046>]/Index[12 96]/Info 11 0 R/Length 151/Prev 468246/Root 13 0 R/Size 108/Type/XRef/W[1 3 1]>>stream Well also include reminders in the Blue Review. 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. The plan will pay up to $30 (plus $5 for shipping) for each order. Our doctors and staff make decisions about your care based on need and benefits. For some services/members, prior authorization may be required through BCBSIL. See below for details, including the Zoom registration link. Our doctors and staff make decisions about your care based only on need and benefits. Registration is required. One option is Adobe Reader which has a built-in reader. New User? Lunch will be provided. Prior Authorization Doctors and Hospitals When choosing a doctor, make sure the doctor is part of the Blue Cross Community MMAI (Medicare-Medicaid Plan) SM network. Most PDF readers are a free download. k+:6@1)^]WNQj sGG& hFa`@,%LFPBA7Xmxt$.=e0ne}#IoE 20iF 6Xg8Sf;+-P > Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com Your doctors will use other tools to check prior authorization needs. According to AllTrails.com, the longest historic site trail in Wetter is RuhrtalRadweg Etappe 4: Wetter (Ruhr) - Essen. To view this file, you may need to install a PDF reader program. Who is responsible for getting the prior authorization? You also have the right to ask for a coverage decision. How to File a Claims Dispute using Enterprise Appeals Application (EAA) Tracking ID 1. 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. Prime Therapeutics LLC (Prime) is a pharmacy benefit management company. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors. 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. @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%,(( Frequently asked questions about historic site trails in Wetter. When faxing prior authorization requests, you must use the Medicaid Prior Authorization Request Form. If you have any questions, call the number on the member's BCBSIL ID card. BCBSIL adheres to the standards for addressing all urgent concurrent requests, meeting or exceeding National Committee for Quality Assurance (NCQA) standards. 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. This step helps you confirm membership, coverage and other details, including prior authorization requirements and utilization management vendors. 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. The most popular and difficult historic site trail in Wetter is, RuhrtalRadweg Etappe 4: Wetter (Ruhr) - Essen, WestfalenWanderWeg Etappe 3: Wetter - Schwerte. 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. related information. To view this file, you may need to install a PDF reader program. Most PDF readers are a free download. %PDF-1.6 % Use the links below to view BCBSIL and vendor guidelines that may apply. Subscribe now to receive the monthly Blue Review via email. 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 endstream endobj 374 0 obj <. Procedure code lists are provided for reference purposes. Providers are instructed to exercise their own clinical judgment based on each individual patients health care needs. The tool returns a list of services that may require prior authorization through BCBSIL or eviCore healthcare (eviCore) for BCCHP and MMAI members. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. Out-of-Network Coverage. The Customer Service representative will provide you a reference number, which can be used to track the dispute. For other services/members, BCBSIL has contracted with eviCore healthcare (eviCore) for utilization management and related services. 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. Whens the meeting for the next quarter? Recently, we added a digital lookup tool that gives you a different way to view prior authorization requirements that may apply to our BCCHP and MMAI members. April 24, 2023. Its a great chance to work with faith leaders, advocacy groups and other community-based organizations that support our members health and well-being. New to Blue Access for Members? 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 digital lookup tool is intended for reference purposes only. Medicaid Prior Authorization Request Form, Provider Service Authorization Dispute Resolution Request Form. What is the most popular and difficult historic site trail in Wetter? If an appeal has been filed, the peer-to-peer discussion is no longer available. Please note that, effective May 1, 2021, there will be a change to the BCCHP peer-to-peer discussion process, as specified below. For some services/members, prior authorization may be required through BCBSIL. Stage 3 of the long-distance hiking trail WestfalenWanderWeg, North Rhine-Westphalia. Also, some services need approval before treatment or services are received. The peer-to-peer discussion is not required, nor does it affect the providers right to an appeal on behalf of a member. <> The site may also contain non-Medicare related information. %%EOF In addition, some sites may require you to agree to their terms of use and privacy policy. Davis Vision is an independent company that has contracted with BCBSIL to provide vision benefits administration for government programs members with coverage through BCBSIL. From Siegen with the beautiful day ticket (33 euros for 5 people) to Wetter / Ruhr. ALLTRAILS and the AllTrails Mountain Design are registered trademarks of AllTrails, LLC in the United States as well as certain other jurisdictions. Failing to provide clinical information or timely notification of prior authorization requests may affect the outcome of a Service Authorization Dispute. This approval is called "prior authorization." As of this date, providers may submit a new packet for clinical re-review OR do a peer-to-peer discussion. Non-Discrimination Notice. This step also helps you identify prior authorization requirements and utilization management vendors, if applicable. At every meeting, we share updates for MMAI and BCCHP providers, such as new programs and resources to share with your patients. All Rights Reserved. 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. Our doctors and staff make decisions about your care based on need and benefits. 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. Which historic site trail has the most elevation gain in Wetter? Out of area dialysis services. It will open in a new window. 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. These tools used by PCPs (or specialists) include medical codes. Simply enter a 5-digit code, service description or drug name in the search field. Related Resources File is in portable document format (PDF). 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. Members should contact the customer service number on their member ID card for more specific coverage information. All Rights Reserved. You can: Pay a bill online or sign up for auto bill pay. This step will help you confirm prior authorization requirements and utilization management vendor information, if applicable. 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. You can get one shipment every three months. Search for doctors, dentists, hospitals and other health care providers. Search articles and watch videos; ask questions and get answers. To protect your health and keep you safe, make sure your doctor and pharmacist know what medicines you are taking, including OTC drugs. When: Thursday, May 18, 2023, from 1 to 2:30 p.m. CST The above material is for informational purposes only and is not intended to be a substitute for the independent medical judgment of a physician. For other services/members, BCBSIL has contracted witheviCore healthcare (eviCore)for utilization management and related services. Your PCP will handle the prior authorization process. Prior authorization requests for administrative days (ADs) may not be submitted online at this time. Customer Service: File the dispute by calling Customer Service at 1-877-860-2837. 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. DV. From the train station through the underpass, it goes straight across the street to the Ruhr cycle path. All Rights Reserved. Register Now. 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. For BCCHP and MMAI: Peer-to-peer discussions are allowed for requests where clinical information was submitted with the original request. 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. Log in to your account to get the most accurate, personalized search results based on your plan. Sign up for theLifeTimes newsletterto get health and benefits articles delivered to your inbox every month. The Drug List (sometimes called a formulary) is a list showing the drugs that can be covered by the plan. Luckily, your health insurance can change with you. Additionally, the Provider Service Authorization Dispute process is available when an adverse service authorization has been rendered and the UM process has been followed. To view this file, you may need to install a PDF reader program. Blue Cross and Blue Shield of Illinois is proud to be the states only statewide, customer-owned health insurer. Prior Authorization Support Materials (Government Programs). 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. Provider Finder. How do I know if I need a prior authorization? Why participate? Members should contact the vendor(s) directly with questions about the products or services offered by third parties. 101 S. River Street In addition, some sites may require you to agree to their terms of use and privacy policy. Click here to see prior authorization tools, clinical review criteria and MMAI Medical Policies used by your doctor to make a decision. In addition, some sites may require you to agree to their terms of use and privacy policy. Create an account. FIND YOUR WAY OUTSIDE is a trademark of AllTrails, LLC. Those exceptions are: Emergency care or urgently needed care. Welcome. Copyright document.write(new Date().getFullYear()); Health Care Service Corporation. <>/Metadata 528 0 R/ViewerPreferences 529 0 R>> At Blue Cross Community MMAI (Medicare-Medicaid Plan) SM, we take great pride in ensuring that you receive the care you need. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. To support the decision process, BCBSIL gives providers the opportunity to discuss UM determinations with a peer physician. If you want to know more about the utilization management process or how decisions are made about your care, Contact Us. If you have a complaint about how we handle any services provided to you, you can file a grievance or an appeal. While not included in the digital lookup tool, some services always require prior authorization, such as inpatient facility admissions. 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 Doctors are not paid to deny care. 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. One option is Adobe Reader which has a built-in screen reader. To return to our website, simply close the new window. According to AllTrails.com, the longest historic site trail in Wetter is. GDChv0O{Q~ $W0!&~(c~;=1^!GD=q2z5OR%AG.)H&lz'9|^f!(@.ib New User? 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. Search your plan's drug list, find a pharmacy, and more. Copyright 2021 Health Care Service Corporation. Your plan covers the items in the Drug List as long as you: To see your plan's Drug List, go toForms & Documents. Its important to check eligibility and benefits first for each patient at every visit to confirm coverage details. End along the Ruhr meadows over Lake Kemader to Lake Baldeney in Essen. The next highest ascent for historic site trails is. Other Adobe accessibility tools and information can be downloaded at http://access.adobe.com. Some benefit plans administered by BCBSIL, such as some self-funded employer plans or governmental plans, may not utilize BCBSIL Medical Policies. % 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. Copyright document.write(new Date().getFullYear()) Health Care Service Corporation. Medical Policies are based on scientific and medical research. %PDF-1.6 % How Does Blue Cross Community MMAI (Medicare-Medicaid Plan)SMMake Decisions for Prior Authorizations? 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. How Does Blue Cross Community MMAI (Medicare-Medicaid Plan)SM Make Decisions for Prior Authorizations? What is the longest historic site trail in Wetter? The most popular and difficult historic site trail in Wetter is Von Wetter zum Nacken with a 3.6-star rating from 2 reviews. 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. R'sYI D@ zmG@5msm!T%FN3_z. Santori Library 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. endobj They use what is called clinical criteria to make sure you get the health care you need. All Rights Reserved. For more than 85 years, weve provided our members with comprehensive, affordable health plans, making Illinois a healthier place to live, work and play. All rights reserved. External link You are leaving this website/app (site). Request a new replacement member ID card, or download a temporary copy. endobj To view this file, you may need to install a PDF reader program. Want to be part of our amazing team? 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. 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. Refer to our Medicaid prior authorization summary for more 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. See Chapter 4 of theMember Handbookon the Forms & Documents page for more details. As you transition to Medicare, we hope you'll Stay with Blue and get Medicare coverage from a company you trust. Medical Benefits Blue Cross Community MMAI (Medicare-Medicaid Plan) SM covers many of your health care needs. In addition, some sites may require you to agree to their terms of use and privacy policy. Legal and Privacy #5 - RuhrtalRadweg Etappe 4: Wetter (Ruhr) - Essen, #6 - WestfalenWanderWeg Etappe 3: Wetter - Schwerte. 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. The BCBSIL Provider Manuals are comprehensive guides for Blue Cross Community Health Plans SM, Blue Cross Community MMAI (Medicare-Medicaid Plan) SM, Blue Cross Medicare Advantage (HMO) SM, Blue Cross Medicare Advantage (PPO) SM, Blue Choice PPO SM, HMO, PPO and Blue High Performance Network (Blue HPN ) EPO professional and facility providers. If a request does not meet medical necessity criteria for approval, the request will be assigned to a BCBSIL medical director for determination. Blue Cross Community MMAI (Medicare-Medicaid Plan) SM includes coverage for selected prescription and over-the-counter (OTC) drugs, and selected medical supplies. Providers are allowed the opportunity to schedule one peer-to-peer discussion per adverse determination. Your feedback is vital to improving the care and services these members receive. Home 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. File is in portable document format (PDF). The site may also contain non-Medicare related information. Limitations of Covered Benefits by Member Contract In addition, some sites may require you to agree to their terms of use and privacy policy. It also includes the drugs covered by Medicare Part D. As a member, you have no copay for covered items on the Drug List. Availity provides administrative services to 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. Your doctor will choose which drug is best for you. For Medicaid (BCCHP and MMAI) members, prior authorization requirements are found in the last column of the BCCHP drug list and MMAI drug list. 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. Sign up! To access the BCCHP and MMAI digital lookup tool, refer to the Prior Authorization Support Materials (Government Programs) page in our Utilization Management section. This new site may be offered by a vendor or an independent third party. These tools used by PCPs (or specialists) include medical codes. Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. This new site may be offered by a vendor or an independent third party. endstream endobj startxref You are leaving this website/app ("site"). During weekend hours, UM reviewers and medical directors continue to review requests and make decisions. 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. Your doctors will use other tools to check prior authorization needs. 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. 415 0 obj <>stream You pay nothing ($0) when you go to a doctor or health care provider in the plan's network. Drug Coverage. This new site may be offered by a vendor or an independent third party. 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. 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. 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. Get the most from your BCBSIL pharmacy benefits.