This new site may be offered by a vendor or an independent third party. During weekend hours, UM reviewers and medical directors continue to review requests and make decisions. Sign up! Our doctors and staff make decisions about your care based only on need and benefits. This list includes generic and brand drugs and medical supplies. How Does Blue Cross Community MMAI (Medicare-Medicaid Plan)SMMake Decisions for Prior Authorizations? We'd like to invite you to join us for our next committee meeting on May 18, 2023. Your PCP will handle the prior authorization process. Your doctors will use other tools to check prior authorization needs. If you have any questions, call the number on the members ID card. 0 To see if you are eligible, Contact:Blue Cross and Blue Shield of Illinois' OTC vendor,Convey Health Solutions, at: 1-855-891-5274. Clear and timely submission of prior authorization requests and clinical documentation is very important to process requests within the required timeframes. Out of area dialysis services. Medical policies are also used to guide care decisions. This step helps you confirm membership, coverage and other details, including prior authorization requirements and utilization management vendors. Government Programs Prior Authorization Summary and Code ListsRefer to the Summary documents below for an overview of prior authorization requirements, reminders and helpful links. 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. 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. 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. Providers are instructed to exercise their own clinical judgment based on each individual patients health care needs. 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. Topics include everything from improving your well-being to explaining health coverage. This approval is called "prior authorization." Whens the meeting for the next quarter? 415 0 obj <>stream Checking eligibility and benefits and/or obtaining prior authorization is not a guarantee of payment of benefits. <> hb```) ea&pd:Se Those exceptions are: Emergency care or urgently needed care. Prime Therapeutics LLC (Prime) is a pharmacy benefit management company. Learn about the many ways we are contributing to the well-being of our local Illinois communities in the latest Corporate Social Responsibility Report. The next highest ascent for historic site trails is. Whats new on the web? 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. 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. The site may also contain non-Medicare Our trusted community experts can give you the one-on-one help you need to shop for health insurance. To view this file, you may need to install a PDF reader program. Qf#yQ>u(KpRE{UIQp[)5T:p:jBFp*WWhwIA36YwNG)!G/!Yr6v7e|12 rUp3?R1H-6Kre vh) yj?O&y]\x,$aU7Mm'a 5a1owahiT@IC+ The site may also contain non-Medicare related information. What is the most popular and difficult historic site trail in Wetter? Blue Access for MembersSM is a powerful tool for managing all your health plan benefits. Luckily, your health insurance can change with you. Information on Service Authorization Disputes can be found on the Provider Service Authorization Dispute Resolution Request Form. Blue Cross and Blue Shield of Illinois (BCBSIL) would like to outline some important updates, tips and reminders on prior authorization processes for independently contracted providers treating our Blue Cross Community Health PlansSM (BCCHPSM) and Blue Cross Community MMAI (Medicare-Medicaid Plan)SM members. Contact Us | Blue Cross and Blue Shield of Illinois Contact Us AIM Specialty Health (AIM) is an operating subsidiary of Anthem and an independent third party vendor that is solely responsible for its products and services. New User? Blue Cross and Blue Shield of Illinois, aDivision of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association, PDF File is in portable document format (PDF). Regardless of any prior authorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider. All Rights Reserved. In addition, some sites may require you to agree to their terms of use and privacy policy. It is the responsibility of the requesting provider to submit clinical documentation to substantiate a request for services at the time of the service authorization request. R{O *L%U}r?:B22Rj=]p ($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 (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). One option is Adobe Reader which has a built-in reader. 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. Also, some services need approval before treatment or services are received. Checking eligibility and benefits and/or obtaining prior authorization is not a guarantee of payment of benefits. Provider Finder. 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. The peer-to-peer discussion is available as a courtesy to providers. All Rights Reserved. Life changes happen at any time. There are no rewards to deny or promote 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 support the decision process, BCBSIL gives providers the opportunity to discuss UM determinations with a peer physician. %%EOF 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. You also have the right to ask for a coverage decision. 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 Davis Vision is an independent company that has contracted with BCBSIL to provide vision benefits administration for government programs members with coverage through BCBSIL. Drug Coverage. 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. 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. <> From the train station through the underpass, it goes straight across the street to the Ruhr cycle path. 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. DV. You also can call the MMAI plan's pharmacy help-line. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors. New User? 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. Additionally, the Provider Service Authorization Dispute process is available when an adverse service authorization has been rendered and the UM process has been followed. The table below contains some of the services covered under your plan. The health of your eyes and teeth can affect your overall health. One Without approval, the drug won't be covered. You may be familiar with some of the Medicaid prior authorization resources on our Provider website. endobj Information provided is not exhaustive and is subject to change. Grievance (Complaint) Appeals 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. Always check eligibility and benefits through Availity or your preferred web vendor before rendering services. Talk with your doctor about your medication. You are leaving this website/app (site). All rights reserved. <>/Metadata 528 0 R/ViewerPreferences 529 0 R>> The site may also contain non-Medicare related information. In most cases, you must receive your care from a Blue Cross Community MMAI (Medicare-Medicaid Plan) SM in-network plan provider. Who is responsible for getting the prior authorization? Your doctor will choose which drug is best for you. Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized is not a guarantee of payment. The plan will pay up to $30 (plus $5 for shipping) for each order. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors. From Siegen with the beautiful day ticket (33 euros for 5 people) to Wetter / Ruhr. To view this file, you may need to install a PDF reader program.