May 2019

BCCHP^SM and MMAI Providers: Utilization Management (UM) Reminders

Availability of UM Criteria
Blue Cross Community Health Plans^SM (BCCHP) makes UM criteria available to practitioners and providers upon request. Practitioners and providers are informed in denial notifications that they may request a copy of the criteria used to make the determination and how to contact BCCHP. 

Practitioners and providers may call BCCHP at 877-860-2837 or Blue Cross Community MMAI(Medicare-Medicaid Plan)^SM at 877-723-7702 to request a copy of UM criteria. Upon request, UM criteria will be mailed, faxed or emailed to practitioners and providers.

UM Determinations
UM determinations are made by licensed clinical personnel based on the benefit policy (coverage) of a member’s health plan, evidence-based medical policies, and the medical necessity of care and service. Blue Cross and Blue Shield of Illinois (BCBSIL) does not provide any reward or incentive to employees, providers or other individuals for decisions that result in determinations that services are not covered; nor do we reward providers for underutilization of services.

If you have questions about criteria for UM decisions and official medical policy, or if you wish to discuss a UM coverage determination, you may contact a medical director at 800-981-2795. All medical policies are available for review in the Standards and Requirements section of our Provider website.

Talking with Health Services Staff
BCBSIL Health Services staff members are available to receive incoming calls, make outbound calls and discuss UM issues with members and providers Monday through Friday, 8 a.m. to 5 p.m. (CST). After hours, callers may leave a message and receive a call back the next business day. For BCCHP members, call 877-860-2837. For MMAI members, call 877-723-7702.

When calling your office, our Health Services staff members will identify themselves as BCBSIL employees and give their names and titles. TTY/TDD and language translation services are available for callers who may need assistance.

*This article does not include members with HMO Illinois^®, Blue Advantage HMO^SM, Blue Precision HMO^SM, BlueCare Direct^SM and Blue FocusCare^SM, Blue Cross Medicare Advantage^SM (HMO and PPO) products.