September 2020
We’ve Made Our HMO Scope of Benefits in the Commercial Provider Manual Easier to Navigate
We appreciate the care and services HMO contracted providers give to our HMO Illinois®, Blue Advantage HMOSM, Blue Precision HMOSM, BlueCare DirectSM and Blue FocusCareSM members. Each HMO member receives an HMO Certificate of Health Care Benefits upon enrollment with the HMO. Many portions of the Certificate are standard for all HMO members, but benefits may vary from plan to plan.
Our Provider website includes a set of guidelines for HMO benefit interpretation – the Scope of Benefits.
The Scope of Benefits is intended to give each Medical Group/Independent Practice Association (MG/IPA) an overview of covered and non-covered services for quick reference purposes.
We know you’re busy and it can be challenging to find specific information you need quickly and easily. So, we’ve made a change to help. Here are the details:
- Previously, the Scope of Benefits for all services was posted as one document on our website.
- You’ll still find the Scope of Benefits information in the Standards and Requirements, Provider Manual section.
- Now you’ll see that each Scope is broken into a separate document, so you can go right to the information you need without having to scroll through multiple pages.*
*Please note that initially, with the launch of this new format, each Scope will have the same revision date. Going forward, as individual guidelines are revised, each Scope will show the applicable date.
Please note that the information in the Scope of Benefits is not all-inclusive. For more information on benefits and/or financial responsibility, refer to the Medical Service Agreement. For more help with benefits interpretation, the MG/IPA may contact the Customer Assistance Unit Staff at 312-653-6600.
The IPA is responsible for providing or arranging for all covered Physician Services, IPA-approved Inpatient and Outpatient Hospital Services, Ancillary Services and non-hospital-based Emergency Services within the scope of benefits of the various Benefit plans. All inpatient hospital admissions, (except those which occur out of area or begin as an emergency), Skilled Nursing Facility days and Home Health visits must be approved by the IPA to be covered by the HMO. Only those services provided for under the Certificate are covered. When the IPA physician recommends non-covered services, the member's financial responsibility must be explained to the member. The explanation should be documented.
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. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment. 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. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.