June 2022

Focus on Behavioral Health 

Behavioral Health Collaboration Requests

If you provide behavioral health services to our members, you may receive a request to work with us as part of our Behavioral Health Case Management program.

Community Involvement

Free Men’s Health Programming at Blue Door Neighborhood Center^SM (BDNC^SM)

Our BDNC locations in the Morgan Park, Pullman and South Lawndale neighborhoods of Chicago are one way we work with you to make a difference in our communities. 

MMAI and BCCHP^SM Providers: Join Our Community Stakeholder Committee

Join us as we host 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.

Provider Education

Provider Learning Opportunities

BCBSIL offers free webinars and workshops for the independently contracted providers who work with us. A preview of upcoming training sessions is included in this month’s issue.

We’re Collecting Physician Education Information for Local and National Provider Directories 

The Blue Cross and Blue Shield Association now requires that Blue Cross and Blue Shield (BCBS) Plans provide medical school and residency information for all participating in-network physicians (M.D.s and D.O.s).

Earn Continuing Education Credit at Webinar on Avoiding Inappropriate Antibiotic Use

Join us for a free webinar on preventing antibiotics overuse. Physicians (M.D.s and D.O.s), physician assistants and nurse practitioners are welcome.

Pharmacy Program

Pharmacy Prior Authorization Update: New Preferred Drug Recommendation Process

Effective Aug. 1, 2022, Blue Cross and Blue Shield of Illinois (BCBSIL) will begin recommending some preferred drugs over other drugs through our medical policies, when clinically appropriate, to improve access to more affordable care for some of our commercial non-HMO members. 

Pharmacy Program Updates: Prior Authorization (PA) Changes Effective July 15, 2022

The pharmacy PA program encourages safe, cost effective medication use by allowing coverage when certain conditions are met. A clinical team of physicians and pharmacists develops and approves the clinical programs and criteria for medications that are appropriate for PA by reviewing U.S. Food and Drug Administration (FDA) approved labeling, scientific literature and nationally recognized guidelines. Read more on News and Updates.

Pharmacy Program Updates: Quarterly Pharmacy Changes Effective July 1, 2022 – Part 1

Based on the availability of new prescription medications and Prime’s National Pharmacy and Therapeutics Committee’s review of changes in the pharmaceuticals market, some additions, revisions (drugs still covered but moved to a higher out-of-pocket payment level) and/or exclusions (drugs no longer covered) were made to the BCBSIL drug lists. Changes effective on or after July 1, 2022, are outlined here.

What's New

Prior Authorization Reform: New Resources on Our Website

BCBSIL made necessary changes related to the Prior Authorization Reform Act (House Bill 711) as of Jan. 1, 2022. We've made additional updates to ensure adherence with all Illinois-state mandated requirements.

Clinical Updates, Resources and Reminders

Check Eligibility and Benefits: Don’t skip this important first step!

Is your patient’s membership with BCBSIL still active? Are you or your practice/medical group in- or out-of-network for a specific patient? Is prior authorization required for a particular member/service?

Prior Authorization Code Updates for Commercial Members and Government Programs, Effective July 1, 2022

BCBSIL is changing prior authorization requirements that may apply to some commercial non-HMO members. We’re also changing PA requirements for Blue Cross Medicare Advantage (PPO)^SM (MA PPO), BCCHP and MMAI members. Refer to the News and Updates for commercial non-HMO and government programs code changes.

Claims and Coding

Billing Reminders and Multiple Procedure Reduction for Certain Diagnostic Imaging Procedures

This is a reminder for physicians and suppliers when billing for diagnostic imaging supplies and services for our PPO, Blue Choice PPO^SM and Blue High Performance Network^SM (BlueHPN^SM) members.

Electronic Options

Availity^® Essentials Claim Status Tool Update

As of May 22, 2022, you must use the "Select a Provider" dropdown list in the Availity Claim Status tool for the National Provider Identifier (NPI) to populate in the Member and Claim Number search options. 

Submit Multiple Clinical Claim Appeal Requests Online

As of May 22, 2022, you can electronically initiate one clinical claim appeal request for multiple claims, when it’s for the same patient and denial reason, using the Availity Claim Status tool. 

Quality Improvement and Reporting

The 2021 HHS-RADV Initial Validation Audit (IVA) Begins May 2022

As an insurer participating in the Affordable Care Act's (ACA) HHS-operated Risk Adjustment Data Validation (HHS-RADV) program, Centers for Medicare & Medicaid Services (CMS) is requiring BCBSIL to perform the required HHS-RADV program/Initial Validation Audit (IVA).

Wellness and Member Education

Help Close Gaps in Care for Group Medicare Advantage Members

If we need medical records for Blue Cross Group Medicare Advantage (PPO)^SM members, you’ll receive requests only from BCBSIL or our vendor, Change Healthcare.

Notification and Disclosure

Has your information changed? Let us know!

When seeking health care services, our members often rely upon the information in our online Provider Finder^®. Prospective patients can use this online tool to confirm if your practice is a contracted in-network provider for their health care benefit plan

ClaimsXten™ Quarterly Update Reminder

BCBSIL will implement its third quarter code update for the ClaimsXten auditing tool on or after Aug. 22, 2022.

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