Blue Review
A Provider Publication

March 2022

Closing Gaps in Care for Group Medicare Advantage Members

Through the Blue Cross and Blue Shield (BCBS) National Coordination of Care program, we can work with you to help close gaps in care for Blue Cross Group Medicare Advantage (PPO)SM (Group MA PPO) members. These include Blue Cross and Blue Shield of Illinois (BCBSIL) members with Group MA PPO coverage and Group MA PPO members enrolled in other BCBS plans who are living in Illinois.

What This Means for Medicare Providers
If we need medical records for Group MA PPO members, you will receive requests only from BCBSIL or our vendor, Change Healthcare. You won’t receive requests from multiple BCBS plans or their vendors. We may request medical records for:

  • Risk adjustment gaps related to claims submitted to BCBSIL
  • Healthcare Effectiveness Data and Information Set (HEDIS®) measures
  • Centers for Medicare & Medicaid Services (CMS) Star Ratings

Important Reminders

  • Please respond quickly to requests related to risk adjustment, HEDIS and other government-required activities as your contract requires.
  • You don’t need patient-authorized information releases to fulfill medical records requests and risk adjustment gaps through this program.
  • Use Availity® Essentials or your preferred vendor to verify BCBSIL and other BCBS members’ eligibility and benefits before every appointment. Eligibility and benefit quotes include:
    • Membership verification
    • Coverage status
    • Prior authorization requirements
    • Provider’s network status for the patient’s policy
    • Applicable copayment, coinsurance and deductible amounts
  • Ask to see the member’s ID card and a photo ID to help guard against medical identity theft.
  • Notify members that they may be billed directly when services may not be covered.

Questions? Call the Customer Service number on the member’s ID card.

Checking eligibility and/or benefit information and/or obtaining prior authorization or pre-notification is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage, including, but not limited to, exclusions and limitations applicable on the date services were rendered. If you have any questions, call the number on the member's ID card.

HEDIS is a registered trademark of the National Committee for Quality Assurance. 

Change Healthcare is an independent company providing coding software to BCBSIL. Change Healthcare is solely responsible for the software and all the contents. 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. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors and the products and services they offer.