November 2022

What’s New 

2022 Blue Review Readership Survey Continues Through November

If you’re a contracted provider with Blue Cross and Blue Shield of Illinois (BCBSIL) and you read our monthly newsletter, you’re an expert! We rely on your feedback to help assess how the Blue Review measures up, and what we can do better next year. Don’t miss this opportunity to tell us what you think! Take the survey now.

Network Innovation/Product Updates

BCBSIL To Offer Medicare Advantage Programs in 61 Additional Counties

In 2023, BCBSIL will offer Medicare Advantage programs in 97 of the 102 counties in Illinois, allowing us the capability to serve 2.2 million Medicare-eligible Illinois residents. To support this expansion, 2,378 providers and 483 facilities will be added to BCBSIL’s Medicare Advantage network. We’re also introducing new plan options for cost-conscious Medicare consumers. View our press release to learn more.

Quality Improvement and Reporting  

Health Equity in Cancer Prevention and Control

Health equity presents the ideal that everyone deserves a fair shot at living their healthiest possible life. But some populations may be at a disadvantage due to social determinants of health (SDoH) – social, economic or physical conditions they experience at home, school, work and elsewhere in their neighborhoods and communities. 

Addressing Disparities in Breast Cancer for Black Women

October was Breast Cancer Awareness Month, but we want to keep the momentum going. Breast cancer is one of the most common cancers among women in the U.S. and, according to the American Cancer Society, it disproportionately affects Black women. What can you do to help? Read more on News and Updates.

Community Involvement

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

We’re hosting 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. Register now for the fourth quarter meeting on Dec. 1, 2022.

National Diabetes Awareness Month events at Blue Door Neighborhood Center^SM

Our Blue Door Neighborhood Center (BDNC^SM) locations will be hosting virtual and in-person National Diabetes Awareness Month events in November.

Wellness and Member Education

BCBSIL Helps Some Rural Members Prevent or Manage Diabetes

In recognition of Diabetes Awareness Month is in November, we’re getting the word out to our members, especially regarding prediabetes. Our members’ wellness can’t wait.

Focus on Behavioral Health

Diabetes Screening for People Using Antipsychotic Medications

People with serious mental illness who use antipsychotic medications are at increased risk of diabetes, according to the National Committee for Quality Assurance (NCQA). Regular screening for diabetes is important for detecting, monitoring and in the treatment of the disease.

Pathways to Success: New Medicaid Initiative To Begin Jan. 1, 2023

You may have participated in the recent Illinois Medicaid webinars, facilitated by the Illinois Department of Healthcare and Family Services (HFS), regarding the rollout of the new Pathways to Success initiative. BCBSIL will implement Pathways to Success for our BCCHP members beginning Jan. 1, 2023.

Provider Education

Critical Incident Reporting Guidance

Mandated reporting makes specific professionals required by law to report all suspected abuse, neglect and exploitation of children, disabled adults or senior citizens to the appropriate referral entity. Mandated reporters include, but are not limited to: Daycare workers, social workers, law enforcement, teachers, homemaker and adult day care providers, nurses and doctors.

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.

Claims and Coding

Illinois Medicaid Claims Alert: Hospice Room and Board Adjustments and Repayment

On Aug. 29, 2022, HFS issued a provider notice regarding incorrect submission of hospice room and board claims to HFS, as these claims should be submitted to the appropriate Managed Care Organizations (MCOs). In response to this notice, BCBSIL will work with hospice providers to resolve claims submission and reimbursement discrepancies, if applicable, for services rendered to BCCHP members. Read more on News and Updates.

New Laboratory Benefit Management Program: Revised Effective Date for Some Policies

Our new program with Avalon Healthcare Solutions for claims for certain outpatient laboratory services provided to many of our commercial, non-HMO members became effective Nov. 1, 2022. Previously, we alerted you that Clinical Payment and Coding Policies (CPCPs) related to certain laboratory services, tests and procedures would be implemented using a phased approach.

Reminder: CPT^® Codes May Change

As a reminder, Current Procedural Terminology (CPT) codes may change throughout the year due to changes (new, replaced or removed codes) implemented by the American Medical Association (AMA).

Electronic Options

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? 

Confirm Receipt Status Online for Prior Authorization Medical Records Sent via Fax or Mail

We’ve enhanced our Medical Record Status Viewer so you can use it to confirm receipt of medical records submitted by fax or mail to BCBSIL for commercial prior authorization medical record requests.

Clinical Updates, Reminders and Resources

Prior Authorization Requirement Changes for Some Commercial Members and Code Updates Effective Jan. 1, 2023 

BCBSIL is changing prior authorization requirements that may apply to some commercial non-HMO members. Changes are based on updates from Utilization Management prior authorization assessment, CPT code changes released by the AMA or Healthcare Common Procedure Coding System (HCPCS) code changes from the Centers for Medicaid & Medicare Services (CMS).

Prior Authorization Requirement Changes for Some Government Programs Members and Code Updates Effective Jan. 1, 2023

BCBSIL is changing prior authorization requirements for Blue Cross Medicare Advantage (PPO)^SM (MA PPO), BCCHP and MMAI members. See the article in this month’s issue for a summary of code changes in certain care categories.

Postponed: Use Our Automated Phone System to Request Prior Authorization for FEP^® Members

In August 2022, we announced the launch of a new feature to offer prior authorization for Federal Employee Program^® (FEP) members through our interactive voice response (IVR) phone system. On Oct. 11, 2022, we alerted you that this new feature has been postponed. Please continue to watch the News and Updates for future program announcements.

Pharmacy Program

Pharmacy Program Updates: Prior Authorization (PA) Changes Effective December 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 Oct. 1, 2022 – Part 2

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 Oct. 1, 2022, are outlined here.

Notification and Disclosure

Medical Policy Updates

Approved, new or revised BCBSIL Medical Policies and their effective dates are usually posted on our Provider website the first day of each month.

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