November 2022

Critical Incident Reporting Guidance

A critical incident is an actual or alleged case of abuse, neglect, exploitation, or any incident that has the potential to place a member or a member's health care services at risk, including incidents that may escalate to the level of abuse, neglect or exploitation. Events that may cause substantial or serious harm to the physical or mental health of a member, or the safety of a member’s services, must be considered as critical incidents.

Examples may include:

• An elderly member has worsening bed sores and appears not to be well cared for by a nursing home
• A disabled member was pushed by her caregiver resulting in a bone fracture

What is mandated reporting and who are mandated reporters?
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. It’s important to know that willful failure to report suspected incidents of abuse or neglect is a misdemeanor or a class 4 felony and Illinois law protects the identity of all mandated reporters.

Mandated reporters include but are not limited to: Daycare workers, social workers, law enforcement, teachers, homemaker and adult day care providers, nurses, and doctors.

Here’s a list of whom to call and when to report suspected abuse, neglect or exploitation:

Collaboration With Care Coordinators Is Important
After a critical incident involving a Blue Cross and Blue Shield of Illinois (BCBSIL) member is identified, a BCBSIL Care Coordinators may reach out to applicable providers regarding details of the member’s health, such as wounds/bed sores, falls, member’s cognition and decision making ability, long term care placement, and other related information. BCBSIL also asks providers to collaborate with the member’s assigned Care Coordinator when a critical incident is identified by the provider.

How to report a critical incident to BCBSIL:
To report a critical incident involving our Blue Cross Community Health Plans^SM (BCCHP^SM) or Blue Cross Community MMAI (Medicare-Medicaid Plan)^SM members, providers may call 855-334-4780 or complete the Critical Incident Reporting Form located on our website.

When calling to report a critical incident for BCCHP and MMAI members, please have the following information available:

• The member’s name and BCBSIL member ID number;
• A brief synopsis of what occurred; and
• Steps taken to ensure the safety of the member.