Moving the Needle: Closing Gaps to Improve Outcomes for Our Members

Quality measures, including Healthcare Effectiveness Data and Information Set^® measures from the National Committee for Quality Assurance, help our members receive appropriate care that supports their health and wellbeing. Here are some resources on measures where our members may need your help. 

Chronic Kidney Disease Management Strategies for Primary Care Providers

Blue Cross and Blue Shield of Illinois invites primary care providers to an online learning series on chronic kidney disease management strategies. The courses offer continuing medical education credit at no cost to you. 

Encourage Annual Eye Exams for Members with Diabetes

You may play an important role in supporting our members with diabetes by encouraging an annual retinal or dilated eye exam by an eye care specialist. 

BlueApprovR^SM Now Accepts Recommended Clinical Reviews for Behavioral Health

BCBSIL continues to streamline the pre-service review process to reduce your workload with BlueApprovR. This tool, accessible in Availity^® Essentials, now processes optional recommended clinical reviews for behavioral health services, in addition to medical and surgical services and pharmacy drugs for many of our commercial, non-HMO members.

Training Resources for Behavioral Health Care

Here are some training opportunities and resources that providers across disciplines may find helpful to support patients presenting with behavioral health concerns.

New ‘Plan Documents Viewer’ for NDC Fee Schedules via Availity Essentials

A new Plan Documents Viewer application is available via Availity Essentials for providers contracted with BCBSIL to view, download and/or save the National Drug Code Fee Schedules. Read more on News and Updates.

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?

New Email Address for Electronic Commerce Services

Please update your records with the new email address. For your convenience, inquiries sent to the previous Electronic Commerce Services email address will be forwarded to the new email address during this transition. Read more on News and Updates.

See Updates to Claim Editing Changes for Emergency Department Services

We’re enhancing our claims editing and review process with Cotiviti for emergency department evaluation and management services for some of our commercial members. Read more on News and Updates.

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.

BCCHP^SM and MMAI Provider Alert: Mandatory Annual Training Must Be Completed by Dec. 31, 2023

This reminder applies to all providers that are independently contracted with BCBSIL to provide care and services to the following government programs members: Blue Cross Community MMAI^SM and/or Blue Cross Community Health Plans^SM. 

BCCHP Instructions to Hospital Providers Regarding Recent HFS Notice: Hospital Inpatient Payment for Long-Acting Injectable Antipsychotic Drugs per Public Act 102-0043

BCBSIL is working on system updates to align with the Illinois Department of Healthcare and Family Services’ new billing guidance for add-on payments applicable to psychiatric inpatient claims for certain long-acting injectable antipsychotic drugs effective with dates of service beginning Jan.1, 2022.

Pharmacy Program Updates: Prior Authorization Changes Effective Dec. 1, 2023

The BCBSIL 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 approved labeling, scientific literature, and nationally recognized guidelines. Read more on News and Updates.

Pharmacy Program Updates: Quarterly Changes Effective Jan. 1, 2024 – 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 Jan. 1, 2024, are outlined here.

Help Close Gaps in Care for Group Medicare Advantage Members: Medical Records and Vendor Reminders

If we need medical records for Blue Cross Group Medicare Advantage^SM members, you will receive requests from BCBSIL or our vendor, Change Healthcare, as part of the Blue Cross and Blue Shield National Coordination of Care program. In addition, you may receive requests from EXL Health for select inpatient, diagnosis-related group claims for any out-of-area PPO members. Please respond quickly to our requests, including requests related to risk adjustment gaps and HEDIS^® measures.

Take Our 2023 Readership Survey

Our annual Blue Review survey will be open just a couple more weeks. It’s brief and easy to complete. There are several questions to help you rate your experience as a reader – what you like, and what we can do to improve. We value your experience and unique point of view. If you’ve already completed the survey, thank you! If not, now’s your chance: Take the 2023 survey now.

Working To Fight Health Care Fraud

Each year, our Fraud Hotline receives calls reporting possible health care fraud, waste and abuse. Our Special Investigations Department reviews every call to determine if there’s enough information to investigate suspected fraud.

Reminder: Hospital 30-day Readmission Review Process for BCCHP and MMAI Members

BCBSIL conducts readmission review of hospital services provided to our BCCHP and MMAI members.