January 2023

What’s New

BlueApprovR^SM is here! Join Us for a Webinar To See What This New Online Prior Authorization Tool Can Do For You

In November 2022, we announced the launch of BlueApprovR – a new tool to expedite prior authorization approvals for some behavioral health services for many of our commercial, non-HMO members. We’ll soon be expanding this tool to handle additional types of prior authorization requests for these members. We’ve added more webinars in January and February 2023. Read more on News and Updates.

Focus on Behavioral Health

CMO Perspective Spotlights Illinois House Bill 2595

The Generally Accepted Standards of Behavioral Health Care Act of 2021 requires that insurers cover all medically necessary behavioral health care services as essential health care services, beginning Jan. 1, 2023. In a recent CMO Perspective blog post, Our vice president and chief medical officer, Derek Robinson, M.D., summarized key points related to IL HB 2595 that may be of interest to providers.

Expanding Access to Behavioral Health Care Services: Coverage for Services Provided by Pre-licensed Behavioral Health Interns and Postdoctoral Fellows

This is the first article in a series that’s committed to increasing awareness of ways we’re partnering with health care providers and other community organizations to expand access to behavioral health services for our members, their families and the community.

Provider Education

Provider Learning Opportunities

Blue Cross and Blue Shield of Illinois (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’ve Made Updates to the Policy and Procedure Information on Our Provider Website

The BCBSIL Provider Manuals for the following lines of business have been updated, effective Jan. 1, 2023: Blue Cross Community Health Plans^SM (BCCHP^SM), Blue Cross Community MMAI (Medicare-Medicaid Plan)^SM, Blue Cross Medicare Advantage (HMO)^SM, Blue Cross Medicare Advantage (PPO)^SM and Commercial PPO plans.

Claims and Coding

Fighting Fraud, Waste and Abuse Reminder: Inaccurate Identification of Rendering Providers May Lead to Improperly Paid Claims

BCBSIL is aware of several cases involving providers/groups filing claims under the rendering National Provider Identifier (NPI) of a physician or medical doctor; however, these services were actually performed by a mid-level provider, resulting in claims being inaccurately paid at inflated reimbursement rates. 

Electronic Options

Updates to ‘Message This Payer’ Option via Availity^® Essentials as of Dec. 12, 2022

In August 2022, we announced a new option for you to send secure claim messages electronically to BCBSIL for commercial member claims. To better serve you and ensure timely responses, BCBSIL is limiting the Message This Payer capability to BCBSIL member claims only.

Clinical Updates, Reminders and Resources

‘Predetermination’ Is Now ‘Recommended Clinical Review’

Effective Jan. 1, 2023, BCBSIL is changing the name of its long-standing pre-service review, previously called predetermination, to recommended clinical review. This type of pre-service review is available for commercial non-HMO members. 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?

Pharmacy Program

Pharmacy Prior Authorization (PA) Program Changes Effective February 2023

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.

Quality Improvement and Reporting

2023 Consumer Assessment of Healthcare Providers and Systems (CAHPS^®) Survey Reminder

Each year, we conduct a CAHPS survey to monitor BCCHP and MMAI member satisfaction with BCBSIL, contracted providers and medical groups. During the months of February and March, if your patients receive a survey, please encourage them to participate.

Wellness and Member Education

Wellness Can’t Wait: Cervical Cancer Is a Preventable Disease

January is Cervical Cancer Awareness Month. The American Cancer Society estimates about 14,000 new cases of invasive cervical cancer will be diagnosed this year and about 4,200 women will die from it.

Community Involvement

Jump Start Your New Year at Our Blue Door Neighborhood Center^SM (BDNC^SM)

Happy New Year! Our BCBSIL BDNC locations may help your patients stay healthy in 2023. All programming – in-person and virtual – at BDNC locations is free and open to BCBSIL members and non-members.

Network Innovation/Product Updates

Medicare Providers May Treat Medicare Advantage Flex and Group Medicare Advantage Open Access PPO Members

If you’re a Medicare provider, you may treat Blue Cross Group Medicare Advantage Open Access (PPO)^SM and Blue Cross Medicare Advantage Flex (PPO)^SM members.

Notification and Disclosure

Hospitals Must Provide Medicare Outpatient Observation Notice

Hospitals and Critical Access Hospitals (CAH) are required to give the standardized Medicare Outpatient Observation Notice (MOON) to our Blue Cross Medicare Advantage^SM members who are under outpatient observation for more than 24 hours. The notice explains why the members aren’t inpatients and what their coverage and cost-sharing obligations will be.

Patients in the Qualified Medicare Beneficiary Program Should Not Be Billed

If you participate in Blue Cross Medicare Advantage plans, you may not bill our members enrolled in the Qualified Medicare Beneficiary (QMB) program, a federal Medicare savings program.

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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