TABLE OF CONTENTS. Medical Management. BCBSIL Provider Manual Rev 10/13 1

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1 TABLE OF CONTENTS Medical Management... 2 Benefit Pre-certification... 2 Benefit Pre-certification for Inpatient and Ancillary Medical Services... 2 Benefit Pre-certification for Outpatient Medical/Surgical Services... 2 Time Frames... 2 Responsibility for Benefit Pre-certification... 3 How to Obtain Benefit Pre-certification... 3 Specific Member Benefit Plan Information... 3 HMO Members... 3 Behavioral Health (Mental Health and Substance Abuse)... 3 Care Management... 3 Benefit Preauthorization Requirements for Behavioral Health Services... 4 Services That Require Benefit Preauthorization... 4 The Process and Associated Steps to Benefit Preauthorization... 5 Resources... 6 Utilization Management (UM)... 6 Utilization Management Criteria... 6 Utilization Management Accessibility... 6 Utilization Management Affirmation Statement... 6 Condition Management or Chronic Care Programs... 7 Case Management (CM)... 7 A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association BCBSIL Provider Manual Rev 10/13 1

2 Medical Management Blue Cross and Blue Shield of Illinois (BCBSIL) operates the Medical Management Department to help ensure our members have access to affordable, quality health care. Our programs are designed to promote the optimal use of health care resources to improve health care outcomes. We believe the efficient and effective use of health care service results in quality health care outcomes. We use various resources, including Milliman Care Guidelines, which are evidence and consensus based guidelines to support effective care and efficient resource utilization. BCBSIL meets the Blue Cross Association Consortium, National Committee for Quality Assurance (NCQA) and Utilization Review Accreditation Commission (URAC) standards. Medical Management does not make determinations about whether services are medically appropriate, only if benefits are available. The final determination about what treatment or services should be received is between the patient and their health care provider. Benefit Pre-certification Pre-certification also called benefit pre-authorization or pre-notification is the process of determining whether the proposed treatment or service meets the definition of medically necessary as set forth in the member s benefit plan by contacting BCBSIL or the appropriate pre-certification vendor for approval of services. Verification of benefits and /or approval of services after pre-certification are not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation and other terms, conditions, limitations and exclusions set forth in the member s policy certificate and/or benefits booklet and/or summary plan description as well as any preexisting conditions waiting period, if any, at the time services are rendered Benefit Pre-certification for Inpatient and Ancillary Medical Services Most PPO member benefit plans require that benefit pre-certification is requested from BCBSIL or the precertification vendor for the following services: Inpatient hospital admission and rehabilitation Inpatient Skilled Nursing Facility (SNF) admission Long-term acute care Coordinated home health care Inpatient hospice (for some groups) Many groups also require benefit pre-certification for private duty nursing visits, IV medication and certain outpatient services. When eligibility and benefits are verified, providers will be able to determine if an employer group requires benefit pre-certification for outpatient services. Benefit Pre-certification for Outpatient Medical/Surgical Services It is important to note that some employer benefit plans may require benefit pre-certification for outpatient services. When eligibility and benefits are verified, providers will be able to determine if an employer group requires benefit pre-certification for outpatient services. Time Frames Elective or non-emergency admissions have to be pre-certified prior to admission or within two business days of an emergency or maternity admission. Specific timeframes for pre-certification may vary according to employer requirements. When eligibility and benefits are verified, providers will be able to determine the specific timeframes an employer group may require for pre-certification. BCBSIL Provider Manual Rev 10/13 2

3 Responsibility for Benefit Pre-certification In accordance with the PPO member s benefit plan document with BCBSIL, the member is responsible for requesting benefit pre-certification of services. Professional providers may request authorization on behalf of a member. In accordance with the PPO Provider s Hospital contract with BCBSIL, the PPO Facility Provider has agreed to participate in a Utilization Review Program that includes pre-certification by the PPO Facility for inpatient admission and certain outpatient procedures. The member is required to be held harmless if the PPO Facility Provider fails to pre-certify an inpatient admission and certain outpatient services; penalties may apply to the contracting PPO Facility Provider. BlueCard (out-of-area) members are responsible for pre-certification and must call their Home plan. How to Obtain Benefit Pre-certification Electronic Requests Providers registered with Availity or RealMed may submit pre-certification and preauthorization requests and inquiries online (ANSI 278 transaction). Telephone Inquiries Call the benefit pre-certification number on the back of the member s ID card. If the member s ID card is not available, providers may call the Customer Care Call Center (CCCC) at or Provider Telecommunications Center (PTC) at Upon verification of eligibility and benefits, you will be advised how to proceed. Online Approvals Sign-in to iexchange, our automated preauthorization tool that supports direct submissions and provides online approval, benefits for inpatient admissions and select outpatient services. Visit the Claims and Eligibility/Prior Authorization section of our website to learn more about iexchange. Specific Member Benefit Plan Information Information related to specific member benefit plans such as, time frames, benefit pre-certification requirements for outpatient procedures, penalties for lack of pre-certification and pre-certification phone numbers, is available using the following options: Phone number located on the back of the member s ID card Availity NDAS Online (ecare Online) RealMed Provider Telecommunications Center (PTC) HMO Members BCBSIL has delegated medical management and pre-certification for the HMO benefit products (HMO Illinois and BlueAdvantage SM HMO) to the Medical Group and Independent Practice Associations (MG/IPAs). Services provided to HMO members must have prior MG/IPA approval in order to be eligible for benefits. Refer to the HMO sections in the Provider Manual on our website for additional information. Behavioral Health (Mental Health and Substance Abuse) BCBSIL manages benefits for behavioral health care services for the following products: PPO BlueChoice Select Exception: Some employer groups are managed by other behavioral health vendors. Care Management The BCBSIL Behavioral Health Program encompasses a portfolio of resources that help BCBSIL members access benefits for behavioral health (mental health and substance abuse) conditions as part of an overall care management program. BCBSIL has integrated behavioral health care management with our member Blue Care BCBSIL Provider Manual Rev 10/13 3

4 Connection (BCC) medical care management program with the goal to provide better care management services across the health care continuum. It also allows our staff to assist in the early identification of members who could benefit from co-management of behavioral health and medical conditions. The staff is available to respond to member calls 24 hours a day, 7 days a week. Benefit Preauthorization Requirements for Behavioral Health Services Benefit preauthorization is the process of determining whether the proposed treatment or service meets the definition of medically necessary as set forth in the member s benefit plan by contacting BCBSIL or the appropriate behavioral health vendor for approval of services. Verification of benefits and/or approval of services after preauthorization are not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation and other terms, conditions, limitations and exclusions set forth in the member s policy certificate and/or benefits booklet and/or summary plan description as well as any preexisting conditions waiting period, if any at the time services are rendered Services That Require Benefit Preauthorization Inpatient Elective, non-emergency or partial hospital admissions must be preauthorized at least one day prior to admission or within two business days of an emergency admission. Note: In emergencies, the physician or other professional provider must first ensure that the member is safe. Benefit preauthorization will then occur prior to or concurrent with, but not more than two business days following the admission. A life-threatening emergency or crisis is a condition that requires immediate interaction to prevent death or serious harm to the member or others. It is characterized by sudden onset, rapid deterioration of cognition, judgment, behavior and is time limited in intensity and duration. Although BCBSIL self-insured employer groups generally exclude admissions into a Residential Treatment Center (RTC), there are some employer groups that have elected to cover this service. All Illinois fully insured plans cover licensed Residential Treatment Centers for the treatment of substance use disorders. To determine eligibility and benefit coverage prior to service and determine if RTC is covered, members or behavioral health professionals and physicians may call the Behavioral Health number that is listed on the back of the member s ID card. Outpatient The five covered behavioral health services listed below require benefit preauthorization before initiation of service. To preauthorize these services, call the number on the back of the member s ID card or (800) Outpatient electroconvulsive therapy (ECT)* 2. Intensive outpatient programs (IOP)* 3. Partial hospital admissions (PHP) - Non-emergency care must be preauthorized at least one day prior to admission or within two business days of an emergency admission. 4. Psychological testing* 5. Neuropsychological testing* *For indicated services, benefit preauthorization requires completion of the appropriate form located in the Education and Reference Center/Forms section. Follow instructions on the form regarding where to fax your information. Note: This does not apply to Federal Employee Program (FEP) members. For FEP members, prior benefit authorization is not required before receiving outpatient professional or outpatient facility care for behavioral health services. BCBSIL Provider Manual Rev 10/13 4

5 The Process and Associated Steps to Benefit Preauthorization Behavioral health professionals and physicians should always verify eligibility and benefits prior to providing services: Online: Electronically submit an eligibility inquiry (HIPAA 270 transaction) to BCBSIL through your preferred vendor portal, or Telephone: Call the number that is listed on the back of the member's ID card. Inpatient Members are responsible for requesting benefit preauthorization for inpatient services. Behavioral health professionals and physicians may request benefit preauthorization on behalf of the member. Call the appropriate number on the back of the member s ID card. All services must be medically necessary. Failure to Preauthorize Benefits: Members who do not request benefit preauthorization for inpatient behavioral health treatment or services may experience the same benefit reductions that apply for inpatient medical services. Claims for services that do not meet the criteria for medical necessity in the member s benefit plan will not be reimbursed Outpatient When benefit preauthorization is required for outpatient services, the member should call the Pre-auth MH/SA number listed on the back of their ID card. Behavioral health professionals and physicians, or the member s family, acting on behalf of the member, may also place the call. This number will direct the preauthorization call to BCBSIL or to the appropriate behavioral health vendor. Failure to preauthorize benefits: If a member receives outpatient behavioral health services that require preauthorization without requesting preauthorization, the behavioral health professional or physician will be asked to submit clinical information for a medical necessity review. The member will also receive notification. Medically unnecessary claims will not be reimbursed. All behavioral health professionals and physicians, both BCBSIL in-network and out-of-network, must submit clinical information/forms, as requested, to: Fax: Mail: Blue Cross and Blue Shield of Illinois Behavioral Health Unit P.O. Box Dallas, TX Behavioral Health Condition and Case Management Programs are available to most BCBSIL members. The Condition Management program provides an, integrated approach to the coordination of care for members with chronic mental health/substance use disease. Conditions are managed for lower severity issues and require less intensive level of intervention than Case Management. Interventions are provider and member focused. The program includes the following targeted diagnoses: Depression Alcohol/Substance Abuse Disorders Anxiety/Panic Disorders Bipolar Disorder Eating Disorders Schizophrenia and other Psychotic Disorders ADD and ADHD BCBSIL Provider Manual Rev 10/13 5

6 The Case Management Program is designed to help address the needs of members with complex behavioral health diagnoses based on the severity of the member s condition and the intervention intensity that is required. There two levels: Standard Case Management and Intensive Case Management. If you would like to refer a member to one of these programs or have any questions, please call and ask to be transferred to Case Management. Resources Additional information on our Behavioral Health Care Management Program can be found in the Clinical Resources section of our website. There you can view Related Resources such as Clinical Practice Guidelines for common behavioral health conditions, a description of the Medical Necessity criteria, links to forms and other resources. The health condition and case management programs are not a substitute for the sound medical judgment of a member s doctor. The final decision regarding any treatment or services is between the patient and their health care provider. Utilization Management (UM) Based in part on industry and national standard of care guidelines, the UM program helps identified members receive benefits for the appropriate level of care in the most cost-effective setting, through short-term discharge planning, facilitating transitions between levels of care or pre-admission and post-discharge calls. For additional information, you may refer to the Health Care Management Utilization Management Policy and Procedure and the Health Care Management Reference Policy and Procedure on Utilization Management Non-Certifications located in the Policy section. Utilization Management Criteria Utilization Management review criteria is available to BCBSIL contracted physicians or other professional providers upon request. To receive guidelines on a specific condition, please contact the Utilization Management Department. Utilization Management Accessibility Utilization Management: Available Hours: 8 a.m. to 5 p.m. (CT), Monday through Friday Precertification Requests: 7 a.m. to 5:30 p.m. (CT), Monday through Friday Outside of regular business hours, calls are received through a contracted answering service. BCBSIL provides Telecommunication Device for Deaf (TDD)/Text Telephone (TTY) services and language assistance for incoming callers. Toll-free and collect calls are accepted throughout Illinois and all states within the Continental U.S., as well as Alaska and Hawaii. An Automated Call Directing (ACD) system allows callers using touch-tone phones to self-direct to the appropriate area. Medical Management personnel will refer the caller or transfer the call to other appropriate departments as needed. Outbound calls to members and/or their authorized representative, providers and vendors will be made during normal business hours. Service calls and messages are often responded to immediately during working hours, but no later than within one business day after receipt of a message. Utilization Management Affirmation Statement BCBSIL distributes an affirmation statement to all staff and practitioners involved in UM decision-making, affirming that: UM decisions are based on medical necessity, as defined in the member s benefit plan, which takes into consideration appropriateness of care and services, and the existence of available benefits. The organization does not specifically reward health plan staff, providers or other individuals for issuing denials of coverage, care or service. Incentive programs are not utilized to encourage decisions that result in underutilization. BCBSIL Provider Manual Rev 10/13 6

7 Condition Management or Chronic Care Programs BCBSIL has designed programs to assist members with knowledge and treatment of their clinical condition. Our goal is to further enhance the physician/patient relationship by providing members with information to help them take charge of their health status and understand the treatment plan from their physician. The focus is to help close the clinical gaps in care that members may experience and to guide members toward adopting healthier behavioral habits. These programs change from time to time and are not included in all benefit plans. Referrals may originate from Utilization Management, Case Management, Lifestyle Management, employer requests, selfreferral, providers, Health Risk Assessment (HRA) completions or biometric screening. Outreach is provided electronically, telephonically and by mail. The Top Five Condition Management Programs currently available for PPO members are as follows: Coronary Artery Disease Congestive Heart Failure Chronic Obstructive Pulmonary Disease Asthma Diabetes Other programs may be available based on member benefit plan agreements. If you have any questions or concerns, contact the Condition Management Department at For HMO members, providers may call the Quality Improvement (QI) Department at for more information about Disease Management Programs. HMO Disease Management Programs currently available include: Cardiovascular Disease Asthma Diabetes Hypertension You may also contact the QI Department if you believe BCBSIL can assist you with a patient who has a chronic or complex condition. The health condition management programs are not a substitute for the sound medical judgment of a member s doctor. The final decision regarding any treatment or services is between the patient and their health care provider. Case Management (CM) CM services are available for many PPO and BlueChoice Select members. The services of CM help to facilitate benefits for clinically appropriate care. This results in optimized outcomes through cost-effective services to members with chronic, complex or catastrophic disorders requiring coordination of care across multiple provider disciplines and settings. CM referrals may originate from a member, physician, employer, hospital discharge planner, Integrative Predictive Modeling, Condition Management/Wellness, Utilization Management, an account executive, private duty nurse or other provider of services. For additional information providers may contact a BCBSIL Case Manager by calling You may also refer to the Case Management policy in the Health Care Management Reference Policy and Procedure section on our Provider website. BCBSIL Provider Manual Rev 10/13 7

8 Availity is a registered trademark of Availity, LLC. Availity is a partially owned subsidiary of Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC), an independent licensee of the Blue Cross and Blue Shield Association. Availity operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL, a Division of HCSC. Availity is solely responsible for the products and services it provides. ecare is the registered trademark of Nebo Systems, a division of Passport Health Communications, Inc. (Passport/Nebo Systems offers the NDAS Online product to independently contracted BCBSIL providers). RealMed is a registered trademark of RealMed Corporation, an Availity Company. Passport/Nebo Systems and RealMed Corporation are independent third party vendors and are solely responsible for their products and services. BCBSIL makes no representations or warranties regarding any of these vendors. If you have any questions or concerns about the products or services they offer, you should contact the vendor(s) directly. BCBSIL Provider Manual Rev 10/13 8