Blue cross community mmai

Listed below are those insurance payers and products with which Horizon Health has direct participation agreements In Network at our Illinois locations.

If you have questions about plans and in-network status, please contact Springfield Clinic's Patient Advocate Center at Medicare Supplement XOS. This can be identified by "BCO" on the front of the card, as well as information concerning Tiered Plans on the back of the card. Please verify network status with BCBS. Refer to the chart above to determine network status.

Blue cross community mmai

The screening results, along with claims data, are used to determine if there may be potential gaps in care, particularly for members with complex medical conditions. Care coordination is offered to help identified members understand and utilize their health care benefits. How can a care coordinator help a discharge planner? The care coordinator is able to pick up where the discharge planner leaves off by meeting the member in the community to support adherence to the discharge plan and related interventions. For example, the care coordinator may be able to determine how many other facilities a member has been admitted to, for what reasons, and what the discharge plan was. The care coordinator also may know what resources have been accessed for the member, what the member has been eligible to receive, and why the member may be ineligible for some services. The care coordination program is designed with the goal to assist health care providers and members in better coordinating care and improving health outcomes. The program is not a substitute for the independent medical judgment of a health care provider. Health care providers are instructed to use their own best medical judgment based upon all available information and the condition of the patient in determining a course of treatment. Regardless of any benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.

This helps the plan to organize and manage the prescription cost-sharing. All medication are divided into tiers within the plans formulary.

It will open in a new window. To return to our website, simply close the new window. Refer to important information for our linking policy. The resources on this page are intended to help you navigate prior authorization requirements for Blue Cross and Blue Shield of Illinois BCBSIL government programs members enrolled in any of the following plans:. Government Programs Prior Authorization Summary and Code Lists Refer to the Summary documents below for an overview of prior authorization requirements, reminders and helpful links. Procedure code lists are provided for reference purposes.

It will open in a new window. To return to our website, simply close the new window. Refer to important information for our linking policy. Learn more. As a new independently contracted Blue Cross and Blue Shield of Illinois BCBSIL Medicaid provider or a new employee of a provider's office , we encourage you to take advantage of the online information and other reference material available to you. A person centered practice involves primary health care that is relationship-based with a focus on the individual. Coordination by a health care team is critical to help ensure that each member receives all services as needed, according to their health benefit plan. To help ensure the health, safety and well-being of vulnerable individuals, it is important to report critical incidents of abuse, neglect and financial exploitation to the appropriate authorities.

Blue cross community mmai

The table below contains some of the services covered under your plan. Some of these services may require a prior authorization getting an approval from your plan. To learn more about prior authorizations, visit the Prior Authorization page. For a more in-depth list of covered services, limits, exclusions and services that require prior authorizations see your summary of benefits document.

The brick warehouse

If you still have questions, the best way to determine if your plan is in-network with Springfield Clinic providers is to reach out to your insurance carrier or the human resource department of your employer. Patients with questions on whether their plan allows this or not should reach out to BCBS in order to confirm. Some Medicare Part D plans offer coverage during the Coverage Gap that is beyond the mandated discounts. The BCBSIL Medical Policies are for informational purposes only and are not a substitute for the independent medical judgment of health care providers. This would depend on your Blue Cross benefits. All patients are encouraged to verify their benefits with their plan administrator. Home health services - Medicare-Medicaid plans. Pharmacy Benefit Prior Authorization Requirements — Prime Therapeutics, our pharmacy benefit manager, conducts all reviews of prior authorization requests from physicians for BCBSIL members with prescription drug coverage. To view this file, you may need to install a PDF reader program. Horizon Health Illinois locations have direct participation agreements with the following plans:. The above material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. It is best to contact your plan to verify coverage and contracted providers. Physicians and other health care providers are encouraged to use their own medical judgment based upon all available information and the conditions of the patient in determining the appropriate course of treatment. If the patient has a Blue Choice plan, however, the Continuity of Care will still be needed.

In addition to the above appointment timeframes, providers are contractually required to ensure that provider coverage is available for members 24 hours a day, seven days a week. In addition, providers must maintain a hour answering service and ensure that each primary care physician PCP provides a hour answering arrangement, including a hour on-call PCP arrangement for all members. We routinely monitor for compliance with the above standards.

To switch to a different Medicare Advantage plan or to change your location, click here. The following section will describe these benefits in detail. If you've seen your provider within the past three years, you're still an established or active patient. Home health services - Medicare-Medicaid plans. Out-of-network plans may have higher expense for the patient. If you're an established patient, you can use the patient portal to communicate with your provider. Have questions about billing and insurance? It will open in a new window. Health care providers are instructed to use their own best medical judgment based upon all available information and the condition of the patient in determining a course of treatment. Please contact your provider office via their new direct line phone numbers listed on their provider profile page or review the new direct dial location phone numbers on our website. If your plan is not listed, we may be out-of-network , resulting in a higher out-of-pocket expense for you as determined by your insurance carrier. The program is not a substitute for the independent medical judgment of a health care provider. Any services that were provided prior to Jan.