Blue Cross and Blue Shield of Illinois (BCBSIL) manages behavioral health services for all commercial, non-HMO members who have behavioral health benefits through our group or retail products. Similar behavioral health programs are implemented across product lines but may differ by product.
Behavioral health care management is integrated with our medical care management program, as part of Well Being Management (WBM), to help members access their behavioral health benefits and to improve coordination of care between medical and behavioral health providers. This program helps BCBSIL clinical staff identify members who could benefit from co-management earlier, and may result in:
- Improved outcomes
- Enhanced continuity of care
- Greater clinical efficiencies
- Reduced costs over time
Some members* may be referred to other WBM medical care management programs that are designed to help identify and help close potential gaps in care through evidence-based and member-focused approaches to health care and benefit decisions.
Behavioral health services for Federal Employee Program® (FEP®) members are managed by BCBSIL, but different processes may apply. Also watch for exceptions/different processes for government programs members (Medicare Advantage and Illinois Medicaid). For HMO members, all behavioral health services (mental health and substance use disorders) are managed by the member's Medical Group/Independent Practice Association (MG/IPA).
All behavioral health benefits are subject to the terms and conditions as listed in the member's benefit plan.
*Members experiencing inpatient hospitalization, complex or special health care needs or who are at risk for medical complications may be referred to WBM programs through a variety of mechanisms such as predictive modeling, claim utilization, inbound calls, self-referrals and physician referrals. If members do not have WBM as part of their group health plans, they will not be referred to other WBM programs.
Our program includes a portfolio of resources to help our members access benefits for behavioral health (mental health and substance abuse) conditions as part of an overall care management program. Learn more
Clinical Practice Guidelines
Clinical Practice Guidelines (CPGs) adopted by BCBSIL are the foundation for the Behavioral Health Care Management Programs. Updates to CPGs are reviewed and adopted at least every two years. Learn more
Utilization Management Program Overview
Our Behavioral Health team follows members as they step down from intensive inpatient, residential or partial hospitalization to less intensive levels of care (outpatient). Learn more
Medical Necessity Criteria
The BCBSIL Behavioral Health (BH) team uses nationally recognized, evidence-based and/or state or federally mandated clinical review criteria for all behavioral health clinical decisions. Learn more
Prior Authorization Requirements and Process
Members are responsible for requesting benefit preauthorization when it is required. Behavioral health providers or authorized family members may request benefit preauthorization on behalf of the member. Learn more
Behavioral Health providers have contractually agreed to offer appointments to our members according to specific appointment access standards. Learn more
Quality Improvement Program
Our Behavioral Health Quality Improvement (QI) department continually monitors and evaluates the Behavioral Health Care Management program for BCBSIL to identify enhancement opportunities. Learn more
Our Behavioral Health Care Management Program has been accredited for Health Utilization Management since October 2012. Learn more
Different guidelines and processes are in place for behavioral health care and services provided to our government programs members. Learn more
Questions? We’re here to help. Learn more