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Reminder: Utilization Management Reviews for Inpatient and Outpatient Services

Posted June 28, 2017

As a reminder, medical management at Blue Cross and Blue Shield of Illinois (BCBSIL) includes utilization management reviews across the continuum of care for both inpatient and outpatient services that are covered services under the member's health benefit plan.*  

The medical management team, which includes physicians and nurses, evaluate hospital admissions (anticipated or unanticipated) and continued stays as well as outpatient services. The team utilizes a variety of resources, including, but not limited to, MCGTM (formerly Milliman Care Guidelines) criteria and BCBSIL Medical Policy to inform benefit determinations regarding the level of care, transition of care and the management of home care needs.  

Medical management does not make determinations about whether services are medically appropriate, only if the services meet the definition of medically necessary under the terms of the applicable benefit plan. If a service does not meet the definition of medically necessary initially, the case is referred to a medical director for a review of the medical necessity determination. 

Board certified physicians are available to review referred cases, make medical necessity determinations, as defined in the member’s benefit plan, and resolve appeals. See the provider manual for guidance on provider requirements when requesting services. The final determination about what treatment or services should be received is between the patient and their health care provider. 

This information does not apply to HMO Illinois®, Blue Advantage HMOSM and Blue Precision HMOSM, BlueCare DirectSM and Blue FocusCareSM

MCG (formerly Milliman Care Guidelines) is a trademark of MCG Health, LLC (part of the Hearst Health network), an independent third party vendor. BCBSIL makes no endorsement, representations or warranties regarding any products or services offered by third party vendors such as MCG. If you have any questions about the products or services offered by such vendors, you should contact the vendor(s) directly. 

Medical management decisions are solely to determine if the medical services meet the definition of medical necessity as defined in the member’s benefit plan. Regardless of the benefit determination, the final decision about any medical treatment is between the patient and their health care provider. 

Blue Cross®, Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.