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BCBS National Coordination of CareSM Program to Serve Group Medicare Advantage PPO Members

Posted January 30, 2020

On Jan. 1, 2020, Blue Cross and Blue Shield of Illinois (BCBSIL) began participating in a new Blue Cross and Blue Shield Association (BCBSA) National Coordination of Care program to help improve care and services for Blue Cross Group Medicare Advantage (PPO)SM (Group MA PPO) members nationwide. This program may help streamline administrative processes for providers.

As announced in our November 2019 Blue Review, Blue Cross Group Medicare Advantage (PPO) is the new name of Blue Cross Medicare Advantage (PPO)SM for BCBSIL members who purchase Group MA PPO coverage through their employers or other groups. While the name has changed, the program retains its traditional PPO network that allows members to seek care in-network and out-of-network, typically providing cost savings for in-network care.

Through the BCBS National Coordination of Care program, BCBSIL will collaborate with you to identify gaps in care and retrieve medical records for claims you submit to BCBSIL for Group MA PPO members living in Illinois. This includes BCBSIL members with Group MA PPO coverage, as well as Group MA PPO members enrolled in other Blue Cross and Blue Shield (BCBS) plans who are living in Illinois.

You will receive requests only from BCBSIL or our vendor when medical records are needed, or when potential gaps in care or risk adjustment gaps are identified related to claims submitted to BCBSIL for these members. You will no longer receive these requests from multiple BCBS plans or their vendors.

This program is part of our ongoing initiative to support our members in receiving the right care at the right time and place. As a result of concerns about gaps in care, this program may help encourage members to come into your practice more frequently, allowing for greater continuity of care. For out-of-area members with Group MA PPO coverage, this program will help BCBSIL give these members’ BCBS plans a fuller understanding of their members’ health status.

Questions? Call the Customer Service number on the member’s ID card.

Important Reminders

  • As outlined in your contract with us, you are required to respond to medical record retrieval requests in support of risk adjustment, Healthcare Effectiveness Data and Information Set (HEDIS®) and other government-required activities within the requested timeframe. This includes requests related to this program. 
  • It is important that you use the Availity® Provider Portal or your preferred vendor to check eligibility and benefits for all BCBSIL patients, including Group MA PPO members, before every scheduled appointment. Eligibility and benefit quotes include membership confirmation, coverage status and applicable copayment, coinsurance and deductible amounts. The benefit quote may also include information on applicable benefit prior authorization requirements. Ask to see the member’s BCBSIL ID card and a driver’s license or other photo ID to help guard against medical identity theft. See our Eligibility and Benefits page for more details.
  • Patient-authorized information releases are not required in order for you to fulfill medical records requests and/or risk adjustment gaps received through this care coordination program.

HEDIS is a registered trademark of NCQA.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity. If you have any questions about the products or services provided by the vendor, you should contact the vendor directly.