The Centers for Medicare & Medicaid Services and the state of Illinois have contracted with Blue Cross and Blue Shield of Illinois and other Managed Care Organizations to implement Medicaid to all counties in Illinois. For Medicaid-eligible members, BCBSIL offers Blue Cross Community Health PlansSM . BCBSIL offers two plans:
Our Medicaid network includes independently contracted providers (physicians, hospitals, skilled nursing facilities, ancillary providers, managed long-term services and support, and other health care providers) through which eligible members may obtain covered services.
BCCHPSM is a program developed and administered by BCBSIL to support delivery of integrated and quality managed care services to Medicaid enrollees. Enrollees qualify for the Illinois Department of Healthcare and Family Services Medical Program under the Affordable Care Act and include:
MMAI is a plan developed to better serve individuals eligible for both Medicare and Medicaid. MMAI combines Medicare and Medicaid funding under a blended payment agreement to provide integrated, comprehensive care to benefit dual-eligible enrollees.
For more information, including network code, three-character prefix, member criteria, network summary and geographic area, see Government Programs Networks and Benefit Products.
To join our Medicaid network, follow the process for contracting.
The state of Illinois is responsible for credentialing and recredentialing of physicians and certain other providers who participate in Medicaid plans.
To be eligible to participate, providers must be enrolled and credentialed through the Illinois Medicaid Program Advanced Cloud Technology system. For more information, visit the IMPACT website. Providers with general questions about IMPACT or provider enrollment may email IMPACT Help or call 877-782-5565 (select option 1).
Our Medicaid service authorization program focuses on utilization management of health care services to help ensure our members get the right care, at the right time, in the right setting.
Use our tools and resources noted below to determine coverage and find important information on our service authorization program for Medicaid members.
Program details:
Important reminders:
Three general steps providers should follow for prior authorization requests are listed below. Be sure to refer to the provider manual for more specific information.
Prior to rendering care and services, check eligibility and benefits using Availity Essentials or your preferred web vendor. In addition to verifying membership and coverage status, this step returns information on prior authorization requirements.
You can also refer to prior authorization support materials for current code lists or use our digital lookup tool. For more information, see our service authorization program summary.
If prior authorization is required, have the following details ready:
For some services for Medicaid members, prior authorization may be required through BCBSIL. For other services, BCBSIL has contracted with Carelon Medical Benefits Management for utilization management and related services for BCCHP, and Evicore healthcare for MMAI. Submit your request online or by phone as noted below.
Prior authorization requests handled by BCBSIL:
Prior authorization requests handled by Carelon for BCCHP:
Prior authorization requests handled by Evicore for MMAI:
Once a prior authorization request for a Medicaid member is received and processed, the decision is communicated to the provider. Review your determination letter for details and instructions. If you have questions on a request handled by Carelon, contact the vendor at 866-455-8415. If you have questions on a request handled by BCBSIL, contact our Medical Management department at 877-860-2837 (BCCHP) or 877-723-7702 (MMAI).
Pharmacy benefit reminder: Prime Therapeutics® conducts all reviews of prior authorization requests from physicians for our members with prescription drug coverage.
We may provide reimbursement for authorized inpatient stays extended beyond medical necessity, also known as administrative days, for some members with BCCHP. For details, refer to our process for requesting administrative days.
If the utilization management decision rendered by the medical director for BCBSIL is an adverse determination, providers have an additional 10 calendar days from the date on the notification of the adverse determination (denial letter) to schedule a peer-to-peer discussion and/or to submit an updated clinical packet for review. Refer to our service authorization program tip sheet for more information.
A member, a member’s representative, or provider acting on behalf of the member can request a standard appeal within 60 calendar days from the date of the Notice of Action letter. Refer to the Medicaid appeal process for details.
If you disagree with the decision made on an appeal, you can request an external review within 30 calendar days of the date on the decision notice. Learn more about the process for external independent review.
We’ve prepared tools and resources to help when you’re submitting claims for Medicaid members.
The fastest way to conduct business with BCBSIL is via electronic data interchange. See claim submission for an introduction to filing claims, including a list of documentation and coding resources, and links to claim filing tips.
Claims for BCCHP and MMAI must be submitted within 180 days of the date of service or discharge date.
After submitting a claim, you can check status online through Availity Essentials. You can confirm if your claim has been received, pended or finalized. You can also verify the descriptions for any claim denials.
Refer to the provider manual for detailed information.
Our Medicaid provider dispute process overview spotlights the following topics:
Refer to the dispute process overview for details.
Claims for subsequent hospital admissions that are determined to be readmissions may be denied unless exception criteria are met. For denial disputes, medical records for both hospitalizations are required. View our hospital 30-day readmission review process for details.
We collaborate with network providers to help improve the quality of clinical care and services for our members.
Our Medicaid Quality Improvement program uses data and other tools to measure quality across all aspects of care, including effectiveness, access, availability and utilization. View more information on quality resources, including measures, results and surveys for BCCHP and other members.
In accordance with the provider manual, providers must notify our Care Coordination team at least two business days prior to the disruption or discontinuance of a member’s services. This notification will allow the Care Coordination team to assess the situation and assist in the coordination of services for the affected members.
To notify the Care Coordination team, providers must fill out the Gaps in LTSS Services form and email or fax it as instructed on the form.
Your patients with BCCHP may earn cash rewards for certain medical services. See information about rewards that may apply to them.
Review important information on required training and where to go for help, if needed.
It's a Centers for Medicare & Medicaid Services and/or State state of Illinois requirement for Blue Cross and Blue Shield of Illinois to make available provider training on specified topics related to Blue Cross Community Health PlansSM and Blue Cross Community MMAI (Medicare-Medicaid Plan)SM. Completion of training is mandatory for all MMAI and BCCHP contracted providers.
Required Training Modules
The following training modules have been prepared for you by BCBSIL. Select a topic to complete each training module online.
Instructions: After exiting out of the module, a new window will appear, and a training completion certificate will generate automatically. Once generated, the certificate can be saved or printed. A copy of the certificate will also be sent to the email address provided on the Guestbook registration form. Please be advised, the generation of the certificate is not acceptable in lieu of attesting. The certificate is for your records only. To properly attest and notify us that the training has been completed, please utilize the electronic attestation linked below.
Completion of training is mandatory for all BCCHP and MMAI contracted providers and staff who interact with patients.
ADA Site Compliance Survey
Additionally, to determine compliance with the Americans with Disabilities Act, CMS accessibility and language requirements, professional providers are required to complete the BCBSIL survey for their primary office location annually and facility providers are required to complete the survey for each location annually.
*Alternative option for compliance training completion: You may complete the online attestation of training completion which certifies that your practice has completed the annual BCCHP and MMAI Medicaid compliance training from another government contracted Managed Care Organization. If you cannot complete the electronic attestation, you can download the Medicaid Attestation of Training form.
Refer to the provider manual for a listing of key contacts.
Related Resources:
Checking eligibility and/or benefit information and/or obtaining prior authorization is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage, including, but not limited to, exclusions and limitations applicable on the date services were rendered. If you have any questions, call the number on the member's ID card. Regardless of any prior authorization or benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.
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. Carelon Medical Benefits Management is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSIL. Prime Therapeutics LLC (Prime) is a pharmacy benefit management company. BCBSIL contracts with Prime to provide pharmacy benefit management and other related services. BCBSIL, as well as several independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. BCBSIL makes no endorsement, representations or warranties regarding third party vendors and the products or services they offer.
