This information applies to Blue Cross Community Health PlansSM members.
Term |
Definition |
| Administrative Days | Inpatient hospital days for members who no longer need acute care but are waiting for a bed in a lower level of care |
| Admission Notification | Notification required for non-emergent or urgent care inpatient services within one business day after a member is admitted |
| Adverse Benefit Determination | Denial or limited authorization of a service authorization request for coverage of a health care service. Includes determinations based on the type or level or service, requirements for medical necessity, appropriateness, setting or effectiveness of a covered benefit |
| Appeal of an Adverse Benefit Determination | Process by which a person challenges a decision made by a health insurance plan or benefit provider that denies, reduces or terminates coverage or payment for a healthcare service or benefit |
| ASAM | American Society of Addiction Medicine, the most widely used and comprehensive set of standards for placement, continued stay, transfer, or discharge of patients with addiction and co-occurring conditions |
| A secure portal providers can use this secure multi-payer vendor portal to check eligibility and benefits information prior to rendering care; this step also confirms authorization requirements and utilization management vendors, if applicable (www.Availity.com) | |
| Clinical Criteria | Specific set of signs, symptoms, laboratory tests and other medical observations used to determine whether a person has a particular disease or condition |
| Concurrent Review | Review that occurs while a patient is receiving care to assess the need for continued treatment |
| EOB/EOP | Explanation of Benefits/Explanation of Payment |
| EPSDT (Early and periodic screening, diagnostic and treatment) | Mandatory set of services and benefits for all individuals under age 21 who are enrolled in Medicaid |
| External Independent Review Entity | Organization or individual certified to conduct impartial reviews of adverse determinations made by health insurance carriers or managed care plans |
| Generally Accepted Standards of Care | Refers to the level and type of care that a reasonably competent healthcare professional, with similar training and experience, would provide under similar circumstances. These standards are widely recognized and practiced by medical professionals and are considered appropriate for treating specific conditions |
| IMPACT | Illinois Medicaid Program Advanced Cloud Technology system; all providers (contracted and non-contracted) are required to enroll in IMPACT to bill for services under the medical benefit |
| MCG (formerly Milliman Care Guidelines) | Nationally recognized evidence-based criteria used to evaluate care guidelines for patient-centered care decisions |
| Medical Necessity or Medically Necessary | Means a service addresses the specific needs of an enrollee for the purpose of screening, preventing, diagnosing, managing or treating an illness, injury, or condition or disorder that results in health impairment or disability or its symptoms and comorbidities; minimizing the progression of an illness, injury or condition or its symptoms or comorbidities; achieving age-appropriate growth and development; attaining, maintaining, or regaining functional capacity and in a manner that is all of the following: in accordance with generally accepted standards of care; clinically appropriate in terms of type, frequency, extent, site and duration; and not primarily for the economic benefit of the managed care organization or for the convenience of the enrollee or provider |
| Medical Policy | Refers to a set of guidelines, rules or coverage terms established by a healthcare organization or an insurance provider to govern medical care and reimbursement. These include outlining what medical services, procedures, and treatments are covered under a health insurance plan, and are used to determine whether a claim for a specific treatment is medically necessary and eligible for reimbursement |
| Peer-to-Peer Review or Peer Review | The provision of an additional 10 calendar days from the date on the notification of the adverse determination (denial letter) for the provider to schedule a peer-to-peer discussion and/or to submit an updated clinical packet for review |
| Prenotification | Process by which BCBSIL is typically alerted before a member undergoes a course of treatment such as a hospital admission or a complex diagnostic test |
| Prior Authorization | Means the process by which health insurance issuers or their contracted utilization review organizations determine the medical necessity and medical appropriateness of otherwise covered health care services before the rendering of such health care services. Includes any health insurance issuers or its contracted utilization review organization's requirement that an enrollee, health care professional, or health care provider notify the health insurance issuer or its contracted utilization review organization before, at the time of, or concurrent to providing a health care service |
| Prior Authorization Change Log | Refers to document tracking MCO changes to prior authorization requirements including the date of the change and rationale for the change |
| Quality Review | A systematic evaluation of a process or service to ensure it meets defined standards and expectations and is used to maintain and improve performance |
| Retrospective Review | Review and authorization determination after services have been delivered |
| Routine or Standard Decision Timeline | Decision will be completed no later than 5 calendar days from receipt of request with notification of decision within 5 calendar days of making the decision |
| Service Authorization Determination | Means a decision made by a service authorization program in advance of, concurrent to, or after the provision of a health care service to approve, change the level of care, partially deny, deny, or otherwise limit coverage and reimbursement for a health care service upon review of a service authorization request |
| Service Authorization Program | Means any utilization review, utilization management, peer review, quality review, or other medical management activity conducted by an MCO including but not limited to, prior authorization, prior approval, pre-certification, concurrent review, retrospective review, or certification of admission, of health care services provided in an inpatient or outpatient hospital setting. Unless otherwise specifically stated in this section, inpatient hospital setting means as defined in 89 Ill. Adm. Code 148.25 (b)(1). Outpatient hospital setting means as defined in 89 Ill. Adm. Code 148.25 (b)(2) |
| Service Authorization Request | Means a request submitted by a provider to a service authorization program for a service authorization determination |
| Urgent or Expedited Decision Timeline | For situations that without prompt attention, could lead to a life-threatening condition, serious impairment of bodily function, worsening of organ dysfunction, severe pain, or inability to regain maximum function, decisions will be completed within 48 hours of receipt of request with written notification within 24 hours of the decision |
Checking eligibility and benefits and/or obtaining prior authorization is not a guarantee of payment of benefits. Payment of benefits is subject to several factors, including, but not limited to, eligibility at the time of service, payment of premiums/contributions, amounts allowable for services, supporting medical documentation, and other terms, conditions, limitations, and exclusions set forth in the member’s policy certificate and/or benefits booklet and or summary plan description. Regardless of any prior authorization or benefit determination, the final decision regarding any treatment or service is between the patient and their 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.
The ASAM Criteria®, ©2024 American Society of Addiction Medicine. All rights reserved.
MCG Care Guidelines are administered and provided by MCG Health, an independent company that has contracted with BCBSIL to provide care and disease management for members with coverage through BCBSIL.
BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors.