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The manual is organized into the following sections for your convenience. Click on a section title to view the content.


The BCBSIL Commercial Provider Manual is organized into the following sections for providers participating in PPO, Blue Choice PPOSM, HMO and the Blue High Performance NetworkSM (Blue HPNSM) EPO. Click on a section title to view the content.


HMO Policy and Procedures

 

Policy Name Policy NumberReview Date
3rd Trimester Pregnancy IPA Transfer  Admin 37 12/1/2020
A Woman's Principal Healthcare  Admin 44 11/1/2020
Ancillary Hospital Institution Care Transition Exceptions  Admin 11 1/1/2021
Automatic Approval Process  Admin 53 12/1/2020
Complex Case Management  Admin 71 6/1/2021
Contract Management Firms Confidentiality Agreement  Admin 14 11/1/2020
Corrective Action for Failed Utilization Management Audit of Participating IPAs  Admin 33 11/1/2020
Collaborative Improvement Coaching for HMO Quality Improvement Projects QI 27 1/1/2021
Corrective Action for QI Site Visits of Participating Practitioners and IPAs  QI 4 12/1/2020
Emergency Room Services  UM 1 4/1/2021
HMO Administered Complaints Policy  Admin 39 6/1/2021
HMO Administered Complaints Procedure  Admin 39A 6/1/2021
HMO Financial Risk Claims  Admin 67 12/1/2020
IPA Availability and Accessibility Requirements for Immediate Care Services  Admin 83 2/1/2021
IPA Guidelines for Member Complaints, Inquiries, Appeals and Grievances Admin 22 4/1/2021
IPA Infertility Guidelines  Admin 56 3/1/2021
IPA Process for Establishing Out of Area for Emergency Services Admin 23 4/1/2021
IPAs Request for Member Transfer Policy  Admin 28 6/1/2021
IPAs Request for Member Transfer Procedure  Admin 28A 6/1/2021
Member Access to Behavioral Health Services  Admin 64 2/1/2021
Member Notification Process when a Provider Leaves the IPA  Admin 82 4/1/2021
Newborn Claim Responsibility  Admin 31 4/1/2021
Participating IPA or Practitioner Appeal Process of Failed Quality Improvement (QI) Site Visit Results  QI 2 12/1/2020
Past Due Claims Process  Admin 42 11/1/2020
Physician Access Standards  Admin 10 12/1/2020
Primary Care Physician (PCP) Affiliation with Multiple IPAs  Admin 2 11/1/2020
Retroactive IPA Member Changes Policy  Admin 32 5/1/2021
Retroactive IPA Member Changes Procedure  Admin 32A 5/1/2021
Transition of Medical Care  Med Support 1 4/1/2021
UM Fund Challenge  Admin 66 9/1/2020
Utilization Management and Case Management Adherence Audit of Participating IPAs  Admin 60 2/1/2021

 

Health Care Delivery Policy and Procedures 

 

Policy Name Policy NumberReview Date
Accountable Care Organization (ACO) Dual Claimed Physician Admin 84 4/1/2021
BCBSIL Marketing Communications HLA Policy Procedure MC 2 2/1/2021
Blue Cross Blue Shield of Illinois Quality of Complaints & Occurrences Process QI 30 4/1/2021
Case Management  Ref 9 3/1/2021
Investigations of Complaints Related to Provider Office Site Policy  QI 11 5/1/2021
Investigations of Complaints Related to Provider Office Site Procedure  QI 11A 5/1/2021
Member Clinical Appeal and External Independent Review - ASO Groups Not Voluntarily Complying with the Illinois External Review Act (Federal) UM 10 6/1/2021
Member Clinical Appeal and Independent External Review – Fully Insured & ACA Regulated ASO Groups Voluntarily Complying with the Illinois External Review Act (State)  UM 15 1/1/2021
Member Communication  RR 5 1/1/2021
Member Non-Clinical Appeals  UM 11 1/1/2021
Member Rights and Responsibilities  RR 1 9/1/2020
Oversight of Contracted Infertility Vendor  UM 3 6/1/2021
Professional Liability Insurance  Ref 5 12/1/2020
Provider Handling of Member Inquiries Complaints and Appeals  Ref 1 12/1/2020
Provider Manual  Admin 20 7/1/2020
Quality Site Visit Standards for Behavioral Health (BH) Providers Policy QI 6 5/1/2021
Quality Site Visit Standards for Behavioral Health (BH) Providers Procedure QI 6A 5/1/2021
Quality Site Visit Standards for High Volume/High Impact (HVIHI) Specialists  QI 14 11/1/2019
Quality Site Visit Standards for Primary Care Physicians (PCP) Policy  QI 1 5/1/2021
Quality Site Visit Standards for Primary Care Physicians (PCP) Procedure  QI 1A 5/1/2021
Recovery of Provider Overpayments due BCBSIL  Admin 3 8/1/2020
Reimbursement  Admin 8 5/1/2021

Compliance, Fraud, Waste and Abuse Program and Reporting:

 

HCSC and its subsidiaries are founded on the basic principles of good business behavior. Among these principles are a commitment to the highest standard of business ethics and integrity. This includes strict observance of and compliance with the laws and regulations governing the business operations of HCSC, and in particular, the services that it performs or has delegated to others to perform pursuant to its Medicare and Medicaid contract(s).

 

Any individuals who impact HCSC's Medicare or Medicaid contract(s) are expected to abide by the Medicare and Government Contracts Compliance Program, the Code of Business Ethics and Conduct and the Medicare Compliance Policies. These documents are located in http://www.hisccompliance.com.

 

Provided on the website you will find the following documents:

 

Vendor Code of Conduct

Medicare and Government Contracts Compliance Program

HCSC Compliance Program

HCSC Code of Conduct

Compliance Program Guidelines

Debarment Screening Process

Fraud, Waste, and Abuse Training