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Blue Cross CommunityHealth PlansSM (BCCHPSM)and Blue CrossCommunity MMAI(Medicare-Medicaid)SMProvider OrientationBlue Cross and Blue Shield of Illinois (BCBSIL)Revised June 2021
What You Will Learn Service Delivery Models Claims/Payment Member Criteria Claim Submission Enrollment Process Claim Status Inquiry Care Coordination Eligibility Benefits Claim Dispute Rejected & Denied Claims Third Party Vendors EFT/ERA Dental Credentialing/Roster Updates Vision Required Provider Training Transportation Member Appeals/Grievances Pharmacy Reporting Critical Incidents Benefit Preauthorization Additional Resources Provider Network Consultant Surveys QuestionsConfidential and Proprietary.2
Service Delivery ModelsConfidential and Proprietary.3
Highlights: BCCHP/MMAIThe Blue Cross Community Health Plans (BCCHP) refers to the delivery ofintegrated and quality managed care. This program is designed to help improvemember health through care coordination while preventing unnecessary healthcare costs. Seniors and Adults with disabilities who are Medicaid eligible but not eligiblefor Medicare Non-Disabled Children and Adults (NDCA) ACA ExpansionAdults Children with Disabilities Managed Long Term Services and Support (MLTSS)The Medicare-Medicaid Alignment Initiative (MMAI) is a demonstration plan of theIllinois Department of Healthcare and Family Services (HFS) and the Centers forMedicare & Medicaid Services (CMS) designed to improve health care forseniors and persons with disabilities.Medicare-Medicaid Plan provided by Blue Cross and Blue Shield of Illinois, a Div ision of Health Care Serv ice Corporation, a Mutual Legal Reserve Company (HCSC), anindependent licensee of the Blue Cross and Blue Shield Association. HCSC is a health plan that contracts w ith both Medicare and Illinois Medicaid to prov ide benefits ofboth programs to enrollees. Enrollment in HCSC’s plan depends on contract renew al.Confidential and Proprietary.4
Blue Cross Community Health Plans (BCCHP)Blue Cross Community MMAI (Medicare-Medicaid Plan)These service delivery models were developed to help provide: Better care coordination Improved preventive care Enhanced quality of care Integration of physical and behavioral health Rebalancing from institutional to community care Education and self-sufficiency Community support for member ongoing needs Manage costs without compromising quality or access to careThe Blue Cross and Blue Shield of Illinois (BCBSIL) Medicaid productalso known as Blue Cross Community Health Plans (BCCHP) isavailable throughout the state of Illinois, servicing 102 counties.Effective 7/1/2021, the BCBSIL Medicare-Medicaid product alsoknown as Medicare- Medicaid Alignment Initiative (MMAI) isavailable in the following istianClarkClayClintonColesCookCumberlandDe uoisJacksonJeffersonConfidential and Proprietary.JohnsonKaneKankakeeKendallKnoxLa nWarrenWashingtonWayneWhiteWill5
Member CriteriaConfidential and Proprietary.6
Blue Cross Community Health PlansMember Criteria Medicaid eligibleSeniors and adults (19 years of age) with disabilitiesParents / guardians living with and caring for children(age 19 or younger), mothers and babiesACA expansion: low income members, ages 19-64MLTSS members who elected to opt out of MMAIIncludes Medicaid waiver membersThe additional waiver coverage is broken down into fiveHome Community Based Service categories: Persons with Disabilities Persons with Brain Injuries Persons with HIV/AIDS Persons who are Elderly Supportive Living FacilitiesConfidential and Proprietary.7
Medicare-Medicaid Alignment (MMAI)Member Criteria Age 21 or older Entitled to Medicare Part A Enrolled in Medicare Part B and Part D Enrolled in Medicaid Aid to the Aged, Blindand Disabled (ABD) Living in the community or nursing facility Includes Medicaid waiver membersConfidential and Proprietary.8
Waiver ServiceEligibility for Waiver Services: Medicaid Waivers are determined by one of two state agencies: Illinois Department of Aging(IDoA) or the Department of Rehabilitation Services (DRS). Determination of Needs (DON) Once a member becomes eligible, a DON score is assigned to determine level of need. Themember will then be enrolled in the waiver program.Confidential and Proprietary.9
Home and Community Based ServiceWaiver Service SummaryConfidential and Proprietary.10
Enrollment ProcessConfidential and Proprietary.11
Enrollment for MedicaidThe State of Illinois –Client Enrollment Services (ICES)Processes all enrollments and disenrollmentsEnsures unbiased education and information about health plansAssists members in the enrollment processenrollhfs.illinois.gov877-912-8880Monday – Friday 8 a.m. – 7 p.m., Saturday 9 a.m. – 3 p.m.Free interpretation servicesBest advice: For enrollment information, encourage your patients to contact ICES as soon as possible. If they cannotmake this call, a family member or friend can call on their behalf. See the ICES website for more information on howthis can be done.Confidential and Proprietary.12
Enrollment Process - BCCHPNew Members:Existing Members: Enrollment in a Managed CareOrganization (MCO) is mandatoryexcept for those that are part of theexcluded population. New members will have a 30 dayenrollment period to select a MCO All members who do not select an MCOwill be automatically assigned one. After the initial Enrollment Period, once every12 months thereafter, each member shall havea 60 day period in which to change MCOs. Members will have a 90 day changeperiod after their effective date to selectanother MCO. Members will only be able to changeMCO’s once during the 90 day period.Confidential and Proprietary. No later than 64 days prior to each Enrollee’sAnniversary Date, ICES shall send notice tothe member of their opportunity to changeMCOs and the 60 day deadline for doing so. If the member selects a different MCO duringthe Open Enrollment Period, enrollment in thenew MCO will be effective on the member’sanniversary date. Members who make no selection will continueto be enrolled with the same MCO. Enrolleesmay not change MCOs at any time other thanthe Open Enrollment Period.13
Enrollment Process - MMAINew Members: Enrollment is voluntary for a90 day period. Newmembers can select theMCO they wish to enroll induring this period. All members who do notselect a MCO will beautomatically assigned one.Confidential and Proprietary.Existing Members: Members can switch MCO plans or optout of MMAI at any time on a monthlybasis by contacting ICES. If the choice to enroll is made by the 12thof the month, enrollment will be effectivethe first of the following month.Enrollment requests received after the12th of the month will be effective the firstof the second month following therequest. Members with Long Term Services andSupports (LTSS) Medicaid Waivers maychoose to opt-out from the Medicare sideof MMAI. However, for the Medicaid sideof MMAI, waiver members are requiredto remain enrolled with a MCO tocontinue receiving waiver services.14
Primary Care Physician (PCP) Changes /PCP Panel Report Members may choose their PCP during the enrollment process. If they do not choose a PCP, aPCP will be auto assigned to the member to coordinate their care. BCCHP members may change their PCP at any time. In order for the member to change their PCP, the member mustcontact our customer service number at 877-860-2837. PCP changes are effective within 30 days of the members request to change PCPs. There is no limit to the number of times a member may change their PCP. A new member ID card will be issued with the new PCP’s name and contact details on it. A member can see their newly assigned PCP prior to receiving their new ID card. PCP assignment does not impact claim payment, however it will impact Quality and HealthcareEffectiveness Data and Information Set (HEDIS ) rates. PCPs may obtain their PCP Panel Report through Altruista Health’s GuidingCare portal orrequest it from their PNC.HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).Confidential and Proprietary.15
Care CoordinationConfidential and Proprietary.16
Program Foundations: PhilosophyPersonCenteredHealth System Navigation Com m unication Collaboration Alignm entHealth Care Delivery Connected Unified Multidim sInclusive/Multidisciplinary Mem ber Fam ily/Authorizedrepresentatives Providers Caregivers Com m unity resourcesConfidential and Proprietary.Considers Individual Preferences Cultural needs Linguistic needs Potential to self direct careTeam BasedCom prehensive in Scope Cognitive needs Psychosocial and Behavioralneeds Physical needs FunctionalRight To Be treated w ith respect and dignity Privacy Be offered treatmentoptions/alternatives Participate in health care decisions Refuse treatment Be free from restraint/seclusion Have access to m edical records; m ayam end/correct Receive inform ation in an easilyunderstood format17
Care Coordination Members will be assigned a Care Coordinator who leads an Interdisciplinary Care Team and coordinates carebetween all providers and services. A risk assessment (health screening) will be completed for each BCCHP and MMAI member within 60 days ofenrollment. If you are treating a member who has not completed a Health Risk Screening (HRS) please encourage themto do so by calling 855-334-4780. Please note that translation services are available for those who call tocomplete the HRS. Members will be assigned a risk level (i.e., low, moderate, high) based on results from theHRS. The intensity of care coordination involvement is as follows: Low risk: prevention and wellness messaging and condition-specific education materials along withmonthly surveillance monitoring using claims data; support is primarily telephonic. Moderate risk: members are provided with problem solving interventions, and monthly surveillancemonitoring using claims data. Support is both telephonic andface-to-face. High risk: intensive care management for reasons such as addressing acute and chronic health needs,behavioral health needs, or addressing lack of social support. Members are contacted every 90 days;support is both telephonic and face-to-face. All Special Needs Children are categorized as high risk.Confidential and Proprietary.18
Transition of Care BCBSIL will help facilitate transition of care when a member needs assistance inmoving from one level of care to another or from one provider to another. Transition of care protocols are applicable when a member is displaced by physiciande-participation or is displaced by termination of a provider contract. Members in the first trimester of pregnancy may request assistance to continue withestablished provider for a defined time. Our Customer Service team may assist withsuch requests.Confidential and Proprietary.19
Continuity of Care Period Continuity of Care: The continued care of a member as they change between different MCOs orbetween Managed Care and Fee-for-Service (FFS), whether due to eligibility changes or achange in MCO enrollment. The Care Coordinator facilitates selection of an in-network provider for the member.BCCHP transition of care period: 90 daysMMAI transition of care period: 180 daysExample: A member has changed from one MCO to another and now their course of care is with anout of network provider. The member may continue services with the non-participating provider for90 days. It is strongly encouraged for the non-participating provider to submit an authorizationrequest for the continuity of care period.Confidential and Proprietary.20
Special Beginnings ProgramSpecial Beginnings helps expectant mothers and their babies get off to a healthy start by providingprenatal and postnatal health education and guidance from pregnancy to 6-8 weeks after delivery. Purpose of Special Beginnings Program:- To encourage prenatal and postpartum care- To educate new moms on healthy options during pregnancy- To inform members of resources for pregnant women in their community Benefits:- Crib or car seat for attending prenatal care- Diaper Program for attending post-partum care Process to Enroll:- Members may contact Care Coordination at 888-421-7781Confidential and Proprietary.21
Coordination with Other Service ProvidersBCBSIL encourages providers to cooperate and communicate with other service providers who serve Medicaidmembers. Such other service providers may include but are not limited to WIC programs, Head Start programs,Early Intervention programs, day care programs, and schools systems. Such cooperation may includeperforming annual physical examinations for school and the sharing of information (with the consent of themember, parent or legal guardian if the member is underage). Annual health examinations for school include anage-appropriate developmental screening, and an age-appropriate social and emotional screening, as requiredby Public Act 99-927.22
Eligibility/BenefitsConfidential and Proprietary.23
Member Identification CardMMAI-Member CardGroup Number – HMM00002BCCHP Member CardGroup Number – HMM00004MLTSS Member CardGroup Number – HMM00004BCCHP and MMAI member ID Prefix is XOG. Possession of a member ID carddoes not guarantee coverage.Confidential and Proprietary.24
Eligibility and Benefit DeterminationEligibility and benefit inquiries should be completed each and every time prior to rendering servicesto a Member. Coverage decisions are always subject to all terms, conditions, limitations andexclusions of the applicable benefit plan.Eligibility: Electronically: Availity Provider Portal MEDI (Medical Electronic DataExchange Practice Management System Telephonically: BCCHP – 877-860-2837 MMAI – 877-723-7702 Customer Service hours are 8 a.m.to 8 p.m. Monday – FridayVerification of eligibility and/or or benefit information is not a guarantee of pay ment. Benefits w ill bedetermined once a claim is receiv ed and w ill be based upon, among other things, the member’s eligibilityand the terms of the member’s certificate of cov erage applicable on the date serv ices w ere rendered.Benefit Determinations: Telephonically: BCCHP – 877-860-2837 MMAI – 877-723-7702 Customer Service hours are 8 a.m. to 8p.m. Monday – Friday Information to have ready when calling foreligibility and benefits: Provider’s NPI and Tax ID number Member’s BCCHP ID number Member’s date of birth For benefit inquiries: type of servicebeing rendered, CPT code(s) and placeof service Status of provider (par or non-par)Confidential and Proprietary.24
Additional Benefits 24/7 access to nurse hotline 30 every 3 months for over the counter items Gift cards to buy health care items if you complete certain preventive measures Extra dental care for adults Pregnancy and healthy kids Special Beginnings Program Transportation to appointments, pharmacy, medical equipment provider and Women Infant and Children’soffices Vision - 40 toward a pair of upgraded eyeglass frames every 2 years Mobile Crisis Response Services Translation services (written and verbal) In-house chaplain services Community Health Workers Program Long Term Services and Supports (LTSS) support center Transition of Care TeamConfidential and Proprietary.25
Third Party Vendors:Dental, Vision,Transportation and PharmacyConfidential and Proprietary.27
Dental, Vision, Transportation and Pharmacy ContactInformationDentaQuest DentaQuest Customer Service Phone Number: 888-286-2447 Provider Relations Phone Number: 888-281-2076 Provider Website: dentaquest.com/dentists/Davis Vision Davis Vision Customer Service Phone: 800 283-9374 Provider Relations Phone Number: 800-584-3140 Provider Website: davisvision.com/become-a-providerModivCare ModivCare Customer Service Phone Number: 844-452-9379 Provider Relations Phone Number: 877-917-4149 Provider Website: logisticare.com/drive-with-logisticare(formerly LogistiCare) Prime TherapeuticsLLC (Prime)Confidential and Proprietary. Prime Therapeutics Customer ServicePhone Number: 855-457-0173Provider Relations Phone Number: 800-821-4795Provider ists.html28
Transportation Claim AdministrationProvider Types and DescriptionsAMBULANCE PROVIDERS(Provider Types 70 and 74)* Ambulance (ground or air)* Service car* MedicarNON-AMBULANCE PROVIDERS* Service car* Medicar* Stretcher van* Taxi/livery* Private auto* Mass transit including bus and train* Commerical airplanClaim Administrator Dates ofservice through Jan. 31, 2020Claim Administrator Dates ofservice on or after Feb. 1,2020LogistiCareBCBSILLogistiCareLogistiCareFor detailed billing guidelines, view the Illinois Association of Medicaid Health Plans (IAMHP) ProviderMemorandumTo learn more about PCS form guidelines, refer to the Illinois Department of Health and Family Services (HFS)Provider Notice.Confidential and Proprietary.29
Pharmacy BenefitsThe following items may be found on our website:Drug List BCCHP uses a Preferred Drug List (PDL) The PDL is a list that indicates the drugs that may be covered by BCCHP The list includes generic, brand and OTC drugs and medical supplies The list can be found at: bcbsil.com/bcchp/pdf/bcchp drug list il.pdfPharmacy Directory The Pharmacy Directory can be found at:bcbsil.com/bcchp/pdf/bcchp pharmacy directory il.pdf In network pharmacy chains include: Kmart, Kroger, Sam’s Club, Walgreens and Walmart Many local pharmacies are also included in our network Prescriptions may also be filled through our mail order programConfidential and Proprietary.30
Pharmacy Benefits con’tForms Home Delivery Prescriber Fax Form - bcbsil.com/pdf/pharmacy/mail-dr-fax-il.pdf Specialty Pharmacy Fax Order Form - .pdf Prime Therapeutics BCCHP Forms - myprime.com/en/forms.htmlPrior Authorization Providers may access, complete and submit prior authorization and step therapy request formselectronically - covermymeds.com/main/Other important information All covered medications have a 0.00copay Medications may be subject to: Prior Authorization Quantity Limits Step Therapy Age Limits Morphine equivalent dose limitConfidential and Proprietary. Vaccines – the following vaccines may berendered at a participating pharmacy ifnot stocked at a provider’s office: Influenza Zoster Pneumococcal pneumonia Tdap31
Benefit PreauthorizationConfidential and Proprietary.32
Benefit PreauthorizationAuthorizations are performed by the BCBSIL plan as well as eviCore healthcare (eviCore) Services that do not require authorization: Emergency and Urgent Care Services,referrals to in-network specialists and OB/GYN Services All non-participating providers (excluding Emergency and Urgent Care requireauthorization)Services authorized by BCBSILServices authorized by eviCoreInpatient Services including but not limitedto: Medical, Surgical, Maternity, NICU andTransplantsOutpatient Services: Please see the MedicaidBenefit Procedure Code List 2020Select Outpatient Services including but notlimited to:Radiation Therapy, Musculoskeletal Services,Cardiology, Radiology Imaging, MedicalOncology, Sleep Studies, Post-acute care, andSpecialty DrugsIf a service has been denied, providers may dispute the decision by completing ServiceAuthorization Dispute Resolution Request FormConfidential and Proprietary.33
4Tools to assist with Authorization Medicaid Benefit Procedure Code List is posted on our websitebcbsil.com/provider/network/medicaid index.html This list provides by CPT code whether the service is authorized by BCBSIL or eviCoreServices authorized by BCBSILServices authorized by eviCoreAll Services Except BH Intensive OutpatientProgram (IOP):Availity Authorizations online via availity.com Select the Patient Registration menu option, chooseAuthorizations & Referrals, then Authorizations Select Payer BCBSIL, then choose your organization Select Inpatient Authorization or OutpatientAuthorization Review and submit your requestOnline via evicore.comBH IOP Only:iExchange online via availity.comPhone: 877-860-2837Fax: 312-233-4060Confidential and Proprietary.Phone: 855-252-1117Additional resources or clinical guidelinesrelated to these services –Visit eviCore websiteat: evicore.com/healthplan/bcbs
Claims/PaymentConfidential and Proprietary.35
Claim Submission Providers shall prepare and submit claims to BCBSIL according to the billing proceduresestablished for BCCHP and MMAI by Illinois HFS and/or CMS for Members who receiveCovered Services. BCCHP and MMAI utilize custom built clearinghouse edits or pre-edits for IL Medicaid toensure that only claims compliant with HFS and/or CMS requirements are accepted forprocessing.Electronic Claim Submissions: Claims may be submitted via the web portal or existing Practice Management Vendor The Electronic Payer ID for Availity is: MCDIL Should you utilize a clearinghouse other than Availity, please check with your clearinghouse for the correct electronic payer ID.Confidential and Proprietary.36
Paper Claim SubmissionPaper claims should be sent to: Blue Cross Community Health Plans, c/oProvider Services, P.O. Box 3418, Scranton,PA 18505 Blue Cross Community MMAI (MedicareMedicaid Plan), c/o Provider Services, P.O.Box 4168, Scranton, PA 18505Confidential and Proprietary. 36
Claim Status InquiryClaims Status Inquiries may be accomplished by any of the following methods: Claim Inquiry Form Complete and fax form to 855-756-8727 Typically a 10 day response time Form can be found at:bcbsil.com/pdf/network/medicaid claims inquiry dispute request form.pdf Availity Telephone Contact Customer Service at 877-860-2837Confidential and Proprietary.38
Claim DisputePurpose: Provider disagreement with a payment decision regarding a BCCHP/MMAI claim.BCBSIL must be notified within 60 days of receipt of payment. After 60 days the payment isconsidered final and will not be further reviewed.How to Dispute Claims:1. Contact our customer service department to start the dispute process 877-860-2837.Customer service will provide the provider a reference number to use during the disputeprocess.2. Mail claim disputes to:Blue Cross Community Health PlansClaim Disputesc/o Provider ServicesP.O. Box 4168Scranton, PA 185053. Complete a Claim Dispute Form and fax to 855-322-0717. Form can be located on our websiteat bcbsil.com/pdf/network/medicaid claims inquiry dispute request form.pdf All disputes and inquiries should initially go to customer service Standard resolution timeframe is 30-45 days Provider Network Consultants may be engaged for any education or assistance needsConfidential and Proprietary.39
Payment BCCHP and MMAI adheres to HFS and/or CMS reimbursement guidelines. The HFS website is monitored daily for any policy changes or pricing methodology. Any claims processed prior to the implementation of the changes, and subject to achange are reprocessed. Blue Cross Community Health Plans payments are separate from the commercialpayments and are excluded from UPP and the experience report.Confidential and Proprietary.40
Electronic Funds Transfer (EFT)/Electronic Remittance Advice (ERA) Prior to enrolling for ERA/EFT, providers must be registered with Availity. Availity supports the exchange ofelectronic transactions. There is no charge to register withAvaility. Providers already enrolled with Availity for ERA/EFT do not need to enroll again for the BCCHP. There is noneed for separate enrollment.How to access Availity’s Transaction Enrollment option: Login in to Availity Select My Account Dashboard on the Availity homepage Select Enrollments Center Select Transaction Enrollment* Complete and submitAdditional information regarding EFT and ERA transactions is available on our Availity EFT & ERA Enrollment tipsheet.*The EFT Transaction Enrollment option is only available toAvaility administrators and/or registered Availity users whohave been granted access.Confidential and Proprietary.41
Electronic Funds Transfer (EFT)/ElectronicRemittance Advice (ERA) (Con’t) Providers can enroll with Availity to receive ERA/EFT as soon as they are showing asparticipating. After enrolling with Availity to receive ERA/EFT, providers can obtain enrollment status by callingBCBSIL Electronic Commerce Center 800-746-4614. Providers receive a confirmation letter inthe mail with their confirmation date. Providers who enroll online can track their progress throughtheir online submission. If you have any questions regarding the Electronic Transaction enrollment process, emailElectronic Commerce Services.Confidential and Proprietary.42
Credentialing/Roster UpdatesConfidential and Proprietary.43
Credentialing Effective Jan. 1, 2018, Illinois Medicaid Program Advanced Cloud Technology (IMPACT) handlesall of the credentialing for the new HealthChoice Illinois program. Once the provider application isapproved by HFS/IMPACT, the provider will be considered credentialed with the Blue CrossCommunity Health Plans. Important features: This applies to MMAI and Medicaid. Although providers will be credentialed through IMPACT, they will still be required to provideadditional information to BCBSIL that is required for our network operations department. Since June 15, 2018, HFS has implemented a new data element template that is uniformacross all of the Managed Care Organizations. This new template will be used to verify andload additional information for each provider, such as NPI’s, office hours, and billinginformation.Practitioner InformationNPIConfidential and Proprietary.Last Name First NameMiddle Name Suffix DegreeDate Of BirthSSN # (NoGender(MM/DD/YYYY)Dashes)(M/F)Practice As (PCP,SPEC, Hospitalist,Hospital Based)IllinoisMedicare IDMedicaid IDCAQH ID44
Adding New ProvidersThere are two ways you may add new providers to your group:Roster Submission ProcessProvider Onboarding Form Process for new groups or for adding 5 or more Available for adding providers to aproviders at one timecurrently contracted group New: Complete and Submit the Universal Roster The Provider Onboarding Form isTemplate which will be provided by the contractingavailable on our website atdepartment and/or PNC. Send Universal Rosterbcbsil.com/providerupdate to You will receive a case number whenGov NetOps Provider Update@bcbsil.comyou submit the form. The case Adding: Request a copy of your current rosternumber will be requested whenfrom Provider Roster Requests atasking for status updates or inquiries.ILProviderRosterRequests@bcbsil.com Make necessary corrections and update column“A” to notify operations of changes needed:New/No Change/ Update/ Term Send back to Provider Roster Requests atILProviderRosterRequests@bcbsil.com or contactfor assistance.*YouPNCcan checkthe status of your submission by entering the case number you received in your confirmation email in ourCase Status Checker.Confidential and Proprietary.44
Demographic UpdatesDemographic updates are defined as adding a location, changing an address, phone number,removing a provider from group, etc. The full list can be found atbcbsil.com/provider/network/information update.htmlRoster Submission Process Request a copy of your current roster from IL ProviderRoster Requests atILProviderRosterRequests@bcbsil.com Make necessary corrections and update column “A” tonotify operations of changes needed: New/No Change/Update/ Term Send back to IL Provider Roster Requests atILProviderRosterRequests@bcbsil.com or contactPNC for assistance.Demographic Change Form The Demographic Change Form is locatedon our website at bcbsil.com/provider*You can check the status of your submission by entering the case number you received in your confirmation email in our Case Status Checker.Confidential and Proprietary.46
Required Provider TrainingConfidential and Proprietary.47
Provider Training It is a CMS and State of Illinois requirement for BCBSIL to make available training on specified topics forBCCHP and MMAI contracted providers. These trainings are mandatory in order to comply with the terms ofyour provider contract. Please have your staff participate in the BCBSIL online training. To access the BCCHP & MMAI provider training tutorials, visit the Network Participation/Provider TrainingRequirements/Resources section on our website at bcbsil.com/provider/network/training medicaid.html. BCBSIL Online Training Tutorials* Model of Care/Medical Home(Person Centered Practice) Combating Medicare Parts C and DFraud, Waste and Abuse Abuse, Neglect, Exploitation/Critical Incidents Cultural Competency Americans with Disabilities Act (ADA)/Independent Living Medicare Parts C & D General Compliance Training (only MMAI providers) ADA Site Compliance Survey*Alternative option for compliance training completion: You may complete the online attestation oftraining completion which certifies that your practice has completed the annual BCCHP and MMAIcompliance training from another government contracted Managed Care Organization (MCO).Confidential and Proprietary. 47
Member Appeals andGrievancesConfidential and Proprietary.49
Member Appeals and GrievancesMedical Appeals and Grievances are the Member’s right.Appeals are defined as a member’s dissatisfaction with an organization’s determination. i.e.Benefit Preauthorization denials.Grievances are defined as member’s dissatisfaction with health care s
The Blue Cross and Blue Shield of Illinois (BCBSIL) Medicaid product also known as Blue Cross Community Health Plans (BCCHP) is available throughout the state of Illinois, servicing 102 counties. Effective 7/1/2021, the BCBSIL Medicare-Medicaid product also known as Medicare- Medicaid Alignment Initiative (MMAI) is available in the following .
