Blue Cross and Blue Shield has established the Utilization Review Program to perform a review of the following Covered Services prior to such services being rendered:
S Inpatient admissions
S Skilled Nursing Facility services
S Services received in a Coordinated Home Care Program S Private Duty Nursing Services
S Hospice Care Program Services
The Utilization Review Program is staffed primarily by registered nurses and other personnel with clinical backgrounds. The Physicians in our Medical De
partment are an essential part of the Utilization Review Program.
PREAUTHORIZATION REQUIREMENTS
You are required to obtain preauthorization from Blue Cross and Blue Shield before you receive certain types of Covered Services designated by Blue Cross and Blue Shield in order to be eligible for maximum benefits under this Certificate. Failure to contact Blue Cross and Blue Shield may result in a re
duction in benefits. These reductions in benefits are in addition to the applicable Copayments, Coinsurance, deductibles and out-of-pocket amounts that are your responsibility under this Certificate. Providers may bill you for any reduction in payment resulting from failure to contact Blue Cross and Blue Shield.
You are encouraged to call ahead if the availability of payment under this Certificate is important to your decision to receive care. Blue Cross and Blue Shield may be reached twenty-four (24) hours a day, 7 days a week at the toll-free telephone number on your Blue Cross and Blue Shield
identification card. Please read the provisions below very carefully. Your Providers may call Blue Cross and Blue Shield for you, when required, but it is your responsibility to ensure preauthorization requirements are satisfied.
Preauthorization review is not a guarantee of benefits. Actual availability of benefits is subject to eligibility and the other terms, conditions, limitations, and exclusions of this Certificate.
The reductions in benefits are specified below in the FAILURE TO PREAU
THORIZE OR NOTIFY provision within this section of this Certificate.
The procedures for notifying Blue Cross and Blue Shield are specified below in the UTILIZATION REVIEW PROCEDURE provision within this section of this Certificate.
The provisions of this section do not apply to the treatment of Mental Illness and Substance Use Disorder Rehabilitation Treatment. The provisions for the treatment of Mental Illness and Substance Use Disorder Rehabilitation Treat
ment are specified in the BEHAVIORAL HEALTH PROGRAM section of
PREAUTHORIZATION REVIEW S Inpatient Preadmission Review
Inpatient preadmission review is not a guarantee of benefits. Actual availability of benefits is subject to eligibility and the other terms, conditions, limitations, and exclusions of this Certificate.
Whenever a nonemergency or non-maternity Inpatient admission is re
commended by your Physician, you must, in order to receive maximum benefits under this Certificate, call Blue Cross and Blue Shield. This call must be made at least one business day prior to the Inpatient admission and the performance of any preadmission tests. When you call, a case manager may be assigned to assist you throughout the duration of your care.
If the proposed Inpatient admission or health care services are not Med
ically Necessary, it will be referred to a Blue Cross and Blue Shield Physician for review. If the Blue Cross and Blue Shield Physician con
curs that the proposed admission or health care services are not Medically Necessary, some days, services or the entire Inpatient admis
sion will be denied. Blue Cross and Blue Shield will send a letter to you, your Physician and the Hospital or facility with a determination of your preauthorization review no later than 15 calendar days after Blue Cross and Blue Shield receives the request for preauthorization review.
However, in some instances, these letters will not be received prior to your scheduled date of admission.
S Emergency Admission Review
Emergency admission review is not a guarantee of benefits. Actual availability of benefits is subject to eligibility and the other terms, conditions, limitations, and exclusions of this Certificate.
In the event of an emergency admission, you or someone who calls on your behalf must, in order to receive maximum benefits under this Cer
tificate, notify Blue Cross and Blue Shield no later than two business days after the admission has occurred or as soon as reasonably possible after the admission has occurred. If the call is made any later than the specified time period, you will not be eligible for maximum benefits.
S Maternity Admission Review
Maternity admission review is not a guarantee of benefits. Actual availability of benefits is subject to eligibility and the other terms, conditions, limitations and exclusions of this Certificate.
In the event of a maternity admission, you or someone who calls on your behalf must, in order to receive maximum benefits under this Certificate, notify Blue Cross and Blue Shield no later than two business days after the admission has occurred in order to have the maternity admission re
viewed. If the call is made any later than the specified time period, you will not be eligible for maximum benefits.
Even though you are not required to call Blue Cross and Blue Shield pri
or to your maternity admission, if you call Blue Cross and Blue Shield as soon as you find out you are pregnant, Blue Cross and Blue Shield will begin to provide you access to additional Utilization Review services to help you maximize your benefits. When you contact Blue Cross and Blue Shield, you will be asked to answer a series of questions regarding your pregnancy. Blue Cross and Blue Shield will provide you with edu
cational materials which may be informative for you and which you may want to discuss with your Physician. A letter will be sent to your Physi
cian stating that you contacted Blue Cross and Blue Shield. Blue Cross and Blue Shield will be available should you have questions about your maternity benefits.
S Skilled Nursing Facility Preadmission Review
Skilled Nursing Facility preadmission review is not a guarantee of benefits. Actual availability of benefits is subject to eligibility and the other terms, conditions, limitations, and exclusions of this Certific
ate.
Whenever an admission to a Skilled Nursing Facility is recommended by your Physician, you must, in order to receive maximum benefits under this Certificate, call Blue Cross and Blue Shield. This call must be made at least one business day prior to the admission.
S Coordinated Home Care Program Service Review
Coordinated Home Care Program service review is not a guarantee of benefits. Actual availability of benefits is subject to eligibility and the other terms, conditions, limitations, and exclusions of this Certi
ficate.
Whenever Coordinated Home Care Program service is recommended by your Physician, you must, in order to receive maximum benefits under this Certificate, call Blue Cross and Blue Shield. This call must be made at least one business day prior to receiving services.
S Private Duty Nursing Service Review
Private Duty Nursing Service review is not a guarantee of benefits.
Actual availability of benefits is subject to eligibility and the other terms, conditions, limitations, and exclusions of this Certificate.
Whenever Private Duty Nursing Service is recommended by your Physi
cian, you must, in order to receive maximum benefits under this Certificate, call Blue Cross and Blue Shield. This call must be made at least one business day prior to receiving services.
S Hospice Care Program Service Review
Hospice Care Program Service review is not a guarantee of benefits.
Actual availability of benefits is subject to eligibility and the other
Whenever Hospice Care Program Service is recommended by your Physician, you must, in order to receive maximum benefits under this Certificate, call Blue Cross and Blue Shield. This call must be made at least one business day prior to receiving services.
IMPORTANT: The complete list of Covered Services requiring preau
thorization review is subject to review and change by Blue Cross and Blue Shield. You are encouraged to call the toll-free number on your Blue Cross and Blue Shield identification card to verify preauthorization re
quirements.
LENGTH OF STAY/SERVICE REVIEW
Length of stay/service review is not a guarantee of benefits. Actual avail
ability of benefits is subject to eligibility and the other terms, conditions, limitations, and exclusions of this Certificate.
Upon completion of the preadmission or emergency admission review, Blue Cross and Blue Shield will send you a letter confirming that you or your rep
resentative called Blue Cross and Blue Shield. A letter authorizing a length of service or length of stay will be sent to you, your Physician and/or the Hospital or facility.
An extension of the length of stay/service will be based solely on whether con
tinued Inpatient care or other health care service is Medically Necessary. In the event that the extension is determined not to be Medically Necessary, the coverage for the length of stay/service will not be extended.
S Services received in a Coordinated Home Care Program S Private Duty Nursing Services
S Home Hospice Care Program Services
OUTPATIENT SERVICE PREAUTHORIZATION REVIEW Outpatient Service Preauthorization Review is not a guarantee of benefits, Actual availability of benefits is subject to eligibility and the other terms, conditions, limitations, and exclusions of this Certificate.
Whenever the following Outpatient services(s), received by a Participating Provider, are recommended by your Physician, you must, in order to receive maximum benefits under this Certificate, call Blue Cross and Blue Shield.
This call must be made at least two business days prior to receiving these ser
vices:
S Services received in a Coordinated Home Care Program S Home Hospice Care Program Services
S Private Duty Nursing Services
Whenever the following Outpatient services(s), received by a Non-Participat
ing Provider, are recommended by your Physician, you must, in order to receive maximum benefits under this Certificate, call Blue Cross and Blue
Shield. This call must be made at least two business days prior to receiving these services:
S Dialysis
S Elective Surgery CASE MANAGEMENT
When you receive Covered Services in an emergency room or are hospitalized for a complex medical situation such as an organ transplant, accident or seri
ous disease, you may be contacted by a case manager. Case managers are registered nurses (or other health care professionals) who have professional training and clinical experience. They may answer questions about your med
ical condition, help you understand what to expect when you are discharged from the Hospital to your home or to another care facility and help coordinate special care you may need.
In some cases, if your condition would require care in a Hospital or other health care facility, the case manager may provide an alternative treatment plan. If you and your Physician choose the alternative treatment plan, then al
ternative benefits may be provided as described in this Certificate.
Alternative benefits will be provided only so long as it has been determined that the alternative services are Medically Necessary and cost‐effective. The case manager will continue to be available for the duration of your condition.
The total maximum payment for alternative services shall not exceed the total benefits for which you would otherwise be entitled under this Certificate.
Provision of alternative benefits in one instance shall not result in an obliga
tion to provide the same or similar benefits in any other instance. In addition, the provision of alternative benefits shall not be construed as a waiver of any of the terms, conditions, limitations, and exclusions of this Certificate.
MEDICALLY NECESSARY DETERMINATION
The decision that Inpatient care or other health care services or supplies are not Medically Necessary will be determined based on generally accepted medical standards. Should it be determined that the Inpatient care or other health care services or supplies are not Medically Necessary, written notifica
tion of the decision will be provided to you, your Physician, and/or the Hospital or other Provider, and will specify the dates or services that are not considered Covered Services. For further details regarding Medically Neces
sary care and other exclusions from coverage under this Certificate, see the section entitled, “EXCLUSIONS—WHAT IS NOT COVERED."
Blue Cross and Blue Shield does not determine your course of treatment or whether you receive particular health care services. The decision regarding the course of treatment and receipt of particular health care services is a mat
ter entirely between you and your Physician. Blue Cross and Blue Shield's determination of Medically Necessary care is limited to merely whether a pro
posed admission, continued hospitalization, Outpatient service or other health care service is Medically Necessary under this Certificate.
Blue Cross and Blue Shield will make the initial decision whether hospitaliza
tion, Outpatient service or other health care services or supplies were not Medically Necessary. In most instances, this decision is made by Blue Cross and Blue Shield after you have been hospitalized or have received other health care services or supplies and after a claim for payment has been submitted.
Remember that your Blue Cross and Blue Shield Certificate does not cover the cost of hospitalization or any health care services and supplies that are not Medically Necessary. The fact that your Physician or another health care Pro
vider may prescribe, order, recommend or approve an Inpatient stay, Outpatient service or other health care service or supply does not of itself make such admission, service or supply Medically Necessary. Even if your Physician prescribes, orders, recommends, approves, or views an admission or other health care services or supplies as Medically Necessary, Blue Cross and Blue Shield will not pay for the admission, services or supplies if Blue Cross and Blue Shield and the Blue Cross and Blue Shield Physician decide they were not Medically Necessary.
UTILIZATION REVIEW PROCEDURE
When you contact Blue Cross and Blue Shield, you should be prepared to provide the following information:
1. The name of the attending and/or admitting Physician;
2. The name of the Hospital or facility where the admission has been sched
uled and/or the location where the service has been scheduled;
3. The scheduled admission and/or service date; and
4. A preliminary diagnosis or reason for the admission and/or service.
Once contacted, Blue Cross and Blue Shield:
1. will review the medical information provided and may follow‐up with the Provider;
2. may determine that the services rendered or to be rendered are not Med
ically Necessary.
APPEAL PROCEDURE
If you or your Physician disagree with the determination of Blue Cross and Blue Shield prior to or while receiving services, you may appeal that decision by contacting Blue Cross and Blue Shield.
In some instances, the resolution of the appeal process will not be completed until your admission or service has occurred and/or your assigned length of stay/service has elapsed. If you disagree with a decision after claim processing has taken place or upon receipt of the notification letter from Blue Cross and Blue Shield, you may appeal that decision by having your Physician call the contact person indicated in the notification letter or by submitting a written request to:
Blue Cross and Blue Shield of Illinois Claim Review Section
P.O. Box 2401
Chicago, Illinois 60690
You must exercise the right to this appeal as a precondition to taking any ac
tion against Blue Cross and Blue Shield, either at law or in equity.
Additional information about appeals procedures is set forth in the CLAIM APPEAL PROCEDURES provision of the HOW TO FILE A CLAIM sec
tion of this Certificate.
FAILURE TO PREAUTHORIZE OR NOTIFY
The final decision regarding your course of treatment is solely your responsib
ility and Blue Cross and Blue Shield will not interfere with your relationship with any Provider. However, Blue Cross and Blue Shield has established the Utilization Review Program for the specific purpose of assisting you in de
termining the course of treatment which will maximize your benefits provided under this Certificate.
Should you fail to preauthorize or notify Blue Cross and Blue Shield as re
quired in the PREAUTHORIZATION REVIEW provision within this section of this Certificate, you will then be responsible for the first $1,000 or 50%, whichever is less, of the Hospital or facility charges for an eligible Inpatient stay, and/or the first or $1,000 or 50%, whichever is less, of the charges for eligible Covered Services for Private Duty Nursing Service in addition to any deductibles, Copayments, Coinsurance and/or out-of-pocket amounts that are your responsibility under this Certificate. This amount shall not be eligible for later consideration as an unreimbursed expense under any benefit section of this Certificate nor can it be applied to your out‐of‐pocket expense limit, if applicable under this Certificate.
Should you fail to preauthorize or notify Blue Cross and Blue Shield as re
quired in the Outpatient Service Preauthorization Review provision of this section for Outpatient Covered Services received from a Non-Participating Provider, prior to receiving Outpatient services, you will then be responsible for $1,000 or 50%, whichever is less, of the charges, for eligible Covered Ser
vices in addition to any deductibles, Copayments and/or Coinsurance applicable to this Certificate. This amount shall not be eligible for later con
sideration as an unreimbursed expense under any Benefit Section of this Certificate not can it be applied to your out-of-pocket expense limit, if applic
able to this Certificate.
IMPORTANT: If you decide to receive health care that is not a Covered Service, such as services that are determined through the preauthoriza
tion review process not to be Medically Necessary, then no reimbursement is available under this Certificate and you are responsible to pay the full amount billed by the Provider you chose. For additional details, please read the above MEDICALLY NECESSARY DETERMINATION provi
sion within this section of this Certificate.
MEDICARE ELIGIBLE MEMBERS
The provisions of this Utilization Review Program section do not apply to you if you are Medicare eligible and have secondary coverage provided under this Certificate.