 |
 |
      |
 |
  |
|
|
|
|
 |
|
Home > Health Plan > When to Call Us
WHEN TO CALL THE BENEFITS FUND OFFICE Some plans do not include every benefit mentioned. Refer to your plan booklet to verify which benefits are included in your plan.
Cost-Containment Features of the Health Plan
Your Health Plan includes programs designed to manage your costs for health care and ensure that you get the most out of
the benefits available to you and your family.
The Pre-Certification and Utilization Review Program lets you be assured that your medical treatment is covered under the
Plan and is received in an appropriate and cost-effective manner.
The Second Opinion Program helps to determine if a proposed surgery is
medically necessary, or if an effective alternative approach
exists.
The Plan also offers you further opportunity to save on your out-of-pocket costs for health care through use of the BlueCross
BlueShield of Illinois Participating Provider Option (PPO). Participants in this network of hospitals and physicians agree to
provide health services at a lower rate than they normally charge. This means that your share of the cost for covered
services is automatically reduced.
The ultimate decisions regarding your medical care must be made by you or your doctor. The Pre-Certification and
Second Opinion Programs only determine the medical necessity
of a service or supply according to the Plan’s benefits and provisions.
When to Notify Health Information Services
You can reach Health Information Services by calling 847-384-7000 extension 7050 or toll-free 800-621-5133
extension 7050, Monday–Friday from 8:00 a.m.–4:30 p.m.
Inpatient Hospital Admissions. Health Information Services must be notified two weeks before the start of the
hospital stay. If you do not pre-certify your hospitalization, an additional $100 deductible will be applied. This penalty
does not apply to maternity stays that are less than 48 hours postpartum for a vaginal delivery and less than 96 hours
postpartum for delivery by caesarian section.
Emergency Care. When emergency care is required that results in you or an eligible dependent being admitted to
the hospital, call Health Information Services within 48 hours of being admitted to the hospital. If you do not contact Health
Information Services, an additional $100 deductible will be applied.
Surgery. Health Information Services must be notified at least two weeks before a scheduled surgery. If you do
not pre-certify your surgery, an additional $100 deductible will be applied before any benefits are paid. If you do not
pre-certify expenses for obesity surgery, the Plan will not cover it.
Second Opinion Surgery. You may be required to obtain a Second Opinion. The types of surgeries that require
a Second Opinion are:
Obesity Surgery. Before incurring expenses
for surgical treatment of obesity, contact Health Information Services for approval. If certain conditions are not met and if the
expense is not approved, it will not be considered medically necessary
and the Plan will not cover it.
Advanced Diagnostic Testing. It is required that you contact Health Information Services (not BlueCross BlueShield)
before undergoing advanced testing such as magnetic resonance imaging (MRI) scans, computerized tomography (CT) scans, positron emission
tomography (PET) scans, Thallium stress tests, sleep studies, nerve conduction studies, or echo Doppler tests. If you do not
pre-certify the expense for advanced testing, an additional $100 deductible will be applied.
The pre-certification must be done by Health Information Services, not by BlueCross BlueShield—you or your doctor
should speak directly with Health Information Services
Skilled Nursing Facility Care, Rehabilitation Therapy, Home Health Care and Hospice. Before incurring expenses
for care in a skilled nursing facility, for rehabilitation therapy, for home health care, or for care in a hospice, you must
contact Health Information Services for approval. If the expense is not approved, it will not be considered
medically necessary and the Plan will not cover it.
Durable Medical Equipment. Before purchasing or renting durable medical equipment, you should call Health
Information Services for approval. If the expense is not approved, it will not be considered
medically necessary and the Plan will not cover it.
Penalties for Failure to Notify Health Information Services
If you do not notify Health Information Services to pre-certify expenses for your hospital stay, for surgery, or for advanced
diagnostic testing, an additional $100 deductible, called a Non-Compliance Deductible, will be applied.
If you have surgery without obtaining a Second Opinion when required, the Plan will pay 50% of all covered expenses
related to the surgery. You will be responsible for the remaining charges. The additional amount you pay does not count
towards your out-of-pocket maximum.
If you have expenses for:
BlueCross BlueShield Participating Provider Option
BlueCross BlueShield has made arrangements with certain hospitals and physicians to provide health care to you and your
eligible dependents at lower rates than normally charged.
To request a listing of network hospitals in Illinois, click on PPO Hospital Listing. For
hospitals and doctors inside or outside of Illinois, go to www.bcbs.com and click on
"Find a Doctor or Hospital" or call 800-810-BLUE (2583).
Simply by choosing a hospital and physician in the PPO network and showing your Health ID card when you receive
medical care, you will receive a discount on your medical bill. Discounts vary and may change from time to time, but the
Plan will pay a greater portion of your expenses when you use a PPO hospital and physician.
You save three ways when you use the BlueCross BlueShield Participating Provider Option:
|
||||||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||
