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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.
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 at the Benefits Fund Office.
Surgery. Health Information Services must be notified at least two weeks before a scheduled surgery (inpatient or outpatient). 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 bariatric 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:
Nutritional Counseling. Expenses for nutritional counseling sessions are covered if ordered by your physician as part of a comprehensive treatment plan and are approved by Health Information Services at the Benefits Fund Office. If the expense is not approved, it will not be considered medically necessary and the Plan will not cover it. For specific information on Nutritional Counseling benefits, see the Comprehensive Medical Benefits section under your plan (either Plan D5 or Plan B5).
Weight Loss Treatment. Before incurring expenses for weight loss treatment, including surgery, 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.
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.
Physical Therapy. Physical therapy is limited to 25 sessions per injury or illness. Additional benefits may be payable for treatment of certain conditions. These additional benefits must be pre-certified by Health Information Services or payment will be limited to 50% of covered charges. For specific information on physical therapy benefits, see the Comprehensive Medical Benefits section under your plan (either Plan D5 or Plan B5).
Occupational Therapy. Occupational therapy is limited to 25 sessions per injury or illness. Additional benefits may be payable for treatment of certain conditions. These additional benefits must be pre-certified by Health Information Services or payment will be limited to 50% of covered charges. For specific information on occupational therapy benefits, see the Comprehensive Medical Benefits section under your plan (either Plan D5 or Plan B5).
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 exceed the 25 session limit for Physical Therapy or for Occupational Therapy without first pre-certifying the expenses, the Plan will pay 50% of covered charges.
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:
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