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In addition to covered medical treatment from a covered Provider, for purposes of the Plan’s claims and appeals procedures, medical claims include wellness, hearing, optical services, prescription drug, and dental claims.

For medical treatment at a Hospital or through a Physician Provider, all claims should be submitted to Blue Cross Blue Shield of Illinois (including non-network Hospital or Provider claims). Present your card at the time of treatment, and the Provider will take care of submitting your claim for payment. You are responsible for ensuring that the claim is filed with the Plan.

Pre-Approval of Hospitalization or Inpatient Surgery – Blue Cross Blue Shield Medical Service Advisory (MSA)

If your Physician recommends elective or non-emergency hospitalization or elective Inpatient surgery, you must call the Blue Cross Blue Shield Medical Service Advisory (MSA) at least one business day before you go into the Hospital. If it is an emergency admission, you, your doctor, the Hospital or a family member must call the Blue Cross Blue Shield MSA within two business days of the date of admission. If you do not call the Blue Cross Blue Shield MSA within these periods of time, you will have to pay an additional copayment of $250 before the Fund will pay any benefits. The telephone number for the Blue Cross Blue Shield MSA is 1-800-255-5192. For maternity admissions, you are encouraged, but not required, to contact the Blue Cross Blue Shield MSA before you are admitted into the Hospital.

 

Pre-Approval of Certain Medical Benefits Through the Fund Office

If your Physician prescribes contraceptives for a Medically Necessary reason, other than contraception, you must contact the Fund Office for prior approval. In addition, if your Physician prescribes physical, occupational, or speech therapy, you must contact the Fund Office for prior approval of your treatment plan, as described in Covered Expenses. The Fund Office may submit your claim to its Contracted Medical Claim Review Provider to determine whether your claim will be covered by the Plan.

If your Physician prescribes the use of Medically Necessary Durable Medical Equipment, you must contact the Fund Office for prior approval of the equipment, as provided in Covered Expenses.

Pre-Service Medical Claims

You are required to get Plan approval in advance of elective surgery, hospitalization, and certain other benefits. The Plan will make a decision on your pre-service claim and notify you of the decision within a reasonable period of time appropriate to the medical circumstances, but no later than 15 days after receiving your claim. If the Plan requires an extension of time due to matters beyond the control of the Plan, the Plan will notify you of the reason for the delay and when the decision will be made. This notification will occur before the expiration of the 15-day period. A decision will be made within 15 days of the time the Plan notifies you of the delay.

If the Plan needs additional information from you to make its decision, you will be notified as to what information must be submitted. You will have at least 45 days to submit the additional information. Once the Plan receives the information from you, you will be notified of the Plan’s decision on the claim within 15 days.

Urgent Care Medical Claims

Urgent care claims are claims for medical care or treatment that would:

  • Seriously jeopardize your life or health if normal pre-service standards were applied, or
     
  • Subject you to severe pain that cannot be adequately managed without the care or treatment for which approval is sought, in the opinion of a Physician with knowledge of your condition.

If your claim involves urgent care, the Plan will make a decision on your claim and notify you of the decision as soon as possible, taking into account your medical needs, but not later than 72 hours after the Plan receives your claim.

If you do not provide sufficient information to determine whether or to what extent benefits are covered or payable for urgent care, the Fund Administrator or its designee will notify you as soon as possible, but not later than 24 hours after receipt of the claim, of the specific information necessary to complete the claim. You must provide the specified information within 48 hours. If you do not provide the information, your claim will be denied.

Concurrent Care Medical Claims

Concurrent claims involve a reconsideration of services you are currently receiving. In some cases, the Plan may approve your claim for a certain number of visits or for a certain length of time. For example, the Plan may approve a Hospital stay for five days for treatment of a medical condition.

 

The Plan may decide to reduce or terminate the number of visits or length of time that was previously approved. If such a decision is made, the Plan will inform you of the decision sufficiently in advance of the reduction or termination so that you can request and receive a review of the decision before it takes effect.

If you request an extension of the number of visits or length of time at least two hours before the expiration of the approved limit and your request involves urgent care, the Plan will make a decision on your request and notify you of the decision within 24 hours. All other requests for extensions will be handled as Pre-Service Claims.

Post-Service Medical Claims

For claims you submit after you have received the services, the Plan will make a decision on your claim and notify you of the decision within 30 days of receiving your post-service claim. If the Plan requires an extension of time due to matters beyond the control of the Plan, the Plan will notify you of the reason for the delay and when the decision will be made. This notification will occur before the expiration of the 30-day period. A decision will be made within 15 days of the time the Plan notifies you of the delay.

If the Plan needs additional information from you to make its decision, you will be notified as to what information must be submitted. You will have at least 45 days to submit the additional information. Once the Plan receives the information from you, you will be notified of the Plan’s decision on the claim within 15 days.