Blue Cross Blue Shield HMO Illinois

HMO Illinois®, Blue Advantage
HMO℠ and Blue Precision℠

Member Brochure

 

Blue Cross Blue Shield HMO Website

At Swedish Covenant Physician Partners we affirm that:
• Utilization management decision making is based only on appropriateness of
care and service and existence of coverage.
• Swedish Covenant Physician Partners does not specifically reward practitioners
or other individuals for issuing denials of coverage or service care.
• Incentive programs are not utilized to encourage decisions that result in
under-utilization.
• There is no conflict of interest between Swedish Covenant Physician Partners
and its utilization management decision makers.

As an active participant in the maintenance of your health and the recipient of
medical service, you are responsible for:
• Reading your HMO Benefit Manual, having knowledge of your benefits,
referral procedures and co-payments.
• Establishing a relationship with your primary care physician by:
– Making an appointment for an initial visit and physical.
– Assisting your new primary care physician in becoming familiar with your
health status by transferring your past medical records.
Presenting for your appointment at the scheduled appointment time or
allowing your physician’s office a minimum of 24-hour notice cancelation.
• Notifying your primary care physician of any medical emergency.
• Cooperating and communicating with your physician with recommended
treatment plans.
• Discussing any part of your care that you do not understand with your
primary care physician.
• Providing your insurance card, upon request. You will be asked to show your card anytime you visit the doctor, receive tests, upon admission to a hospital, receive emergency room care and/or receive a prescription. Because insurance plans are designed by your employer, benefits may vary. There may be some services you require which are not covered by your managed care policy. Please make sure you read and are familiar with your handbook and plan. If you have any questions regarding a particular benefit, please contact your HMO.

• Pre-Admission Certification and Concurrent Review are two programs established to ensure that you receive the most appropriate and cost-effective health care.
• Your PCP must obtain approval from SCPP prior to inpatient hospital admission other than emergency situations.
• SCPP may recommend other courses of treatment that could help you avoid an inpatient stay.
• It is your responsibility to cooperate with the recommendations made by your PCP.
• If you or covered family members are hospitalized at a facility other than Swedish Covenant Hospital or another in-network hospital, your initial stay will be approved when your PCP is notified by you or the out-of-network
hospital. You may be transferred to an in-network hospital as soon as it is medically safe.
• Concurrent review ensures that your length of stay is appropriate given your diagnosis and treatment plan.
• You may contact us to discuss the Utilization Management Process or any issues regarding it by calling 773-271-0880.
• Your physician is not prevented from providing care that your insurance plan does not cover; however, if you and your physician decide to proceed with such treatment, your health insurance may not pay for that procedure or service.
• Your care is coordinated by your physician who works closely with nursing professionals and hospital caregivers to coordinate both inpatient and outpatient services.

Your plan requires that you choose a Primary Care Physician (PCP). That physician will be responsible for providing and coordinating your health care. Please refer to the enclosed physician list. If your insurance
plan is HMO Illinois®, Blue Advantage HMOSM or Blue Precision- SM please complete and return
the enclosed selection form. You must return this form to our office even if you already indicated your
physician choice on your employer’s enrollment application. If you have any questions about selecting your PCP contact Swedish Covenant Physician Partners at 773-271-0880. If you wish to change your primary care physician, please contact Swedish Covenant Physician Partners at 773-271-0880 and we will make the necessary adjustment and/or direct you appropriately.

A Women’s Principal Health Care Provider (WPHCP) is an obstetrician/gynecologist (OB/GYNE) who has been selected to be directly accessible for treating and coordinating a female Member’s health care needs. Your WPHCP should coordinate care with your Primary Care Physician. You may access this physician without a referral; however, a referral is necessary for all services this physician recommends. Please make sure the WPHCP you have selected is on the enclosed list. All of SCPP’s WPHCPs on the enclosed list have referral arrangements with SCPP Primary Care Physicians. You must contact Swedish Covenant Physician Partners to inform them of your choice of Women’s Principal Health Care Provider. Anytime you wish to change your OB/GYNE within SCPP network you must notify us at 773-271-0880.
The availability of early morning, evening, and weekend hours may vary by PCP and WPHCP. At your get acquainted visit your PCP will be able to advise you on how you can receive services during these time frames for Immediate care androutine appointments.

SCPP encourages teens and young adults to become involved in managing their health care as early as possible. In accordance with the American Academy of Pediatrics, we ask that members begin to transition to adult Primary and Specialty Care Providers between their 18th and 21st birthday. Teens will begin preparing
for this transition by sharing concerns and learning how to talk about your health history with your Pediatrician. Your Pediatrician will work with you and your family to outline any needs to ensure a successful transition into adulthood. Our providers and staff welcome any questions regarding the youth transition policy
and will assist with finding the right health care providers for you.

If you have medical records which need to be transferred to your PCP, please have those records transferred as soon as possible. If you need a copy of your medical record, you must contact your Primary Care Physician. All medical records are kept in strict confidence. Please note that some health plans allow providers to charge a
nominal fee for the service of copying medical records.

Be sure to check your benefits to determine if any services require a co-payment. If your coverage requires a co-payment, you may be responsible for payment at the time of service. Please be aware that co-payment amounts vary by HMO plan and are payable at the time of the visit.

Your PCP will coordinate your overall health care and determine the needs for specialty care referrals for medically necessary services. You must obtain a written or electronic referral from you PCP before obtaining care from another health care provider. Such referrals include specialists and outpatient procedures provided by Swedish Covenant Physician Partners providers. Failure to obtain a referral may result in denial of payment. All referrals undergo a review process. If a referral is denied, the reason for the denial, the alternative treatment, a telephone number for questions and the mechanism for an appeal will be communicated to you in writing.

• Your PCP may wish to examine you before a referral is provided.
• In most cases, your referral is issued for one visit and is good for 90 days
from the date it is issued.
• Be sure to verify the date and type of referral you receive.
• If your coverage ends before you use your referral, the referral is invalid and
you may be responsible for payment.

• Communication with your physician is an important part of your health care.
If you do not understand any course of your care, please discuss this with
your PCP.
• You can also contact our Patient Advocate at 773-271-0880. The role of the
Patient Advocate is to help with Member issues and concerns that cannot be
resolved through normal channels.
• As an HMO member, you have the right to appeal any payment or denial
of covered services by contacting the HMOs of Blue Cross Blue Shield of
Illinois at (800)-538-8833 (TTY/TDD 711) or in writing at the address
listed below.

 If you are an HMO Illinois® Member, a Blue Advantage HMOSM Member, a
Blue Precision MemberSM (group number on your ID card begins with and R)
or a BlueCare DirectSM Member (group number on your ID card begins with A):

Blue Cross Blue Shield of Illinois
Claims Review Section
PO Box 2401
Chicago, IL. 60690

 If you are a Blue Precision HMOSM (group number on your ID card
begins with and I) or a BlueCare DirectSM Member (group number on
your ID card begins with I):

Blue Cross Blue Shield of Illinois
Claims Review Section
PO Box 3122
Naperville, IL. 60566-9744

• Following an adverse determination (denial) for a clinical service, procedure
or treatment that is not reviewed as medically necessary, any involved party
may request an external independent review.

(early morning, evenings, weekends)
• If you need medical care for a non-life threatening emergency and your
PCP’s office is closed, your PCP may direct you one of our immediate care
centers:

Swedish Covenant Immediate Care in Sauganash, 6141 N. Cicero Ave,
Chicago, IL 60646, 773-293-8788 Hours of Operation Monday – Friday:
8 a.m. to 8 p.m., Saturday – Sunday: 8 a.m. to 4 p.m.

 Immediate MD, with multiple locations in Chicago, Hours of Operation
Monday – Friday 8am – 8pm, Saturday – Sunday 8am – 4pm. For more
information, visit http://immediatemd.com/.

Prior to seeking care in an emergency room, we recommend that you call your PCP for treatment advice. Often your PCP can see you the same day or next day for urgent care needs. In situations where you feel you can’t call your PCP, such as when you think you may be having a heart attack or stroke, go directly to the nearest hospital emergency room. Notify your PCP as soon as possible of any treatment you receive. To contact your PCP call his/her office.

If you are in need of Behavior Health Care or Chemical Dependency services, you should contact your Primary Care Physician.

The goal of Care Coordination is to provide you with focused one-on-one attention to help you become an active participant in your own health care. Your Case Manager will work directly with you, your family, and the rest of your entire care team to maximize your health care experience. SCPP offers a range of services including: Short term Case Management, Complex Case Management and Disease Management Programs for Asthma and Diabetes. If you think you might be a candidate for these services, you or your PCP may contact us at 773-271-0880 and request the
Case Management Department Monday through Friday 8:30am – 4:30pm.

For the following issues or concerns, please call Swedish Covenant Physician Partners 773-271-0880.
• Select or change a Primary Care Physician
(PCP) or a Woman’s Principal Health Care
Provider (WPHCP)
• Question about a claim
• Utilization Management concerns*
• Selection of a Behavioral Health Care Provider or Substance Use Disorder (Chemical Dependency) Provider

For a medical problem or to make a physician appointment, please call your Primary Care Physician.
Please be advised that after hours calls regarding utilization management decisions for referrals, outpatient surgeries, and inpatient care are taken by a voice mail system. Instructions for leaving a message are given by the after hours greeting by calling our office at 773-271-0880. Messages that are left for staff regarding utilization management issues are returned within one business day of receipt. Language assistance and TTY/TDD for the
deaf, hard of hearing or speech impaired members are available during normal business hours.
*Collect calls will be accepted in regard to Utilization Management concerns.