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Blue Cross Community ICP is provided by Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual
Legal Reserve Company (HCSC), an Independent Licensee of the Blue Cross and Blue Shield Association.
ILICPCOC15_Approved 03262015 227604.0115
2015 Certificate of Coverage
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Blue Cross Community Integrated Care Plan
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2015 Certificate of Coverage
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Blue Cross Community Integrated Care Plan
For members with special needs, we cover practice visits to Early Periodic Screening, Diagnosis and
the dentist. Treatment (EPSDT) Services
EPSDT program is covered for members under the age of 21.
The Plan covers limited emergency dental services for the The program includes:
following:
Physical exams
Dislocated jaw Development screenings
Traumatic damage to teeth and supporting structures Lab work
Removal of cysts Immunization
Treatment of oral abscess of tooth or gum origin Health history and education
Treatment and devices for craniofacial anomalies
Drugs for any of the above conditions You do not need an OK from us to receive these services.
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2015 Certificate of Coverage
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Blue Cross Community Integrated Care Plan
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2015 Certificate of Coverage
We cover costs within the limits of what is covered by Nursing Care also covers transitioning children from a
Medicaid and when given for use in the home. Medical hospital to home placement or other appropriate setting
equipment and supplies are not covered if: for members under 21.
They are used for exercise
They are still being tested or are research equipment Nursing Facilities Services
More than one piece of equipment serves the same use
They are used only for making the room or home A Nursing Facility (NF) sometimes goes by different names
comfortable, such as: such as Nursing Home, Long-Term Care Facility,
- Air conditioning or Skilled Nursing Facility. A Nursing Facility is a licensed
- Air filters facility that provides skilled nursing or long-term
- Air purifiers care services after you have been in the hospital.
- Spas/Swimming Pools
- Elevators
- Supplies for hygiene or looks Over-the-Counter Drugs
Over-the-counter drugs (OTC) are medicines you can
purchase at the pharmacy without a prescription. The Plan
Non-Emergency covers at no cost to you certain OTC drugs that are included
Transportation Services on the Preferred Drug List (PDL).
The Plan offers this service free of charge when you have no You will need a valid medication order from your doctor to use
other way to get to: this benefit. These products are to be filled at a Plan network
A doctors appointment pharmacy and for quantities up to a 30-day supply.
An appointment with another health care provider
If you need a ride to the doctor, call Member Services for a Prescription Drugs
ride at least 24 hours before the appointment. Call 911 for
The Plans list of covered drugs is called our Preferred Drug
emergency transport only. (You do not need an OK from the
List (PDL). You pay $0 for covered drugs on this list. Certain
Plan for emergency transport.) The hours of operation are
drugs on this list need an OK ahead of time or have limits
Monday Friday, 8 a.m. to 8 p.m. Central time.
based on medical necessity. To find out if a drug is on the
If you have a complaint about the service or staff, call PDL, please call Member Services or visit our website. A copy
Member Services to talk about your concerns. of the list is also included in your member packet.
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Blue Cross Community Integrated Care Plan
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2015 Certificate of Coverage
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Blue Cross Community Integrated Care Plan
Emergency Care Do not use the ER for routine care. If you do, you will have to
pay for those services. We do not cover ER visits for routine
If you have a true emergency, call 911 or go to the nearest care. You should call your PCP after any emergency (home or
ER. Emergency services are covered even if the provider is not away) so your doctor can plan your follow-up care. You must
part of the Plan network. An Emergency Medical Condition is also call your Care Coordinator after an emergency. He or she
a recent condition or serious injury with severe symptoms that needs to know an emergency occurred to make sure you get
without immediate medical care could result in: all the care and benefits you may be eligible to receive. You
Serious danger to the patients health should call within 24 hours of leaving the ER. Call 911 if you
Serious damage to bodily functions including organs need emergency transport. You do not need an approval from
Disfigurement the Plan for this service.
In the case of a pregnant woman, threat to the health of
the woman or her unborn child
Care while traveling
Call Member Services using the number on your ID card and
Emergency Services and Urgent Care we will help you find a doctor. If you need emergency care, go
Inpatient and outpatient services are given by qualified to a nearby hospital then call Member Services. Emergency
providers and are needed to assess or treat emergency care is covered in all of the United States.
medical or behavioral conditions, including follow-up care.
All these services are covered, including post stabilization
services after an emergency. You will be seen as quickly as Care outside the United States
possible. Call 911 or go to the ER if a person: Medical services performed out of the country are not covered
Has chest pains by Medicaid.
Cannot breathe or is choking
Has passed out or is having a seizure Service Area
Is sick from poison or a drug overdose
Has a broken bone The Plan covers members who live in Cook, DuPage, Kane,
Is bleeding a lot Kankakee, Lake, and Will county, Illinois.
Has been attacked
Is about to deliver a baby
Has a serious injury to the arm, leg, hand, foot or head
Has a severe burn
Has a severe allergic reaction
Has an animal bite
Has trouble controlling behavior and, without treatment,
is a danger to him/herself or others
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2015 Certificate of Coverage
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Blue Cross Community Integrated Care Plan
Complaints, Grievances You can file your grievance on the phone by calling Member
Services. You can also file your grievance in writing via mail or
and Appeals fax to:
Blue Cross Community ICP
Call Member Services if you have a complaint. Your Attn: Grievance and Appeals Unit
satisfaction is important to us. P.O. Box 27838
Albuquerque, NM 87125-9705
Grievances and Appeals Fax: 1-866-643-7069
We want you to be happy with services you get from Blue In the grievance letter, give us as much information as you
Cross Community Integrated Care Plan and our providers. If can. For example, include the date and place the incident
you are not happy, you can file a grievance or appeal. happened, names of the people involved, and details about
what happened. Be sure to include your name and your
member ID number. You can ask us to help you file your
Grievances grievance by calling Member Services.
A grievance is a complaint about any matter other than a If you do not speak English, we can provide an interpreter
denied, reduced or terminated service or item. Blue Cross at no cost to you. Please include this request when you file
Community Integrated Care Plan takes member grievances your grievance. If you are hearing-impaired, call TTY/TDD
very seriously. We want to know what is wrong so we can 711.
make our services better. If you have a grievance about a
provider or about the quality of care or services you have At any time during the grievance process, you can have
received, you should let us know right away. Blue Cross someone you know represent you or act on your behalf.
Community Integrated Care Plan has special procedures in This person will be your representative. If you decide to
place to help members who file grievances. have someone represent you or act for you, inform Blue Cross
We will do our best to answer your questions or help to Community ICP in writing the name of your representative and
resolve your concern. Filing a grievance will not affect your his or her contact information.
health care services or your benefits coverage.
These are examples of when you might want to file Time Limits for Filing a Grievance
a grievance: You may file a grievance either by phone or in writing within
Your provider or a Blue Cross Community Integrated Care 90 calendar days of the problem. We will send you a letter
Plan staff member did not respect your rights. within three business days after we receive your grievance
You had trouble getting an appointment with your provider to let you know we received it and are working to resolve it
in an appropriate amount of time. within 90 calendar days. If you have information that supports
You were unhappy with the quality of care or treatment your grievance, please send that to us as well. We will add it
you received. to your file for consideration.
Your provider or a Blue Cross Community Integrated Care
Plan staff member was rude to you.
Your provider or Blue Cross Community Integrated Care
Plan staff member was insensitive to your cultural needs
or other special needs you may have.
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2015 Certificate of Coverage
Time Frame for an Answer to a Here are two ways to file an appeal.
Grievance 1) Call Member Services at 1-888-657-1211 TTY/TDD 711.
Blue Cross Community ICP has 90 calendar days to If you file an appeal over the phone, you must follow it with a
review and respond to your concerns or as fast as your written signed appeal request.
health condition requires. Your grievance will be reviewed 2) Mail or fax your written appeal request to:
by someone who was not involved and can research the Blue Cross Community ICP
problem. We will send you another letter within 90 calendar Attn: Grievance and Appeals Unit
days to let you know how your concerns were answered. P.O. Box 27838
Albuquerque, NM 87125-9705
Fax: 1-866-643-7069
Appeals
You may not agree with a decision or an action made by Blue If you do not speak English, we can provide an interpreter at
Cross Community ICP about your services or an item you no cost to you. Please include this request when you file your
requested. An appeal is a way for you to ask for a review of appeal. If you are hearing-impaired, call TTY/TDD 711.
our actions. You may appeal within 60 calendar days of the
date on our Notice of Action form. If you want your services
to stay the same while you appeal, you must say so when Can someone help you with the appeal
you appeal, and you must file your appeal no later than 10 process?
calendar days from the date on our Notice of Action form. You have several options for assistance. You may:
The list below includes examples of when you might want to Ask someone you know to assist in representing you.
file an appeal: This could be your PCP or a family member, for example.
Not approving or paying for a service or item your provider Choose to be represented by a legal professional.
asks for If you are in the Disabilities Waiver, Traumatic Brain Injury
Stopping a service that was approved before Waiver, or HIV/AIDS Waiver, you may also call CAP (Client
Not giving you the service or items in a timely manner Assistance Program) to request their assistance at
Not advising you of your right to freedom of choice of 1-800- 641-3929 (Voice) or 1-888-460-5111 TTY/TDD.
providers
Not approving a service for you because it was not in our To appoint someone to represent you, either 1) Send a letter
network informing us that you want someone else to represent you and
include in the letter his or her contact information or, 2) fill out
If we decide that a requested service or item cannot be approved, the Authorized Representative Appeals form. You may find this
or if a service is reduced or stopped, you will get a Notice of form on our web site at www.bcbsilcommunityicp.com.
Action letter from us. This letter will tell you the following:
What action was taken and the reason for it
Your right to file an appeal and how to do it
Your right to ask for a State Fair Hearing and how to do it
Your right in some circumstances to ask for an expedited
appeal and how to do it
Your right to ask to have benefits continue during your
appeal, how to do it and when you may have to pay for the
services
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Blue Cross Community Integrated Care Plan
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2015 Certificate of Coverage
What happens next? You can ask for a State Fair Hearing in one of the following ways:
After you receive the Blue Cross Community ICP appeal Your local Family Community Resource Center can give
Decision Notice in writing, you do not have to take any action you an appeal form to request a State Fair Hearing and will
and your appeal file will be closed. However, if you disagree help you fill it out, if you wish.
with the decision made on your appeal, you can take action If you want to file a State Fair Hearing Appeal related to
by asking for a State Fair Hearing Appeal and/or asking for your medical services or items, or Elderly Waiver
an External Review of your appeal within 30 calendar days (Community Care Program (CCP)) services, send your
of the date on the Decision Notice. You can choose to ask for request in writing to:
both a State Fair Hearing Appeal and an External Review or Illinois Department of Healthcare and Family Services
you may choose to ask for only one of them. Bureau of Administrative Hearings
69 W. Washington Street, 4th Floor
Chicago, IL 60602
State Fair Hearing Fax: (312) 793-2005
Email: HFS.FairHearings@illinois.gov
If you choose, you may ask for a State Fair Hearing Appeal
Or you may call 855-418-4421, TTY 800-526-5812
within 30 calendar days of the date on the Decision Notice,
but you must ask for a State Fair Hearing Appeal within 10
calendar days of the date on the Decision Notice if you want If you want to file a State Fair Hearing Appeal related to
to continue your services. If you do not win this appeal, you mental health services or items, substance abuse services,
may be responsible for paying for the services provided to you Persons with Disabilities Waiver services, Traumatic Brain
during the appeal process. Injury Waiver services, HIV/AIDS Waiver services, or any
Home Services Program (HSP) service, send your request in
At the State Fair Hearing, just like during the Blue Cross writing to:
Community ICP Appeals process, you may ask someone to Illinois Department of Human Services
represent you, such as a lawyer or have a relative or friend Bureau of Hearings
speak for you. To appoint someone to represent you, send us 69 W. Washington Street, 4th Floor
a letter informing us that you want someone else to represent Chicago, IL 60602
you and include in the letter his or her contact information. Fax: (312) 793-8573
Email: DHS.HSPAppeals@illinois.gov
Or you may call 800-435-0774, TTY 877-734-7429
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Blue Cross Community Integrated Care Plan
At least three business days before the hearing, you will receive Your hearing may be rescheduled, if you let us know within
information from Blue Cross Community ICP. This will include all 10 calendar days from the date you received the Dismissal
evidence we will present at the hearing. This will also be sent to Notice, if the reason for your failure to appear was:
the Impartial Hearing Officer. You must provide all the evidence A death in the family
you will present at the hearing to Blue Cross Community ICP Personal injury or illness which reasonably would prohibit
and the Impartial Hearing Officer at least three business days your appearance
before the hearing. This includes a list of any witnesses who will A sudden and unexpected emergency
appear on your behalf, as well as all documents you will use to
support your appeal. If the appeal hearing is rescheduled, the Hearings Office
will send you or your authorized representative a letter
You will need to notify the appropriate Hearings Office of any rescheduling the hearing with copies to all parties to the
accommodation you may need. Your hearing may be conducted appeal. If we deny your request to reset your hearing, you
over the phone. Please be sure to provide the best phone will receive a letter in the mail informing you of our denial.
number to reach you during business hours in your request for
a State Fair Hearing. The hearing may be recorded.
The State Fair Hearing Decision
A Final Administrative Decision will be sent to you and all
Continuance or Postponement interested parties in writing by the appropriate Hearings
You may request a continuance during the hearing, or a Office. This Final Administrative Decision is reviewable only
postponement prior to the hearing, which may be granted if through the Circuit Courts of the State of Illinois. The time
good cause exists. If the Impartial Hearing Officer agrees, the Circuit Court will allow for filing of such review may be
you and all parties to the appeal will be notified in writing as short as 35 days from the date of this letter. If you have
of a new date, time and place. The time limit for the appeal questions, please call the Hearing Office.
process to be completed will be extended by the length of
the continuation or postponement.
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2015 Certificate of Coverage
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Blue Cross Community Integrated Care Plan
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2015 Certificate of Coverage
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Blue Cross Community Integrated Care Plan
Member Responsibilities: If you think you have been treated unfairly or discriminated
against, call the U.S. Department of Health and Human
1. Read and follow the member handbook.
Services (HHS) toll-free at 1-800-368-1019. You can also
2. K eep your scheduled appointments or call your provider view information concerning the HHS Office for Civil Rights
to reschedule or cancel at least 24 hours before your online at www.hhs.gov/ocr.
appointment.
3. Show your ID card to each provider before getting
medical services. Privacy Policy
4. Call your PCP or 24/7 Nurseline before going to an We have the right to get information from anyone giving you
emergency room, except in situations that you believe are life care. We use this information so we can pay for and manage
threatening or that could permanently damage your health. your health care. We keep this information private between
5. Y ou can see a Blue Cross and Blue Shield of Illinois you, your health care provider, and us, except as the law
specialist without a referral from your PCP, but it is allows. Refer to the Notice of Privacy Practices to read about
important that your PCP knows which doctors you see. your right to privacy. This notice was included in your new
member packet. If you would like a copy of the notice, please
6. C
all Member Services if you change your phone number or
call Member Services.
your address. You also should contact your Case Worker at
Department of Human Services (DHS).
7. Share information about your health with your primary care
provider and learn about service and treatment options.
That includes the responsibility to:
a. Tell your primary care provider about your health
b. T alk to your providers about your health care needs
and ask questions about the different ways your health
problems can be treated
c. Help your providers get your medical records
d. T reat your providers and other health care employees
with respect and courtesy
8. Be involved in service and treatment option decisions.
Make personal choices to keep yourself healthy. That
includes the responsibility to:
a. Work as a team with your provider in deciding what
health care is best for you
b. Understand how the things you do can affect your health
c. Do the best you can to stay healthy
d. T reat providers and staff with respect
e. Talk to your provider about all of your medications
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