Certain services can be done for preventive or diagnostic reasons. When a service is performed for preventive screening reasons and is appropriately reported it will be adjudicated under the Preventive Care Services benefit. Preventive services are done on a person who: has not had the preventive screening done before and does not have symptoms or other abnormal studies suggesting abnormalities; or has had screening done within the recommended interval with the findings considered normal; or has had diagnostic services results that were normal after which the physician recommendation would be for future preventive screening studies using the preventive services intervals. has a preventive service done that results in a therapeutic service done at the same encounter and as an integral part of the preventive service (e.g. polyp removal during a preventive colonoscopy), the therapeutic service would still be considered a preventive service. Examples: Preventive services A woman had an abnormal finding on a preventive screening mammography and the follow up study was found to be normal, and the woman was returned to normal mammography screening protocol, then future mammography would be considered preventive. If a polyp is encountered during a preventive screening colonoscopy, the colonoscopy, removal of the polyp, and associated facility, lab and anesthesia fees done at the same time as the preventive colonoscopy, are covered under the Preventive Care Services benefit.
Ccsd #59 employee education slides 10 23-2013
Understanding Your Blue Cross Blue Shield of Illinois
Coverage: 5 Things Every CCSD #59 Employee Needs to
1. How do I stay within the PPO Network?
• It is YOUR responsibility to stay
within the PPO network.
• How do I know if my provider
participates in the PPO network?
• Go online at www.BCBSIL.com using
the “Find a doctor” link. Or• Call the toll-free number on the back
of your Medical ID card.
• Talk with your provider and ask the
“Do you take BlueCross?”
“Are you a participating BlueCross
BlueShield PPO Provider?”
The BCBS IL Network is important!
If you are an HMO Member, your
network is either the the Blue
Advantage HMO Network or the
HMO of Illinois network. remember,
all care has to be directed by your
Primary Care Physician.
70% or 60%
70% or 60%
Benefits are always better when you receive
services within the BCBS IL PPO network.
•Better Co-Insurance (either 90% or 80% in
network, depending on which plan you are
•Lower Out-of-Pocket Maximums
Why are benefits better?
•BlueCross negotiates with doctors and
hospitals. If they come to an
agreement/contract, the providers agree to
provide services at lower costs and greater
discounts. In return, the providers see
greater utilization due to BlueCross’ large
These lower costs and greater discounts are passed on
to the member with better benefits and lower out of
Blue Distinction Centers
Blue Distinction® Centers
Complicated surgeries – and their results – can vary
significantly from one hospital to another. You need
the facts so you can make smart decisions about
where to go for your specialty medical care. Blue
Distinction is a special, quality-based designation
given to certain hospitals nationwide that deliver
proven results for quality care and treatment.
More than 1,600 Blue Distinction hospitals and
treatment centers are available nationwide for
these types of specialty care:
Complex and Rare Cancers
Knee and Hip Replacements
Your Life is Mobile…
Secure Site – Log-in required
•ID Card. Instant digital membership
•Coverage. Benefits and eligibility
•Claims. By patient, date or status
•Health and Wellness.
My Care Profile
Blue ExtrasSM discounts
Nutrition and Fitness
•User Profile. Manage profile settings
Integrated Provider Finder
Use the Integrated Provider Finder tool to:
Find a network primary care physician, specialist or
Make an appointment to consult with a provider
View Patient Feedback or Add your Review for a
View Quality, certifications and recognitions for
BCBS IL Customer Service
Service that Takes You Out
of the Middle
Call your BCBS customer service team for:
• Claim questions or status
Your benefit plan requires that you
contact the Preauthorization number one
day prior to hospitalization or within two
days of an admission for emergency or
maternity care. Failure to preauthorize
may reduce your benefits.
• Medical benefit coverage
For questions regarding benefits,
membership and claims please call the
Customer Service number and select the
Medical Providers: Please file all
medical claims with your local Blue Cross
and Blue Shield Plan.
• Help with finding network
• Membership and eligibility
• ID card requests
• Help with navigating online tools
• Health education and transfer
to other health programs
Members: If a provider does not file a claim
on your behalf, please contact Customer
BlueCross BlueShield of Illinois, an
independent licensee of the BlueCross
BlueShield Association, provides
administrative claims payment services only
and does not assume any financial risk or
obligation with respect to claims.
3. Know Your Preventive Guidelines and
Certain services can be billed as preventive or diagnostic. Preventive
services are covered 100% In-Network – make sure billed as
Covered preventive services performed specifically for preventive
screening, with no known symptoms, illnesses, or history, are generally
covered as Preventive Care, subject to age and gender guidelines,
and health status.
Preventive services are usually covered when performed on a person who:
• has not had the preventive screening done before
• does not have symptoms or abnormalities
• has had a screening done within the recommended age/gender guidelines with the
findings considered “normal”
• has had previous diagnostic services with the results being “normal”
• has a preventive service done that results in a therapeutic service done at the same
time, and as an integral part of the preventive service (e.g. polyp removal during a
preventive colonoscopy), the therapeutic service would still be considered
BCBS IL Well onTarget
Health & Wellness Interactive Tools and Resources
Well onTarget is designed to give you
the support you need to make healthy
choices. All while rewarding you for
your hard work.
Well onTarget Member Wellness Portal
• Onmytime Self-Directed Courses
• Health and Wellnes Library
• Tools and Trackers
• Onmyway Health Assessment
• Life Points Program
BCBS IL Wellness onTarget
Health & Wellness Interactive Tools and Resources
Articles & Tools
Interactive tools to help educate
you on a topic of interest
Food & Exercise Diary
Tool indicating calories consumed,
Calories burned &daily calorie budget.
A resource for you designed
to assess your medical
BCBS IL Fitness Programs
The BCBS IL Fitness Program offers
membership to a national network
of leading national, regional and
local fitness centers for one low
monthly price of $25 and no contract.
There are more than 8,600 fitness
centers in the Fitness Program
24 Hour Fitness
Buy-up option with BCC Enhanced or Custom
Offerings that earn points
− Health Assessment
− Self-directed courses
− Fitness Programs
Life Points Redemption
− # of levels
− Amazon Like store
− Buy Ups are available
Davis VisionSM (877) 393-8844, TruVision (877) 882-2020
Save on eyeglasses, as well as contact lenses, laser vision correction services,
examinations and accessories. Find out more when you log in to BAM.
Jenny Craig® (877) JENNY70 (877-536-6970)
Jenny Craig can help you reach your weight loss goals. You will get one-on-one support
given by a trained weight loss expert.
Life Time® Fitness
Life Time Fitness offers a total health fitness experience no matter your fitness level,
interests, schedule or budget.
Procter & Gamble (P&G) Dental Products (877) 333-0121
Get savings on dental packages containing the latest in Oral B® power toothbrushes and
Seattle Sutton’s Healthy Eating® (800) 442- DIET (800) 442-3438
These freshly prepared, calorie-controlled meals are designed to help with weight loss
and managing certain health problems.
TruHearing® (800) 687-4617
Save on digital hearing aids through TruHearing. Get a hearing test at no extra charge
when performed to fit a hearing aid.
4. Understand Your Prescription Drug Plan
Generic Drugs: These are drugs where the patient has expired and competing pharmaceutical manufactures can no produce and sell that formulary.
plan to pass the savings onto you with a lower copay.
These lower cost generics allow the
Brand Name Drugs: Brand name drugs are still within the patient. These drugs are heavily advertised and cost considerably more than generic alternatives.
A Formulary is a list created by your insurance carrier BlueCross BlueShield of Illinois. They will negotiate with drug companies for discounted rates. These drugs are put on a formulary list
and some of the savings is passed to the consumer at a lower copay.
Non Formulary are brand name drugs that do not fall onto the formulary list. These drugs have the highest copayments.
A copy of the formulary list can be found on www.bcbsil.com
Save Money on Prescription Drugs
Save Money on Prescriptions- ask about lower cost/no cost drugs;
ask for samples; shop different pharmacies for discount drug
programs (www.walmart.com , www.target.com,
www.meijer.com, www.costco.com, www.samsclub.com)