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Blue Cross Community ICP SM

Member Handbook

Effective January 2015 www.bcbsilcommunityicp.com

ILICPMBH15_Approved 03262015 227597.0115


WELCOME! Thank you for becoming a member of the Integrated Care Program,
Blue Cross Community ICP (the Plan) from Blue Cross and Blue Shield of Illinois
(BCBSIL). This handbook will help you get the most from the Plan, including:
H ow to use providers in the Plan network approved before going to get treatment
Important phone numbers to know (prior authorization).
H ow your health plan works W hen to use the emergency room (ER)
W hat your plan covers and what it doesnt H ow to use the 24/7 NurselineSM
When you need health care services H ow your Care Coordinator can help

This handbook also explains:


Health information privacy Grievances and appeals  ember rights and responsibilities
M

When you need to contact Member Services


Our goal is to serve your health care needs through all of lifes changes. If you have any questions,
our team stands ready to help.

Call 1-888-657-1211 TTY/TDD 711


We are open between 8 a.m. to 8 p.m. Central time, seven days a week from
October 1 to February 14. From February 15 to September 30, we are open 8 a.m. to
8 p.m. Central time, Monday through Friday. Alternate technologies (for example,
voicemail) will be used on the weekends and Federal holidays. The call is free.
You can find the phone number at the bottom of each page of this handbook.
Llame al <1-888-657-1211> TTY/TDD <711>. Estamos abiertos de 8 a.m. a 8 p.m., hora
central, los siete das de la semana del 1 de octubre al 14 de febrero. Durante el 15
de febrero al 30 de septiembre, estamos abiertos 8 a.m. a 8 p.m., hora central, lunes
a viernes. Se usar tecnologas alternas (por ejemplo, correo de voz) durante los fines
de semana y feriados. La llamada es gratuita.

Website www.bcbsilcommunityicp.com

Write Blue Cross Community ICP P.O. Box 3865 Scranton, PA 18505
(For General Correspondence)

Help In Other Languages


Call Member Services if you want help in another language. The Plan offers interpreter services. Please see page 5 for more details.
Help For Members With Hearing or Vision Loss
The Plan has a toll-free number for members with hearing or speech loss. Call the Member Services TTY/TDD line during normal
business hours. Members with hearing or vision loss can get this handbook and important plan details in other formats.
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

Member Services:1-888-657-1211
MemberServices: 1-888-657-1211TTY/TDD
TTY/TDD711
711www.bcbsilcommunityicp.com
www.bcbsilcommunityicp.com24/7 Nurseline:1-888-343-2697
24/7Nurseline: 1-888-343-2697
Whats Inside

Blue Cross Community ICP SM

Member Handbook

Get Started. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
How to Use this Book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Important Things to Do . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Get Care How to Use Your Blue Cross Community ICP Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Help in Other Languages. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Your ID Card. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Get a Primary Care Provider (PCP). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4


Provider Directory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Changing Your PCP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Make an Appointment with Your Doctor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Making Changes to Your Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Programs to Help Keep You Well. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Emergency and Urgent Care Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Get the Most from Your Plan: Details & Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12


What is covered by Blue Cross Community ICP?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Added Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
What is not covered by Blue Cross Community ICP?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
How to Fill Your Prescriptions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Help with Long-Term Services and Support. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Additional Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
How to Resolve a Problem with Blue Cross Community ICP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Other Things You May Need to Know. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Your Health Care Rights and Responsibilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Important Phone Numbers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Member Services: 1-888-657-1211 TTY/TDD 711 www.bcbsilcommunityicp.com 24/7 Nurseline: 1-888-343-2697 1


Get Started
How to Use This Book Important Things to Do
You will find this handbook easy to use. Here are Keep your Blue Cross Community ICP
some tips to help you to get started and save time: identification card (ID) with you at all times,
along with your Illinois Department of
Read these parts first: Healthcare and Family Services (HFS) medical
Important Things to Do card. Show it every time you need health care
How to use your Blue Cross Community ICP Plan services. Dont let anyone else use your card.
Emergency and Urgent Care Services Make sure the doctor on your ID card is the one
you want. Your ID card lists your Primary Care
Then read: Provider (PCP). This doctor is your main health care
What is Covered by Blue Cross Community ICP provider. If you want a different PCP, let us know
What is Not Covered by Blue Cross Community ICP right away.
Programs to Help Keep You Well Make sure you use providers in the Plan network.
If no one in the network can give you the care you
Also read:
need, your PCP may ask us for an OK to send you
Other Things You May Need to Know to a provider that is not in the Plan network. If you
Additional Resources, including the Appeals dont have a health care emergency, you should use
Process
a provider in the network.
Your Health Care Rights and Responsibilities
Set up an initial health exam with your PCP right
Important Phone Numbers away. If you are an adult, your first health exam
If you need help with this handbook, call Member should to be within 30 days of joining the Plan.
Services (see phone number at bottom of each During the first exam, the PCP will learn about your
page). health care needs to help you stay healthy. Call
Member Services if you need a ride to and from
non-emergency medical visits.
If its an emergency, get help right away. Call
911 or go to the nearest emergency room (ER)
for medical care. Call an ambulance if there is
no 911 service in your area. You dont need an
approval from the Plan or your PCP for emergency
care. It doesnt matter if you are inside or outside
the network service area. Youll be covered for
emergency services in the U.S. even if the provider
isnt part of the Plan.
If you have a health problem, you can talk to
a nurse at 24/7 Nurseline (see phone number
at bottom of each page). Have your ID card ready
when you call.

2 Member Services: 1-888-657-1211 TTY/TDD 711 www.bcbsilcommunityicp.com 24/7 Nurseline: 1-888-343-2697


Get Care How to Use Your Blue Cross Community ICP Plan
Help in Other Languages www.bcbsilcommunityicp.com
www.bcbsilcommunityicp.com
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Can someone interpret for me when I speak with

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MEMBERS: Medical & Behavioral Health Claims:

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MEMBERS: Medical & Behavioral Health Claims:

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Member Services: <888-657-1211>
Member Services: <888-657-1211> BlueBlue
CrossCross Community
Community ICP ICP
my doctor?
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TDD/TTY: 711 Attn: Claims
TDD/TTY: 711<888-343-2697> Attn: Claims

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24/7 Nurse Line: PO Box 805107
24/7 Nurse Line: <888-343-2697>
PROVIDERS: PO Box
Chicago, 805107
IL 60680-4112

PROVIDERS:
<888-657-1211> Chicago, IL 60680-4112
The Plan offers interpreter services for many
For all other claims (including dental,
PHARMACISTS ONLY: vision, and transportation) call <888-
<888-657-1211>
<888-274-5218> For allforother
657-1211> paperclaims (including
claim address. dental,
PHARMACISTS ONLY: vision, andBlue
transportation) call <888-
languages, and includes: Blue Cross and Blue Shield
<888-274-5218>
of Illinois, a
Division of Health Care Service
licensee of the
657-1211>
Shield
Cross and Blue
for paper claim address.
Association.

Health education materials in English


Corporation, a Mutual Legal Reserve
Blue Cross and Blue Shield of Illinois, licensee of the Blue Cross and Blue
Company (HCSC), an independent
a Division of Health Care Service Shield Association.
Corporation, a Mutual Legal Reserve
and Spanish Blue Cross
Company (HCSC), Community
an independent ICPSM

Member Services staff that speaks English Member Name: Medicaid ID: <123456789>

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and Spanish <John A Doe>

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Member ID: <123456789>

Phone interpreter services


Sign language and face-to-face
interpreter services SA M P
Group Name:<XXXX>
Enrollment Effective Date:
<MM,DD,YYYY>
PCP:<PCP NAME>
RxBIN: <011552>
RxPCN: <XXXX>
<PCP PHONE NUMBER>
Providers who speak two languages
How can I get a face-to-face interpreter in the Your ID Card
providers office?
If you need help in a language other than English How to read it, how to use it
(that your physician does not speak) during your Show your ID card to your doctor, hospital or other
medical visit, you can ask for a face-to-face or provider when you go for health care services.
phone interpreter at no charge. The Plans Provider
Directory tells you what languages the providers Your ID card has these important details
speak. about you:
Name
Who do I call for an interpreter? Member ID number
Call Member Services and we will get someone who Medicaid ID number
speaks your language. Effective date of coverage
How far in advance do I need to call?
Member Services phone number and TTY line
If you need someone to translate for you while
PCPs name and phone number
youre at your PCPs office, call us at least 72 hours Blue Cross Community ICP plan name and claims
address
(three business days) in advance. Well be glad to
help. You dont have to use a family member or a The phone number for the 24/7 Nurseline,
the toll-free nurse help line
friend to translate for you unless thats your choice.
Youll get a new plan ID card if:
You change your PCP
Your PCPs address or phone number changes
You lose your ID card

Call Member Services to replace your ID card


if it is lost.

Member Services: 1-888-657-1211 TTY/TDD 711 www.bcbsilcommunityicp.com 24/7 Nurseline: 1-888-343-2697 3


Get a Primary Care Provider (PCP)
Your ID card will have the name and phone number Provider Directory
of the Primary Care Provider (PCP) you chose or the You may view the Provider Directory online or in
PCP assigned if you didnt choose one. print. Look under Family Practice, Internal Medicine
or Geriatrics to choose a PCP. Call Member Services
What is a Primary Care Provider (PCP) or Womens
if you need a copy of the directory or need help.
Health Care Provider (WHCP)?
A PCP/WHCP is your main health care provider. It is important to find the right PCP. The Provider
They also recommend you see special doctors Directory answers questions such as:
(specialists) when needed. Does the PCP have handicap accessible facilities?
A PCP/WHCP can be a: What language does the PCP speak?
Family or general practitioner Is the PCPs office open on weekends?
Geriatrician
Internist Changing Your PCP
Obstetrician/gynecologist (OB/GYN) How can I change my PCP?
(for women)
Nurse Practitioner (NP) or Call Member Services to change your PCP. Unless a
Physician Assistant (PA) change is truly needed, its best to keep the same
PCP so he or she can get to know your health needs
Call your PCP before you get any medical care,
and history.
unless its an emergency. You can reach your PCP 24
hours a day at the PCP number on your card. After If you do change your PCP, be sure to have your
regular business hours, leave your name and phone medical records sent to the new PCP.
number with the answering service. Either your PCP
or an on-call doctor will call you back. If you have an How many times can I change my PCP?
emergency, call 911 or go to the nearest ER. You can Theres no limit on how many times you can change
also call the 24/7 Nurseline. your PCP.

Can I choose any WHCP as my PCP? What are the reasons a request to change a PCP may
A woman can go to a WHCP as her PCP, however be denied?
the WHCP must be an in-network provider and PCP is not taking new patients
accepting new patients. PCP is not in your network
PCP is outside your service area
Can I stay with my WHCP if he or she is not with the
Plan? Will I need prior authorization? When will my PCP change be made?
The WHCP must be included as part of the network. If you ask to change your PCP anytime during the
No prior authorization is needed to see a WHCP. month, you may see your new PCP the first
calendar day of the next month.
How do I choose a WHCP or PCP? For example: If you call on April 13, you may see
your new PCP on or after May 1.
Look in the Plan Provider Directory for PCPs and
WHCPs who work with the Plan and who are taking
Please get care from your current PCP until the
change takes place.
new patients.
Youll get a new ID card with your PCPs name and
Call Member Services or visit the website to get the contact details on it
most up-to-date information about the network.

4 Member Services: 1-888-657-1211 TTY/TDD 711 www.bcbsilcommunityicp.com 24/7 Nurseline: 1-888-343-2697


Get a Primary Care Provider (PCP)
What if I choose to go to a doctor who is not my PCP? Initial Health Exam
You may have to pay for services by a doctor whos The first meeting with your new PCP is important.
not your PCP. You should: Its a time for you to get to know each other and talk
Call us first to change your PCP, or about your health. Your PCP will:
Get an OK from us before you use the Take your medical history
non-PCP doctor Give you a physical exam
Provide you with health information
Make an Appointment with Your Assess your health care needs
Doctor
Call your PCP for an appointment. Tell him or her
youre a Plan member. Have your ID card with you
when you call.

When going to your doctors appointment:


Take your plan ID card and HFS medical card
with you
Be on time for your appointment
Call the doctors office as soon as possible if
youre going to be late or need to cancel
Keep in mind, your PCP may not be able to see you
if youre late.

What if I need to cancel an appointment?


Routine Medical Care
Call your PCPs office and someone will help you set
up a new appointment. What is routine (regular) medical care?
How soon can I expect to be seen?
You get regular care, such as checkups, from your
PCP to help keep you healthy. You should be able
to see your PCP within fourteen (14) days from the
date you call to make your appointment.
Note: If you need family planning, you may go to any
provider who takes Medicaid (see the section called
Get the Most from Your Plan, to learn more about
family planning).

Member Services: 1-888-657-1211 TTY/TDD 711 www.bcbsilcommunityicp.com 24/7 Nurseline: 1-888-343-2697 5


Get a Primary Care Provider (PCP)
Urgent Medical Care
What is urgent medical care? How soon can I expect
to be seen?
An urgent medical condition isnt an emergency,
but needs attention quickly. Your PCP will see you
within24 hours for urgent care. If you cant reach
your PCP:
Call Member Services
Call 24/7 Nurseline
Specialty Care

What if I need to see a special doctor (specialist)?


Your PCP may send you to a different doctor for
special care or treatment. Someone at the PCPs Care Coordination
office can help you make the appointment. Members will complete a Health Risk Assessment
T ell your PCP as much as you can about your (HRA) at least annually. The HRA helps us to assign
health so both of you can decide whats best. a Care Coordinator who will be your health care
A specialist may treat you for as long as he or she coach. He or she will oversee the Plan of care you
thinks you need it. and your Care Team decide is right and help you
reach your health goals using your benefits. Your
How soon can I expect to be seen by a specialist? Care Coordinator will also:
You will get your appointment within 30 days of P lan in-person visits or phone calls with you
the request. Out-of-network services arent covered L isten to your concerns
unless you get an OK from us before you get the H elp you get services and find health issues
service. before they get worse (preventive care)

Who do I call if I have special health care needs and


H elp set up care with your doctor and other
health care team members
need someone to help me?
H elp you, your family and your caregiver better
Call Member Services for help getting the care you understand your health condition(s), medications
need. The Plan will allow you to be seen by the and treatments
specialists you may need for identified conditions.
This includes a standing (on-going) authorization to
a specialist or having him or her as a PCP if needed.

6 Member Services: 1-888-657-1211 TTY/TDD 711 www.bcbsilcommunityicp.com 24/7 Nurseline: 1-888-343-2697


Get a Primary Care Provider (PCP)
Prior Authorization Deductibles and Copays
(Getting an OK from the Plan) You dont have to pay any deductibles or copays for
Your PCP will get an OK from the Plan for some approved services.
services to make sure they are covered. This means
that both the Plan and your PCP (or specialist) agree What if I get a bill from my doctor?
that the services are medically necessary. Medically In most cases, you shouldnt get a bill from a Plan
necessary refers to services that: provider. You may have to pay for charges if:
Protect life Y ou agree to pay for services that arent covered
Keep you from getting seriously ill or disabled or OKd by the Plan
Reduce severe pain by finding out whats wrong Y ou agree to pay for services from a provider who
or treating the disease, illness or injury doesnt work with the Plan and you didnt get an
OK ahead of time.
Getting an OK takes no more than 14 business days,
or if needed faster, no more than three business Who do I call?
days. To check service limits, see the section called
Call Member Services if you get a bill and dont think
What is Covered by Blue Cross Community ICP.
you should have.
Your PCP can also tell you about this.
We may ask your PCP why you need special care Getting a Second Medical Opinion
and we may not always OK requested services. If
that happens, we will send you and your PCP a How can I ask for a second opinion?
letter stating why the services wont be covered. The You may have questions about care your PCP or
letter will tell you how to appeal our decision if you doctor says you need. You may want a second
disagree. opinion to:
We wont pay for services from a provider that isnt D iagnose an illness
part of the Plan network if you didnt get an OK from M ake sure your treatment plan is right for you
us before getting the services. You should speak to your PCP if you want a second
opinion. He or she will send you to a doctor who:
What services do not need a referral (or an OK from
my PCP)? A lso works with the Plan
Primary Care Is the same kind of doctor you saw first
In-network specialist You may get an OK from the Plan to see a doctor
Family Planning who isnt with the Plan.
WHCP Services - you must choose doctors Call Member Services for help getting a second
in the network. opinion or call the 24/7 Nurseline to learn more.
Emergency Care

Member Services: 1-888-657-1211 TTY/TDD 711 www.bcbsilcommunityicp.com 24/7 Nurseline: 1-888-343-2697 7


Get a Primary Care Provider (PCP)
Service Area Making Changes to Your Plan
The Plan covers members who live in Cook, DuPage,
What should I do if I move?
Kane, Kankakee, Lake, and Will county, Illinois.
Call Member Services for your next steps as soon as
What if Im traveling? you have your new address.
If you get sick in some other county or state, the
Can I change health plans?
Plan will only pay for emergency services. We cover
emergencies anywhere in the United States. The If you are new to the Plan, you will have ninety 90
Plan does not cover services outside the United days from the date of your first enrollment to try it.
States. D uring the first 90 days, if you want
to change plans for any reason, call the
If you have an emergency while youre away Illinois Client Enrollment Services (ICES) at
from home: 1-877-912-8880 (TTY/TDD 1-866-565-8576)
G o to the nearest hospital A fter 90 days, if you are still eligible, youll stay
S how them your member ID card enrolled in (locked into) the current Plan for the
next nine months.
D o not make a payment
A ll charges should be billed to the Plan At the end of your enrollment year, youll get a letter
from the ICES. The letter will tell you about open
You may have to pay if you get care outside your enrollment, the time when you can change health
service area if its not an emergency and you do not plans if youd like. Youll have 60 days to make a
have an OK from us. change. You can change health plans during open
enrollment every year.
If you change plans, you will be a member in
your chosen new plan at the end of your current
enrollment year. Whether you pick a new plan or
stay with the current Plan, you will be locked into
that plan for the next 12 months.

Dis-enroll from (drop out of) the Plan


Reasons you may request to drop out of the Plan at
any time include, but arent limited to:
1. Moving out of the service area
2. The Plan not covering services you need
3. Related covered services needed at the same
time arent available through the Plan, and your
PCP or other doctor believes getting the services
separately would risk your health
4. Poor quality of care
5. Lack of access to providers who treat your health
care needs

8 Member Services: 1-888-657-1211 TTY/TDD 711 www.bcbsilcommunityicp.com 24/7 Nurseline: 1-888-343-2697


Get a Primary Care Provider (PCP)
What happens if I lose my Medicaid coverage?
If you lose Medicaid eligibility for 60 days or less and then become eligible again, you will be re enrolled
with the Plan. We will assign you to your past PCP if they are still accepting patients.

Healthy Living
Below is a list of yearly recommended preventive exams you should review this with your PCP.

If You Are You Need


Annual Physical Exam, Annual Flu Shot, Tetanus-Diphtheria
Male or Female age 19-20 Booster (needed every 10 years), Additional Immunizations as
recommended by your PCP
Annual Physical Exam, Annual Flu Shot, Tetanus-Diphtheria Booster
Male age 21-34
(needed every 10 years)
Annual Physical Exam, Annual Flu Shot, Tetanus-Diphtheria Booster
Female age 21-34 (needed every 10 years), Pap Smear, Chlamydia Screening,
HPV Vaccine (if you are under 26)
Annual Physical Exam, Annual Flu Shot, Tetanus-Diphtheria Booster
Male age 35-49 (needed every 10 years), Cholesterol Testing, Glaucoma Screening
(if you are over 39)
Annual Physical Exam, Annual Flu Shot, Tetanus-Diphtheria Booster
(needed every 10 years), Pap Smear, Cholesterol Testing
Female age 35-49 (if you are over 44), Glaucoma Screening (if you are over 39)
Baseline Mammogram (covered once/lifetime for women 35 or
older). Annual Screening Mammogram for women 40 or older
Annual Physical Exam, Annual Flu Shot, Tetanus-Diphtheria Booster
Male age 50-64 (needed every 10 years), Cholesterol Testing, Colorectal Cancer
Screening, Glaucoma Screening
Annual Physical Exam, Annual Flu Shot, Tetanus-Diphtheria Booster
Female age 50-64 (needed every ten [10] years), Pap Smear, Mammogram, Cholesterol
Testing, Colorectal Cancer Screening, Glaucoma Screening
Annual Physical Exam, Annual Flu Shot, Tetanus-Diphtheria Booster
(needed every 10 years), Pneumococcal Vaccine, Cholesterol
Male age 65+
Testing, Colorectal Cancer Screening (to age 75), Glaucoma
Screening, Hearing Screening
Annual Physical Exam, Annual Flu Shot, Tetanus-Diphtheria Booster
(needed every 10 years), Pneumococcal Vaccine, Mammogram
Female age 65+
(to age 74), Cholesterol Testing, Colorectal Cancer Screening
(to age 75), Glaucoma Screening, Hearing Screening

Member Services: 1-888-657-1211 TTY/TDD 711 www.bcbsilcommunityicp.com 24/7 Nurseline: 1-888-343-2697 9


Get a Primary Care Provider (PCP)
Programs to Help Keep You Well Healthy Living
Each person has special needs at every stage of life, Your Care Coordinator and Interdisciplinary Care
and we have programs to help you stay healthy and Team will help you get the information and care you
to manage illness. need to be healthy. And they will assist in managing
your health condition. This includes:
You can use these programs and get information
about them at no cost. Call Member Services to Tips on how to help manage your weight, eat
better and stay fit with an exercise program
learn more about these programs, or check out our
website and look under the Member Resources at Brochures with heart-healthy tips on how to help
control blood pressure and cholesterol
bcbsilcommunityicp.com. If you have hearing or
speech loss, call the Member Services TTY/TDD line. Brochures on drugs and alcohol show you how to
stop problems before they start
We hope you use them. We want you to be well and Well-woman care with tips about healthy
to stay that way. behaviors and the need for routine exams,
mammograms and cancer screenings
Information about managing on-going medical
conditions such as asthma, diabetes, and heart
disease
Family planning to help teach you:
How to be as healthy as you can before you get
pregnant
How to prevent pregnancy
How to prevent sexually transmitted diseases
(STDs) such as HIV/AIDS

For Your Peace of Mind


24/7 Nurseline allows you to talk to a nurse 24 hours
a day, seven days a week. To learn more about 24/7
Nurseline, see the section under Whats Covered
24/7 Nurseline on page 14.

10 Member Services: 1-888-657-1211 TTY/TDD 711 www.bcbsilcommunityicp.com 24/7 Nurseline: 1-888-343-2697


Get a Primary Care Provider (PCP)
Emergency and Urgent Care
Services If you have a true emergency, call 911
or go to the nearest ER
Emergency services are covered even if the provider
isnt part of the Plan network.

An Emergency Medical Condition is:


A recent condition or serious injury with severe
symptoms that without immediate medical care
could result in:
Serious danger to the patients health
Serious damage to bodily functions
including organs
Disfigurement Call 911 or go to the ER if a person:
In the case of a pregnant woman, threat to the Has chest pains
health of the woman or her unborn child Cannot breathe or is choking
Has passed out or is having a seizure
What are Emergency Services and Urgent Care? Is sick from poison or a drug overdose
Inpatient and outpatient services are given by Has a broken bone
qualified providers and are needed to assess or Is bleeding a lot
treat emergency medical or behavioral conditions,
including follow-up care. All these services are Has been attacked
covered. 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 dangerous to him/herself or others
Do not use the ER for routine care. If you do, youll
have to pay for those services. We do not cover ER
visits for routine care.

How soon can I expect to be seen?


You will be seen as soon as possible. You should call
your PCP after any emergency (home or away) so
your doctor can plan your follow-up care. You must
also call your Care Coordinator after an emergency.
He or she needs to know an emergency occurred
to make sure you get all the care and benefits you
may be eligible to receive. You should call within 24
hours of leaving the ER.

Member Services: 1-888-657-1211 TTY/TDD 711 www.bcbsilcommunityicp.com 24/7 Nurseline: 1-888-343-2697 11


Get the Most from Your Plan: Details and Benefits
What is covered by Blue Cross or WHCP. Physical exams are not part of family
Community ICP? planning. A physical exam may include:
Family counseling
The kinds of care the Plan covers are listed Nutrition
in alphabetical order. Please note that these
services must be medically necessary to
Exercise
be covered. Substance abuse
Sexual practices
What does medically necessary mean? Injury prevention
Medically necessary services or supplies are needed
to diagnose or treat your medical condition. They Audiology Services
must meet accepted medical standards. We wont Hearing aids are covered for all members but
pay for services that are not deemed medically require prior authorization. Hearing aids are limited
necessary. to 1 hearing aid/ear every three years. Batteries
are limited to 32 per 60 days and require no prior
We will pay for all covered services on the authorization. Hearing screenings are only covered
following list. if you are under the age of 21, or are over the age of
You may have to pay for care or services that arent 21 and having symptoms of an ear problem.
listed here, or arent medically necessary. If they are
listed here and are medically necessary, we will pay Behavioral Health Services
the full cost of the services. If you have a behavioral health crisis, call
1-888-657-1211 TTY/TDD 711 and someone will
Call Member Services if you have questions about
assist you, 24 hours a day seven days a week.
what the Plan covers.
Some of the behavioral health services we cover
24/7 Nurseline include:
24/7 Nurseline lets you talk in private with a nurse Mental Health Assessment and/or Psychological
about your health. Call toll-free, 24 hours a day, Evaluation
seven 7 days a week at 1-888-343-2697 TTY/TDD Medication Management
711. A nurse can give you details about health Therapy/Counseling (individual, family, group)
issues and community health services. If you prefer, Community Treatment and Support (individual,
you can also listen to audio tapes on more than 300 family, group)
health topics such as:
If you see a provider in the network, you dont need
Allergies and Immune System a referral. Services may require prior authorization
Childrens Health so call Member Services to check if you are not sure.
Diabetes
High blood pressure Chiropractor Services
Sexually transmitted diseases such as HIV/AIDS Covered services are limited to spinal manipulation
for subluxation of the spine for members under 21.
Abortion If you see an in-network provider, you dont need
Abortion services covered if the mothers life is a referral.
endangered, or to end a pregnancy caused by
Colorectal Cancer Screening
rape or incest.
Colorectal cancer screenings are covered.
Annual Adult Well Exams
Annual adult well exams are done by your PCP

12 Member Services: 1-888-657-1211 TTY/TDD 711 www.bcbsilcommunityicp.com 24/7 Nurseline: 1-888-343-2697


Get the Most from Your Plan: Details and Benefits
Diagnostic and Therapeutic Radiology
Some radiology services need an OK from us before
you get the service:
Non-invasive X-rays and testing to help find out
whats wrong must be ordered and done by (or
under the guidance of ) your PCP.
Screening mammograms are not covered
until age 40. You may receive one baseline
mammogram after you turn 35 years of age.
Dental Services
Dental providers take care of your teeth. You dont need
CTs and MRIs need an OK from your PCP and
the Plan.
an OK from your PCP for dental care. Visit our website to
find a dental provider, or call Member Services. Doctor Services
The plan covers the following dental services*: Well pay for your annual adult well exam as well as
Oral exams Teeth cleanings visits to:
Your PCP
Fillings Crowns
Your WHCP
Root Canals Dentures Your Advanced Practice Nurse
Extractions Visits to Federally Qualified Health Centers
Flouride treatments for members ages 19-20 (FQHCs) and Rural Health Centers (RHCs)
*Some limits apply to general dentistry above. A specialist (with an OK from your PCP)
Eligible pregnant women can get the additional
Other providers (with an OK from your PCP)
dental services prior to the birth of their babies as Early Periodic Screening, Diagnosis and
below: Treatment (EPSDT) Services
Periodic oral examination ESPDT program is covered for members under the
Teeth cleaning age of 21. The program includes:
Periodontal work
Physical exams
Development screenings
For members with special needs, we cover practice
visits to the dentist
Lab work
Immunization
Are emergency dental services covered? Health history and education
The Plan covers limited emergency dental services You do not need an OK from us to receive these services.
for the following:
Emergency and Urgent Care Services
Dislocated jaw
If you have a true emergency, call 911 or go to the
Traumatic damage to teeth and supporting nearest ER. We dont need to OK hospital emergency
structures
and urgent care services including transportation
Removal of cysts for them to be covered. Read more about what an
Treatment of oral abscess of tooth or gum origin emergency is on page 13. Call your PCP for
Treatment and devices for craniofacial anomalies follow-up care within two days of your emergency, or as
Drugs for any of the above conditions soon as you can. You are also required to call Member
Services to let the Plan know you received services.
Post-Stabilization Services after an emergency are covered.

Member Services: 1-888-657-1211 TTY/TDD 711 www.bcbsilcommunityicp.com 24/7 Nurseline: 1-888-343-2697 13


Get the Most from Your Plan: Details and Benefits
Family Planning Services  edical
M
Covered family planning services include: Social
Medical visits for birth control Support
Marriage and family planning, education
and counseling Hospital Services
Birth control Your PCP can send you to any in-network hospital.
Pregnancy tests Look in the Provider Directory to find one. Go to the
nearest hospital in an emergency.
Lab tests
Tests for sexually transmitted diseases (STDs) Inpatient Hospital Services
Sterilization Inpatient hospital services need an OK from us.
You do not need an OK from your PCP to get Covered services include:
family planning help. Members may use any Rehab services
qualified family planning clinic, certified nurse Surgery to repair the breast after a complete or
midwife or provider. The provider doesnt need to partial removal for any medical reason
be part of the Plan network. Medical stabilization for chemical dependency in
Limits a general acute hospital
Some services arent covered: A hospital room with two or more beds
Surgery to reverse sterilization Care in special units
Fertility treatments Operating, delivery and special treatment rooms
Artificial insemination Supplies
In vitro fertilization Medical testing
You can find family planning providers near you Taking X-rays
at our website, or call Member Services for help Drugs the hospital gives you during your stay
finding one. (includes oxygen)
Giving you donated blood
Home Health Care Services Radiation therapy
Home health care services need an OK from us. Chemotherapy
Home health coverage is limited to those services
needed after you are discharged from an in-patient
Dialysis
hospital stay. Some services covered at your home Meals and special diets
include: General nursing care
Home health aide services Anesthesia
Speech therapy Respiratory therapy
Physical therapy visits Diagnostic, therapeutic and
Occupational therapy visits rehabilitative services
DME Staying in the hospital overnight for dental
procedures due to medical problems or serious
Disposable medical supplies dental work
Hospice Services (including Palliative)
Coordination of discharge planning, including
continuing care
For members who arent expected to live for more Detoxification
than six months, services include:

14 Member Services: 1-888-657-1211 TTY/TDD 711 www.bcbsilcommunityicp.com 24/7 Nurseline: 1-888-343-2697


Get the Most from Your Plan: Details and Benefits
Outpatient Hospital Services Air filters
Some outpatient hospital services need an OK Air purifiers
from us. Spas/Swimming Pools
Covered services include: Elevators
Dialysis Supplies for hygiene or looks
Emergency room use
Physical, occupational or speech therapy Non-Emergency Transportation Services
Audiologists If I do not have a car, how can I get a ride to a
Drugs ordered by a doctor doctors office?
Giving you donated blood The Plan offers this service free of charge when
Limited oral surgery you have no other way to get to:
Services to prevent or diagnose problems A doctors appointment
Therapeutic and rehabilitative services An appointment with another health care
provider
Ambulatory surgical treatment centers
Hospital ambulatory services How far in advance do I need to call?
Call Member Services for a ride at least 24 hours
Laboratory and X-ray Services
before the appointment.
These services must be ordered by your provider
and done by a licensed provider in an appropriate Who do I call for a ride to a medical appointment?
place.
If you need a ride to the doctor, call Member
Covered services include: Services. Call 911 for emergency transport
All medically necessary lab services only. (You do not need an OK from the Plan for
Cancer tests emergency transport.)
X-ray services What are the hours of operation for transport
Medical Equipment and Supplies services?
Most need an OK from the Plan ahead of time. The hours of operation are:
Covered supplies include: Monday Friday
Prosthetics and Orthotics 8 a.m 8 p.m. Central time
Respiratory Equipment and Supplies Who do I call if I have a complaint about the
Well cover costs within the limits of whats service or staff?
covered by Medicaid and when given for use in Call Member Services to talk about your concerns.
the home. Medical equipment and supplies are
not covered if: Nursing Care Services
They are used for exercise Covered for members under 21 not in the HCBS
They are still being tested or are research Waiver and for individuals who are Medically
equipment Fragile Technology Dependent (MFTD) Waiver.
More than one piece of equipment serves the Nursing Care also covers transitioning children
same use from a hospital to home placement or other
They are used only for making the room or appropriate setting for members under 21.
home comfortable, such as:
These services need an OK from the Plan.
Air conditioning

Member Services: 1-888-657-1211 TTY/TDD 711 www.bcbsilcommunityicp.com 24/7 Nurseline: 1-888-343-2697 15


Get the Most from Your Plan: Details and Benefits
Podiatry (Foot Care)
If you are under the age of 21, or are 21 and over
these services are covered:
Medical problems of the feet
Medical or surgical treatment of disease, injury or
defects of the feet
Cutting or removing corns, warts or calluses
Routine foot care
For those members under 21, additional services
include:
Treatment of flat feet
Treating the feet when the bones are not in line
Nursing Facilities Services and surgery is not needed
A Nursing Facility (NF) sometimes goes by different Limits
names such as Nursing Home, Long-Term Care
The following arent covered:
Facility, or Skilled Nursing Facility. A Nursing Facility
is a licensed facility that provides skilled nursing or Procedures that are still being tested
long-term care services after you have been in the Acupuncture
hospital. Shoe inserts unless they are OKd by the Plan
These services need an OK from the Plan. (DME)
Any service not listed as covered
Physical Therapy, Occupational Therapy and
Speech Pathology Prostate and Rectal Exams
These services need an OK from the Plan. They are Prostate-specific antigen (PSA) and digital rectal
covered when ordered by a doctor and part of a exam (DRE) tests for men are covered for men 40
written plan of care. or older.

Substance Abuse
If you see a provider in the network, you dont
need a referral; however you may need a prior
authorization from us before you get services.
Substance abuse treatments we cover include:
Inpatient treatment
Outpatient treatment
Detoxification
Day treatment
Psychiatric evaluation services

16 Member Services: 1-888-657-1211 TTY/TDD 711 www.bcbsilcommunityicp.com 24/7 Nurseline: 1-888-343-2697


Get the Most from Your Plan: Details and Benefits
Transplants Added Benefits
This service needs an OK from the Plan. Transplants
covered include: No copays
Lungs $ 0 for doctor visits
Combined heart and lung $ 0 for emergency room (ER) visits
Liver $ 0 for prescriptions
Kidney Prescriptions
Cornea 9 0-day supply mailed to your home
Stem cell M edicaids four prescription limit per month does
not apply
Limits
Dental
The first transplant is covered, but only one future
re-transplant because of rejection is allowed. Blue Cross Community ICP also covers:
T wo Cleanings per year
Vision Services T wo Exams per year
Vision providers take care of your eyes. You do not O ne set of preventive X-Rays per year
need an OK from your PCP for vision care. Visit our
website to find a vision provider, or call Member Cell Phone
Services. You may qualify for a free cell phone to call your
Services include: doctor, care coordinator, or 911 emergency services
O ne eye exam every 12 months Transportation
per member
G lasses covered every two years for members In addition to the standard benefit of transportation
21 and older; replaced as needed for members to covered services, as an added benefit you may
under 21 also get transportation to the pharmacy after a
C ontact lenses when medically necessary, if provider appointment
glasses cannot provide the intended result
Optical (Vision)
If glasses or contacts are lost or stolen, contact
As part of your standard benefit, you receive one
Davis Vision at 1-888-715-6716. You can always call
pair of eyeglasses every two years. As an added
Member Services if you have any questions about
benefit, you can receive up to $100 towards a pair of
what is and is not covered. We will pay only for
upgraded eyeglass frames.
those services we OK.
Healthy Incentives Program
You may qualify for gift cards for completing
preventive services or going to your doctor after
certain hospital or ER visits

Member Services: 1-888-657-1211 TTY/TDD 711 www.bcbsilcommunityicp.com 24/7 Nurseline: 1-888-343-2697 17


Get the Most from Your Plan: Details and Benefits
What is not covered by Blue Cross Community ICP?
You can always call Member Services if you have any questions about what is and isnt covered.
We will pay only for those services we OK.

Here are the Kinds of Services not included in the Plan:


M
 edical equipment and supplies that are: R outine physical exams asked for by a job, school,
Used only for your comfort or hygiene or insurance
Used for exercise  edical services that you get in a setting for
M
emergency care for health issues that are not
New or still being tested emergencies
More than one piece of equipment that does Any service not covered under the Fee-for-
the same thing Service program that is not listed as covered.
S upplies for hygiene or looks
C are you got for health problems that have to
do with work, if they can be paid for by workers
compensation, your employer, or by a disease
law that has to do with your job
P ersonal or comfort items given for the ease of
use for any of these:
Members
Families
Doctors
Other providers
P rocedures that are new or still are being tested
S terilization reversals
F ertility treatments, such as artificial insemination
or in-vitro fertilization
D rugs that are not approved by the U.S. Food and
Drug Administration
W eight loss drugs or diet aids
C osmetic drugs
D rugs that help to grow hair
S yringes or needles that are not ordered by your
doctor
A cupuncture
C osmetic surgery done to change or reshape
normal body parts so they look better
T his doesnt apply to reconstructive surgery
to give you back the use of a body part or to
correct a deformity caused by an injury.

Note: This is not a full list of services not covered.

18 Member Services: 1-888-657-1211 TTY/TDD 711 www.bcbsilcommunityicp.com 24/7 Nurseline: 1-888-343-2697


Get the Most from Your Plan: Details and Benefits
How to Fill Your Prescriptions Over-The-Counter (OTC) Drugs
Over-the-counter drugs (OTC) are medicines
How Do I Get My Medicines? you can purchase at the pharmacy without a
The Plan uses a Preferred Drug List (PDL) to help prescription. The Plan covers at no cost to you
your doctor choose which drugs to give you. Certain certain OTC drugs that are included on the PDL.
drugs on this list need an OK ahead of time or have Youll need a valid medication order from your
limits based on medical necessity. Even though a doctor to use this benefit. These products are to be
drug is on the PDL, your doctor will choose which filled at a Plan network pharmacy and for quantities
drug is best for you. up to a 30-day supply.
To find out if a drug is on the PDL, please call
Member Services or visit our website. A copy of
the list is also included in your member packet.
You will need to get your medication at a network
pharmacy, and you will receive up to a 30 day supply.
We offer a mail-order program that lets you get up
to a 90-day supply of your prescription drugs sent
directly to your home. There is no cost to you. Call
Member Services if you have questions or need help.
To protect your health and keep you safe, make
sure your doctor and pharmacist know what
medicines youre taking including over-the-
counter drugs.

Member Services: 1-888-657-1211 TTY/TDD 711 www.bcbsilcommunityicp.com 24/7 Nurseline: 1-888-343-2697 19


Get the Most from Your Plan: Details and Benefits
Network Pharmacies
There are many pharmacies in the network.
To find one in your area, visit our website or call
Member Services.

Mail-Order Program
We offer a mail-order program that lets you get up to a
90-day supply of your medicines sent directly to your
home. There is no cost to you. Call Member Services for
more information.
Make sure to take your Member ID card, HFS medical
card and your prescription/medicine order from your
doctor when you visit the pharmacy.

Help with Long-Term Services and Support


Please see the Long-Term Services and Support Handbook for information
about plan coverage and benefits. This was included in your Member packet.
If you did not receive it, please call Member Services for a new one.

Drugs not on the PDL


Call Member Services to find out if your drug is on the PDL. If it is not, you have
two options:
T alk to your doctor to decide if you can first try a drug on the PDL before you
request an exception.
C all Member Services to request an exception to cover your drug. Send a
ity ICP
statement from your doctor backing your request. We must decide within
10 days of getting your doctors statement.
SM

Blue Cross Commun

Long-Term Services and


ok
Support (LTSS) Handbo We usually only approve requests for exceptions if other drugs on the PDL or
Effective December2014
www.bcb silcommunityicp.com

227552.1214
added-use limits would make your treatment less effective and/or would be
ILCFHPLTSS14
harmful to your health.
You or your doctor can ask for a rush decision if you both believe that your health could be harmed by
waiting up to 10 days for a decision. If we agree to rush, we must give you a decision within 24 hours
(one day) after we get the statement from your doctor.

If you need help getting to your pharmacy


Call Member Services if you need help getting to your pharmacy. There is also information on
Non-Emergency Transportation on page 17.

20 Member Services: 1-888-657-1211 TTY/TDD 711 www.bcbsilcommunityicp.com 24/7 Nurseline: 1-888-343-2697


Additional Resources
How to Resolve a Problem with Blue Cross Community ICP
Call Member Services if you have a complaint. Your These are examples of when you might want to file a
satisfaction is important to us. grievance:
Grievances and Appeals Your provider or a Blue Cross Community ICP staff
member did not respect your rights.
We want you to be happy with services you get from You had trouble getting an appointment with your
Blue Cross Community ICP and our providers. If you provider in an appropriate amount of time.
are not happy, you can file a grievance or appeal. You were unhappy with the quality of care or
Grievances treatment you received.
A grievance is a complaint about any matter other Your provider or a Blue Cross Community ICP staff
member was rude to you.
than a denied, reduced or terminated service or item.
Blue Cross Community ICP takes member grievances
Your provider or Blue Cross Community ICP staff
member was insensitive to your cultural needs or
very seriously. We want to know what is wrong other special needs you may have.
so we can make our services better. If you have a
You can file your grievance on the phone by calling
grievance about a provider or about the quality of
Member Services. You can also file your grievance in
care or services you have received, you should let
writing via mail or fax at:
us know right away. Blue Cross Community ICP has
special procedures in place to help members who Blue Cross Community ICP
file grievances. We will do our best to answer your Attn: Grievance and Appeals Unit
questions or help to resolve your concern. Filing a P.O. Box 27838
grievance will not affect your health care services or Albuquerque, NM 87125-9705
your benefits coverage. Fax: 1-866-643-7069

Time Limits for Filing a Grievance In the grievance letter, give us as much information
as you can. For example, include the date and
You may file a grievance either by phone or in
place the incident happened, names of the people
writing within 90 calendar days of the problem. We
involved and details about what happened.
will send you a letter within three business days
after we receive your grievance to let you know we Be sure to include your name and your member
received it and are working to resolve it within 90 ID number. You can ask us to help you file your
calendar days. If you have information that supports grievance by calling Member Services.
your grievance, please send that to us as well. We will If you do not speak English, we can provide an
add it to your file for consideration. interpreter at no cost to you. Please include this
Time Frame for an Answer to a Grievance request when you file your grievance. If you are
hearing-impaired, call TTY/TDD 711.
Blue Cross Community ICP has 90 calendar days to
review and respond to your concerns or as fast as At any time during the grievance process, you can
your health condition requires. Your grievance will have someone you know represent you or act on
be reviewed by someone who was not involved and your behalf. This person will be your representative.
can research the problem. We will send you another If you decide to have someone represent you or act
letter within 90 calendar days to let you know how for you, inform Blue Cross Community ICP in writing
your concerns were answered. the name of your representative and his or her
contact information.

Member Services: 1-888-657-1211 TTY/TDD 711 www.bcbsilcommunityicp.com 24/7 Nurseline: 1-888-343-2697 21


Additional Resources
Appeals Here are two ways to file an appeal.
You may not agree with a decision or an action made 1. Call Member Services at 1-888-657-1211 TTY/
by Blue Cross Community ICP about your services TDD 711. If you file an appeal over the phone,
or an item you requested. An appeal is a way for you you must follow it with a written signed appeal
to ask for a review of our actions. You may appeal request.
within 60 calendar days of the date on our Notice 2. Mail or fax your written appeal request to:
of Action form. If you want your services to stay the
same while you appeal, you must say so when you Blue Cross Community ICP
appeal, and you must file your appeal no later than Attn: Grievance and Appeals Unit
10 calendar days from the date on our Notice of P.O. Box 27838
Action form. Albuquerque, NM 87125-9705
Fax: 1-866-643-7069
The list below includes examples of when you might
want to file an appeal. If you do not speak English, we can provide an
interpreter at no cost to you. Please include this
N ot approving or paying for a service or item your request when you file your appeal. If you are
provider asks for
hearing-impaired, call TTY/TDD 711.
S topping a service that was approved before
N ot giving you the service or items in Can someone help you with the appeal process?
a timely manner
You have several options for assistance. You may:
N ot advising you of your right to freedom of Ask someone you know to assist in representing
choice of providers
you. This could be your PCP or a family member,
N ot approving a service for you because it was for example.
not in our network
Choose to be represented by a legal professional.
If we decide that a requested service or item cannot
be approved, or if a service is reduced or stopped,
If you are in the Disabilities Waiver, Traumatic Brain
Injury Waiver, or HIV/AIDS Waiver, you may also
you will get a Notice of Action letter from us. This call CAP (Client Assistance Program) to request
letter will tell you the following: their assistance at 1-800-641-3929 (Voice) or
What action was taken and the reason for it 1-888-460-5111 (TTY).
Your right to file an appeal and how to do it To appoint someone to represent you, either 1) Send
Your right to ask for a State Fair Hearing and how a letter informing us that you want someone else
to do it to represent you and include in the letter his or her
Your right in some circumstances to ask for an contact information or, 2) fill out the Authorized
expedited appeal and how to do it Representative Appeals form. You may find this form
Your right to ask to have benefits continue during on our web site at www.bcbsilcommunityicp.com.
your appeal, how to do it and when you may have
to pay for the services

22 Member Services: 1-888-657-1211 TTY/TDD 711 www.bcbsilcommunityicp.com 24/7 Nurseline: 1-888-343-2697


Additional Resources
Appeal Process How can you expedite your appeal?
We will send you an acknowledgement letter within If you or your provider believes our standard
three (3) business days saying we received your timeframe of 15 business days to make a decision
appeal. We will tell you if we need more information on your appeal will seriously jeopardize your life
and how to give us such information in person or in or health, you can ask for an expedited appeal
writing. by writing or calling us. If you write to us, please
A provider with the same or similar specialty as your include your name, member ID number, the date
treating provider will review your appeal. It will of your Notice of Action letter, information about
not be the same provider who made the original your case, and why you are asking for the expedited
decision to deny, reduce or stop the medical service. appeal.
Blue Cross Community ICP will send our decision We will let you know within 24 hours if we need
in writing to you within 15 business days of the more information. Once all information is provided,
date we received your appeal request. Blue Cross we will call you within 24 hours to inform you of our
Community ICP may request an extension up to 14 decision and will also send the Decision Notice to
more calendar days to make a decision on your case you and your authorized representative.
if we need to get more information before we make
a decision. You can also ask us for an extension, How can you withdraw an appeal?
if you need more time to obtain additional You have the right to withdraw your appeal for
documents to support your appeal. any reason, at any time, during the appeal process.
However, you or your authorized representative
We will call to tell you our decision and send you
must do so in writing, using the same address used
and your authorized representative the Decision
for filing your appeal. Withdrawing your appeal
Notice. The Decision Notice will tell you what we will
will end the appeal process and no decision will be
do and why.
made by us on your appeal request.
If Blue Cross Community ICPs decision agrees
Blue Cross Community ICP will acknowledge the
with the Notice of Action, you may have to pay for
withdrawal of your appeal by sending a notice to
the cost of the services you got during the appeal
you or your authorized representative. If you need
review.
further information about withdrawing your appeal,
If Blue Cross Community ICPs decision does not
call Blue Cross Community ICP at 1-888-657-1211
agree with the Notice of Action, we will approve the
TTY/TDD 711.
services to start right away.
What happens next?
Things to keep in mind during the appeal process:
A t any time, you can provide us with more After you receive the Blue Cross Community ICP
information about your appeal, if needed. appeal Decision Notice in writing, you do not have
Y ou have the option to see your appeal file. to take any action and your appeal file will be
closed. However, if you disagree with the decision
Y ou have the option to be there when Blue Cross made on your appeal, you can take action by asking
Community ICP reviews your appeal.
for a State Fair Hearing Appeal and/or asking for an
External Review of your appeal within 30 calendar
days of the date on the Decision Notice. You can
choose to ask for both a State Fair Hearing Appeal
and an External Review or you may choose to ask for
only one of them.

Member Services: 1-888-657-1211 TTY/TDD 711 www.bcbsilcommunityicp.com 24/7 Nurseline: 1-888-343-2697 23


Additional Resources
State Fair Hearing Fax: (312) 793-8573
If you choose, you may ask for a State Fair Hearing Email:DHS.HSPAppeals@illinois.gov
Appeal within 30 calendar days of the date on the Or you may call 800-435-0774
Decision Notice, but you must ask for a State Fair TTY: 877-734-7429
Hearing Appeal within 10 calendar days of the date
on the Decision Notice if you want to continue your State Fair Hearing Process
services. If you do not win this appeal, you may be The hearing will be conducted by an Impartial
responsible for paying for the services provided to Hearing Officer authorized to conduct State
you during the appeal process. Fair Hearings. You will receive a letter from the
At the State Fair Hearing, just like during the Blue appropriate Hearings Office informing you of the
Cross Community ICP Appeals process, you may date, time and place of the hearing. This letter will
ask someone to represent you, such as a lawyer also provide information about the hearing. It is
or have a relative or friend speak for you. To important that you read this letter carefully.
appoint someone to represent you, send us a At least three business days before the hearing, you
letter informing us that you want someone else to will receive information from Blue Cross Community
represent you and include in the letter his or her ICP. This will include all evidence we will present at
contact information. the hearing. This will also be sent to the Impartial
You can ask for a State Fair Hearing in one of the Hearing Officer. You must provide all the evidence
following ways: you will present at the hearing to Blue Cross
Y our local Family Community Resource Center can Community ICP and the Impartial Hearing Officer at
give you an appeal form to request a State Fair least three business days before the hearing. This
Hearing and will help you fill it out, if you wish. includes a list of any witnesses who will appear on
If you want to file a State Fair Hearing Appeal your behalf, as well as all documents you will use to
related to your medical services or items, or Elderly support your appeal.
Waiver (Community Care Program (CCP)) services,
send your request in writing to: You will need to notify the appropriate Hearings
Office of any accommodation you may need. Your
Illinois Department of Healthcare
hearing may be conducted over the phone. Please
and Family Services
be sure to provide the best phone number to reach
Bureau of Administrative Hearings
you during business hours in your request for a
69 W. Washington Street, 4th Floor
State Fair Hearing. The hearing may be recorded.
Chicago, IL 60602
Fax: (312) 793-2005
Continuance or Postponement
HFS.FairHearings@illinois.gov
You may request a continuance during the hearing,
Or you may call 855-418-4421
or a postponement prior to the hearing, which may
TTY: 800-526-5812
be granted if good cause exists. If the Impartial
If you want to file a State Fair Hearing Appeal Hearing Officer agrees, you and all parties to the
related to mental health services or items, appeal will be notified in writing of a new date, time
substance abuse services, Persons with
Disabilities Waiver services, Traumatic Brain and place. The time limit for the appeal process to
Injury Waiver services, HIV/AIDS Waiver services, be completed will be extended by the length of the
or any Home Services Program (HSP) service, continuation or postponement.
send your request in writing to:
Illinois Department of Human Services
Bureau of Hearings
69 W. Washington Street, 4th Floor
Chicago, IL 60602

24 Member Services: 1-888-657-1211 TTY/TDD 711 www.bcbsilcommunityicp.com 24/7 Nurseline: 1-888-343-2697


Additional Resources
Failure to appear at the hearing External Review (for medical services only)
Your appeal will be dismissed if you, or your Within 30 calendar days after the date on the
authorized representative, do not appear at the Blue Cross Community ICP appeal Decision Notice,
hearing at the time, date and place on the notice you may choose to ask for a review by someone
and you have not requested postponement in outside of Blue Cross Community ICP. This is called
writing. If your hearing is conducted via telephone, an external review. The outside reviewer must meet
your appeal will be dismissed if you do not answer the following requirements:
your telephone at the scheduled appeal time. A B oard certified provider with the same or like
Dismissal Notice will be sent to all parties to the specialty as your treating provider
appeal. C urrently practicing
Your hearing may be rescheduled, if you let us know H ave no financial interest in the decision
within 10 calendar days from the date you received N ot know you and will not know your identity
the Dismissal Notice, if the reason for your failure to during the review
appear was: External Review is not available for appeals related
A death in the family to services received through the Elderly Waiver,
P ersonal injury or illness which reasonably would Persons with Disabilities Waiver, Traumatic Brain
prohibit your appearance Injury Waiver, HIV/Aids Waiver, or the Home Services
A sudden and unexpected emergency Program.
If the appeal hearing is rescheduled, the Your letter must ask for an external review of
Hearings Office will send you or your authorized that action and should be sent to:
representative a letter rescheduling the hearing Blue Cross Community ICP
with copies to all parties to the appeal. Attn: Grievance and Appeals Unit
If we deny your request to reset your hearing, you P.O. Box 27838
will receive a letter in the mail informing you of our Albuquerque, NM 87125-9705
denial. Fax: 1-866-643-7069
The State Fair Hearing Decision
What happens next?
A Final Administrative Decision will be sent to W e will review your request to see if it meets
you and all interested parties in writing by the the qualifications for external review. We have
appropriate Hearings Office. This Final Administrative five business days to do this. We will send you
Decision is reviewable only through the Circuit a letter letting you know if your request meets
Courts of the State of Illinois. The time the Circuit these requirements. If your request meets the
Court will allow for filing of such review may be as requirements, the letter will have the name of
the external reviewer.
short as 35 days from the date of this letter. If you
have questions, please call the Hearing Office. Y ou have five business days from the letter we
send you to send any additional information
about your request to the external reviewer.
The external reviewer will send you and/or your
representative and Blue Cross Community ICP
a letter with their decision within five calendar
days of receiving all the information they need to
complete their review.

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Additional Resources
Expedited External Review Other Things You May Need to Know
If the normal time frame for an external review You may have questions that have not have been
could jeopardize your life or your health, you or your answered in this book. Look through this section for
representative can ask for an expedited external the answers.
review. You can do this over the phone or in writing.
To ask for an expedited external review over Contacting Member Services
the phone, call Member Services toll-free at Call Member Services:
1-888-657-1211 TTY/TDD 711. To ask in writing, 1-888-657-1211 TTY/TDD 711
send us a letter at the address below. You can only
ask one time for an external review about a specific Hours of Operation:
action. Your letter must ask for an external review of W
 e are open between 8 a.m. to 8 p.m. Central
that action. time, seven days a week from October 1 to
February 14.
Your letter must ask for an expedited external F rom February 15 to September 30, we
review of that action and should be sent to: are open 8 a.m. to 8 p.m. Central time, Monday
Blue Cross Community ICP through Friday.
Attn: Grievance and Appeals Unit Alternative technologies (for example, voicemail)
P.O. Box 27838 will be used on the weekends and federal holidays.
Albuquerque, NM 87125-9705 The call is free.
Fax: 1-866-643-7069 Our staff is trained to help you understand your
health plan. We can give you details about:
What happens next?
O nce we receive the phone call or letter asking E ligibility
for an expedited external review, we will B enefits
immediately review your request to see if it G etting services
qualifies for an expedited external review. If it Interpreter services, language services including
does, we will contact you or your representative sign language
to give you the name of the reviewer.
W e will also send the necessary information to C hoosing or changing your PCP
the external reviewer so they can begin their Y our health plan
review. V ision and Dental services
A s quickly as your health condition requires, but H ow to get prescription drugs
no more than two business days after receiving
all information needed, the external reviewer T ransportation
will make a decision about your request. They C omplaints and appeals
will let you and/or your representative and Blue
Cross Community ICP know what their decision
Rights and Responsibilities
is verbally. They will also follow up with a letter
to you and/or your representative and Blue Cross How do I get medical care after my Primary Care
Community ICP with the decision within 48 Providers office is closed?
hours. If you call your doctor after business hours, you will:
F ind out how to reach an on-call doctor
G et connected to an on-call doctor
G et a call back within 30 minutes

26 Member Services: 1-888-657-1211 TTY/TDD 711 www.bcbsilcommunityicp.com 24/7 Nurseline: 1-888-343-2697


Additional Resources
Abuse, Neglect, Fraud What is Fraud?
Abuse can happen to anyone, anywherein a Fraud takes place when a person receives benefits
persons own home, in nursing homes or assisted or payments to which they are not entitled. Please
living facilities, even in hospitals. let us know if you are aware of someone who is
committing fraud under the Medicaid program. This
Warning Signs could be a provider or a member.
Abuse can take many different forms: Some examples of fraud include:
P hysical abuse is any inappropriate contact that A lie on an application
causes bodily harm. Examples of physical abuse
include being slapped, scratched, pushed or Using another persons ID card
threatened with a weapon such as a knife or gun. A provider (doctor) billing for services that were
Warning signs may include unexplained fractures, not done
bruises, welts, cuts, sores, or burns. Transportation (Improper usage of transportation
S exual abuse is any sexual behavior or intimate meant for medical appointments.)
physical contact that occurs without a persons
permission. This can include touching a persons If You Suspect Abuse, Report It
genital area, buttocks or breasts.
By law, it is your responsibility to report allegations
M ental abuse is emotional distress caused by of abuse and neglect to the Illinois Department of
the use of demeaning or threatening words.
Mental abuse can also include signs, gestures and Human Services (DHS), Illinois Department of Public
other actions. For example, controlling behavior, Health (DPH), or Illinois Department on Aging (DOA).
embarrassment or social isolation are types of If the person is enrolled in a program or lives in a
mental abuse. setting funded, licensed or certified by DHS or
F inancial abuse is the use of a persons money lives in a private home, call the OIG Hotline:
without their consent. Examples of financial 1-800-368-1463
abuse can include improper use of guardianship If the person with disabilities is enrolled in a
or power of attorney, using your credit card or program or lives in a setting funded, licensed
cashing your checks without your consent. or certified by DPH (e.g. nursing home) and the
abuse/ neglect occurs when services are being
What is Neglect? provided, call the DPH Nursing Home Hotline:
1-800-252-4343 TTY 1-800-547-0466.
Neglect is another form of abuse that takes place
when someone fails to provide, or withholds, the If the abuse or neglect is an adult 18 years and
necessities of life, such as food, clothing, shelter, older who is not in a nursing home or a supported
living facility call DOAs Hotline at 1-866-800-1409;
or medical care. The warning signs of neglect can TTY: 1-800-358-5117
include a lack of basic hygiene or not providing
proper food or fluids. You can also report any suspected areas of fraud or
abuse to us by calling Blue Cross Community ICP
Member Services at 1-888-657-1211 TTY/TDD 711.
You can also use our Fraud and Abuse hotline at
1-800-543-0867.
All information will be kept private. Eliminating
abuse, neglect and fraud is the responsibility of
everyone.

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Additional Resources
Advance Directives (Living Wills) Your Medical Records
Federal and state laws allow you to see your medical
What are Advance Directives? records. Ask for your records from your PCP first. If
Advance directives are legal documents that state you have a problem getting your medical records
how you want to be treated if you cannot talk or from your PCP, call Member Services.
make decisions.
Privacy Policies
What if I am too sick to make a decision about my We have the right to get information from anyone
medical care? giving you care. We use this information so we can
You can name a person who will make decisions for pay for and manage your health care. We keep this
you if you are too sick to do so. This is called a health information private between you, your health care
care power of attorney. You must give this person provider, and us, except as the law allows. Refer to
permission in writing to make your health care the Notice of Privacy Practices to read about your
decisions for you. right to privacy. This notice was included in your
You may want to list the types of care you do or do new member packet. If you would like a copy of the
not want. For instance, some people do not want notice, please call Member Services.
to be put on life-support machines if they go into
a coma. Your PCP will note your Living Will in your Information available to members
medical records. That way, your doctor caring for you As a member, you can ask for and get the following
will know what you want. information each year:
You have the right to set up papers with these details Information about network providers at a
minimum, primary care doctors, specialists and
for your doctor and other health care providers to hospitals in our service area. This information will
use. These are called Advance Directives for Health include names, addresses, telephone numbers
Care. Ask your family, PCP, or someone you trust to and languages spoken (other than English) for
help you. You may change or take back your Living primary care providers, plus identification of
Will at any time. providers that are not accepting new patients
P rovider information is updated on our website at
How do I get an Advance Directive? minimum two times each month. You can call the
Member Services if you do not have access to the
Illinois law allows for the following three types Internet
of advance directives: (1) health care power of
attorney; (2) living will; and (3) mental health A ny limits on your freedom of choice among
network providers
treatment preference declaration. In addition, you
can ask your physician to work with you to prepare Y our rights and responsibilities
a Do Not Resuscitate (DNR) order. You may choose Information on complaint, appeal and fair hearing
to discuss with your health-care professional and/or procedures
attorney these different types of advance directives Information about benefits available under the
as well as a DNR order. For more information, visit Medicaid program, including amount, duration
and scope of benefits. This is designed to make
the State of Illinois Department of Health at sure you understand the benefits to which you
www.idph.state.il.us/public/books/advin.htm are entitled
or call the departments customer service line
1-217-782-4977.

28 Member Services: 1-888-657-1211 TTY/TDD 711 www.bcbsilcommunityicp.com 24/7 Nurseline: 1-888-343-2697


Additional Resources
H ow you get benefits including authorization
requirements
H ow you get benefits, including family planning
services, from out-of-network providers and/or
the limits to those benefits
H ow you get after hours and emergency
coverage and/or the limits to those kinds of
benefits, including:
What makes up emergency medical
conditions, emergency services and
post-stabilization services
The fact that you do not need prior
authorization from your primary care provider
for emergency care services
How to get emergency services, including
instructions on how to use the 911 telephone
system or its local equivalent
The addresses of any places where providers
and hospitals furnish emergency services
covered by Medicaid
A statement saying you have a right to
use any hospital or other settings for
emergency care
Post-stabilization rules
 olicy on referrals for specialty care and for other
P
benefits you cannot get through your Primary
Care Provider
T he Plan practice guidelines

Americans with Disabilities Act


We follow the rules of the Americans with
Disabilities Act (ADA) of 1990. This act protects you
from being treated in a different way by us because
of a disability. If you feel you have been treated in
a different way because of a disability, call Member
Services.

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Additional Resources
Your Health Care Rights and Responsibilities
Member Rights and Responsibilities 5. You have the right to use each complaint and
Every member has the following rights and appeal process available through the Managed
responsibilities: Care Organization and through Medicaid. That
includes the right to:
1. You have the right to respect, dignity, and
privacy. That includes the right to: a. Make a complaint to your health plan or
to the state Medicaid program about your
a. Nondiscrimination
health care, your provider or your health
b. Know that your medical records and plan
discussions with your providers will be kept
b. Get a timely answer to your complaint
private and confidential
c. Use the Plans appeal process and be
c. Request and receive your medical records
informed on how to submit a complaint
and if needed, have them corrected
d. Ask for a fair hearing from the state
2. You have the right to a fair opportunity to
Medicaid program and get information
choose a health care plan and primary care
about how that process works
provider, the doctor or health care provider
you will see most of the time. You also have 6. You have the right to quick and easy access to
the right to change your plan or your provider care. That includes the right to:
without penalty at any time. That includes the a. Have telephone access to a medical
right to: professional 24 hours a day, seven days a
a. Be told how to choose a health plan and week for any emergency or urgent care you
primary care provider available in your area need
b. Be told how to change your health plan or b. Receive medical care in a timely manner
your primary care provider c. Get in and out of a health care providers
3. You have the right to ask questions and office easily. There shouldnt be any
get answers about anything you do not conditions that limit movement for
understand. That includes the right to: people with disabilities according to the
Americans with Disabilities Act
a. Have your provider explain your health
care needs to you and talk to you about the d. Have interpreters, if needed, during
different ways your health care problems appointments with your providers
can be treated and when talking to your health plan.
Interpreters are people who can speak in
b. Be told why care or services were denied
your native language, help someone with
and not given
a disability, or help you understand the
4. You have the right to agree to or refuse information
treatment and have a say in treatment
e. Be given information you can understand
decisions. That includes the right to:
about your health plan rules, the health care
a. Work as part of a team with your provider services you can get and how to get them
in deciding what health care is best for you
7. You have the right to refuse to be restrained or
b. Say yes or no to the care recommended secluded for someone elses convenience or as
by your provider a way of forcing you to do something you dont
want to do, or as punishment.

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Additional Resources

8. You have a right to know that your health d. Treat your providers and other health care
plan cant prevent doctors, hospitals and others employees with respect and courtesy
who care for you from advising you about your 8. Be involved in service and treatment
health status, medical care and treatment, even option decisions. Make personal choices
if the care or treatment is not a covered service. to keep yourself healthy. That includes the
9. You have a right to know that youre not responsibility to:
responsible for paying for covered services. a. Work as a team with your provider in
Doctors, hospitals and others cant require you deciding what health care is best for you
to pay copayments or any other amounts for
b. Understand how the things you do can
covered services.
affect your health
Your Responsibilities: c. Do the best you can to stay healthy
1. Read and follow the member handbook. d. Treat providers and staff with respect
2. Keep your scheduled appointments or call your e. Talk to your provider about all of your
provider to reschedule or cancel at least 24 medications
hours before your appointment.
If you think you have been treated unfairly or
3. Show your ID card to each provider before discriminated against, call the U.S. Department of
getting medical services. Health and Human Services (HHS) toll-free at
4. Call your PCP or 24/7 Nurseline before going to 1-800-368-1019. You can also view information
an emergency room, except in situations that concerning the HHS Office for Civil Rights online
you believe are life threatening or that could at www.hhs.gov/ocr.
permanently damage your health.
5. Be sure you have approval from your primary
care provider before going to a specialist.
6. Call Member Services if you change your phone
number or 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. Talk 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

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Notes
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Notes
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Important Phone Numbers

Important Blue Cross Community ICP Phone Numbers

24/7 Nurseline 24-hour a day help line. . . . . . . . . . . . . . . . . . . . . . . 1-888-343-2697, TTY/TDD 711


Emergency Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 911
Blue Cross Community ICP Member Services . . . . . . . . . . . . . . . . . . 1-888-657-1211, TTY/TDD 711
Member Services Business Hours:
We are open between 8 a.m. to 8 p.m. Central time, seven days a week from October 1 to February 14. From
February 15 to September 30, we are open 8 a.m. to 8 p.m. Central time, Monday through Friday. Alternate
technologies (for example, voicemail) will be used on the weekends and Federal holidays. The call is free.

Blue Cross Community ICP Special Investigation Department (SID) . . . . . . . . . . 1-877-272-9741


National Poison Control Center. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-222-1222
Calls are routed to the office closest to you.

Non-Emergency Medical Transportation. . . . . . . . . . . . . . . . . . . . . . . 1-888-657-1211, TTY/TDD 711


Dental (DentaQuest). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-888-657-1211, TTY/TDD 711
Vision (Davis Vision) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-888-657-1211, TTY/TDD 711
Transportation (MTM) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-888-657-1211, TTY/TDD 711
Behavioral Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-888-657-1211, TTY/TDD 711
Pharmacy Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-888-657-1211, TTY/TDD 711
Grievances and Appeals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-888-657-1211, TTY/TDD 711
Fraud and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-543-0867
Adult Protective Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-866-800-1409, TTY 1-888-206-1327
Nursing Home Hotline. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-252-4343, TTY 1-800-547-0466
Critical Incident Hotline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-855-653-8127
Department of Rehabilitation Services (DORS). . . . . . . . . 1-800-843-6154, TTY 1-800-447-6404
Department of Aging (DOA). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-800-252-8966, TTY 1-888-206-1327

34 Member Services: 1-888-657-1211 TTY/TDD 711 www.bcbsilcommunityicp.com 24/7 Nurseline: 1-888-343-2697