BCBS-Orthonet: Appeal Information

BCBS-Orthonet: Appeal Information

Other Information

Tiering Survey – Available for all.

Provider Network Consultants Listing

Patient Advocacy

The ICS is receiving word from many of our members that they have now received their letters from BCBSIL identifying the tier in which they have been placed in the Orthonet utilization management program. In order to verify the information previously given to the ICS by BCBS, we will be distributing a survey next week to all chiropractic physicians in our network. We would ask you to participate when you receive the email.

Additionally, we are strongly encouraging you to appeal your tier assignment. Appealing is a pro-active step you can take to indicate your objection. The lack of an appeal may be viewed as your agreement with the assignment.

BCBSIL has stated your appeal letter must be received by BCBSIL BEFORE October 31, 2013, in order to request a reconsideration of your tier level. Therefore, the ICS recommends that any appeal letters be mailed or faxed in a manner for BCBS to receive it no later than October 30, 2013. BCBSIL’s instructions state you should include the rationale for reconsideration with emphasis on the clinical reasons supporting your request.

In order to help you prepare your rationale for your appeal, you may want to include the following statistics, in addition to clinical reasons supporting your request, regarding your BCBS patient visits:

  1. The average number of visits per patient over the last 12 months,
  2. The average number of services per visit over the last 12 months,
  3. Patients with significantly higher statistics (from 1 and 2),
  4. Statistical results if you remove the patients identified in 3, and
  5. All other statistics you may deem important for BCBS to consider in the appeal.

Additionally, there are other considerations that may apply to your office.  Include information which demonstrates why your patient population has a need for additional care that has potentially skewed your statistics:

  • A large number of chronic care patients;
  • Greater number of repetitive injury patients;
  • Under-served populations where your practice acts as primary care, thus creating more visits;
  • The older population of patients requiring long term treatment plans and who are prone to more frequent injuries;
  • Greater number of patients with occupations that lend to a greater number of injuries (i.e. construction, farming, etc.);
  • A large number of active athletes requiring a greater amount of care; and
  • Other practice specific anomalies that may skew overall visit statistics.

Utilize these results to help BCBS re-evaluate your tiering assignment, using factual and not inflammatory language.  Lastly, include a copy of your tier notification letter and indicate your return address and a phone number at which you may be contacted.

According to BCBSIL, appeal letters should be mailed to:

BCBSIL Network Management

Attn: E. Reyes

300 E. Randolph, 23rd Floor

Chicago, Illinois 60601

If faxing your appeal letter, fax to (312) 729-6833 to the attention of E. Reyes.

As mentioned in previous communications, the ICS will continue to advocate for chiropractic physicians in Illinois. As an example, here are just a few of the steps the ICS has taken regarding these changes:

  • Filed a letter of inquiry with the Illinois Department of Insurance regarding Orthonet’s utilization review program functions being performed out of state.
  • Filed a letter requesting an advisory opinion from the Illinois Department of Insurance regarding whether this program will violate the Affordable Care Act’s provider non-discrimination clause, which will become law January 2014.
  • Filed a letter requesting an advisory opinion from the US Department of Health and Human Services’ (HHS) Secretary Sibelius regarding whether this program will violate the Affordable Care Act’s provider non-discrimination clause, which will become law January 2014.
  • Launched a patient information campaign to ensure patients are aware of how this proposed program may affect their coverage of chiropractic services, physical therapy, and occupational therapy from BCBS-IL.

We will keep you informed of our progress with these requests and other efforts.

About Author

Marc Abla, CAE

Marc Abla began working at the Illinois Chiropractic Society in 2002 and became the Executive Director in 2008. He brings his extensive financial, administrative and association experience to the ICS. He is a Certified Association Executive and a graduate of the Certified Leadership Series through the Illinois Society of Association Executives. Additionally, he is a member of the Illinois Society of Association Executives, the American Society of Association Executives, Association Forum, Congress of Chiropractic State Associations, and the American Chiropractic Association.


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