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Clinical Practice Guidelines

Clinical Practice Guidelines for Illinois Commercial, Marketplace and Medicare plans

Clinical Practice Guidelines (CPGs) and Preventive Care Guidelines are adopted by BCBSIL and are the foundation for selected Condition Management Programs. These guidelines are based on established evidence-based standards of care, publicized by specialty societies and national clinical organizations. These guidelines are updated at least every 2 years and when new significant findings or major advancements in evidence-based practices and standards of care are established. These guidelines are current and have been reviewed and approved by the BCBSIL Clinical Quality Committee. BCBSIL uses evidence-based clinical guidelines from nationally recognized sources to guide our quality and health management programs. Guidelines are designed to support the decision-making processes in patient care. Recommendations from other national entities may vary. If you have any questions about the guidelines, or wish to provide feedback, this can be done by contacting the Quality Improvement Department at 312-653-3465.

The Clinical Practice Guidelines (CPGs) are meant to serve as general guidelines and are not intended to substitute for clinical judgment in individual cases. At this time, BCBSIL endorses the AAFP and ACP criteria for defining high blood pressure, which varies from the values provided in other guidelines. Providers are encouraged to make decisions based on their own judgment and most current evidence-based information available. The links below provide information about the CPGs:

Clinical Practice Guidelines for Illinois Medicaid Plans

The Clinical Practice Guidelines for Illinois Medicaid plans are adopted by BCBSIL through the Quality Assurance Committee. These guidelines are based on established evidence-based best practice standards of care, publicized by leading academic and national clinical organizations. BCBSIL uses evidence-based clinical guidelines from nationally recognized sources to guide our quality and health management programs. Guidelines are designed to support the decision-making processes in patient care. Recommendations from other national entities may vary. These guidelines are updated annually and when new significant findings or major advancements in evidence-based best practices and standards of care are established. If you have questions about the guidelines, or wish to provide feedback on the guidelines, email the Illinois Medical Quality Improvement Department at IL_Medicaid_QI@bcbsil.com.

The Clinical Practice Guidelines (CPG’s) are meant to serve as general guidelines and are not intended to substitute for clinical judgment in individual cases. At this time, BCBSIL endorses the AAFP and ACP criteria for defining high blood pressure, which varies from the values provided in other guidelines. Providers are encouraged to make decisions based on their own judgment and most current evidence-based information available. The links below provide information about the CPGs:

Shared Decision-Making Aids for all Plans

Shared decision-making is a communications process. It’s a way for providers and patients to make informed health care decisions that align with what matters most to patients. Below are resources to help you involve your patients in shared decision-making. 

These evidence-based aids provide information about treatment options, lifestyle changes and outcomes. They don’t replace your guidance but can help your conversations with patients. 

Why it’s important: When patients help make decisions about their health care, it can lead to improved patient experience, better outcomes and quality of life.

Mayo Clinic Knowledge and Evaluation Research Unit Care That Fits Tools 

The above material is for informational purposes only and is not intended to be a substitute for the independent medical judgment of a physician. Physicians and other health care providers are encouraged to use their own best medical judgment based upon all available information and the condition of the patient in determining the best course of treatment. References to other third party sources or organizations are not a representation, warranty or endorsement of such organization. Any questions regarding those organizations should be addressed to them directly. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.