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February 2018
To submit out-of-state claims for IBU PPO members, follow these guidelines for exceptions
Beginning Jan. 1, 2018, BlueCard home claims for individual business unit PPO members will be processed through the BlueCard program. Out-of-network cost share will apply, with some exceptions.
Below are the exceptions to out-of-network cost share on home claims, if the services are part of the member’s benefits:
- Emergency
- Urgent care
- Accidental injury
- Online visits
- Dental
- Vision
- Pharmacy
There may be some circumstances in which it’s appropriate to reprocess claims to change the cost share from out of network to in-network, but such exceptions are only granted when specific criteria are met. Specific out-of-network claims can be reprocessed as in-network claims at the customer’s request without having to go through the exception approval process. These claim types are:
- Autism
- Clinical trials
- Oncology clinical trials
- Human organ transplant
- Mental health and substance abuse treatments not available in Michigan
- Services for emergency, urgent care or accidental injury services, including follow-up visits
- Member is admitted to a hospital immediately following an emergency room visit
- Member is transferred by ambulance on an emergency basis to nearest hospital equipped to handle continued care
- Claims from an out-of-state provider who can bill with a PPO Michigan PIN
- Claims from an out-of-state ancillary prosthetic and orthotic, durable medical equipment or medical supplier that can bill with a Michigan PIN
- Claims from an out-of-state provider when the services are performed at a Michigan facility
- Service has preapproval on file; only services and diagnoses that match the preapproved exception form can be adjusted as in-network
Exception criteria |
All other claims must meet the criteria below to be considered for an exception. If the claim meets the criteria for an out-of-state exception, fill out the Individual Business PPO Out of State Exception Form and email it to IBU_OOS_Claims@bcbsm.com. |
Claim is from an out-of-state provider because no participating PPO provider is available in Michigan. |
Claim is from an out-of-state provider because a Michigan PPO provider isn’t located within 100 miles of the member’s Michigan residence. Additionally, the out-of-state provider must be located within 100 miles of the member’s Michigan residence. Note: If an out-of-state provider isn’t located within 100 miles of the member’s Michigan residence, then the nearest out-of-state provider will be paid as in-network. |
Claim resulted from a Michigan provider who sends laboratory or diagnostic services to an out-of-state provider for processing and interpretation that are subsequently billed through BlueCard. |
Note: Out-of-network cost share can’t be waived for out-of-state college students and Michigan residents who live outside Michigan part of the year. The member must live in Michigan throughout the calendar year.
For more information, read our blog at mibluesperspectives.com/outofstate.
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