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April 2018

Updates to Medicare Plus BlueSM PPO outpatient claim editing process coming in May

Starting in May 2018, Blue Cross Blue Shield of Michigan will update its Medicare Plus Blue PPO outpatient claim editing processes. We’re doing this to:

  • Promote correct coding.
  • Integrate local and national coverage determination guidelines in a way that will simplify our claims payment system.

These improvements will make our claims payment system easier for you and your billing staff to navigate. Unique clinical editing reason codes will appear on the 835 response files or provider vouchers.

As a Medicare Advantage organization, our Medicare Plus Blue PPO medical and payment policies comply with:

  • National coverage determinations
  • General coverage guidelines within original Medicare manuals and instructions
  • Written coverage decisions of the local Medicare administrative contractor

Reminder: When billing Medicare Plus Blue PPO claims, you should follow:

  • Centers for Medicare & Medicaid Services medical policies
  • American Medical Association Current Procedural Terminology coding guidelines
  • National bundling edits, including the National Correct Coding Initiative

As part of your contract with us, health care providers affiliated with the Medicare Plus Blue PPO network agree to supply services to Blue Cross members and bill according to the above guidelines and requirements.

If you have questions about the Medicare Advantage PPO claim editing process, contact Provider Inquiry at 1-866-309-1719.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2017 American Medical Association. All rights reserved.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.