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April 2018
What you need to know about Blue Cross
How to access our online provider manuals
Everything you need to know to do business with Blue Cross is included in our online provider manuals. From the home page of web-DENIS, click on Provider Manuals to access them.
There’s certain information our participating providers need to know about doing business with Blue Cross Blue Shield of Michigan. This article provides a summary of key information.
Access and availability guidelines
When a member requests an appointment, Blue Cross providers are required to comply with the following standards.
Access to primary care |
- Regular and routine care – within 30 business days
- Urgent care – within 48 hours
- After-hours care – 24 hours, seven days a week
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Access to behavioral health care |
- Not life-threatening emergency – within six hours
- Urgent care – within 48 hours
- Initial visit for routine care – within10 business days
- Follow-up routine care – within 30 business days of request
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Access to specialty care |
High-volume specialist including, but not limited to:
OB-GYN
- Regular and routine care – within 30 business days
- Urgent care – within 48 hours
High-impact specialist:
Oncologist
- Regular and routine care – within 30 business days
- Urgent care – within 48 hours
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For more detailed information, see the “PPO Policies” chapter in the provider manual or contact your provider consultant.
Affirmative statement about incentives
Medical decisions are based only on appropriateness of care and service and existence of coverage. See the affirmation statement in the “Participation” chapter of the provider manual. It’s located in the section titled Requirements and Guidelines.
Clinical practice guidelines
For medical and behavioral health care, Blue Cross follows Michigan Quality Improvement Consortium guidelines, which can be found on the mqic.org** website.
Comprehensive care management
To learn about Blue Cross comprehensive care management, use your online provider manual. To find the information on bcbsm.com:
- Click on the For Members tab.
- Click on Health and Wellness
- Scroll down to Case Management or Chronic Condition Management and click on Learn More.
Criteria used for level of care utilization management decisions
For hospitals and facilities, Blue Cross uses InterQual criteria to assess medical necessity and the appropriate level of care. Criteria encompasses acute care (adult and pediatric), rehabilitation (adult and pediatric), long-term acute care, skilled nursing facility and home health care.
Blue Cross modifications of the InterQual criteria (local rules) can be accessed online by following these steps:
- Log in to web-DENIS.
- Click on BCBSM Provider Publications and Resources.
- Click on Newsletters & Resources.
- Click on Clinical Criteria & Resources.
If you have questions about InterQual, send an email to CESupport@mckesson.com. Provide your name and address and reference that the question pertains to InterQual.
Note: Criteria for Federal Employee Program® utilization management decision-making can be found at fepblue.org.
Medical policies
To review additional Blue Cross medical policies, go to bcbsm.com/providers.
- Click on Quick Links.
- Click on Preauthorization and precertification.
- Click on then Medical policy, precertification and preauthorization router. Use the button to select Medical Policy, then follow online prompts.
FEP policies can be found at fepblue.org.
Member rights and responsibilities
Blue Cross outlines the rights and responsibilities of our members, including how members can file a complaint or grievance. Go to the Important Information page on our website and click on Learn More under “Rights and responsibilities” for more information.
Pharmacy management
It’s important for you to be familiar with our drug lists and our pharmacy management programs, such as step therapy, quantity limits, dose optimization, use of generics and specialty pharmacy. You also need to know how to request prior authorization and the information needed to support your request.
Note: Generic substitution may be required for Blue Cross members. If both the generic and brand name are listed on our drug list, members are encouraged to receive the generic equivalent when available. Some members may be required to pay the difference between the brand-name and generic drug, as well as applicable copay, depending on the member’s plan. See the Pharmacy Services page on our website for more details.
We recommend that you visit this page at least quarterly to access our drug lists and view updates. Go to bcbsm.com/providers. You can also call 1-800-437-3803 for the most up-to-date pharmaceutical information.
Translation services
Members who need language assistance can call the Customer Service number on the back of their member ID card. TTY users should call 711.
Utilization management staff availability
Department telephone numbers and hours are shown in the Preapproval Decisions/Utilization Management Decisions section of the “Appeals and problem resolution chapter” of the provider manuals.
Behavioral health care — New Directions
New Directions Behavioral Health is an independent company administering behavioral health benefits on behalf of Blue Cross. For information on the New Directions Behavioral Health Quality Improvement Program, click here.**
Contact information:
- Commercial PPO and Traditional programs: 1-800-762-2382
- Federal Employee Program: 1-800-342-5849
Behavioral health criteria |
New Directions medical necessity criteria for behavioral health admissions are reviewed annually and updated as needed. Providers may download it at ndbh.com** or request a printed
copy by contacting New Directions at 1-800-528-5763.
Providers may also view or print this document by
accessing via web-DENIS. |
Behavioral health member rights and responsibilities |
For members’ behavioral health services rights and responsibilities, click here.** |
Behavioral health statement about incentives |
Decisions about utilization of behavioral health services are
made only on the basis of eligibility, coverage and appropriateness of care and services. New Directions doesn’t specifically reward, hire, promote or terminate practitioners or other individuals for issuing denials of coverage. Utilization decision-makers don’t receive incentives that would result in under-utilization. |
For more information
- Information about our programs and additional resources are available on the Important Information page of our website.
- To request a printed copy of any of the information contained in this article, call Quality and Population Health at 248-455-2808.
- If you have any questions about the information in this article, contact your provider consultant.
**Blue Cross Blue Shield of Michigan doesn’t own or control this website.
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