Members who don’t meet criteria for covered services pay only the amount allowed by Blue Cross

When providers perform services that are covered under a member’s benefit plan but the coverage criteria isn’t met, the member is responsible for payment. However, the health care provider is obligated to accept the Blue Cross Blue Shield of Michigan allowed amount as payment in full.

This includes emergency department visits, ambulance services and non-cosmetic procedures. It doesn’t include services that aren’t covered under the benefit plan.

In addition, members are fully liable for any deductibles that haven’t been satisfied or if they failed to meet prior authorization requirements required by certain benefit plans. Again, their liability would be limited to the allowed amount for services that are covered under the benefit plan.

Our requirements for communicating the expected cost of services that aren’t part of the benefits under a plan haven’t changed.