Requesting a coverage decision for a medical service
(organization determination)

The first step is to call Member Services at the number printed on the back of your ID card. Our representatives may be able to provide you benefit information about the medical care you are requesting. This could minimize the need for you to compile and submit paperwork.

If you do not want to call, or if you've called but still would like to submit a request for a coverage decision, you should:

  1. Ask the person who will be providing the service to write a supporting statement to us that describes the service and why the service is required. Remind them to attach all information they believe supports their request to provide this service
  2. Ask them to return the information to us:

    Mail:
    Blue Cross Blue Shield of Michigan
    Grievance and Appeals Department
    P.O. Box 2627
    Detroit, MI 48231-2627

    Fax:
    1-877-348-2251

Although you may receive this information from your provider and submit it yourself, it is usually easier for the provider to submit this information on your behalf.

We will generally use the standard timelines for responding, which means we will generate a response to you within 14 days of receipt. Sometimes we may extend this timeframe by 14 days. If this occurs, we will notify you and advise of your right to file a "fast complaint" regarding the extension.

Certain situations allow you to request a "fast decision" about whether or not we will pay for the service. You can only ask for a "fast decision" when:

You may ask for a reconsideration (appeal) of our coverage decision if we have advised you we will not provide the service you have requested. Learn how to file an appeal.

For expedited requests ("fast decisions") only, you may call 1-877-241-2583, 8 a.m to 8 p.m. seven days a week. TTY users may call 1-800-579-0235. You may also fax to 1-877-348-2251.

The information above is a brief summary. For more information, please refer to your Evidence of Coverage (reference Chapter 9 for Medicare Plus BlueSM PPO members).

H9572 S5584_W_Apr14BCBSMAdvWeb Pending CMS Approval

Important information about these plans

Medicare Plus Blue and Prescription Blue are PPO and PDP plans with a Medicare contract. Enrollment in Medicare Plus Blue and Prescription Blue depends on contract renewal.

Medicare Plus Blue PPO

Medicare Plus Blue PPO is available to all Medicare beneficiaries who are Michigan residents and are entitled to receive services under Medicare Part A and enrolled in Part B.

With the exception of emergency or urgent care, it will cost more to get care from non-plan or non-preferred providers. Your responsibility will be greater out-of-network when the out-of-network coinsurance is based on the Medicare-allowed amount and the contracted amount is lower. You may receive services from any provider who accepts Original Medicare. Your out-of-pocket costs will be lower if you choose a network provider. To find a network provider, visit http://www.bcbsm.com/medicare/find-a-doctor/.

Prescription Blue PDP

Prescription Blue PDP is available to all Medicare beneficiaries who are Michigan residents entitled to receive services under Medicare Part A and/or enrolled in Part B.

Medicare Plus Blue PPO and Prescription Blue PDP

Premiums vary by county. You must continue to pay your Medicare Part B premium. You may enroll in only one Part D plan at a time.

Limitations, copayments and restrictions may apply.

Our network includes approximately 2,400 Michigan retail pharmacies, representing approximately 98 percent of all Michigan pharmacies. Nationwide, most chain pharmacies are in our network, as well as long-term care and home infusion pharmacies and Indian/Tribal/Urban (Indian Health Service) pharmacies.

In general, benefits are only available at contracted network pharmacies. Plan drugs may be covered in special circumstances; for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. Quantity limitation and restrictions may apply. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Blue Cross Blue Shield of Michigan. For additional information on network pharmacies, please call Member Services at 1-877-241-2583, 8 a.m. to 9 p.m. Eastern time, Monday through Friday, Feb. 15 through Sept. 30, with weekend hours Oct. 1 through Feb. 14. TTY users call 711. Certain services available 24/7 through our automated telephone response system. You may also write to: Blue Cross Blue Shield of Michigan, 600 E. Lafayette Blvd., Mail Code X521, Detroit, MI 48226.

If you decide to have your plan premium withheld from your Social Security check or deducted from your checking or savings account, it may take up to three months for the automatic deduction to begin. If your premium amount is currently withheld from your Social Security check or deducted from your checking or savings account and you wish to receive a monthly bill instead, the change may also take up to three months to become effective. During this time, you will be responsible for paying your premium.

The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and or copayments/coinsurance may change on Jan. 1 of each year.

Medicare beneficiaries may enroll in Medicare Plus Blue PPO or Prescription Blue PDP through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. BCBSM does not control Medicare's website and is not responsible for its content. You may only enroll in Medicare Plus Blue PPO or Prescription Blue PDP during specific times of the year.

For more information, please contact Blue Cross Blue Shield of Michigan at 1-888-563-3307. TTY users call 711. Hours are: 8 a.m. to 9 p.m. Eastern time, Monday through Friday, Feb. 15 through Sept. 30, with weekend hours Oct. 1 through Feb. 14.

LegacySM Medigap

Legacy Medigap offers access to any hospital, doctor or other health care provider in the U.S. or its territories that accepts Medicare assignment. The plan does not require members to use a specified provider network. Legacy Medigap is a Medigap health insurance policy administered by Blue Cross Blue Shield of Michigan. Neither Blue Cross Blue Shield of Michigan nor agents authorized to sell Blue Cross Blue Shield of Michigan policies are connected with Medicare.