For more information, see the Medicare Plus Blue PPO manual (PDF).
Collect copayments or coinsurance at time of service
The member is responsible for cost-sharing amounts and you may collect them at the time of service.
Balance billing is not allowed
You may collect only applicable cost-sharing from Medicare Plus Blue PPOSM members and may not otherwise charge or bill them.
Refund over-billed members
If you collect more from a member than the applicable cost-sharing, you must refund the difference.
Coordination of benefits
If a member has primary coverage with another plan, submit a claim for payment to that plan first. Bill BCBSM as the secondary coverage and include the Explanation of Benefit Payments statement from the primary plan with your claim. The amount we will pay depends on the amount paid by the primary plan. We follow all Medicare secondary-payer laws (PDF).
Sometimes you and your patient may decide that a service or treatment is the best course of care, even though it isn't covered by Medicare Plus Blue PPO.
If you believe that a service won't be covered, you need to tell the member before the service is performed. If the member acknowledges that it won't be covered by Medicare Plus Blue PPO and agrees that he or she will be solely responsible for paying you, you may perform and bill the member for the noncovered service. This decision is between you and your patient, and the process is called Advanced Beneficiary Notification (ABN).
The notification and member acknowledgement must be in writing, although Centers for Medicare & Medicaid Services does not require documentation on a CMS approved ABN form.