Frequently Asked Questions About PPO

Click on one of the sections below to read our frequently asked questions about the Medicare Plus Blue℠ PPO. Find answers to more questions on the general provider FAQ page.

Billing and claims
Eligibility
Evaluation and management
Plan basics
Reimbursement
Pharmacists

Billing and claims

What does CMS mean by a clean claim?

Refer to section 80.2 of the Medicare Claims Processing Manual (PDF).

How do I bill Medicare Plus Blue PPO?

You may find more information about billing Medicare Plus Blue PPO on the submitting claims page.

May I bill a member for noncovered services?

You may find more information about billing noncovered services on the billing members page.

Have questions about Inovalon℠ reviews?

Inovalon FAQ (PDF).

I'm a dental provider, how do I submit an electronic claim?

Dental providers typically work with their clearinghouses to submit electronic claims. However, if you'd prefer to submit the electronic claims directly, please visit this page to learn more.

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Eligibility

How do I know if this patient is eligible?

You may find more information about patient eligibility on the eligibility and coverage page.

Where can I verify coverage?

You may find more information about patient eligibility on the eligibility and coverage page.

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Evaluation and management

Where can I find information about evaluation and management services?
You may find more information via PARS, the BCBSM MA PPO Manual and The Record.

Where can I find information about home health care?

If a Medicare Plus Blue PPO member's Medicare coverage changes at the end of a calendar year during a home health care episode, how should the agency bill for the episode?

If a patient had Original Medicare coverage when the home health care episode began and then enrolled in Medicare Plus Blue PPO before the episode ended, take the following steps:

  • Submit a claim to the regional home health and hospice intermediary to close the episode.
  • Complete a new Outcome and Assessment Information Set (OASIS).
  • Submit a request for anticipated payment based on the new OASIS to BCBSM to open a new episode.

If a patient had Medicare Plus Blue PPO coverage when the home health care episode began and then enrolled in Original Medicare before the episode ended, take the following steps:

  • Submit a claim to BCBSM to close the episode.
  • Complete a new OASIS and submit it to the state.
  • Submit a request for anticipated payment based on the new OASIS to the regional home health and hospice intermediary to open a new episode.

Where can I find information about hospice?

For Medicare Plus Blue PPO members who have elected hospice care, bill all Medicare-covered services, including those not related to the terminal condition, to the appropriate Original Medicare contractor, not to BCBSM.

Exceptions to this rule occur when billing for members who have had a lapse in hospice coverage, or for enhanced benefits that are only available through the member's Medicare Advantage plan.

Use these guidelines to determine where to send your claim:

  • If the service is related to the member's terminal condition, submit the claim to the regional home health intermediary.
  • If the service is not related to the member's terminal condition, submit the claim to the appropriate Original Medicare contractor (fiscal intermediary, carrier, Medicare administrative contractor, DME regional carrier, or Part D or prescription drug plan).
  • If the service is provided during a lapse in hospice coverage, submit the claim to BCBSM.
  • If the service is not covered under Original Medicare but offered as an enhanced benefit under the member's Medicare Advantage plan (for example, acupuncture), submit the claim to BCBSM.
  • Enhanced Medicare Advantage benefits are described here.

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Plan basics

What is the Medicare Plus Blue PPO manual?

The Medicare Plus Blue PPO manual (PDF) describes BCBSM's Medicare Advantage PPO program and gives detailed information you need to treat our members.

How will providers know when the Medicare Plus Blue PPO manual is updated?
The date of the last revision will be clearly displayed at the bottom of the last page of the manual. We encourage providers to reference the Medicare Plus Blue PPO manual online to ensure they are viewing the most current, up-to-date version.

I am not a Michigan provider. Where can I find more information about Medicare Plus Blue PPO?

Refer to the fact sheet titled Information for non-Michigan providers about Medicare Plus Blue PPO (PDF) for answers to your questions about treating Medicare Plus Blue PPO members who travel or live outside of Michigan.

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Reimbursement

Where can I find information about provider contracts?

You may find more information about provider contracts on the contract amendments page.

Where is the current Medicare Advantage PPO Fee Schedule?

Access the current Medicare Advantage PPO fee schedule via web-DENIS. Go to BCBSM Provider Publications and Resources and click on Entire Fee Schedules.

How will network providers be reimbursed for covered services?

Network practitioners are reimbursed for covered services as indicated on the Medicare Advantage PPO fee schedule. Exceptions apply to:

  • Network lab providers – JVHL and Quest Laboratories will be reimbursed at 80 percent of the Medicare fee schedule amount for in-network lab services
  • ESRD and Rural Health Clinics – In-network ESRD and RHC facilities have non-Medicare contracted rates

How will out-of-network providers be reimbursed?

You may find more information about reimbursement on the reimbursement page.

What will I be reimbursed by Medicare Plus Blue PPO?

You may find more information about reimbursement on the reimbursement page.

Where can I find more information about the Medicare Advantage PPO lab network?

You may find more information about lab networks on the lab networks page.

Which lab procedures can be performed in-office?

You may find more information on the Medicare Advantage PPO physician office laboratory list (PDF).

What is the AIM Radiology Management Program?

You may find more information about the AIM Radiology Management Program on the Prenotification and utilization management page.

If preauthorization is not obtained for a radiology service that requires preauthorization, will the provider be liable for the cost of that service?

Yes. See Prenotification and utilization management for more information.

If a Medicare Plus Blue PPO member is admitted to an out-of-network facility and elects to transfer to an in-network facility does BCBSM impose any distance limitations?

For non-emergency situations, members can choose to have an ambulance transport them from an out-of-network facility to an in-network facility. The mileage limits are based on Original Medicare guidelines.

Will critical access hospitals be reimbursed based on their interim rate letters?

Critical access hospitals should submit written requests for reimbursement to BCBSM on an annual basis. BCBSM will review the information and give the hospital a written determination within 180 days from the date the notification is received. Refer to the Medicare Plus Blue PPO manual (PDF) under "Cost settlement" for more information.

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