Medicare Guidelines

Medicare Plus Blue℠ PPO follows most original Medicare guidelines.

We follow most Medicare guidelines including:

  • The 72-hour admission rule
  • Correct coding polices
  • Consolidated billing guidelines
  • Trauma rules
  • A required 60-day period of nonconfinement to qualify for a new benefit period
  • Therapy limitations – occupational, physical and speech therapy combined (no therapy limitations for certain groups)
  • No required three-day hospital stay prior to admission into a skilled nursing facility for Medicare Plus Blue individual plans. May be required for group plans
  • Outcome and Assessment Information Set is not submitted to the state.
    Rural health clinics and federally qualified health centers must bill their local Blue plans for flu and pneumonia vaccines. Both the vaccines and their administration are reimbursed on a fee-for-service basis
  • National and local coverage determinations – Centers for Medicare & Medicaid Services gave Medicare Plus Blue approval to process claims using Michigan local coverage determinations for group plans regardless of location

If your claim is denied and you submit documentation such as a remittance advice from a Medicare carrier showing that the services can be paid according to the local rules, we will reprocess the claim.

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