Reimbursement

Medicare Advantage PPO fee schedule

The BCBSM Medicare Advantage PPO Fee Schedule's maximum payment levels are consistent with Original Medicare. ESRD facilities should refer to the Medicare Advantage PPO ESRD fee schedule under Facility Fee Schedules.

For information about reimbursement of enhanced benefits, refer to the enhanced benefits fee schedule (PDF).

Out-of-network claims for Medicare Plus Blue PPO members will be reimbursed using the CMS fee schedule.

When can you expect payment?

We will process and pay clean claims within 30 days of receipt. If a clean claim is not paid within the 30-day time frame, then we will pay interest in accordance with CMS regulations and the Medicare Advantage PPO Provider Agreement.

Reimbursement for dental providers

Some Medicare Plus Blue PPO plans provide coverage for routine dental procedures as an enhanced benefit. These procedures are typically performed and billed by general dentists.

Oral surgeons who perform routine dental procedures for Medicare Plus Blue PPO members must have a dental PIN in order to be reimbursed by BCBSM dental. Reimbursement will be based on the traditional dental fee schedule. Refer to your Guide for Dental Care Providers for more information.

Out-of-network reimbursement for DME/P&O, medical supplies and pharmacists

Out-of-network claims for Medicare Plus Blue PPO members will be reimbursed using the CMS fee schedule with a higher level of member cost sharing applied.

Medical Chart Reimbursement

When a medical chart retrieval vendor asks for your medical charts, providers can ask for reimbursement. 

  • CIOX Health performs risk adjustment retrievals for Medicare Advantage members. You can request reimbursement as a facility (PDF) or a provider (PDF). Read about our process in our frequently asked questions (PDF) for CIOX Health. 
  • Inovalon performs HEDIS retrievals from March to May for Blue Cross PPO, Blue Cross EPO and Medicare Advantage PPO members. You can request reimbursement as a provider (PDF)