PPO program policies, responsibilities

We want to ensure that you understand the following about our preferred provider organization plans and programs:

• Our quality program
• Our members’ rights and responsibilities
• Statement about incentives

We also make this information and additional resources available at bcbsm.com/importantinfo.

Guaranteeing quality management

Blue Cross Blue Shield of Michigan conducts quality initiatives to improve health care for our members. You can learn more about our quality program (PDF) at bcbsm.com/importantinfo.

Member rights and responsibilities

Blue Cross Blue Shield of Michigan members have the right to:

• Receive information about their care in a manner that is easy to understand
• Receive medically necessary care as outlined in the New Member Handbook
• Receive considerate and courteous care with respect to their privacy and human dignity
• Candidly discuss appropriate medically necessary treatment options for their health conditions, regardless of cost or benefit coverage
• Participate in decision-making regarding their health care
• Review their medical records at your office by scheduling an appointment during regular business hours
• Expect confidentiality regarding their care and that Blue Cross Blue Shield of Michigan adheres to strict internal and external guidelines concerning their personal health information. This includes the use, access and disclosure of that information or any other information that is of a confidential nature.
• Refuse treatment to the extent permitted by law and be informed of the consequences of their actions
• Voice concerns or complaints about their health care by contacting the Customer Service department or submitting a formal, written grievance through the Blue Cross Blue Shield of Michigan appeals process
• Receive clear and understandable written information about Blue Cross Blue Shield of Michigan, its service, practitioners and providers and their member rights and responsibilities
• Make recommendations regarding the member rights and responsibilities policies of Blue Cross Blue Shield of Michigan
• Request the following information from Blue Cross Blue Shield of Michigan:
  • The current provider network in their region
  • The professional credentials of the health care practitioners who are participating with Blue Cross Blue Shield of Michigan, including participating practitioners who are board-certified in the specialty of pain medicine and the evaluation and treatment of pain
  • The names of participating hospitals where individual participating physicians have privileges for treatment
  • How to contact the appropriate Michigan agency to obtain information about complaints or disciplinary actions against a health care practitioner
  • Any prior authorization requirement and limitation, restriction or exclusion by service, benefit or type of drug
  • Information about the financial relationships between Blue Cross Blue Shield of Michigan and a participating practitioner

Blues members have the responsibility to:

• Read all Blue Cross Blue Shield of Michigan materials provided for members, and call our Customer Service department with any questions
• Coordinate all nonemergency care through their primary care physicians
• Use the Blue Cross Blue Shield of Michigan provider network unless otherwise approved by Blue Cross and their primary care physicians
• Comply with the plans and instructions for care that they agreed to with their practitioners
• Provide, to the extent possible, complete and accurate information that Blue Cross Blue Shield of Michigan and its practitioners need in order to provide care
• Make and keep appointments for nonemergency medical care. They must call their doctor’s offices to cancel appointments.
• Participate in the medical decisions regarding their health
• Be considerate and courteous to practitioners, providers, their staff and other patients
• Notify Blue Cross Blue Shield of Michigan of address changes and additions or deletions of dependents covered by their contracts
• Protect their identification cards against misuse and contact Customer Service immediately if their cards are lost or stolen
• Report all other health care coverage or insurance programs that cover their health and their family’s health
• Participate in understanding their health problems and the development of mutually agreed upon treatment

Statement about incentives

• Utilization management decision-making is based only on appropriateness of care and service and existence of coverage.
• Blue Cross Blue Shield of Michigan does not specifically reward practitioners or other individuals for issuing denials of coverage.
• Financial incentives for utilization management decision-makers do not encourage decisions that result in underutilization.

If you have any questions about any of this information, please contact your provider consultant.