BCBSM provides official notice of changes to appeals process

As we’ve been telling you, earlier this year Governor Snyder signed Public Acts 4 and 5, the acts that enabled BCBSM to begin a transition to a nonprofit mutual insurer, governed by the Michigan Insurance Code rather than Public Act 350. During the transition, we discovered that it was necessary to revise the provider appeals process. The information in this article will serve as official notification of the appeal process changes.

Background of appeals changes
Under PA 350, providers had access to the Department of Insurance and Financial Services for appeals of BCBSM decisions regarding post payment audits and post service claims. Under the Michigan Insurance Code, DIFS will no longer serve that function. Therefore, we must eliminate this step in our provider appeals process and change the language in our agreements and provider manuals to reflect this change.

BCBSM has documented a process that replaces binding arbitration and access to DIFS with an external peer review by an independent review organization for non-policy (medical and clinical) issues. As such, providers who are dissatisfied with the internal appeals process findings regarding non-policy issues such as medical necessity, pre-existing conditions, or coding accuracy may request an appeal by an independent review organization.

All providers will continue to have access to their current internal appeal process, which includes written inquiry and informal managerial conferences.

Changes to the appeals process have been approved by the board of directors and will be effective Jan. 1, 2014.

Where to find more information about the appeals process changes
For the provider types listed below, the participation agreements have been updated to include the revised appeals process. Those agreements are located in the provider manuals on web-DENIS:

• Ambulance
• Certified Registered Nurse Anesthetist
• End Stage Renal Disease Facility (Traditional contract)
• End Stage Renal Disease Facility (TRUST contract)
• Hearing Specialist
• Hospice
• Long-Term Acute Care Hospital
• Practitioners (M.D., D.O., chiropractors, fully-licensed psychologists and podiatrists)
• Vision Specialists (ophthalmologists and optometrists)
• Freestanding and Hospital-Based Substance Abuse Facility
• Skilled Nursing Facility

For all other provider types, be sure to check your online provider manual beginning Oct. 1, 2013, to see the most up-to-date appeals process.

Note: The changes outlined above impact all health care providers except for hospitals.

If you have questions, contact your provider consultant.