BCBSM’s Medicare Plus Blue^SM Group PPO gains members in Michigan for 2014

Members of the UAW Retiree Medical Benefits Trust who live in Michigan may choose medical and surgical coverage through Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus Blue Group PPO.

ID cards
Members of the UAW Retiree Medical Benefits Trust who reside in Michigan will have new ID cards that reflect alpha prefix “XYL” for Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus Blue Group PPO. UAW Trust Medicare Advantage PPO members will have medical and surgical benefits as well as coverage for hearing, routine vision exams provided by VSP and the SilverSneakers^® Fitness Program.

Eligibility
You can verify eligibility and coverage online through web-DENIS by using the alpha prefix located on the ID card. Information obtained regarding member eligibility is not a guarantee or a promise of payment. Payment determination only occurs after the claim is processed according to the member’s benefits. You can also verify eligibility and coverage using CAREN by calling 1-866-309-1719.

Precertification
Precertification is required by BCBSM for its Medicare Advantage PPO members for certain services in Michigan. Providers should contact BCBSM to obtain precertification or recertification for:

• Skilled nursing facility, long term acute care and inpatient acute rehabilitation admissions
• Facilities are required to complete the appropriate facility request form (either the Skilled Nursing Facility and Acute Rehabilitation Facility Assessment form or the Long-Term Acute Care Facility form) and submit it by fax to 1-866-464-8223. Facilities can also email requests to MedicarePlusBlueFacilityFax@bcbsm.com.
• Expedited and urgent care requests must be attested to by the physician, indicating that this is an urgent admission for a condition jeopardizing the member’s life or health and is deemed life-threatening. Please submit expedited and urgent requests to 1-866-225-4905 or email urgentinpatientprecertrequests@bcbsm.com for processing within 72 hours or as quickly as the patient’s condition requires.

• Behavioral health admissions and intensive outpatient behavioral health services
• For inpatient, partial hospitalization and intensive outpatient behavioral health services, providers should contact Michigan Medicare Plus Blue PPO Behavioral Health at 1-888-803-4960.
• SNF, acute rehabilitation, long-term acute care and expedited, urgent admission (for those admissions attested to by a physician as urgent) assessment forms are available online via BCBSM’s provider website at bcbsm.com/provider/ma.

Pre-notification
For acute care admissions to hospitals, providers are required to use web-DENIS to notify BCBSM of the admission.

While pre-approval of hospital admissions is not required, we highly recommend that hospitals use InterQual^® criteria to assess the medical necessity of the admission. InterQual criteria should be applied prior to executing the pre-notification process, but it will not be used to accept or modify the admission.

• Hospitals will be required to reference InterQual criteria for inpatient admissions and indicate which subset was referenced and met. If a doctor is overriding InterQual inpatient criteria, then the hospital must provide the doctor’s name and phone number.
• Hospitals will be encouraged to enter symptoms exhibited at admission and the necessary treatment.
• Hospitals will be required to reference the U.S. Centers for Medicare & Medicaid Services inpatient surgical list for Medicare Advantage PPO inpatient surgical procedures that are considered elective. If a physician is overriding the CMS inpatient surgical list, then the hospital must provide the physician’s name and phone number.
• Hospitals will be required to provide an ICD-9-CM narrative for admissions. We ask that hospitals also enter the ICD-9-CM diagnosis code that corresponds with the narrative.

Radiology Management Program preauthorization
The National Radiology Utilization Management Program requires preauthorization for outpatient advanced diagnostic services to ensure that the procedures are appropriate and medically necessary.

The preauthorization requirement includes the following outpatient advanced diagnostic imaging services:

• Computed tomography
• Magnetic resonance imaging
• Nuclear cardiology
• Positron emission tomography
• Stress echocardiography
• Resting transesophageal echocardiography
• Transthoracic echocardiography

Note: Imaging studies performed along with emergency room services, inpatient hospitalization, outpatient surgery (hospitals and freestanding surgery centers), urgent care centers and 23-hour observations are excluded from this requirement.

High-tech diagnostic radiology pre-authorizations can be obtained from AIM^SM Specialty Health as directed in the Medicare Plus Blue PPO Provider Manual.