Check member benefits before billing for abortion services

Blue Cross Blue Shield of Michigan and Blue Care Network are aligning the terminology used in our policies and certificates with Michigan’s Abortion Insurance Opt-Out Act, which became effective for plans that are new or renewed on or after March 13.

For BCN, all benefit language was updated March 13. BCBSM groups with plan years beginning January through March 2014, had their benefit language updated by March 31, 2014. BCBSM groups with plan years beginning April 2014 or later will have their benefit language updated on their plan year effective date.

This article will help you know what to look for when filing claims for abortion services.

The law establishes definitions of elective and non-elective abortion services. For providers, this means that some abortion procedures that were previously covered under the medical-surgical benefit are no longer payable unless the patient has a special rider for elective abortion coverage.

Under this new law, abortion coverage for the following circumstances is not available to members without an elective abortion rider:

• Congenital birth defects
• Preserve the health of the mother
• Cases of rape or incest
• An abortion for any other reason that is not a medical reason
• For individual plans only, "increase the probability of a live birth" is considered elective, according to state law. Please note that the Blues’ individual plans do not offer an elective abortion rider.

Elective abortion coverage may only be provided through a rider.

The procedure codes for abortions are listed above at right. Please note that certain procedure codes should not be submitted for reimbursement if the member doesn’t have elective coverage.

Keep in mind that it’s important to check benefits on web-DENIS or CAREN for BCN or Benefit Explainer for Blue Cross to verify whether a member has elective abortion coverage. For BCN, when checking eligibility and benefits on web-DENIS, click on Medical Benefits and scroll down to Elective Abortions to see if the member has coverage. If you do not see elective abortion coverage on web-DENIS or CAREN, you should call Provider Inquiry to determine if the patient has coverage for the specific circumstance. You can also check benefits by the 270/271 electronic standard transaction. For information about the 270/271 electronic standard transaction, send an email to EDICustmgmt@bcbsm.com.

The law only applies to underwritten group and individual plans. Underwritten groups have the opportunity to purchase elective abortion coverage through an optional rider. Elective abortion coverage is not available in plans sold to individuals.

Please see the March Record for background on the Abortion Insurance Opt-Out Act.

More information about the law and the penalties for not complying with it are available at the Michigan.gov** website.

**The Michigan Blues does not control this website or endorse its general content.

The information in this document is based on the Michigan Blues’ review of the applicable legislation and is not intended to impart legal advice. Interpretations of this legislation may vary, and efforts will be made to present accurate information and update it if necessary. This overview is intended as an educational tool only and does not replace a more rigorous review of the law’s applicability to individual circumstances and attendant legal counsel, and should not be relied upon as legal or compliance advice.