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September 2014

Amendments made to Trading Partner Agreement

Blue Cross Blue Shield of Michigan has amended its Trading Partner Agreement to permit us to engage in key business functions in the nonparticipating provider space.

The TPA is the mechanism that governs how electronic data interchange, or electronic claims transactions, will be conducted between BCBSM and its trading partner — typically providers, billing agents and other health plans.

The amended TPA makes it clear that nonparticipating providers must do the following:

  • Comply with billing publications or guidelines issued by BCBSM or ensure that his or her billing agent complies.
  • Retain all original medical and business office records in accordance with BCBSM’s retention period, rules of applicable accrediting organizations and legal requirements.
  • Permit BCBSM or its designee physical access to the premises to review any and all medical and billing records submitted by it or its billing agent for any permissible purpose, including for BCBSM’s risk-adjustment and revenue-management programs.
  • Provide copies of any medical and billing records to BCBSM or its designee for a nominal fee.

Additionally, BCBSM has amended the TPA to make it clear that the nonparticipating provider must agree to the following if he or she agrees to accept assignment, participate with BCBSM or wants to receive payment directly from BCBSM for the services provided to a BCBSM member:

  • Accept BCBSM’s payment as payment in full, and should not, with the exception of applicable deductible, co-payment or co-insurance amounts, balance-bill the member the difference between the charged amount and BCBSM’s payment.
  • Continue to accept payment directly and in full for that same service for all BCBSM members — as long as they are payable benefits — for the remainder of the calendar year.

These amendments will become effective automatically on Nov. 1, 2014. There is no action required on the part of BCBSM’s trading partners in order for the amendment to become effective.

If you have questions about updates to the TPA, please contact your provider consultant.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2013 American Medical Association. All rights reserved.
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and
independent licensees of the Blue Cross and Blue Shield Association.