ACA’s wellness regulations may cause some claims to be reprocessed

Under the terms of the Affordable Care Act, individuals enrolled in wellness programs — such as Blue Cross Blue Shield of Michigan’s Healthy Blue Incentives and Healthy Blue Achieve — must be able to receive the full benefit of program rewards for the entire benefit year.

That means that members who began the year at the standard benefit level but subsequently met the product requirements would be shifted to the enhanced benefit level, retroactive to the first day of the group’s benefit year. For members who have the Healthy Blue Incentives product, all claims incurred during the first six months of the group’s benefit year will be reprocessed at the enhanced benefit level if the member met the product requirements.

Note: A similar approach to claims processing for members with the Healthy Blue Achieve product will begin in the second quarter of 2015.

Following are examples of adjustment reason messages that may appear on your voucher if adjustments need to be made:

WE PREVIOUSLY PAID $42.30 FOR THIS CLAIM. THE CORRECT PAYMENT SHOULD HAVE BEEN $58.33. AN ADDITIONAL PAYMENT HAS BEEN MADE FOR THE DIFFERENCE. (Z989)

THIS CLAIM IS AN ADJUSTMENT TO A PREVIOUSLY PROCESSED CLAIM. (Z998)

If you receive such a message, you will need to refund your patient for any amount they overpaid.

If you have any questions, please contact your provider consultant.