Blue Cross Blue Shield of Michigan announces changes to Traditional program participation criteria

Blue Cross Blue Shield of Michigan is making changes to the Traditional program participation criteria. As of Jan. 1, 2015, the criteria under which a practitioner may be refused participation in the BCBSM Traditional program include, but are not limited to, the following:

• Any felony or misdemeanor conviction, guilty plea, plea of nolo contendere or placement in a diversion program for any crime related to the payment or provision of health care involving BCBSM, Medicare, Medicaid or other health care insurers in the last five years

• Any felony or misdemeanor conviction, guilty plea, plea of nolo contendere or placement in a diversion program for any crime in the last three years

• Termination, suspension, revocation of licensure, certification, registration or accreditation in Michigan or in any other state in the last two years

• Reprimand, censure, restriction or reduction to probationary status of licensure, certification, registration or accreditation in Michigan or any other state in the last year

• Practitioners who have failed to reimburse BCBSM any amounts due and owing as a result of any overpayment or audit identified from previous affiliation with Blue Cross

• Practitioners who are currently on federal sanction list or have been on such a list within the last two years

• Practitioners who have been departicipated by BCBSM within the last five years after being on pre-payment utilization review for at least two years and who did not meet criteria to be removed from PPUR. 

If you have any questions about these changes, please call Provider Enrollment and Data Management at
1-800-822-2761.