Annual notice: What you need to know about our programs

At Blue Cross Blue Shield of Michigan, we continually implement, monitor, measure and evaluate strategies to improve the quality of care delivered to our members. Some improvements we’re proud of include:

• We successfully maintained accreditation with a Commendable rating from the National Committee for Quality Assurance.
• Member satisfaction with providers remains high. Members’ personal doctor satisfaction once again scored in the 90th percentile, based on 2015 Consumer Assessment of Healthcare Providers and Systems member satisfaction surveys.
• We exceeded annual goals for volumes of identified, reached and engaged members for both case management and chronic condition management.
• We established a pharmacy program with 24-hour turnaround time frames. The program helps make coverage decisions for non-formulary drugs in urgent circumstances.
• Sixty-nine Michigan hospitals have signed a value-based contract.
• A total of 1,551 practices have been designated as patient-centered medical homes.

We annually update information about the following:

• Behavioral health care benefits
• Clinical practice guidelines
• Comprehensive care management
• Criteria used for utilization management decisions
• Members rights and responsibilities
• Pharmacy management
• Statement about incentives
• Translation services
• Utilization management staff availability

Here’s a brief rundown:
Behavioral health care benefits
New Directions Behavioral Health is an independent company administering behavioral health benefits on behalf of Blue Cross for our members. Contact information:

• Commercial PPO and Traditional programs: 1-800-762-2382
• Federal Employee Program^®: 1-800-342-5849

For a summary of New Directions annual quality improvement initiatives and outcomes, click here.

Clinical practice guidelines
For medical and behavioral health care, Blue Cross follows Michigan Quality Improvement Consortium guidelines, which can be found at mqic.org.**

Federal Employee Program: In addition to MQIC guidelines, FEP uses Accordant clinical practice guidelines for treating chronic disease. Those guidelines can be found at accordant.com.** Note: User name and password are required; provided by Accordant.

Comprehensive care management
To learn about Blue Cross comprehensive care management, use your online provider manual or go to bcbsm.com and click on the For Members tab. Under Health & Wellness, choose either Case Management or Chronic Condition Management and click on Learn More.

Criteria used for level of care utilization management decisions
InterQual^® criteria: For hospitals and facilities, Blue Cross uses InterQual criteria to assess medical necessity and the appropriate level of care. Criteria encompasses acute care (adult and pediatric), rehabilitation (adult and pediatric), long-term acute care, skilled nursing facility and home health care. For questions about InterQual, email Blue Cross at InterQualCriteria@bcbsm.com

Behavioral health program: New Directions criteria are available for download at ndbh.com.** Medical necessity criteria are reviewed annually and updated as needed. You may call New Directions at 1-800-528-5763 to request a printed copy.

Federal Employee Program: Criteria for FEP utilization management decision-making can be found at fepblue.org.

Additional medical policies: To review additional Blue Cross medical policies, go to bcbsm.com/providers and click Quick Links, then on Medical Policy and Pre-Cert/Pre-Auth Router.

Member rights and responsibilities
Blue Cross Blue Shield of Michigan members have the right to:

• Receive clear and understandable written information about Blue Cross Blue Shield of Michigan, its services, practitioners and providers, and their member rights and responsibilities
• Receive easy-to-understand information about their care
• Receive medically necessary care as outlined in the New Member Handbook and Summary of Benefits and Coverage
• Receive considerate and courteous care with respect to their privacy and human dignity
• Candidly discuss appropriate medically necessary treatment options for their health conditions, regardless of cost or benefit coverage
• Participate in decision-making regarding their health care
• Expect confidentiality regarding their care and know that Blue Cross Blue Shield of Michigan adheres to strict internal and external guidelines concerning their personal health information. This includes the use, access and disclosure of that information or any other information that is of a confidential nature.
• Refuse treatment to the extent permitted by law and be informed of the consequences of their actions
• Voice concerns or complaints about their health care by contacting the Customer Service department or submitting a formal, written grievance through the Blue Cross Blue Shield of Michigan appeals process
• Review their medical records at your office by scheduling an appointment during regular business hours
• Make recommendations regarding the member rights and responsibilities policies of Blue Cross Blue Shield of Michigan
• Request the following information from Blue Cross Blue Shield of Michigan:
• The current provider network in their region
• The professional credentials of the health care practitioners who are participating with Blue Cross Blue Shield of Michigan, including participating practitioners who are board-certified in the specialty of pain medicine and the evaluation and treatment of pain
• The names of participating hospitals where individual participating physicians have privileges for treatment
• How to contact the appropriate Michigan agency to obtain information about complaints or disciplinary actions against a health care practitioner
• Any prior authorization requirement and limitation, restriction or exclusion by service, benefit or type of drug
• Information about the financial relationships between Blue Cross Blue Shield of Michigan and a participating practitioner

Blue Cross members have the responsibility to:

• Read all Blue Cross Blue Shield of Michigan materials provided for members, and call our Customer Service department with any questions
• Coordinate all nonemergency care through their primary care doctors
• Use the Blue Cross Blue Shield of Michigan provider network unless otherwise approved by Blue Cross and their primary care physicians
• Comply with the plans and instructions for care that they agreed to with their providers
• Provide, to the extent possible, complete and accurate information that Blue Cross Blue Shield of Michigan and its providers need in order to provide care
• Make and keep appointments for nonemergency medical care. They must call their doctor’s offices if they need to cancel an appointment.
• Participate in the medical decisions regarding their health
• Be considerate and courteous to practitioners, providers, their staff and other patients
• Notify Blue Cross Blue Shield of Michigan of address changes and additions or deletions of dependents covered by their contracts
• Protect their identification cards against misuse and contact Customer Service immediately if their cards are lost or stolen
• Report all other health care coverage or insurance programs that cover their health and their family’s health
• Participate in understanding their health problems and the development of mutually agreed upon treatment

Behavioral health: For members’ behavioral health service rights and responsibilities, click here.

Pharmacy management
We recommend you visit bcbsm.com/pharmacy at least quarterly and click on Drug Lists or call 1-800-437-3803 for the most up-to-date pharmaceutical information.

Federal Employee Program: CVS/caremark™ provides pharmacy management services for the Federal Employee Program. Below are the links to the FEP drug lists for the FEP Basic Option and FEP Standard Option:

• Basic Option: Click here.
• Standard Option: Click here.

Statement about incentives

• Medical decisions are based only on appropriateness of care and service and existence of coverage.
• Blue Cross Blue Shield of Michigan doesn’t specifically reward doctors or other individuals for issuing denials of coverage.
• Financial incentives for doctors and other health professionals don’t encourage decisions that limit treatment for our members.

Behavioral health: Decisions about utilization of behavioral health services are made only on the basis of eligibility, coverage and appropriateness of care and service. New Directions doesn’t specifically reward, hire, promote or terminate practitioners or other individuals for issuing denials of coverage. Utilization decision-makers don't receive incentives that would result in under-utilization.

Translation services
Members who need language assistance can call the Customer Service number on the back of their ID card. TTY users should dial 711.

Utilization Management staff availability
Blue Cross provides access to Utilization Management staff for members and practitioners seeking information about UM process and authorization of care. Department telephone numbers and hours are shown in the Utilization Management Decisions chart in the Appeals section of your provider manual.

For more information

• Information about our programs and additional resources are available at bcbsm.com/importantinfo.
• To request a printed copy of any of the information contained in this article, contact Vicki Boyle, director of Quality Management and Accreditation, at 313-448-6145.
• If you have any questions about this article or the information in it, contact your provider consultant.

**Blue Cross Blue Shield of Michigan doesn’t own or control the content of this website.