BlueCard^® connection: If an out-of-state plan rejected my claim as experimental, is my patient responsible for the charge?

Yes. You may bill the patient if both of the following apply:

• You receive a rejection on a BlueCard claim.
  
• The plan’s rejection advises you that the service or treatment reported on your claim is considered experimental or investigational and is the member’s liability.

The home plan where your patient is enrolled determines whether the service reported is a covered benefit, according to their member’s contracted benefits and the plan’s medical policy.

Blue Cross Blue Shield of Michigan’s medical policies, including those for experimental services, don’t apply to BlueCard claims.

Use of the Medical Policy and Pre-Cert/Pre-Auth Router can help you confirm the plan’s medical policy criteria. The router can also identify services that a home plan considers experimental or investigational. If a plan has a documented online medical policy, you can access the policy via our router.

You can access the Medical Policy and Pre-Cert/Pre-Auth Router by using any of these options:

• Logging in to web-DENIS and clicking on the BCBSM Provider Publications and Resources link.

• Clicking on a link in the medical records section of the online BlueCard chapter found in every online provider manual

• Going to bcbsm.com and following these steps:

• Click on Providers.
• Click on Quick Links.
• Click on Medical Policy and Pre-Cert/Pre-Auth Router.

On the router’s webpage, you can view a plan’s pre-service authorization requirements or its medical policies. To view the medical policies that a plan has available online, you’ll enter the member’s three-letter alpha-prefix and be routed to the plan’s webpage. The plan’s online policies include effective dates, clinical criteria for the service or treatment and the clinical information the plan used to determine their policy.

Consult the plan’s online policies before rendering a service or treatment to the patient. This BlueCard online tool also is an excellent resource to reference before requesting claim reconsideration on a billed and rejected claim.

For more information on the BlueCard program, including links and articles on online tools, reference the BlueCard chapter of the online provider manuals.

If you’re experiencing issues with the information provided in the BlueCard chapter of the online manual — or if you’d like more information on a particular topic — contact your provider consultant.

Want to suggest a topic to be covered in this series? Send an email to ProvComm@bcbsm.com and put “BlueCard series” in the subject line.