Billing chart: Blues highlight medical, benefit policy changes

Q4132, Q4133

Basic benefit and medical policy

Skin and tissue substitutes

The safety and effectiveness of skin and tissue substitutes approved by the U.S. Food and Drug Administration have been established for patients meeting specified selection criteria. They may be useful therapeutic options when indicated.

Two additional products are covered when medically necessary, effective May 1, 2017.

Modifiers GY, GZ and GA

Basic benefit and medical policy

Advance Notice of Member Responsibility

As a reminder, all professional, non-Medicare claims that include the modifiers GY or GZ, along with modifier GA, will be rejected and the member will be responsible for paying for the services provided.

Blue Cross Blue Shield of Michigan adopted Medicare’s Advance Beneficiary Notice policy and refers to it as Advance Notice of Member Responsibility. Health care providers should include the GA modifier on all claims, including Not Otherwise Classified and Unlisted Procedure Codes, billed with a GY or GZ modifier, which will acknowledge that:

• The services are expected to be rejected.
• The member was informed and agreed to accept total responsibility.
• An ANM responsibility form was signed before were services rendered and is on file.

The ANM billing guidelines don’t apply to Medicare supplemental and MESSA group member claims.

If providers don’t include the GA modifier on claims appended with a GY or GZ, they will be held responsible for the cost of the services.

Providers must present an Advance Notice of Member Responsibility form to the Blue Cross members before providing medical services or supplies that are expected to be rejected.

For the notice to be acceptable, a provider must:

• Complete the form in its entirety.
• Clearly identify the specific item or service that is expected to be denied.
• State the specific reason that Blue Cross will deny payment for the item or service.
• Indicate the estimated cost of the item or service that is associated with the denied claim and the member’s responsible amount.

The  form should be issued before rendering a service or dispensing durable medical equipment, prosthetics and orthotics, or medical supplies that Blue Cross isn’t expected to cover. This form doesn’t supersede or change any member’s benefits.

Here are some reasons the medical claims for those items may be rejected:

• Blue Cross medical criteria haven’t been met.
• Blue Cross doesn’t usually pay for this quantity of treatments or services.
• Blue Cross doesn’t usually pay for this service.
• Blue Cross doesn’t pay for this service because it’s a treatment that hasn’t been proven safe or effective.
• Blue Cross doesn’t pay for this quantity of services within this time period.
• Blue Cross doesn’t pay for such an extensive treatment.
• Blue Cross doesn’t pay for this medical equipment for the illness or condition stated.

If a provider properly issues a notice, the member will be held financially liable for the reason indicated above on the signed form. Keep in mind that a provider who fails to properly issue a notice will be held liable for the medical service. The provider won’t be allowed to bill or collect funds from the member, and the provider must refund money collected from the member.

Other important information about the Advance Member Notice of Responsibility form

• For an extended course of treatment, a member responsibility form is valid for one year. If the course of treatment extends beyond one year, a new form is required each year for the remainder of the treatment.
• Once signed by the member, a member responsibility form may not be modified or revised. When a member must be notified of new information, a new form must be provided and signed.

Experimental or medically unnecessary services

Basic benefit and medical policy

Reminder: Blue Cross doesn’t provide benefits for experimental or medically unnecessary services

Blue Cross Blue Shield of Michigan doesn’t provide benefits for experimental or medically unnecessary procedures, treatments, drugs or devices.

Health care providers may not bill members for such services unless they:

• Give a cost estimate of the services.
• Have the member confirm in writing that he or she assumes financial responsibility and that Blue Cross won’t make a payment.

These statements are required before services can be rendered.

Autoliv ASP Inc.

Autoliv ASP Inc., group number 71772, will join Blue Cross Blue Shield of Michigan, effective Jan. 1, 2018.

Group number: 71772
Alpha prefix: IOD

Platforms:
Member’s Edge – Membership
NASCO – Benefits

Plans offered:
PPO medical/surgical
CDH-HSA

Michigan Automotive Compressor Inc.

Michigan Automotive Compressor Inc., group number 71753, will join Blue Cross Blue Shield of Michigan, effective Jan. 1, 2018.

Group number: 71753
Alpha prefix: PPO (JXP)

Platforms:
Member’s Edge — Membership
NASCO — Benefits

Plans offered:
PPO medical/surgical
Dental
Vision (VSP)

Sheet Metal Workers Local 7 Zone 1

Sheet Metal Workers Local 7 Zone 1, group number 71754, will join Blue Cross Blue Shield of Michigan, effective Jan. 1, 2018.

Group number: 71754
Alpha prefix: PPO (UIW)

Plans offered:
PPO medical/surgical
Prescription drug
Dental
Vision (VSP)

Trinity Health

Effective Jan. 1, 2018, Trinity Health, group number 71349, is adding habilitative physical therapy, occupational therapy and speech therapy to its PPO plans. Habilitative PT, OT and ST will have a combined 60 visit maximum per calendar year.

The rehabilitative PT, OT and ST will remain 60 visits maximum per therapy per calendar year.