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December 2018

Reminder: Updates to PPO professional claims editing process coming in December

In the September 2018 Record, we let you know that Blue Cross Blue Shield of Michigan will update its claims editing processes for select groups in December 2018. The initial implementation will apply to professional claims, including durable medical equipment, prosthetics and orthotics, and medical supplies. The outpatient facility implementation will take place in the second quarter in 2019.

These updates will make our claims payment system easier for you and your billing staff to navigate. Unique clinical editing reason codes will appear on the 835 response files or provider vouchers.

As a reminder, when billing PPO claims, you should follow guidelines from:

  • The American Medical Association’s Current Procedural Terminology code set regarding:
    • Correct modifier usage
    • Evaluation and management reporting guidelines
    • National bundling edits
  • National specialty societies, such as:
    • American College of Surgeons
    • American College of Radiology
    • American Association of Neuromuscular and Electrodiagnostic Medicine
    • American Cancer Society

As part of your contract with us, health care providers affiliated with the PPO network agree to supply services to Blue Cross members and bill according to guidelines and requirements set by the American Medical Association and select specialty societies.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2017 American Medical Association. All rights reserved.