Medicare Plus Blue^SM PPO claim reimbursements

Effective July 1, 2019, Medicare Plus Blue^SM PPO will implement new reimbursement policies for the following claims billed with Healthcare Common Procedure Coding System or Current Procedural Terminology codes that don’t have an assigned Medicare fee.

General reimbursements (for non-durable medical equipment and non-laboratory claims)

• Medicare Plus Blue PPO will reimburse providers 65 percent of the charged amount for all non-DME and non-lab claims that don’t have an assigned Medicare fee.
• For drug claims, pharmacy pricing resources, if available, will be used before reimbursing at 65 percent of charges. For unlisted surgery codes, reimbursement will be made at the rate of a comparable surgery code.

  Note: This payment policy doesn’t apply to procedure codes that currently require an invoice for payment by the Centers for Medicare & Medicaid Services. Also, any CPT codes that are carrier priced will continue to be paid accordingly.

Durable medical equipment

• Medicare Plus Blue PPO will reimburse providers 65 percent of the manufacturer’s suggested retail price for all DME claims that don’t have an assigned Medicare fee.
• Providers must place the manufacturer’s suggested retail price, or MSRP, in the notes section of the claim. If available, DME contracted fees will be utilized before reimbursing at 65 percent of the MSRP.

  Note: This payment policy doesn’t apply to procedure codes that require an invoice for payment either by Medicare Plus Blue or CMS (such as prosthetics, custom-made items, not otherwise specified codes, miscellaneous codes, A4649, A6549 and V2785). Also, any carrier priced CPT codes will continue to be paid accordingly.

Labs (a reminder of the policy that went into effect July 26, 2016)

• Medicare Plus Blue PPO will reimburse providers 65 percent of the charged amount for all lab claims that don’t have an assigned Medicare fee.
• If available, the established lab facility-contracted rate or fee will be used. If there’s no established contracted rate or fee, Blue Cross Blue Shield of Michigan’s commercial rate will be used before reimbursing at 65 percent of charges.

  Note: Supporting documentation for applicable claims is required to determine medical appropriateness and ensure timely processing. Claims will be denied if documentation isn’t attached.