Have questions about our policies? Check out these online resources

Here’s key information our participating health care providers need to know about doing business with Blue Cross Blue Shield of Michigan.

How to access our online provider manuals

Everything you need to do business with Blue Cross is included in our online provider manuals. To access the provider manual through our new provider portal:

1. Log in to availity.com.**
2. Click on Payer Spaces on the Availity menu bar.
3. Click on the BCBSM and BCN logo.
4. Click on Provider manuals under the Resources tab.

Access and availability guidelines

When a member requests an appointment, Blue Cross providers are required to comply with the following standards.

For more detailed information, see the “PPO Policies” chapter in the provider manual or contact your provider consultant.

Affirmative statement about incentives

Medical decisions are based only on appropriateness of care and service and existence of coverage. See the affirmation statement in the “Participation” chapter of the provider manual. It’s located in the section titled “Requirements and Guidelines.”

Clinical practice guidelines

For medical and behavioral health care, Blue Cross follows Michigan Quality Improvement Consortium guidelines, which can be found on the mqic.org** website.

Comprehensive care management

To learn about Blue Cross comprehensive care management, review the “Health, Well-being and Care Management” chapter in your online provider manual. To find the information on bcbsm.com, click on the Providers tab. Type Blue Cross Coordinated Care in the search engine. Scroll down to For Providers: Blue Cross Coordinated Care.

Criteria used for level of care utilization management decisions

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.

Blue Cross modifications of the InterQual criteria (local rules) can be accessed online by following these steps:

1. Log in at availity.com.**
2. Click on Payer Spaces at the top.
3. Click on the BCBSM and BCN logo to reach our payer space.
4. Click on Secure Provider Resources (Blue Cross and BCN) on the Resources tab.
5. Click on Codes and Criteria on the Billing and Claims tab.

If you have questions about InterQual, send an email to InterQualSupport@ChangeHealthcare.com. Provide your name and address, and reference that the question pertains to InterQual.

Note: Policies and criteria for Federal Employee Program^® utilization management decision-making can be found at fepblue.org.

Medical policies

To review additional Blue Cross medical policies, go to bcbsm.com/providers.

1. Click on Quick Links.
2. Click on Preauthorization and precertification.
3. Click on Medical policy, precertification and preauthorization router. Use the button to select Medical Policy, then follow online prompts.

Member rights and responsibilities

Blue Cross outlines the rights and responsibilities of our members, including how members can file a complaint or grievance. For more information, go to the Important Information page on our website, and click on Understanding member rights and responsibilities under Important Notices About How Your Coverage Works.

Pharmacy management

It’s important for you to be familiar with our drug lists and our pharmacy management programs, such as step therapy, quantity limits, dose optimization, use of generics and specialty pharmacy. You also need to know how to request prior authorization or exception requests and the information needed to support your request.

Note: Generic substitution may be required for Blue Cross members. If both the generic and brand name are listed on our drug list, members are encouraged to receive the generic equivalent when available. Some members may be required to pay the difference between the brand-name and generic drug, as well as applicable copay, depending on the member’s plan.

See the For Providers: Drug Lists page on our website for more details. The page contains links to the drug lists, prior authorization, step therapy requirements, quantity limit lists and alternatives for nonpreferred brand and nonformulary drugs.

We recommend that you visit this page at least quarterly to access our pharmacy procedures, drug lists and to view updates. Go to bcbsm.com/providers. You can also call 1-800-437-3803 for the most up-to-date pharmaceutical information.

Translation services

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

Utilization management staff availability

Department telephone numbers and hours are shown in the “Preapproval Decisions/Utilization Management Decisions” section of the “Appeals and problem resolution” chapter of the provider manuals.

Behavioral health care — New Directions

New Directions Behavioral Health is an independent company administering behavioral health benefits on behalf of Blue Cross. For information on the New Directions Behavioral Health Quality Improvement Program, click here.**

Contact information:

• Commercial PPO and Traditional programs: 1-800-762-2382
• Federal Employee Program: 1-800-342-5891
• United Auto Workers Retiree Medical Benefits Trust, or URMBT employer group: 1-877-228-3912

For more information

• Information about our programs and additional resources are available on the Important Information page of our website.
• To request a printed copy of any of the information contained in this article, call HCV Quality Management at 248-455-2808.
• If you have any questions about the information in this article, contact your provider consultant.

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