Here’s some key information for Michigan providers who treat Medicare Plus Blue members

We’ve compiled some important information that we want to make sure health care providers who treat Medicare Plus Blue℠ members know about, including:

• Determining whether prior authorization is required for a Medicare Plus Blue member
• Submitting preservice and post-service appeals
• Submitting claims
• Changes resulting from the end of the COVID-19 public health emergency

Prior authorization

To determine whether prior authorization is required for a service for a Medicare Plus Blue member, see the document Determining prior authorization requirements for members, which you can find at ereferrals.bcbsm.com. The sections for Michigan providers include step-by-step instructions.
When submitting prior authorization requests, always include complete clinical documentation to support medical necessity.

Select elective medical and surgical procedures require prior authorization for members who reside in Michigan and use contracted Medicare Plus Blue providers. See the “Prior authorization of other medical/surgical services” section of the Medicare Plus Blue PPO Provider Manual for information about authorization criteria and medical policies.

Appeals

All Michigan providers should submit preservice and post-service appeals directly to Blue Cross Blue Shield of Michigan. Appeals should include the member’s most recent medical records. Noncontracted providers must submit a waiver of liability.

Claim submissions

Blue Cross follows the Centers for Medicare & Medicaid Services guidelines published in the Medicare Claims Processing Manual** and the Medicare National Coverage Determinations / Local Coverage Determinations.**

To reduce the chance of a claim denial:

• Refer to CMS guidelines to confirm services that require medical records and other criteria.
• Ensure that all appropriate diagnosis codes, procedure codes and modifiers (if applicable) are included on the initial claim.
• Reference CMS coding guidelines to prevent unbundling and other coding errors. Bill in the same manner as you would bill Medicare.
• Before submitting a duplicate claim, allow 30 to 45 days for the initial claim to be processed and a determination to be made.

Helpful resources

Review the following for more information on the topics addressed above:

• Services that require authorization for Michigan providers, available on ereferrals.bcbsm.com
• Provider preauthorization and precertification requirements
• Medicare Plus Blue PPO Provider Manual

Changes resulting from end of COVID-19 public health emergency

Many of the flexibilities and waivers that were put in place during the COVID-19 public health emergency, or PHE, ended when the PHE ended on May 11, 2023. The only changes that remain are those the U.S. government extended or made permanent — telehealth flexibilities, for example. For services provided to Blue Cross members on and after May 12, 2023, normal plan rules apply.

The following utilization management requirements resumed on July 1, 2023:

• Clinical review is required for acute medical inpatient admissions related to COVID-19, flu, pneumonia or respiratory syncytial virus.
• Standard time frames for submitting appeals of prior authorization determinations apply. Refer to the denial letter to determine the time frame.

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