What you need to know about doing business with Blue Cross

Here’s a summary of key information our participating 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 provider portal:

1. Log in to availity.com.**
2. Click on Payer Spaces on the Availity menu bar.
3. Click on the Blue Cross 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

Utilization management 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.”

Comprehensive care management

To learn about Blue Cross comprehensive care management, use your online provider manual “Health, Well-being, and Care Management” chapter. 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.

 Behavioral health criteria can be found in the in the 2024 Behavioral Health Services section on the Services That Need Prior Authorization page on bcsbm.com.

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. Go to the Important Information page on our website. Scroll down to Important Notices About How your Coverage Works and click on Rights and Responsibilities.

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 for drugs covered under the pharmacy and medical benefit 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 Pharmacy Services page on our website for more details.

We recommend you visit this page at least quarterly to access our pharmacy procedures, drug lists including the Prior Authorization Medical Drug List and to view updates. Go to bcbsm.com/providers scroll down to Services that Require an Authorization, then click on Why do I need a prior authorization for a prescription drug. Another useful link for providers is bcbsm.com/rxinfo.

The page contains links to the drug lists, prior authorization and step therapy requirements, quantity limit lists and alternatives for nonpreferred brand and nonformulary drugs. 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 Customer Service at the number on the back of their member ID card. TDD/TTY users should call 711.

Utilization management staff availability

Department telephone numbers and hours are shown in the “Appeals and problem resolution” chapter of the provider manuals.

Behavioral health care — Blue Cross Behavioral Health℠

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 (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.