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Frequently asked questions

Billing and claims

• What does CMS mean by a "clean claim"?
  

  
  Refer to page 206 of the Medicare Claims Processing Manual (PDF).
  
  
• How do I bill:
  • Medicare Plus Blue PFFS^SM
  • Medicare Plus Blue PPO^SM
• What will I be reimbursed by Medicare Plus Blue PPO?
• May I bill a member for noncovered services?

Cost sharing

• Evaluation and management services (PDF)

Eligibility

• How do I know if this patient is eligible?
• Where can I verify coverage?

Home health care

• If a Medicare Plus Blue PFFS or Medicare Plus Blue PPO member's Medicare coverage changes at the end of a calendar year during a home health episode of care, how should the agency bill for the episode?
  

  
  If a patient had Original Medicare coverage when the home health care episode began and then enrolled in Medicare Plus Blue PFFS or Medicare Plus Blue PPO before the episode ended, take the following steps:

  • Submit a claim to the regional home health and hospice intermediary to close the episode.
  • Complete a new Outcome and Assessment Information Set (OASIS).
  • Submit a request for anticipated payment based on the new OASIS to Medicare Plus Blue PFFS or Medicare Plus Blue PPO to open a new episode.

  If a patient had Medicare Plus Blue PFFS or Medicare Plus Blue PPO coverage when the home health care episode began and then enrolled in Original Medicare before the episode ended, take the following steps:

  • Submit a claim to Medicare Plus Blue PFFS or Medicare Plus Blue PPO to close the episode.
  • Complete a new OASIS and submit it to the state.
  • Submit a request for anticipated payment based on the new OASIS to the regional home health and hospice intermediary to open a new episode.

  
  

Medical record reviews

• Do you have questions about MedAssurant reviews? (PDF)

Medicare Plus Blue PFFS

• What are the terms and conditions?
• What is a private fee-for-service plan?
• What is the "deeming" process?
• What do people on Medicare need to know about group private fee-for-service plans? (PDF)
• What do people on Medicare need to know about individual private fee-for-service plans? (PDF)
• Who can I contact for more information?
• Information for all health care providers (PDF)
• What if I don't participate with Medicare?

Medicare Plus Blue PPO

• What is the Medicare Plus Blue PPO manual?
  

  
  The Medicare Plus Blue PPO manual (PDF) describes BCBSM's Medicare Advantage PPO program and gives detailed information you need to treat our members.
  
• How will providers know when the Medicare Plus Blue PPO manual is updated?
  

  
  The date of the last revision will be clearly displayed at the bottom of the last page of the manual. We encourage providers to reference the Medicare Plus Blue PPO manual online to ensure they are viewing the most current, up-to-date version.
  
• Where can I find information about provider contracts?


• Where is the Medicare Advantage PPO Fee Schedule for 2010?
  

  
  Access the 2010 Medicare Advantage PPO fee schedule via web-DENIS. Go to "BCBSM Provider Publications and Resources" and click on Entire Fee Schedules.
  
  
• How will network providers be reimbursed for covered services?
  

  
  Network practitioners are reimbursed for covered services as indicated on the Medicare Advantage PPO fee schedule. Exceptions apply to:

  • Network lab providers — JVHL and Quest Laboratories will be reimbursed at 80 percent of the Medicare fee schedule amount for in-network lab services
  • DME — Refer to the DMEnsion Benefit Management fee schedule
  • ESRD and Rural Health Clinics — In-network ESRD and RHC facilities have non-Medicare contracted rates

• How will out-of-network providers be reimbursed?


• Where can I find more information about the Medicare Advantage PPO lab network?


• Which lab procedures can be performed in-office (PDF)?


• What is the AIM Radiology Management Program?


• If pre-authorization is not obtained for a radiology service that requires pre-authorization, will the provider be liable for the cost of that service?
  

  
  Yes. See Preadmission notification and admission census tracking, precertification, and preauthorization for more information.
  
  
• If a Medicare Plus Blue PPO member is admitted to an out-of-network facility and elects to transfer to a in-network facility does BCBSM impose any distance limitations? For example, if a member from Detroit vacations in Traverse City, can he or she choose to have an ambulance transport them from Munson Medical Center to Beaumont Hospital in Royal Oak?
  

  
  Members can choose to have an ambulance transport them from an out-of-network facility to an in-network facility. The mileage limits are based on Original Medicare guidelines.
  
  
• Will critical access hospitals be reimbursed based on their interim rate letters?
  

  
  Critical access hospitals should submit written requests for reimbursement to BCBSM on an annual basis. BCBSM will review the information and give the hospital a written determination within 180 days from the date the notification is received. Refer to the PPO manual (PDF) under "Hospital Reimbursement Provisions" for more information.
  
  
• Who can I contact for more information?

Other Blue plans

• Which other Blue plans offer Medicare Advantage coverage? (PDF)

Pharmacists

• Questions frequently asked by pharmacists (PDF)