BCC Provider Manual - BCBSM

1 1 ii TABLE OF CONTENTS Section 1: Introduction .. 1 A. Overview: Blue Cross Complete .. 1 B. How to use this Manual .. 2 C. Other electronic resources for providers .. 3 D. Provider communications .. 4 E. Assistance in working with Blue Cross Complete .. 5 Section 2: System of Managed Care .. 6 A. Blue Cross Complete Provider network .. 6 B. Role/responsibilities of practitioners .. 9 C. General responsibilities of all contracted providers .. 11 D. Responsibilities of hospital/ancillary providers .. 13 E. Provider termination.

2 14 F. Blue Cross Complete s commitment to providers .. 15 G. Obligations of recipients of federal funds .. 16 H. Electronic health records .. 17 Section 3: Clinical Practice and Preventive Care Guidelines .. 18 A. About the guidelines .. 18 B. Reporting blood lead tests .. 18 C. Other applicable guidelines .. 19 Section 4: Managing the Quality of Care .. 20 A. Monitoring the quality of care .. 20 B. Peer review process .. 20 C. Disciplinary action or termination .. 22 D. Appealing physician discipline or termination .. 24 E. Facility onsite reviews.

3 26 Section 5: Standards and Ratings .. 28 A. Access to appointments .. 28 B. Waiting room time .. 31 C. Access to after-hours care .. 32 D. CAHPS survey .. 33 Section 6: Multicultural Health Care .. 34 A. Accommodating providers and members needs .. 34 B. Aspects of culturally competent care .. 34 C. Enhancing cultural competency in health care settings .. 35 Section 7: Member Eligibility .. 37 iii A. Membership ID cards .. 37 B. Checking member eligibility .. 41 C. Member eligibility data 41 D. Member eligibility, enrollment, disenrollment, effective date.

4 41 E. Dual-eligible members .. 42 Section 8: Member Benefits .. 44 A. Blue Cross Complete primary care physician services .. 44 B. Blue Cross Complete benefits .. 47 C. Care within Michigan outside the service area .. 50 D. Blue Cross Complete member rights and responsibilities .. 51 Section 9: Managing Noncompliant Care .. 52 A. Assisting practitioners in managing noncompliant care .. 52 B. Special disenrollment from the Medicaid Health Plan .. 52 Section 10: Managing Utilization .. 54 A. Review of services .. 54 B. Guidelines for authorization.

5 54 C. Appealing authorization decisions .. 58 D. Utilization monitoring .. 60 Section 11: Managing Care .. 61 A. Managing members with an integrated approach .. 61 B. Collaboration with practitioners .. 62 C. Pregnancy resources .. 63 D. Rapid Response and Outreach Team .. 64 E. Children s Special Health Care Services .. 64 F. Immunizations .. 65 G. Nurse Help line (for members) .. 66 Section 12: Pharmacy Services .. 67 A. Prescription drug program overview .. 67 B. Drug authorization guidelines .. 69 C. Appealing a decision to deny authorization of drugs.

6 70 D. Drug exclusions .. 70 E. Additional pharmacy information .. 71 Section 13: Claims .. 72 A. Claims overview .. 72 B. General guidelines for filing claims .. 73 C. Filing claims electronically .. 74 D. Filing paper claims .. 75 E. Processing submitted claims .. 75 iv F. Billing laboratory services .. 82 G. Required reporting of events .. 83 H. Other guidelines for submitting claims .. 84 I. Coordination of benefits and subrogation .. 87 Section 14: Provider appeals .. 90 A. Appealing utilization management decisions .. 90 B.

7 Appealing claim denials .. 90 C. Appeals submission guidelines .. 91 D. How to appeal temporary rate increase for primary care services .. 91 Section 15: Electronic Funds Transfer .. 93 A. Blue Cross Complete uses Change Healthcare for Electronic Funds Transfer .. 93 B. Receive electronic remittance advice statements .. 93 C. EFT enrollment forms for new and existing providers .. 93 Section 16: Health Care Fraud, Waste and Abuse .. 94 A. Special Investigations 94 B. Definitions of Fraud, Waste and Abuse .. 94 C. The Federal Fraud Enforcement and Recovery Act.

8 95 D. Reporting and Preventing Fraud, Waste and Abuse .. 96 E. What to expect as a result of SIU activities .. 97 Blue Cross Complete of Michigan has produced this document in accordance with guidelines, policies and procedures current with the date noted on this page. Blue Cross Complete reserves the right to update, modify, change or replace any portion of this document to reflect later guidelines, policies or procedures. The Manual is an extension of the Provider contracts. Nothing in it is intended or should be understood to modify the requirements, limitations and/or exclusions in the Provider contracts.

9 This Manual is the property of Blue Cross Complete and is for use solely in your capacity as a participating Provider . Duplication is limited to your office staff only. Disclosure to unauthorized persons or use for any other purpose is strictly prohibited. Any violation of the above will be dealt with to the full extent of applicable laws. Federal law provides severe civil and criminal penalties for the unauthorized reproduction and distribution of copyrighted materials. Blue Cross Complete does not control any other websites referenced in this publication or endorse their general content.

10 2019 Blue Cross Complete. All rights reserved. Blue Cross Complete is contracted by the Michigan Department of Health and Human Services to provide health care coverage to eligible Medicaid beneficiaries. Blue Cross Complete arranges for the provision of comprehensive and cost-effective coverage to Medicaid members in 32 counties in Michigan. NCQA is a private, nonprofit organization dedicated to improving health care quality. HEDIS is a registered trademark of the National Committee for Quality Assurance. Consumer Assessment of Healthcare Providers and Systems (CAHPS ) is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).