TABLE OF CONTENTS - Blue Cross Blue Shield of Michigan

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 .. 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.

2 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 .. 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.

3 Checking member eligibility .. 41 C. Member eligibility data 41 D. Member eligibility, enrollment, disenrollment, effective date .. 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 .. 54 C. Appealing authorization decisions .. 58 D. Utilization monitoring.

4 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 .. 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.

5 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. 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.

6 94 C. The Federal Fraud Enforcement and Recovery Act .. 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. This manual is the property of blue Cross Complete and is for use solely in your capacity as a participating provider.

7 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 . 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 .

8 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). CPT is copyright 2015 American Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. JANUARY 2019 NOTE: Changes to the blue Cross manual occurring since the previous version are marked with a blue Dot and are explained in the list of blue Dot Changes to the blue Cross Complete Provider Manual, available at Section 1: Introduction 1 SECTION 1: INTRODUCTION A.

9 Overview: blue Cross Complete What is blue Cross Complete? blue Cross Complete of Michigan is an independent licensee of the blue Cross and blue Shield Association. It is a health maintenance organization and is a joint venture between blue Cross blue Shield of Michigan and AmeriHealth Caritas Family of Companies. blue Cross Complete is not contracting as the agent of the Association. No person, entity or organization other than blue Cross Complete will be held accountable or liable for any of blue Cross Complete s obligations created under the contract. blue Cross Complete is solely responsible for its own debts and other obligations. blue Cross Complete is contracted with the Michigan Department of Health and Human Services to provide health care coverage to eligible Medicaid beneficiaries.

10 Note: blue Cross Complete enrolls eligible individuals into the Healthy Michigan Plan, which offers health care coverage to an expanded pool of Medicaid beneficiaries. This includes Adult Benefit Waiver beneficiaries. Providers may access additional information about who is eligible for this plan at blue Cross Complete provides administrative services and arranges for the provision of covered services to all blue Cross Complete members within the blue Cross Complete service area. blue Cross Complete providers offer preventive and wellness care (for example, an annual physical exam) and blue Cross Complete encourages the Medicaid population to use medical services for preventive care. blue Cross Complete, not Medicaid, is the payer for covered health services rendered to a blue Cross Complete member.