Medicare Plus Blue PPO Fact Sheet Form

Fact Sheet Important information for providers who treat Medicare Plus BlueSM PPO and Medicare Plus BlueSM Group PPO members who travel or live outside of Michigan

What is Medicare Plus BlueSM PPO? Medicare Plus Blue PPO and Medicare Plus Blue Group PPO are Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plans for individual and group members, respectively.

What is Medicare Advantage PPO network sharing? Medicare Advantage PPO network sharing allows Medicare Advantage PPO members from all Medicare Advantage PPO Blue plans to obtain in-network benefits when the member travels or lives in the service area of another plan’s Medicare Advantage PPO network and sees a contracted Medicare Advantage PPO provider.

What does Medicare Advantage PPO network sharing mean to providers who participate in Medicare Advantage PPO? If you’re a contracted Medicare Advantage PPO provider with a Blue plan and treat Medicare Plus Blue members, you’ll be reimbursed in accordance with the negotiated rate in your local Blue plan contract, and these members will receive the same access to care and in-network benefits in accordance with their Medicare Plus Blue contract.

What does Medicare Advantage PPO network sharing mean if you aren’t a contracted Medicare Advantage PPO provider? You aren’t required to provide services to Medicare Plus Blue members. Should you decide to provide services to our Medicare Plus Blue members, and you’re a participating Medicare provider, you’ll be reimbursed for covered services up to the Original Medicare allowed amount and under the member’s in-network benefits, including urgent or emergency care services.

Where do I submit claims? Submit claims to your local Blue plan under your current billing practices even if you don’t participate with a Blue plan’s Medicare Advantage PPO. Don’t bill Medicare directly for any services rendered to a Medicare Plus Blue member.

How do I verify benefits and eligibility? Call the inter-plan Medicare Advantage program at 1-800-676-BLUE (2583) and provide the member’s prefix located on the member ID card. Information obtained regarding member eligibility isn’t a guarantee or a promise of payment. Payment determination only occurs after the claim is processed according to the member’s benefits. If you can’t get eligibility information, record the prefix and report it to your local Blue plan.

What will I be reimbursed? If you contract with a Blue plan’s Medicare Advantage PPO, benefits will be based on your contracted Medicare Advantage PPO rate for providing covered services to Medicare Plus Blue members. Once you submit the Medicare Advantage claim, the local plan will work with Blue Cross to determine benefits and send you the payment.

If you don’t participate in a Blue plan’s Medicare Advantage PPO contract, reimbursement for covered services provided to our Medicare Plus Blue members who travel or live out of state will be based on the Original Medicare allowed amount and under the member’s in-network benefits including services for urgent or emergency care. The Original Medicare allowed amount may include reimbursement for bonus or interim payments.

Do Medicare Plus Blue members have cost sharing? Medicare Plus Blue members may have cost-sharing amounts, depending on their particular plan. You may collect any applicable copayment from the member at the time of service.

May I request payment up front? Generally, once the member receives care, you shouldn’t ask for full payment up front. You can collect out-of-pocket expenses (deductible, copayment, coinsurance). Noncovered services: Under certain circumstances, the member may receive advance notification by the plan that a service won’t be covered. In that case, you may request payment before services are rendered or billed to the member. If you’re unsure if a service will be covered, you must request an organization determination from the member’s plan. If the determination shows the service isn’t covered, you can bill the member directly. You may only request payment up front for noncovered services when these guidelines have been followed. If this process isn’t followed, the member must be held harmless.

May I balance bill the member for the difference between charged amounts and allowed amounts? No, you may not balance bill the member for this difference. You may only bill members for any deductibles, coinsurance and copayments.

What if I disagree with the reimbursement amount I received? Contact your local Blue plan.

Who do I contact if I have a question about Medicare Advantage PPO? Contact your local Blue plan.

Where can I find information specific to Medicare Plus Blue and Medicare Plus Blue Group? Visit bcbsm.com/providers for information about Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plans.

Does Blue Cross offer its Medicare Advantage PPO plan outside of Michigan? This network sharing arrangement applies to all groups that have purchased our products. Members of those groups who reside outside of Michigan may be covered by our products. Additionally, Blue Cross’ Medicare Advantage PPO individual products have a visitor travel program that allows members to live and obtain services outside of Michigan.

What medical services and admissions require prior authorization? Out-of-state providers are required to contact Blue Cross to obtain prior authorization and service extension requests for the services listed below. • Inpatient skilled nursing facility admissions and extensions • Long-term acute care admissions and extensions • Inpatient acute rehabilitation admissions and extensions • Inpatient behavioral health or substance abuse admissions • Acute inpatient medical admissions • Musculoskeletal surgical procedures, including orthopedic, pain management and spinal procedures URMBT members Members of the UAW Retiree Medical Benefits Trust, or URMBT, living in Alabama, Florida, Indiana, Missouri, Michigan and Tennessee have additional authorization requirements noted below: • Partial hospitalization behavioral health services
• Advanced imaging and cardiology

Please refer to the “Utilization management” section of the Medicare Plus BlueSM PPO Manual and the Prior authorization requirements for Michigan and non-Michigan providers document for detailed requirements for Medicare Plus Blue members.

Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. SHSPPO December 24 FACTSHEET0004