Blue Cross Complete of Michigan Prescription Drug Program Overview Form
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Blue Cross Complete of Michigan Prescription Drug Program Overview
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For Providers: Forms and Documents
Looking for the right form or document to help care for your patients? Find what you need to get your work done quickly.
Select to a topic
Find out more about registering for Availity ® Essentials.
Assessment forms
Acute inpatient hospital assessment form
Michigan providers should attach the completed form to the request in the e-referral system. Non-Michigan providers should fax the completed form using the fax numbers on the form.
Skilled Nursing Facility and Acute Inpatient Rehabilitation form
Providers with access to Availity Essentials™ should attach the completed form to the request in the e-referral system. Providers without access to Availity Essentials should fax the completed form using the fax numbers on the form.
Long-Term Acute Care Hospital form
Providers with access to Availity Essentials should attach the completed form to the request in the e-referral system. Providers without access to Availity Essentials should fax the completed form using the fax numbers on the form.
Blue Cross Complete
Blue Care Complete of Michigan Prescription Drug Program Overview
This document identifies the basic terms of drug coverage for Blue Cross Complete members.
Blue Cross Complete Specialty Drug Guide
Use this guide to understand which specialty drugs are covered by Blue Cross Complete.
Michigan Department of Community Health - Health Plan Carve-Out
This lists the medicines Medicaid pays for instead of Blue Cross Complete of Michigan.
Blue Cross Complete Preferred Drug List
When prescribing medications for Blue Cross Complete members, please refer to this drug list.
Blue Cross Complete Pharmacy Prior Authorization Guidelines
Refer to this list to see which drugs require prior authorization and what the criteria are for each drug.
Blue Cross Complete Prior Authorization Request Form
Fill out this form to request prescription drug coverage for your patient.
BlueCard appeals
Provider BlueCard Claim Appeal Form
This form should be used for all commercial BlueCard appeals. Please submit the completed form to the appropriate appeals unit as outlined in your denial letter.
BlueCard Executive Escalation Form
This form should be used only by commercial providers that are members of the multidistrict litigation, or MDL, settlement class when requesting escalation for certain BlueCard® claim payments.
Care management and support services
Care Management and Utilization Management e-referral Overview
Learn about our care management and utilization management offerings and how they're covered.
Physician peer-to-peer request form: Blue Cross and BCN
This form provides instructions for out-of-state providers who are unable to submit their peer-to-peer requests electronically.
Physician Verification Form
This form is used with our wellness plans, like Healthy Blue Achieve, to request a medical waiver for a patient or update a patient's progress.
Behavioral Health Crisis Services
Includes information for behavioral health providers about behavioral health crisis services.
Blue Cross Coordinated Care FAQ
Answers frequently asked questions about the Blue Cross Coordinated Care program, which is available to members with commercial plans and with Medicare Advantage plans.
Cancer Support program FAQ
Answers frequently asked questions about the Cancer Support program, which is available to many members with commercial plans.
Family Building and Women’s Health Support Solution
Learn about our Family Building and Women’s Health Support Solution, which is available to many members with commercial plans.
Keep office information secure
Learn about all the steps you can take to maintain a safe, confidential and secure work area regardless of work location.
Prospective editing reconsideration request form
This form is for providers who are unable to submit prospective editing reconsideration requests through Availity™ (formerly titled Clinical Editing Appeal Form).
Submitting a prospective editing reconsideration request: Instructions
Learn how to submit prospective editing reconsideration requests (formerly called clinical editing appeals).
Medical chart review reimbursement
Ciox Medical Chart Review Reimbursement Form
If you've supplied our vendor, Ciox Health, with medical charts for Medicare Plus Blue PPO, you can request reimbursement with this form.
Medicare Advantage
Drug lists and prior authorization guidelines
View all our drugs lists along with guidelines for step therapy and prior authorization requests.
Medicare Plus Blue PPO enhanced benefit policies
Learn about our enhanced benefit policies for Medicare Plus Blue℠ PPO plans for individuals and groups.
BCN Advantage Enhanced Benefit Policies
Learn about our enhanced benefit policies for BCN Advantage plans for individuals.
Waiver of Liability
Medicare sometimes denies payment for certain health care services. If you're a non-contracted provider you can try to appeal a Medicare denial. As part of the process, you'll have to fill out the above form. You can find this and the other requirements for an appeal at the Centers for Medicare & Medicaid Services.
BCN Advantage Fee Schedule for Professional Services
To learn about reimbursement for professional services under BCN Advantage, refer to this fee schedule.
Medicare Plus Blue PPO Provider Agreement
The Medicare Advantage PPO Provider Agreement includes a base agreement that applies to all providers.
Medicare Plus Blue PPO Provider Agreement Practitioner Attachment
This document applies to practitioners participating in Medicare Plus Blue PPO.
Medicare Plus Blue PPO Provider Agreement Hospital Attachment
This document applies to hospitals participating in Medicare Plus Blue PPO.
Medicare Plus Blue PPO Provider Agreement Non-Hospital Attachment
This document applies to non-hospital facilities participating in Medicare Plus Blue PPO.
Medicare Plus Blue PPO Provider Agreement Rural Facilities Attachment
This document applies to rural facilities participating in Medicare Plus Blue PPO.
Medicare Plus Blue PPO Provider Agreement Federally Qualified Health Clinic Attachment
This document applies to federally qualified health clinics participating in Medicare Plus Blue PPO.
End Stage Renal Disease Facility Medicare Plus Blue PPO Payment Rates
ESRD facilities should refer to this fee schedule when caring for a Medicare Plus Blue PPO patient. Member copayments and deductibles apply.
Medicare Plus Blue PPO Enhanced Benefits Fee Schedule
To learn about reimbursement for enhanced benefits under Medicare Plus Blue PPO, refer to this fee schedule.
Advantasure Remote CDI Program for Medicare Plus Blue PPO
Blue Cross Blue Shield of Michigan has partnered with
Advantasure in their Remote Clinical Documentation
Improvement Program. This program helps providers
make complete and accurate diagnoses of our Medicare Plus Blue PPO members.
Advantasure Clinical Documentations Improvement Alert for Medicare Plus Blue PPO
Use this alert as a guide during the face-to-face or telehealth (audio and visual component) patient visit.
COVID-19 testing for pharmacies for Medicare Plus Blue and BCN Advantage members
Read about our testing policies and how to code and bill for tests involving our Medicare Advantage members.
Non-Michigan providers: Prior authorizations, claim submissions, helpful resources and more
This document contains information about prior authorizations, requests for durable medical equipment, preservice and post-service appeals and claims submissions.
Out-of-Area Providers: Advantasure Clinical Documentation Improvement Alert for Medicare Plus Blue PPO
Use this alert as a guide during the face-to-face or telehealth (audio and visual component) patient visit.
Advantasure Remote CDI Completion Tips for Medicare Plus Blue PPO
This tip sheet can help you complete a CDI alert.
Advantasure Remote CDI Stars Guide for CDI Alerts
Use this guide as a reference when completing the Star Measure Gap Closure section of the CDI Alert.
Pharmacy services
Drug lists and prior authorization guidelines
View all our drugs lists along with guidelines for step therapy and prior authorization requests.
Specialty Drug Program Member Guide
Specialty drugs are prescription medications that require special handling, administration or monitoring. They may need special handling and monitoring.
15-Day Specialty Drug Limitation Program
We limit certain specialty drugs to a 15-day supply limit to reduce copays and drug waste.
Michigan Participating Commercial Retail Pharmacies
Here's all the participating pharmacies in Michigan.
Optum Rx® Pharmacist Resource Center
If you need help with an Optum Rx issue, visit their health care professionals website for answers.
Recredentialing
Credentialing and Recredentialing Facility and Allied Provider Form
All hospitals, facilities, and allied providers can
use this form to recredential.
Referral forms
Blue Care Network e-referrals
Use e-referrals to complete referrals for any BCN patients.
Dentist to Physician Referral Form
Dentists can use this form when they see a medical issue that needs a referral to a physician.
Physician to Dentist Referral Form
Physicians can use this to refer a patient for a comprehensive oral assessment and dental treatment.
UAW Trust PPO Program Referral Form
Use this form when you need to refer to a non-UAW Trust PPO participating practitioner, facility, ancillary provider or laboratory.
IBU PPO Out-of-State Exception Form
This is for referring patients with an individual plan who are out of state.
Supply forms
Professional & Facility Supply Requisition Form
Fill this out to order general administrative materials you need when doing business with Blue Cross
Physician Verification Form
This form is used with our wellness plans, like Healthy Blue Achieve, to request a medical waiver for a patient or update a patient's progress.
Vaccine Affiliation program - Michigan pharmacies
Blue Cross Vaccine Affiliation program overview
Learn how to sign up for the Vaccine Affiliation program.
Blue Cross Vaccine Affiliation program payable procedure codes and billing information
Learn about services covered under the program, find answers to frequently asked questions about billing and more.
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Walk through this policy with us
Review how this policy can be converted into cited criteria, prior authorization checks, and operational automation.