Changes from previous publication are identified by a Blue Dot and explained on the final page of this document.
Blue Cross Complete
Plan Notification and Clinical Review Requirements
Contact Blue Cross Complete to request clinical review:
Hours: 8:30 a.m. to 5 p.m., Monday through Friday
Telephone: 1-888-312-5713, press 1 to request clinical review / Fax: 1-888-989-0019
Plan notification alerts Blue Cross Complete to a scheduled service and is used for claims processing purposes. Blue Cross Complete does not perform
clinical reviews on services that require plan notification only. Plan notification must be submitted prior to services being rendered. Benefit / clinical
review is conducted for benefit determination or the application of medical necessity criteria or both. Benefit / clinical review requests must be submitted at
least 14 days prior to services being rendered.
Note: Plan notification and clinical review requirements apply to members who have Blue Cross Complete of Michigan as their primary coverage and to
dual-eligible members whose primary coverage is exhausted or whose primary carrier has denied services. (A dual-eligible member is one who qualifies
for both Medicare and Medicaid. These members are enrolled in either Original Medicare, BCN AdvantageSM HMO-POS, BCN AdvantageSM HMO
ConnectedCare, BCN AdvantageSM HMO MyChoice Wellness or BCBSM’s Medicare Plus Blue PPOSM as their primary plan and Blue Cross Complete as
their secondary plan.)
NONCONTRACTED PROVIDERS must obtain authorization for ALL services.
Inpatient services
Hospice services
Benefit / clinical review is required for all providers.
Inpatient admissions
Benefit / clinical review is required for all providers. This includes long-term acute care, inpatient rehabilitation and
skilled nursing care. Providers should notify Blue Cross Complete of all emergency admissions within 1 business
day.
Maternity: up to 48 hours
following routine delivery / 96
hours following C-section
Plan notification is required for all providers.
Office / outpatient / ancillary services Bone anchored hearing aid
Benefit / clinical review is required for all providers.
Botox §
Benefit / clinical review is required for all providers.
Bariatric surgery
Benefit / clinical review is required for all providers.
Biofeedback for urinary
incompetence and chronic
constipation
Benefit / clinical review is required for all providers.
Cardiac rehabilitation
Benefit / clinical review is required for all providers.
®
For >18 visits per year, benefit / clinical review is required for all providers.
Chiropractic services
Note: Coverage includes one set of X-rays of the spine per year. Chiropractor must be affiliated with Blue Cross
Complete.
Cognitive therapy
Benefit / clinical review is required for all providers.
Contact lenses (See
also: Vision services and
supplies: low vision and
Vision services and supplies,
routine)
Benefit / clinical review is required for all providers.
Note: Routine vision services are covered for Blue Cross Complete members regardless of age effective Oct.
1, 2012, per MSA Bulletin 12-38. These are the benefits that were eliminated for adult members starting Feb. 1,
2010. Routine vision services include routine eye exams, eyeglasses, and other vision services and supplies.
Cosmetic surgery
Benefit / clinical review is required for all providers.
DME / P&O / medical
supplies
Refer to the table of required vendors at the end of Section 1.
Elective termination of
pregnancy
Benefit / clinical review is required for all providers.
Special requirements: The following procedures require a special consent that must be submitted with the claim to
allow for claim processing: hysterectomy, sterilization procedures and elective termination of pregnancy.
Experimental and
investigational
Benefit / clinical review is required for all providers.
Home TPN and enteral
feedings
Benefit / clinical review is required for all providers.
Hospice services (home)
Benefit / clinical review is required for all providers.
Hyperbaric oxygen therapy
Benefit / clinical review is required for all providers.
Neuropsychological /
psychological testing for
bariatric surgery
Benefit / clinical review is required for all providers.
Page 1 of 3
Revised January 2015
Changes from previous publication are identified by a Blue Dot and explained on the final page of this document.
Blue Cross Complete Plan Notification and Clinical Review Requirements
Plan notification alerts Blue Cross Complete to a scheduled service and is used for claims processing purposes. Blue Cross Complete does not perform
clinical reviews on services that require plan notification only. Plan notification must be submitted prior to services being rendered. Benefit / clinical
review is conducted for benefit determination or the application of medical necessity criteria or both. Benefit / clinical review requests must be submitted at
least 14 days prior to services being rendered.
Note: Plan notification and clinical review requirements apply to members who have Blue Cross Complete of Michigan as their primary coverage and to
dual-eligible members whose primary coverage is exhausted or whose primary carrier has denied services. (A dual-eligible member is one who qualifies
for both Medicare and Medicaid. These members are enrolled in either Original Medicare, BCN AdvantageSM HMO-POS, BCN AdvantageSM HMO
ConnectedCare, BCN AdvantageSM HMO MyChoice Wellness or BCBSM’s Medicare Plus Blue PPOSM as their primary plan and Blue Cross Complete as
their secondary plan.)
NONCONTRACTED PROVIDERS must obtain authorization for ALL services.
Office / outpatient / ancillary services (continued)
Physical / occupational /
speech therapy
For >144 units and for any units beyond the initial 12 months, benefit / clinical review is required.
Pulmonary rehabilitation
Benefit / clinical review is required for all providers.
TMJ treatment
Benefit / clinical review is required for all providers.
Transplants
Benefit / clinical review is required for all providers. This includes for solid organ and bone marrow evaluations and
harvesting (except kidney / skin / cornea). Note: Direct members to Blue Distinction Centers for Transplants.
Unclassified procedures
(also called "not otherwise
classified (NOC)," "unlisted"
and "unspecified")
Benefit / clinical review is required for all providers.
For >36 visits and for any visits beyond the initial 12 months, benefit / clinical review is required.
§ For medications covered under the medical benefit that require clinical review, providers are encouraged to submit clinical review requests using the
Blue Cross Complete Medication Prior Authorization Request form, which is available at MiBlueCrossComplete.com/providers. The completed
form must be faxed to PerformRx at 1-855-811-9326.
REQUIRED VENDORS
Provider alignment
Requirements
Blue Cross Complete primary
care physician, specialist and
facility aligned with the University
of Michigan Health System*
No referral, plan
notification or benefit
/ clinical review is
required for members
assigned to UMHS.
Laboratory
Diabetes and incontinence supplies
- MedEquip (734-971-0975)
Contact the required
vendor.
Laboratory
- JVHL (1-800-445-4979)
Blue Cross Complete primary
care physician, specialist and/
or facility not aligned with the
University of Michigan Health
System*
Type of service (outpatient)
Required vendors
- UMHS laboratories
- Chelsea Community Hospital laboratories
DME, P&O and nondiabetic medical supplies - MedEquip (734-971-0975)
- UM Orthotics & Prosthetics (734-973-2400)
DME, P&O and nondiabetic medical supplies - Northwood (1-800-667-8496)
Diabetes and incontinence supplies
- J&B Medical Supply (1-888-896-6233)
* All U-M providers and providers from the IHA group
Page 2 of 3
Revised January 2015
Changes from previous publication are identified by a Blue Dot and explained on the final page of this document.
Blue Dot Changes to Blue Cross Complete
Plan Notification and Clinical Review Requirements
Service
Change Description
Dual-eligible members
The introductory note is revised to show that a dual-eligible member may have BCN Advantage HMO ConnectedCare
as the primary plan and Blue Cross Complete as the secondary plan.
Required vendors
The required vendors list is revised to show that the University of Michigan Health System includes all U-M providers and
providers from the IHA group.
*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2014 American Medical Association. All rights reserved.
Page 3 of 3
Revised January 2015