Blue Cross Complete of Michigan
CONNECTIONS
May 2017
Table of Contents
Claims and utilization management process................2
National Committee for Quality Assurance
issues notification of measure change .........................5
Processing prior authorizations accurately
while safeguarding members’ protected
health information........................................................3
State offers lead abatement services to
eligible individuals .......................................................6
Healthy Michigan requirements for
appointment times and health risk assessment............4
State issues notice of Healthy Michigan Plan
copay increase..............................................................7
Blue Cross Complete offers clarification for
P.O. Box rejection on paper claims submission............5
Providers required to enroll into Community Health
Automated Medicaid Processing System.....................8
State announces early refills for prescription drugs.....5
Report suspected fraud to Blue Cross Complete.........9
Blue Cross Complete of Michigan CONNECTIONS
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Claims and utilization management process
We have noticed an increase in paper claims and appeals being mailed to the Blue Cross Complete office location
in Southfield, Michigan. To prevent a delay in claims or utilization management appeals processing, please submit
applicable documentation to these addresses:
Provider claims appeals
• Blue Cross Complete, Claims Appeals, P.O. Box 7361, London, KY 40742
Blue Cross Complete claim denials may be appealed as follows:
Reason for denial
Documentation required
Timely filing
Supporting documentation must show the claim was filed in a timely manner.
Coding edit (edit denial)
Supporting documentation and medical notes or reports must be submitted.
Payment amount
Supporting documentation must be submitted.
The appeal must be submitted within 30 business days of the decision on the claim. Blue Cross Complete responds
to all appeals within 30 business days.
Utilization management appeals
• Medical Appeals Department, 4390 Belle Oaks Drive, Suite 400, Charleston, SC 29405
A member or a health care professional or provider acting on behalf of the member, with the member’s written
consent, may submit an appeal of an action or service denial by Blue Cross Complete (based on a medical
necessity or appropriateness determination).
Appeals will be handled and processed within the time frames listed below:
Type of appeal
Time frame to file
Decision
Standard appeal
Ninety days from the date of receipt
of the denial
Within 30 calendar days from plan
receipt of appeal request
Expedited appeal
Ninety days from the date of receipt
of the denial
Within seventy-two hours of plan
receipt of appeal request
If you have any questions or would like to status your appeal, please contact Blue Cross Complete Provider Inquiry
at 1-888-312-5713 or your Blue Cross Complete account executive.
Blue Cross Complete of Michigan CONNECTIONS
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Processing prior authorizations accurately while
safeguarding members’ protected health information
To minimize the risk of miscommunications when submitting a prior authorization request, we listed a few tips to
make the process go smoothly while safeguarding members’ protected health information:
• Write legibly when you fax your request for prior authorization. We value our members’ privacy, but risk
incorrectly sharing member PHI by responding to the wrong fax number if the request for prior authorization
isn’t legible.
• Take advantage of our online prior authorization request tools. Eliminate legibility issues by submitting your
prior authorization requests securely through Jiva online at Navinet.net*.
• Submit a prior authorization request by phone at 1-888-312-5713 (option 1, then 4).
• Verify your contact information. Check your listing in our online provider directory to ensure that we have your
most up-to-date contact information.
If you aren’t listed in the provider directory, your contact information is incorrect in the provider directory or if you
need assistance with accessing Jiva, contact your Blue Cross Complete provider account executive.
* Our website is mibluecrosscomplete.com. While website addresses for other organizations are provided for reference,
Blue Cross Complete doesn’t control these sites and isn’t responsible for their content.
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Healthy Michigan requirements for appointment
times and health risk assessment
Blue Cross Complete wants to remind providers of
the requirements for members enrolled in the Healthy
Michigan Plan:
• Members are required to schedule an
appointment with their assigned primary care
physician within 60 days of enrollment.
• Primary care physicians are required to complete
the initial appointment within 150 days of the date
that the member’s coverage starts.
• Primary care physicians are encouraged to help
members schedule an appointment.
• Blue Cross Complete will help coordinate
appointment scheduling and transportation on
behalf of the member.
Providers should identify Healthy Michigan members
prior to the date of service in NaviNet* in the Eligibility
and Benefits Details section.
Health risk assessment required
As a reminder, under the Healthy Michigan Plan,
primary care physicians are required to complete a
health risk assessment at the time of the appointment.
Blue Cross Complete members receive a copy of the
Health Risk Assessment form in their welcome packet
and should bring it to their appointment.
Here are some helpful reminders:
• Blue Cross Complete members must have a
health risk assessment during the first 150 days of
coverage with the health plan and then annually
thereafter.
• Blue Cross Complete members will receive
a copy of the Health Risk Assessment form
in their welcome packet that they may bring
to their appointment. If members forget to
bring the form, you can obtain a copy on
mibluecrosscomplete.com/providers and on
NaviNet.
• The Health Risk Assessment form must be
completed legibly and in its entirety.
• Although the Health Risk Assessment form can be
completed by a member of the clinical team, the
primary care physician must sign it.
• Providers need to fax the entire form to
1-855-287-7886 within five business days of the
appointment.
• A claim must be submitted with CPT code 96160**
with modifier 25 to indicate that a health risk
assessment was completed.
• Blue Cross Complete will pay a $15 incentive
upon receipt of the claim.
• If providers have questions about the status of the
health risk assessment, they can call Blue Cross
Complete Provider Inquiry at 1-888-312-5713.
* Our website is mibluecrosscomplete.com. While website addresses for other organizations are provided for reference,
Blue Cross Complete doesn’t control these sites and isn’t responsible for their content.
** CPT codes, descriptions and two-digit modifiers only are copyright 2013 American Medical Association. All rights reserved.
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Blue Cross Complete offers
clarification for P.O. Box rejection
on paper claims submission
National Committee for Quality
Assurance issues notification
of measure change
Although we recommend that a P.O. Box isn’t billed
on paper claims, Blue Cross Complete will no longer
reject paper claims that have a P.O. Box listed in box
33 of the CMS-1500 form. As a reminder, P.O. Boxes
are still a requirement for electronic claims to be
compliant with the 5010 format.
The National Committee for Quality Assurance, also
known as NCQA*, recently released notification
that the date of discharge will no longer count
for numerator compliance for Follow-Up After
Hospitalization for Mental Illness.
For detailed instructions on submitting claims,
please see section 13 – Claims of the Blue
Cross Complete Provider Manual located at
mibluecrosscomplete.com/provider.
State announces early refills
for prescription drugs
The Michigan Department of Health and Human
Services announced that effective April 1, 2017, early
refill overrides for Fee for Service may be granted one
time per drug per 12 months to replace medication
that has been lost, stolen or destroyed or for the
purpose of vacation or travel. Early refills won’t exceed
a 34-day supply.
According to NCQA, an encounter on the date of
discharge after hospitalization should be viewed as
an intervention designed to support the patient and
improve his or her likelihood of receiving timely followup care. NCQA also states that visits on the date of
discharge shouldn’t be the only follow up that patients
receive and wouldn’t be considered good quality of
care on their own — therefore not meeting the intent
of the measure.
To provide quality care to our members and to meet
the NCQA measure for Follow-Up After Hospitalization
for Mental Illness, we encourage you to assist members
with follow-up care after they are discharged from the
hospital.
If you have any questions, please contact your Blue
Cross Complete provider account executive or Blue
Cross Complete Provider Inquiry at 1-888-312-5713.
MDHHS or its designee may limit the number of
instances early refill overrides are approved in cases of
suspected fraud or abuse, and may request additional
documentation before an override is authorized.
As a note, this policy is already in place for Blue
Cross Complete membership. If a Blue Cross
Complete member needs a refill for these reasons,
contact the PerformRxSM Customer Care Center at
1-888-989-0057.
To request an early refill override for a Fee for Service
member or a Blue Cross Complete member who
receives a carve-out medication, call the MDHHS
Pharmacy Benefits Manager Technical Call Center at
1-877-624-5204.
* The source for data contained in this publication is Quality Compass® 2017 and is used with the permission of the
National Committee for Quality Assurance (NCQA).
Blue Cross Complete of Michigan CONNECTIONS
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State offers lead abatement
services to eligible individuals
Effective February 1, 2017, the Michigan Department of Health and
Human Services issued Medicaid policy MSA 17-05 that detailed the
implementation of a targeted and time-limited health initiative that
will assist federal, state and local efforts to decrease lead hazards
from homes, and improve the health of individuals who are eligible
for Medicaid and the Children’s Health Insurance Program.
According to the proposed policy, coordinated abatement services
have been made available to eligible properties in the impacted
areas of Flint and other areas throughout the state. Abatement
services are defined as the removal of lead hazards, including:
• The permanent removal, enclosure or encapsulation of leadbased paint and lead dust hazards from an eligible residence
• The removal and replacement of surfaces or fixtures within the
eligible residence
• The removal or covering of soil lead hazards up to the eligible
residence property line
• All preparation, lab sampling analysis, clean up, disposal and
pre- and post-abatement paint, dust soil and clearance testing
activities associated with such measures, including pre- and
post-abatement water sampling
Properties eligible for abatement services are:
• Owner-occupied
• Rental
• Residential structures that a Medicaid or CHIP eligible
individual, a person under 19 years old or a pregnant woman is
currently residing in or regularly visiting. Visited regularly means
a residence other than the eligible individual’s legal address
where a significant amount of time is spent (e.g., homes of a
family member, relative or other informal care where a child
often visits).
The proposed policy is effective for services performed on or after
January 1, 2017, and will be in effect for five years from the effective
date or until all homes included in the scope of the initiative have
been abated.
For detailed information on the provision of abatement services,
abatement certification requirements, post-abatement requirements
and key metrics that the state will track, visit www.Michigan.gov.*
* Our website is mibluecrosscomplete.com. While website addresses for other organizations are provided for reference,
Blue Cross Complete doesn’t control these sites and isn’t responsible for their content.
Blue Cross Complete of Michigan CONNECTIONS
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State issues notice of Healthy Michigan Plan copay increase
On February 1, 2017, the Michigan Department of Health and Human Services issued a notice of copay increase
for Healthy Michigan Plan beneficiaries.
For dates of service on or after April 1, 2017, copays will vary based on income as follows:
Covered services
Copay
Income less than or
equal to 100% FPL*
Income more than
100% FPL
$2
$4
$1
$4
$3
$8
Inpatient hospital stay
(with the exception of emergent admissions)
$50
$100
Pharmacy
$1 preferred
$3 nonpreferred
$4 preferred
$8 nonpreferred
Chiropractic visits
$1
$3
Dental visits
$3
$4
Hearing aids
$3 per aid
$3 per aid
Podiatric visits
$2
$4
Vision visits
$2
$2
Physician office visits
(including freestanding urgent care centers)
Outpatient hospital clinic visit
Emergency room visit for nonemergency services:
• Copayment only applies to nonemergency services
• There is no copayment for true emergency services
Providers are directed to check for beneficiary eligibility using the Community Health Automated Medicaid
Processing System. Additionally, effective April 1, 2017, eligibility responses in CHAMPS will also provide tiered
copay amounts applicable to the beneficiary.
Healthy Michigan beneficiaries enrolled in a health plan aren’t responsible for copays at the point of service
as long as the service is covered by the health plan. Copays are collected through the MI Health Account.
Beneficiaries may, however, may be subject to copays for services that aren’t covered by their health plan at the
point of service. Services and populations that are currently exempt from copays will remain exempt. Healthy
Michigan beneficiaries are still required to receive information on potential copays from providers at the point
of service. Download the Information about Healthy Michigan Plan copays document or access it online at
http://www.michigan.gov/healthymichiganplan**.
Healthy Michigan beneficiaries affected by the increase have already started receiving notification from MDHHS
informing them of the revised copay amounts.
For additional information regarding copay increases, contact MDHHS Provider Inquiry at 1-800-292-2550.
* FPL means Federal Poverty Level
** Our website is mibluecrosscomplete.com. While website addresses for other organizations are provided for reference,
Blue Cross Complete doesn’t control these sites and isn’t responsible for their content.
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Providers required to enroll into Community Health
Automated Medicaid Processing System
All current and new Michigan Medicaid providers, including out-of-state providers, are now required to access the
Community Health Automated Medicaid Processing System to register for the Michigan Medicaid program.
CHAMPS is the Michigan Department of Health and Human Services’ Medicaid web-based processing system.
It quickly and efficiently allows the following functions to be completed online:
• Provider enrollment and updates
• Batch claim submission
• Prior authorization
• Claims status
• Claim adjustments or voids
• Eligibility verification
• Direct claim entry
• Payment status
• Member search and ordering or
referring provider verification
Effective January 1, 2018, claims submitted by providers who haven’t fully completed the provider enrollment in
CHAMPS will deny or not appear on a remittance advice. Please be advised that claims submitted to Blue Cross
Complete will also deny.
If you haven’t already registered, get the MDHHS log-in instructions located at Michigan.gov.*
For questions, visit the CHAMPS section of the MDHHS website at Michigan.gov/mdhhs.*
* Our website is mibluecrosscomplete.com. While website addresses for other organizations are provided for reference,
Blue Cross Complete does not control these sites and is not responsible for their content.
Blue Cross Complete of Michigan CONNECTIONS
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Report suspected fraud to
Blue Cross Complete
Providers who suspect that another Blue Cross Complete
provider, employee or member is committing fraud should
notify the Blue Cross Complete Antifraud Unit as follows:
• Phone: 1-855-232-7640. TTY users call 711.
• Fax: 1-215-937-5303
• Email: [email protected]
• U.S. mail:
Blue Cross Complete Antifraud Unit
P.O. Box 018
Essington, PA 19029
The Blue Cross Complete Antifraud Unit supports the efforts
of local and state authorities in the prosecution of reported
cases of fraud. Reports of suspected fraud related to Blue Cross
Complete may also be sent directly to the MDHHS in one of the
following ways:
• Call 1-855-MI-FRAUD (1-855-643-7283)
• Online at michigan.gov/fraud*
• By writing to:
Office of Inspector General
P.O. Box 30062
Lansing, MI 48909
Information may be left anonymously.
* Our website is mibluecrosscomplete.com. While website addresses for other organizations are provided for reference,
Blue Cross Complete does not control these sites and is not responsible for their content.
Blue Cross Complete of Michigan CONNECTIONS
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BCC-17205
MiBlueCrossComplete.com