Currentblue cross blue shield - michiganPolicy N/A

Blood and Blood Components (whole blood and packed red blood cells) coverage and reimbursement

Defines BCN Advantage (Medicare Advantage) coverage, payment, billing and member cost-share rules for whole blood and packed red blood cells furnished inpatient or outpatient; applies to BCN Advantage group and individual plans as specified.

Policy Summary

Payerblue cross blue shield - michigan

PolicyBlood and Blood Components (whole blood and packed red blood cells) coverage and reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionVerify benefits and cost-share via provider portal or 1-800-344-8525 before service and obtain a coverage determination for noncovered items.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

first pint/unit coveredEnhanced benefit begins with first pint/unit

3-unit deductibleOriginal Medicare deductible

No restrictionsNo diagnosis or age restrictions

Lesser of Medicare or chargeReimbursement method

P90xx list

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Coverage and Payment Conditions

Blood and packed RBCs coverage criteria

Coverage and payment conditions for whole blood and packed red blood cells (packed RBCs).

Eligible providers consistent with Original Medicare may furnish covered items in inpatient or outpatient facility settings.

Frequency: As medically necessary each calendar year; no explicit frequency limits beyond medical necessity.

Diagnosis restrictions: No restrictions specified.

Age restrictions: No restrictions specified.

Enhanced coverage begins with the first pint of whole blood or the first unit of packed red blood cells and includes storage and administration when medically necessary.

Coverage applies to BCN Advantage individual plans and select BCN Advantage group plans as specified by the plan; scope, reimbursement methodology, maximum payment amounts, and member cost sharing are determined by Blue Care Network or the group.

Applicable HCPCS codes (P90xx) for covered blood products: P9010, P9011, P9016, P9021, P9022, P9038, P9039, P9040, P9051, P9054, P9056, P9057, P9058.

Reimbursement: Provider will be paid the lesser of Medicare's allowed amount or the provider's charge, minus the member's cost share; this represents payment in full and providers may not balance bill members for the difference.

Member replacement/charge relief: Coverage of the first three pints or equivalent units of packed RBCs relieves the member from the obligation to replace these units and from charges for failing to do so.

Billing/collection: Providers should collect applicable BCN Advantage cost sharing at the time of service when possible and follow BCN Advantage billing instructions.

HCPCS/Coding and Medicare Deductible

HCPCS P90xx blood product codesHCPCSCovered

P9010	Blood (whole), for transfusion, per unit
P9011	Blood, split unit
P9016	Red blood cells, leukocytes reduced, each unit
P9021	Red blood cells, each unit
P9022	Red blood cells, washed, each unit
P9038	Red blood cells, irradiated, each unit
P9039	Red blood cells, deglycerolized, each unit
P9040	Red blood cells, leukocytes reduced, irradiated, each unit
P9051	Whole blood or red blood cells, leukocytes reduced, cmv-negative, each unit
P9054	Whole blood or red blood cells, leukocytes reduced, frozen, deglycerol, washed, each unit

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Medicare three-unit deductible

Original Medicare three-unit deductibleOriginal Medicare does not provide payment for the first three pints of whole blood or equivalent units of packed RBCs in a calendar year and applies a deductible to these first three units; providers may charge the beneficiary customary charge for these units unless replacement is provided or provider accepts replacement.

BCN Advantage enhanced benefit scopeBCN Advantage provides enhanced coverage beginning with the first pint/unit of whole blood or packed RBCs (includes storage and administration) when medically necessary, applying in inpatient and outpatient settings for BCN Advantage individual plans and select group plans.

Member replacement/charge relief under BCN AdvantageCoverage of the first three pints or equivalent units under the enhanced benefit releases the member from the obligation to replace these units and from charges from the provider for failing to do so.

Provider Verification and Coverage Determination

Prior Authorization

Benefit verification and coverage determination

Verify member benefits and applicable cost sharing before providing blood products. If coverage is uncertain, obtain a coverage determination from BCN Advantage prior to furnishing noncovered items.

Use the provider portal or call 1-800-344-8525 to verify benefits and cost-share.
If there is any question about coverage, seek a coverage determination from BCN Advantage before providing the item; members must be held harmless if a noncovered item is provided without prior determination except for applicable cost share.

Key Definitions

Enhanced benefit

Definition of enhanced benefitBCN Advantage coverage that provides payment beginning with the first pint/unit of whole blood or packed RBCs when medically necessary, including storage and administration.

ApplicabilityEnhanced coverage applies to whole blood and packed RBCs furnished in either inpatient or outpatient settings under BCN Advantage individual plans and select group plans.

Effect on member obligationsWhen the enhanced benefit covers the first three pints/units, the member is released from the obligation to replace those units and from any related provider charges.