Currentblue cross blue shield - michiganPolicy N/A

Emergency room care — Medicare Plus Blue Group PPO

Defines coverage, payment, billing, and member cost-sharing rules for emergency department services for Medicare Plus Blue Group PPO members; affects hospitals and providers billing BCBSM Medicare Advantage PPO plans.

Policy Summary

Payerblue cross blue shield - michigan

PolicyEmergency room care — Medicare Plus Blue Group PPO

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionCollect applicable Medicare Plus Blue Group PPO cost-sharing at time of service and verify member benefits via web-DENIS or CAREN.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Original MedicarePayment methodology

May be waivedCopayment waiver

NoBalance billing

web-DENIS/CARENBenefit verification

Emergency Department Coverage Criteria

Emergency department coverage criteria

Policy Summary

Payerblue cross blue shield - michigan

PolicyEmergency room care — Medicare Plus Blue Group PPO

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionCollect applicable Medicare Plus Blue Group PPO cost-sharing at time of service and verify member benefits via web-DENIS or CAREN.

SourceLink

On This Page

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ALL of the following

Eligible providers and payable locations: consistent with Original Medicare.
Frequency: consistent with Original Medicare.
CPT coding: report ED CPT/HCPCS codes to highest specificity; coding and coverage consistent with Original Medicare.
Age restrictions: none.

Diagnosis restrictions: Restrictions apply; a copayment is applied to the facility claim if the submitted diagnosis does not support the level of service billed; the copayment is waived if the diagnosis is considered emergent.

Payment methodology and provider billing: Payment is based on the Medicare Outpatient Prospective Payment System; the plan's maximum payment amount for ED services is consistent with Original Medicare and represents payment in full — providers may not balance-bill members.

Member cost-sharing collection: Collect applicable member cost-sharing (copayment, coinsurance, deductible) at time of service when possible; member copayment amounts are determined by the member's group.

ED Coding and Diagnosis Rules

ED CPT/HCPCS codingCPTCovered

CPT codes for emergency department services are payable consistent with Original Medicare; report codes to highest specificity.

Diagnosis restrictions

Diagnosis restrictionCopayment applied to the facility claim if the submitted diagnosis does not support the level of service billed.

Emergent diagnosis waiverCopayment is waived when the diagnosis is considered emergent.

Member copayment determinationThe member's copayment amount is determined by the member's group plan.

Provider Billing, Verification, and Claims Submission

Note

Provider collection and verification

Medicare Plus Blue Group PPO providers should collect the applicable Medicare Plus Blue Group PPO cost-sharing (flat-dollar copayment, percentage coinsurance, or deductible) from the member at the time of service when possible. If a member elects to receive a noncovered service, the member is responsible for the entire charge. Verify member benefits and cost-share via web-DENIS or by calling CAREN at 1-866-309-1719.

Collect only the appropriate Medicare Plus Blue Group PPO cost-sharing amounts (copayment, coinsurance, deductible) at time of service when possible.
If member elects a noncovered service, member is responsible for full charge.
Verify member benefits/cost-share via web-DENIS or call CAREN: 1-866-309-1719.

Billing Rule

Claims submission requirements

Submit professional and facility claims using standard claim forms or electronic equivalents and follow Medicare Advantage PPO billing rules. Report CPT/HCPCS and diagnosis codes to the highest level of specificity, include your National Provider Identifier (NPI) on all claims, and submit claims to your local Blue Cross Blue Shield plan. Providers should use electronic billing where available and follow the BCBSM 837/835 companion documents for electronic claim and remittance formatting.

Bill on CMS-1500 (8/05), UB-04, or the 837 electronic equivalent.
Follow Medicare Advantage PPO unique billing requirements.
Report CPT/HCPCS and diagnosis codes to highest specificity.
Include your National Provider Identifier (NPI) on all claims.
Submit claims to your local BCBS plan (use local Medicare Advantage claims address as applicable).
Use electronic billing when available. Michigan providers: see BCBSM Electronic Data Interchange (EDI) Institutional 837/835 Companion Document: bcbsm.com/pdf/837_835_institutional_companion.pdf and Professional 837/835 Companion Document: bcbsm.com/pdf/systems_resources_prof_837_835.pdf. Providers outside Michigan: contact your local BCBS plan for electronic billing instructions.

Definitions

Medicare Plus Blue Group PPO

Plan nameMedicare Plus Blue Group PPO

Scope vs Original MedicareProvides at least the same level of benefit coverage as Original Medicare (Part A and Part B) and may include enhanced benefits within a single plan.

Enhanced ED coverageEnhanced coverage for emergency room care is provided to members under select Medicare Plus Blue Group PPO plans.

Original Medicare

Part B coverageOriginal Medicare covers emergency department physician services under Part B.

Part A coverageFacility services, auxiliary personnel, drugs and supplies provided in the ED are Part A benefits.

Relationship to PPO plansMedicare Plus Blue Group PPO uses Original Medicare as the base for benefits (per source context).