Resources for Providers
Blue Cross Complete of Michigan offers a variety of resources to its provider network.
Blue Cross Complete of Michigan offers a variety of resources to its provider network.
Provider appeals
Providers can submit appeals related to an adverse action of a post service request, including service denials, delays or limitations. The appeal must be submitted with documentation to support medical necessity or appropriateness. For more information, refer to the Provider Appeals section of the Provider Manual (PDF).
Trauma-informed care
To improve mental health treatment for members, Blue Cross Complete follows The National Council for Wellbeing’s guideline for trauma-informed primary care – Fostering Resilience and Recovery: A Change Package for Advancing Trauma-Informed Primary Care. Implementing trauma-informed approaches marks a fundamental shift in care delivery that supports improved utilization of services, improved patient outcomes, increased staff satisfaction and healthier work environments.
“Connecting our members to premier ancillary services and specialists” Program Guide
The COMPASS Program Guide (PDF) contains detailed information about the COMPASS program (including a complete list of episode category descriptions, the opt-out process, and how to appeal program determinations).
Independent laboratory drug testing
The Independent laboratory drug testing payment (PDF) provides information about payment for medically necessary presumptive and definitive drug testing for independence.
Michigan Department of Health and Human Services Blood Lead Testing resources
The Michigan Department of Health and Human Services Blood Lead Testing resources provide information on blood lead testing.
Michigan Department of Health and Human Services Blood Pressure Cuffs
Michigan Department of Health and Human Services Blood Pressure Cuffs (PDF) provides information on Medicaid managed care plan benefit and authorization details for blood pressure cuffs.
Neuropsychological testing
Neuropsychological testing guidelines (PDF) provides clarification on conditions in which Blue Cross Complete covers neuropsychological testing.
Explanation of benefit codes
Refer to the Blue Cross Complete explanation of benefit codes (PDF) for new and current EOB codes.
Claims filing instructions
The Claims Filing Instructions Manual (PDF) guides you through submitting clean claims to Blue Cross Complete.
The Appropriate Use of Claims Modifier Guide (PDF) helps you with billing using modifier 25 and 59 appropriately.
Submitting a refund
Use the Provider Claim Refund Form (PDF) to submit a refund of overpayment to Blue Cross Complete.
Dual-eligible members
Dual-eligible members (PDF)
Learn how to serve dual-eligible members who qualify for both Medicare and Medicaid.
Blue Cross Complete guidelines supersede any other applicable guidelines.
Flu prevention resources
To find helpful tips to inform and educate patients about the importance of flu shots:
Hepatitis C resources
Helpful tools and guidance to eliminate hepatitis C as a health threat:
Chronic Kidney Disease resources
The Centers for Disease Control and Prevention estimates that approximately 35.5 million people in the United States have chronic kidney disease, or CKD.
Vaccines for Children Program
Protecting children from diseases that can be prevented by vaccination is a primary goal of Blue Cross Complete and MDHHS. Your active participation in the VFC Program is vital to increasing immunization rates and ensuring all children are protected against vaccine-preventable diseases. To learn more, view the Vaccines for Children Program flyer (PDF).
Michigan Department of Health and Human Services Preventive Services Coverage Guidelines (PDF)
The guidelines provide a list of recommended preventive services and corresponding CPT, HCPCS and diagnoses codes to assist Medicaid health plans and providers in identifying Medicaid covered preventive services.
Telemedicine Quick Reference Guide (PDF)
The reference guide provides information on telemedicine service policies.
View Blue Cross Complete's Clinical Pracitice Guidelines (PDF) for the current professional standards, supported by scientific evidence and research.
Blue Cross Complete endorses the clinical proactive and preventive care guidelines developed by the Michigan Quality Improvement Consortium.
Accurate coding of Healthcare Effectiveness Data and Information Set, or HEDIS, measures can help identify and eliminate gaps in care and disparities in health and health care. This helps to ensure timely and appropriate care; monitor preventive care; and facilitate timely claim adjudication, incentives, and payments. Health plans are measured on how well they perform and improve in quality, effectiveness of care, access to care, and member satisfaction. These measures are calculated using specific CPT and ICD-10 codes found in claims and encounters data.
According to the National Committee for Quality Assurance, HEDIS is the most widely used set of performance measures in the managed care industry. It consists of over 90 measurements that are used to compare health plan quality across the nation and are required for health plan accreditation. Accreditation helps ensure plan members receive quality care from their health plan and providers.
How can you improve HEDIS scores?
HEDIS Documentation and Coding Guidelines
Blue Cross Complete’s HEDIS Documentation and Coding Guidelines can be found in NaviNet, or by contacting a Blue Cross Complete Account Executive. There you can find a detailed overview of the HEDIS measures, including descriptions, coding recommendations, and actionable takeaways.
HEDIS care gaps
Care gaps are recommended preventive care services that are missing. You may address these gaps when your patient comes in for an office visit. Care gaps are based on HEDIS measures and may impact your quality scores. Participating primary care providers can access and resolve HEDIS care gaps for Blue Cross Complete via NaviNet, or by contacting a Blue Cross Complete Account Executive.
As a reminder, it’s important we work together to identify, address, and help eliminate health disparities. When accessing and reviewing care gaps, be sure to also group the data by race, ethnicity, and language (REL) to identify the populations that are experiencing a disparity for a specific measure. Focusing efforts on starting with the population that has the lowest HEDIS compliance rate can help close gaps in care and work toward reducing disparities.
Tools and references
Preferred drug list
A printable version is available by clicking the Preferred Drug List (PDF).
Online drug list
A searchable version is available by searching our online drug list.
The searchable version of the drug list provides additional details regarding quantity limits, prior authorizations or other coverage details not available on the printable version. This includes guidance for obtaining specialty medications.
Pharmacy Reference Guide
Refer to the Pharmacy Reference Guide (PDF) for a quick reference about pharmacy provider services, prior authorizations, member copays, durable medical equipment covered under pharmacy and recipient restrictions.
Medicaid Drug Rebate Program Labeler List
Blue Cross Complete participates in the Medicaid Health Plan Common Formulary. Under the Common Formulary, Medicaid Health Plan formulary coverage only includes products with a National Drug Code from manufacturers who participate in the Medicaid Drug Rebate Program. View the Medicaid Drug Rebate Program Labeler List (PDF).
Pharmacy billing
The PerformRx Pricing Administration Department calculates generic Maximum Allowable Cost and money paid to participating pharmacies. MAC prices are updated each week. To ask for a MAC pricing review, email the PerformRx Pricing Administration Department. You can also call PerformRx Pharmacy Provider Services at 1-888-989-0057.
The electronic processing of retail pharmacy claims requires a NCPDP processor ID number, also known as a BIN, and a processor control number, or a PCN, for plan identification. Blue Cross Complete's D.0 Payer Sheet (PDF) contains our BIN (019595), PCN (PRX00621), member services number, field definitions and other helpful information for pharmacy claim billing and rebilling.