Medical chart review reimbursement
If you've supplied our vendor, Ciox Health, with medical charts for Medicare Plus Blue PPO, you can request reimbursement with this form.
If you've supplied medical records to a Blue Cross HEDIS clinical consultant performing HEDIS retrievals, you may request reimbursement with this form or through your HEDIS clinical consultant. We only reimburse for Blue Cross Medicare Plus Blue, Blue Cross Commercial PPO and Marketplace PPO members.
Recredentialing
If you need to recredential as a clinical independent laboratory, durable medical equipment supplier, freestanding radiology center, Medicare-approved ambulatory surgical facility, Medicare-approved physiological laboratory or urgent care center, use this form.
All other hospitals and facility types can use this form to recredential.
Administrative
Utilization management authorization requirements
Refer to the Utilization management authorization requirements (PDF) to learn more about benefits and services that require prior authorization.
Use the Utilization management authorization request form (PDF) to submit for prior, concurrent or retrospective review authorization requests.
Explanation of benefit codes
Refer to the
Blue Cross Complete explanation of benefit codes (PDF) for new and current EOB codes.
Genetic testing codes
The
Genetic Testing Codes (PDF) tells you which genetic testing codes require prior authorization.
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.
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.
HEDIS handbook
The
Blue Cross Complete HEDIS Supplemental Data Exchange provider handbook (PDF) provides an explanation of our data exchange processes and how we identify the necessary clinical data for closing gaps in care for our members.
Blue Cross Complete of Michigan's self-service tools are valuable resources that can assist you in providing the highest quality of care to our members.
Provider directories
Drug formulary
A comprehensive drug list for Blue Cross Complete can be accessed and reviewed in two ways:
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.
For pharmacies
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.
Prior Authorization Lookup
Find out if a service needs prior authorization. Type a Current Procedural Terminology, or CPT, code or a Healthcare Common Procedure Coding System, or HCPCS, code in the space below to get started.
Directions
- Enter a CPT or HCPCS code in the space below.
- Click Submit.
- The tool will tell you if that service needs prior authorization.
Important notice
This tool provides general information for outpatient services performed by a participating provider.
The following services always require prior authorization:
- Elective inpatient services
- Urgent inpatient services
The results of this tool aren’t a guarantee of coverage or authorization. All results are subject to change in accordance with plan policies and procedures and the Provider Manual (PDF).
If you have questions about this tool or a service or to request a prior authorization, call Blue Cross Complete's Provider Inquiry at 1-888-312-5713.
Healthcare common procedure coding system medications
A prior authorization for healthcare common procedure coding system medications is required before they are covered by Blue Cross Complete. Click the HCPCS PA List (PDF) for a list of codes that require prior authorization.
Prior authorization
Some medicines and benefits require prior authorization by Blue Cross Complete. Submit a prior authorization request using one of the following forms:
- Medication prior authorization online form
- Medication prior authorization request form (PDF)
You must submit a request for a prior authorization for your patient. You must also submit an override of a drug restriction. Request from pharmacies aren't accepted.
Pharmacy billing
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 (600428), PCN (06210000), member services number, field definitions and other helpful information for pharmacy claim billing and rebilling.
NaviNet
By logging on to the Blue Cross Complete payer-provider portal Navinet, you have the opportunity to:
- Receive news alerts in real time
- View Blue Cross Complete member information
- Submit authorization requests
- View gaps in care reports
- Check the status of claims
Visit NaviNet Basics if you have not yet enrolled or would like more information.