Providers

Resources for Providers

Blue Cross Complete of Michigan offers a variety of resources to its provider network.

Provider manuals and guides

Provider Manual

The Provider Manual (PDF) helps providers navigate our comprehensive network of administrative and covered services. Changes to the Provider Manual are marked with a blue dot in the manual and explained in the Blue Dot Changes document (PDF).

Provider Resource Guide

The Resource Guide (PDF) provides the most commonly used contacts for Blue Cross Complete. These contacts include claims, customer service, eligibility verification and pharmacy services.

Non-emergency outpatient diagnostic imaging resources

Effective May 1, 2022, Blue Cross Complete will require prior authorization from National Imaging Associates, Inc. for most non-emergency outpatient diagnostic imaging services. Providers are encouraged to use resources below, visit RadMD.com or call NIA at 1-800-424-5351.

NIA Medical Specialty Solutions Utilization Review Matrix 2022 (PDF)
List of all CPT codes NIA manages on behalf of Blue Cross Complete
NIA Medical Specialty Solutions Prior Authorization Checklist (PDF)
Required information to have ready before logging on to RadMd.com or calling NIA
NIA Medical Specialty Solutions Quick Reference Guide for Providers (PDF)
NIA Frequently Asked Questions for Providers (PDF)
NIA Medical Specialty Solutions Program Tip Sheet for Prior Authorization of Cardiac Services (PDF)

Michigan Quality Improvement Consortium guidelines

Visit the Michigan Quality Improvement Consortium to access the guidelines, physician tools and reports, which provide MQIC community HEDIS^® and non-HEDIS results for over 100 quality improvement measures.

Telehealth resources

Visit telehealth.hhs.gov for more information on telemedicine services and resources.

Flu prevention resources

To find helpful tips to inform and educate patients about the importance of flu shots:

View the English Community Flu Shot Toolkit (PDF)
View the Spanish Community Flu Shot Toolkit (PDF)

Hepatitis C resources

Helpful tools and guidance to eliminate hepatitis C as a health threat:

Visit cdc.gov to see testing recommendations for hepatitis C virus infection
Recommendations for hepatitis C screening among adults: cdc.gov
Recommended Testing Sequence for Identifying Current Hepatitis C Virus (HCV) Infection: cdc.gov
We Treat Hep C: michigan.gov/mdhhs
Michigan Medicaid Preferred Drug List
AbbVie quick reference guides for pretreatment assessment, on-treatment monitoring and post treatment follow-up guide
Recommendations for universal hepatitis C screening in pregnancy
Pregnancy screening recommendations for syphilis, HIV, HBV, HCV, chlamydia and gonorrhea (PDF)

Pharmacy resources

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)

Clinical and administrative resources

Clinical Resources
Administrative

Clinical resources

Blue Cross Complete guidelines supersede any other applicable guidelines.

Abdominoplasty Clinical Guidelines for Coverage (PDF)
Members may receive coverage for an abdominoplasty when clinical guidelines are met. These guidelines assist in defining covered services for an abdominoplasty.

Chronic Obstructive Pulmonary Disease (PDF)
The guidelines for COPD provide evidence-based recommendations for implementing effective disease management for patients with chronic obstructive pulmonary disease.

Endovascular Treatment for Intermittent Claudication (PDF)
Effective 12/01/2021: Endovascular revascularization for treatment of intermittent claudication are considered medically necessary and require prior authorization.

Independent laboratory drug testing payment (PDF)
The guidelines provide information about payment for medically necessary presumptive and definitive drug testing for independent labs.

Michigan Department of Health and Human Services Blood Lead Testing resources
The resources provide information on blood lead testing.

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.

Neuropsychological testing (PDF)
The guidelines provide clarification on conditions in which Blue Cross Complete covers neuropsychological testing.

Orthognathic Surgery Clinical Guidelines for Coverage (PDF)
Members may receive coverage for orthognathic surgery when orthognathic surgery clinical guidelines are met. These guidelines assist in defining covered services for orthognathic surgery.

Administrative

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.

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.

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).

Care Gap Response Form Provider Guide
The Care Gap Response Form Guide (PDF) contains detailed information for providers about how to use NaviNet to enter Care Gap resolution data online. This guide explains how to retrieve and report on specific Care Gap changes.

NaviNet Medical Authorization System
Use the NaviNet Medical Authorizations Participant Guide (PDF) to learn more about using the NaviNet Medical Authorization system. Refer to the NaviNet Medical Authorizations Frequently Asked Questions (PDF) to review commonly asked questions.

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.

Blood pressure cuffs
Refer to the MDHHS coverage of automated home blood pressure cuffs (PDF) for Medicaid managed care plan benefit and authorization details.

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.

Condition Optimization Program Provider User Guide
The Condition Optimization Program Provider User Guide (PDF) contains details about how providers access Condition Optimization Program workflow activities within NaviNet.

“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).

Blue Cross Complete payment systems

Blue Cross Complete has implemented payment systems to meet providers’ requests for more payment options. The payment systems allow providers the ability to receive the following payment options for claims reimbursement:

Electronic funds transfer
Electronic funds transfers allow you to receive your payments directly in the bank account you designate rather than receiving them by virtual credit card or paper check. When enrolling in EFT, you will automatically receive electronic remittance advices for those payments. All generated ERAs and a detailed explanation of payment for each transaction will also be accessible for download from the ECHO provider portal at providerpayments.com.

To sign-up to receive EFT from Blue Cross Complete, visit ECHO Healthcare.

To check the status of an EFT enrollment or obtain technical support, contact ECHO customer service at EDI@EchoHealthinc.com or call 1-888-834-3511.

Virtual credit card
A virtual debit transaction in which randomly generated, temporary credit card numbers are either faxed or mailed to providers for claims reimbursement. The VCC payment notification will contain a number unique to that payment transaction and an instruction page for processing the payment.

Note: Providers who aren’t enrolled to receive EFT will automatically receive the VCC. If you don’t wish to receive your claim payments through VCC, you can opt out by calling ECHO Health at 1-888-492-5579 to receive a paper check.

Electronic remittance advice
Providers may also receive their electronic remittance advice from Change Healthcare and ECHO Health by including both the Change Healthcare Blue Cross Complete payer ID: 32002 and the ECHO Health payer ID: 58379. To receive remittance advice, visit ECHO Healthcare or contact the ECHO Health Enrollment team at 1-888-834-3511.

Download the Blue Cross Complete Payment Systems (PDF) brochure for more information.

To access the ECHO Healthcare provider payments portal quick reference guide, visit ECHO Healthcare and log into your account. The User Guide can be accessed by selecting the Help button on the portal. If you require further assistance, contact your Blue Cross Complete provider account executive.

County-based contacts for providers

For more information on training, Medicaid and other topics, contact a provider account executive in your county. Select a county below for the contact details of that county's account executive.

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