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Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements

View requirements for Local Plan and BlueCard Out-of-Area members.

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Medicare Preferred PPO

PW_A127408
 
Plan & Administrative Changes/Updates for Providers:
Click here for important Medicare Advantage updates!  
 
Blue Value is a Medicare Advantage HMO health plan offered within a select service area. Blue Value features all the health coverage services offered by Original Medicare, and some extra services Original Medicare does not offer, such as annual physical exam, vision benefits and a fitness center membership, see the 2012 Summary of Benefits or the 2013 Summary of Benefits.  
Members must seen non-emergency care from provider network, see Provider Finder
Authorization requirement apply for specific services. See Summary of Benefits for pre-authorization details.
Members of the BlueValue plan have a Medicare Part D prescription drug benefit as part of the plan, see the Prescription Drug Formulary
 
FAST TRACK APPEALS 
Medicare beneficiaries and providers have certain rights and protections related to financial liability under the Medicare Advantage (MA) Programs. Financial liability, appeal rights, and protections are communicated to beneficiaries through notices given by providers or the MA health plan. Download the forms and instructions below.  
Explanation of: What Beneficiary Notice Form to Use
Beneficiary Notice Forms (click health plan form below to retrieve)
NOMNC Notice of Medicare Non-Coverage.
DENC Detailed Explanation of Non-Coverage.
NDMC Notice of Denial of Medical Coverage.
NDP Notice of Denial of Payment.
Beneficiary Notice Forms (on www.cms.hhs.gov/bni)
IM Important Message from Medicare
Detailed Notice of Discharge
 
Additional Information
Medicare Advantage Out of Network Payment Guide
Institutional billing codes are available from the NUBC via the NUBC's Official UB-04 Data Specifications Manual. To be redirected to NUBC click here
ID card
Independent Provider Payment Dispute Process
Medicare Advantage HMO & PPO Provider Guidebook
(Formerly know as the Medicare Advantage HMO & PPO Provider Manual)
Medicare Coverage Homepage
Medicare Part D Coverage Determination Request Form (for use by provider)
Affordable Care Act (ACA)
Formerly known as Patient Protection and Affordable Care Act
Precertification Requirements
*Medicare Advantage Products never require Pre-Existing Condition signoff
Precertification Form
Preventive Health Guidelines
Quick Reference Guide to the CMS 1500
Revision of Definition of Compendium in the Medicare Benefit Policy Manual; Chapter 15; Section 50.4.5
 
Blue Cross Blue Shield encourages our providers to participate in the CMS and HHS quality improvement initiatives. To learn more about these initiatives or find new announcements, please visit www.cms.hhs.gov/home/medicare.asp and scroll to the bottom under browser by Special Topic.  
Contact us
 
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Blue Cross and Blue Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.