BlueCross BlueShield of South Carolina

Blue Cross Blue Shield of Michigan's Medicare Plus Blue Group PPO

December 12, 2012

Beginning Jan. 1, 2013, members of the International Union, United Automobile, Aerospace and Agricultural Implement Workers of America (UAW) Retiree Medical Benefits Trust who live in South Carolina can choose medical and surgical coverage through Blue Cross Blue Shield of Michigan’s (BCBSM) Medicare Advantage PPO plan — Medicare Plus Blue Group PPO. Members’ ID cards will have the alpha prefix XYL.

These members will also have coverage for hearing, routine vision exams and the SilverSneakers^® Fitness Program.

You can verify a member’s plan by viewing his or her current ID card. To verify benefits and eligibility, call BlueCard^® Eligibility at 800-676-BLUE (2583) and provide the member’s alpha prefix on the ID card. You can see a sample ID card at the bottom of this page. Information you get regarding member eligibility is not a guarantee or promise of payment. Payment determination only occurs after the claim is processed according to the member’s benefits.

While member servicing will be centralized in Michigan, you should still use BlueCross BlueShield of South Carolina’s normal claim submission method. We will then use the BlueCard^® program to forward the claims to BCBSM.

UAW Trust Medicare Advantage PPO members will have a combined out-of-pocket maximum for DME, medical and surgical benefits.

Precertification

BCBSM requires precertification for its Medicare Advantage PPO members. Contact BCBSM to get precertification or recertification for:

• Acute inpatient preauthorization
• Skilled nursing facility (SNF) admissions
• Long-term acute care hospitals
• Inpatient acute rehabilitation
• Inpatient behavioral health/substance abuse admissions
• Partial hospitalization behavioral health admissions
• Intensive outpatient behavioral health

To get precertification, please use BCBSM’s e-fax at 866-464-8223 or email MedicarePlusBlueFacilityFax@bcbsm.com.

Acute inpatient, SNF/acute rehabilitation, long-term acute care and expedited/urgent admission (for those admissions attested by a physician as urgent) assessment forms are available at BCBSM’s provider website at bcbsm.com/provider/ma.

Inpatient, Partial Hospitalization and Intensive Outpatient Behavioral Health Services

For behavioral health, contact Michigan Medicare Plus Blue PPO Behavioral Health at 888-803-4960 or via fax at 866-315-0442.

Radiology Management Program

Also beginning Jan. 1, 2013, the UAW Retiree Medical Benefits Trust in partnership with BCBSM and AIM Specialty Health^SM will offer the national Radiology Utilization Management program. AIM is an independent company that offers radiology management services on behalf of BCBSM. The program requires preauthorization for outpatient advanced diagnostic services to ensure that the procedures are appropriate and medically necessary.

The preauthorization requirement includes these outpatient advanced diagnostic imaging services:

• Computed tomography
• Magnetic resonance imaging
• Nuclear cardiology
• Positron emission tomography
• Stress echocardiography (new 2013 service and requirement)
• Resting transesophageal echocardiography (new 2013 service and requirement)
• Transthoracic echocardiography (new 2013 service and requirement)

Imaging studies performed along with emergency room services, inpatient hospitalization, outpatient surgery (hospitals and freestanding surgery centers), urgent care centers and 23-hour observations are excluded from this requirement.

Required Information for Imaging Requests

This checklist is a guideline to help ensure you have all the necessary information when you submit a request for an imaging exam:

• Member’s ID number, name, date of birth and health plan
•  Ordering physician information (name, location)
• Imaging provider information (name, location)
• Imaging exam(s) being requested (body part, right, left or bilateral)
• Patient diagnosis (suspected or confirmed)
• Clinical symptoms and indications (intensity, duration)

For most situations, this information is sufficient. For complex cases, more information may be necessary, including results of past treatment history, such as previous tests, duration of previous therapy and relevant clinical medical history.

Here is a sample UAW BCBSM Medicare Plus Group ID card:

Blue Cross Blue Shield of Michigan is a nonprofit corporate and independent licensee of the Blue Cross and Blue Shield Association.