Q1: What is Blue Medicare PPO?

A:  Blue Cross and Blue Shield of Texas established the Blue Medicare Preferred Provider Organization (BMPPO) as an additional health benefit solution to the Medicare Advantage program for Medicare beneficiaries. Blue Medicare PPO is a plan in which patients or Members receive the maximum level of medical benefits for Medicare Part A and Part B inpatient and outpatient covered services when accessing medical care from participating physicians/professional providers and hospitals.

Note:  CMS under the Medicare Modernization Act of 2003 has changed the name from Medicare + Choice plan to Medicare Advantage (MA).

Q2: Do I need to be a participating physician/professional provider in traditional Medicare to be included in the Blue Medicare PPO network?

A:  To participate in the Blue Medicare PPO, physicians/professional providers:

• Must be a participating Blue Choice physician/professional provider
• Must have admitting privileges at one of the Blue Medicare PPO participating hospitals (unless inpatient admissions are uncommon or not required for the physician's/professional provider's specialty)
• Must have a valid Unique Physician Identifier Number (UPIN) - only applies to MDs, DOs & DPMs
• Must sign a Blue Medicare PPO amendment to his/her BlueChoice agreement, and
• Cannot have opted-out of Medicare or have any sanctions or reprimands by any licensing authority or review organizations.  Blue Medicare PPO participating physicians/professional providers cannot be named on the Office of the Inspector General (OIG) list which identifies physicians/professional providers found guilty of fraudulent billing, misrepresentation of credentials, etc.  Blue Medicare PPO participating physicians/professional providers cannot be sanctioned by the Office of Personnel Management or be prohibited from participation in the Federal Employees Health Benefit Program (FEHBP).

Q3: How is Blue Medicare PPO marketed?

A:  Blue Medicare PPO is marketed directly to people eligible for Medicare Parts A and B that live in its approved Service Area in the state of Texas.

 Service Area includes five (5) counties: El Paso, Galveston (limited only to the Mainland portion of Galveston County*), Harris, Jefferson and Montgomery.

*  The only zip codes included for Galveston County: 77510, 77517, 77518, 77539, 77546, 77549, 77552, 77553, 77555, 77563, 77565, 77568, 77573, 77574, 77590, 77591, 77592, 77617, 77623 & 77650

Q4: What was the effective date for Blue Medicare PPO?

A:  Blue Medicare PPO became effective on 8/1/05.

Q5: Will there be any office visit co-pays?

A:  Yes, the Blue Medicare PPO benefit plan does require a Member to pay a co-pay amount for each office visit, emergency room visit or urgent care visit. Similar to other BCBSTX products, a Member enrolled in the Blue Medicare PPO plan will have an identification card with the Blue Medicare PPO logo. Each Member ID card identifies the benefit plan features including co-pays, deductibles and phone numbers to call for benefits and eligibility, claims status, precertification of certain services and other pertinent information.

Q6: As a Blue Medicare PPO physician/professional provider, can we have a financial agreement with our patients to be responsible for whatever insurance does not cover? Are we able to demand payment from the Member?

A:  A Blue Medicare PPO participating physician/professional provider may only collect for copayments, cost share (coinsurance) and deductibles, where applicable.   

Q7: If I am already participating in the BlueChoice network, is any additional credentialing required?   

A: Additional credentialing will not be required if you are already credentialed in the BlueChoice network and if your recredentialing is current.

Q8: If I am presently not a contracted BlueChoice physician/professional provider but I am a participating Medicare provider, can I opt to participate in Blue Medicare PPO only?

A:  No, you must be a participating BlueChoice physician/professional provider, however, you can start the credentialing process for both BlueChoice and Blue Medicare PPO at the same time.

Q9: Are hospital privileges required to participate in the Blue Medicare PPO network?

A:  Yes, admitting privileges at a participating Blue Medicare PPO hospital are required unless inpatient admissions are uncommon or not required for your specialty.

Q10: Are referrals required?  Will any services require prior certification?

A:  A Member may self-refer to any Blue Medicare PPO participating physician/professional provider.  A referral is not required to access a participating specialty care physician/professional provider, however, some services require precertification.  If it is necessary to utilize a non-participating specialty care physician/professional provider due to network inadequacy or continuity of care concerns, the physician/professional provider must obtain precertification from the UM Department.  If precertification is not obtained, claims will be paid at the out-of-network (OON) benefit level.

Q11: Is BCBSTX using their current claims and membership system for administering the Blue Medicare PPO plan?

A: Claims should be submitted electronically through the Availity Health Information Network for processing.  The Blue Medicare PPO Electronic Payor ID # is TXPPO.  Blue Medicare PPO claims may be submitted (1) electronically in the CMS National Standard format (NSF) or the current version of the ANSI 837 format or (2) on a completed version of the applicable CMS claim form (08/05). Mail claim form to:

Blue Medicare PPO
P.O. Box 3567
Scranton, PA  18503

For benefits and eligibility, physicians/professional providers should call Blue Medicare PPO Provider Customer Service at 1-866-706-7745. 

Q12: What are the time frames for submitting claims?

A:  Effective April 10, 2008*, participating physicians/professional providers must submit claims to Blue Medicare PPO within 180 days of the date of service. Services billed beyond 180 days from date of service are not eligible for reimbursement. Blue Medicare PPO participating physicians/professional providers may not seek payment from the Member for claims submitted after the 180 day filing deadline.

*Note: Prior to April 10, 2008, the claims filing deadline was 95 days.

Q13: Which lab will be used for outpatient clinical reference laboratory services?

A:   Laboratory Corporation of America (LabCorp) is the participating lab for Blue Medicare PPO.

Q14: Will American Imaging Management, Inc. (AIM) be responsible for managing all outpatient, non-emergency diagnostic high tech imaging services for Blue Medicare PPO Members?  

A:Yes, the ordering physician/professional provider must contact American Imaging Management (AIM) to obtain a precertification number for the following outpatient, non-emergency diagnostic high tech imaging services when performed in a physician's/professional provider's office, outpatient department of a hospital or a freestanding center:  CT/CTA scans, MRI/MRA scans, SPECT/Nuclear Cardiology studies and PET scans. (Note:   Whether the services are Medically Necessary must be determined before a precertifcation number will be issued. Claims received that do not have a precertification number will be denied.)

Q15: Will there be additional training offered for Blue Medicare PPO?

A:  Yes, additional training is provided as well as information that you can access through the BCBSTX Web site,  (click on Blue Medicare PPO).  If your office needs additional training, contact your local Professional Provider Network Representative.  

Q16: Who can I call for additional information about Blue Medicare PPO?

A:  Please contact your local Professional Provider Network office.   
 
For additional information, please refer to the Blue Medicare PPO Supplement and to the BlueChoice Provider Manual.