COST MANAGEMENT FEATURES

The PRE-CERT program helps you and your physician use your health care benefits in a cost-effective way. This is accomplished by establishing, before a hospital admission, whether an inpatient hospital is the proper setting and, if so, what is an appropriate length of stay.

PRE-CERT allows your physician to request a review by BCBSM or an out-of-state Blue Cross Blue Shield Plan at least two weeks before admitting you to a hospital for a non-emergency admission. (If a two-week notice is not possible, your physician can call for an immediate review of the requested admission.)

When your physician’s admission request is received, BCBSM will:

Your physician can appeal decisions about any non-approval or the number of days assigned for approved admissions by submitting additional information with the appeal request.
A review will then be made by a panel of physicians, excluding the physician who made the initial decision.

If additional days are required for medical reasons after you are admitted to a hospital, the hospital and your physician can request additional days beyond those initially approved. This extension (or recertification) should be requested at least 48 hours before the end of the initially approved length-of-stay period.

Emergency admissions and maternity admissions do not require advance precertification. However, your physician must notify BCBSM (or the local BCBS Plan) within one working day of the admission so that a length-of-stay decision can be made.

PRE-CERT will not be required if you are enrolled in Medicare and subject to any Medicare preauthorization process.

PRE-CERT will assist you in the effective use of your benefits because you will know, in writing, what is covered before your hospital admission. Call the BCBSM State of Michigan Customer Service Center for more details.

This program covers a second surgical opinion consultation – at no cost to you – when your physician recommends or plans to perform certain types of non-emergency surgery by admitting you to a Michigan hospital on an inpatient basis. This program helps you obtain additional information so you can better weigh the benefits and risks of surgery and become aware of alternate treatment methods that may be available.

The second surgical opinion process will be initiated automatically by the BCBSM Referral Center when your physician contacts BCBSM for a pre-certification of your hospital admission. Based upon the medical data provided by your physician about the procedure to be done, your physician will be advised if a second opinion is required.

The focused second surgical opinion will be required for any of the 16 surgical procedures listed below:

If you are unfamiliar with these terms, discuss them with your physician or the BCBSM Referral Center.

If desired, you and your physician may also arrange for a second opinion for most other non-emergency surgeries to be performed on an inpatient or outpatient basis in a hospital.

After you or your surgeon has been advised of the need for a second opinion appointment, a registered nurse (RN) from the BCBSM Referral Center will call you with the names of several physicians in your area so you can select the physician you want to see for the second opinion. This BCBSM Referral Center nurse will also arrange the appointment for you. You may contact the BCBSM Referral Center directly by calling (313) 225-0700 (Detroit area) or 1-800-845-5982 (other Michigan areas).

If the second opinion does not confirm your surgeon’s recommendation, you or your physician can arrange for a third opinion by calling the BCBSM Referral Center – again at no cost to you. If you still want to have the surgery that was originally recommended – even though the second opinion (and the third opinion, if received) does not confirm this original recommendation – payment will still be made, provided the service is not otherwise specifically excluded from available benefits under the State Health Plan Advantage.

In addition to the second opinion, the second surgical opinion program will also cover a non-surgical (medical) consultation when recommended by the second opinion consulting physician because you have medical complications that may affect your having the surgery.

The second (or third) opinion physician’s recommendation does not affect the BCBSM approved amount for the surgical procedure. Whether or not the recommendation of the second physician favors surgery, YOU make the final decision about having the surgery.

You are not required to obtain a second opinion if:

This program provides you with an alternative to costly inpatient hospital care. You and your enrolled family members are entitled to 120 days of coverage per calendar year for home health care provided through a state-licensed home health care agency when:

All home health care services are paid at 100 percent of BCBSM approved amounts. Covered Home Health Care Program services do not reduce your available benefit for inpatient hospital days.

Covered services include:

NOTE: At times, necessary physical therapy equipment cannot be brought to the patient’s home (i.e., whirlpools). In such instances, services will be approved, on a limited basis, outside the home.

Prior approval, otherwise referred to as predetermination, is required for services received for home health care. This will allow you to know in advance whether or not services will be covered.

Your physician or home health care agency can request prior approval on your behalf. Your provider can contact the BCBSM Central Review Organization (CRO) by calling 1-800-482-4040 (Monday-Friday, 8 a.m. to 5 p.m.) or via fax (24 hours a day, seven days a week) sent to (248) 448-4016 (in Michigan) or 1-800-852-2072 (out of state).

You are free to use any licensed home health care agency of your choice. However, you may receive a balance bill from a non-BCBSM participating (approved) home health care agency.

In addition to the State Health Plan Advantage’s general exclusions, such as personal comfort and convenience items and custodial care – which are never covered – exclusions applicable to the Home Health Care Program include:

This benefit offers an alternative to inpatient hospital care for terminally ill patients. Each enrolled family member is entitled to hospice care when all of the following conditions are met:

The plan will cover up to 210 days – two periods of 90 days each, and one period of 30 days – during the patient’s lifetime. Covered Hospice Care Program benefits include the following:

The costs of transportation, funeral arrangements, financial or legal counseling, pastoral counseling and estate planning services are not covered.