Name of Manual - Blue Cross and Blue Shield of Minnesota

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Upgraded/Deluxe Durable Medical Equipment (DME) DME Waiver Requirement DME Claims Submissions Commercial Business Integrated Health Management Participating durable medical equipment (DME) suppliers may bill members for an equipment upgrade or deluxe charge if a waiver is on file and the DME charges are billed correctly to Blue Cross. We continue to reimburse for medically necessary standard DME. Government Business Participating durable medical equipment (DME) suppliers may bill members for an equipment upgrade or deluxe charge if a waiver is on file and the DME charges are billed correctly to Blue Cross. Participating DME suppliers must obtain a signed, written waiver from the member that includes the cost for the deluxe features or upgrade. The waiver must also state the following: the standard piece of equipment or least costly alternative offered to the member, the member is aware and agrees that Blue Cross will only pay the standard allowance, and the member will be responsible for the deluxe or upgrade charge in addition to his or her contractual obligation. This waiver must be kept on file at your office. If a precertification/authorization are required for the item being provided, please send the waiver form along with your request. For all services that do not require a pre-certification/authorization, do not send it to Blue Cross. We do, however, reserve the right to see it. Two lines of service must be billed. The first line will include the DME HCPCS code and the standard charge for the equipment. The second line must include the same DME HCPCS code with the - GA modifier (waiver of liability statement on file) and the upgrade or deluxe charge. For example: E0202 -- $550.00 (standard charge that will be subject to standard allowance and reductions) E0202 GA -- $150.00 (deluxe/upgrade charge that will be denied as member liability) The -GA modifier must be submitted as the first modifier on the second service line. Other applicable modifiers, such as -NU (Purchase), should be submitted on the first service line. Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12) 4-35
Integrated Health Management Sample DME Waiver A sample waiver for use in your office is available on our website. The waiver includes the information required in order to hold the member financially liable for deluxe features or upgrades to a durable medical equipment purchase. The waiver should be incorporated into your usual business forms and customized to include your business letterhead. 4-36 Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/19/12)
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Blue Cross and Blue Shield of Minne
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Recent Chapter changes: Chapter 11
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Chapter 11 - Coding Policies and Gu
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Durable Medical Equipment Date Topi
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Medical Emergency Date Topic Change
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Rehabilitative Services Date Topic
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Table of Contents Chapter 1 At Your
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Introduction Provider Policy and Pr
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How to Contact Us At Your Service P
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At Your Service Claims Address Subm
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Care Management Numbers and Address
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Care Management Numbers and Address
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Company Phone Number Address Public
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At Your Service Provider Identifica
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ID Cards At Your Service Introducti
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Electronic Commerce Overview An imp
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Remote Access Services (continued)
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Provider Communications Provider Co
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Health Plan Members have the Follow
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Provider Agreements Participation a
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Provider Agreements Responsibilitie
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Provider Agreements Provider Number
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Provider Agreements Accounting for
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Provider Agreements Carrier Replace
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Table of Contents Chapter 3 Quality
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Quality Improvement Leadership Rati
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Quality Improvement Telephone Care:
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Quality Improvement Quality of Care
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Quality Improvement Written Policie
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Page 61 and 62: Quality Improvement Patient Safety
Page 63 and 64: Quality Improvement Medical Record
Page 65 and 66: Quality Improvement Institute for C
Page 67 and 68: Quality Improvement Quality Improve
Page 69 and 70: Quality Improvement Physical Facili
Page 71 and 72: Quality Improvement Treatment Recor
Page 77 and 78: Integrated Health Management Progra
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Page 81 and 82: Integrated Health Management Utiliz
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Page 87 and 88: Integrated Health Management Overvi
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Page 103 and 104: Integrated Health Management Focuse
Page 105 and 106: Integrated Health Management Specia
Page 107 and 108: Integrated Health Management Overvi
Page 109: Integrated Health Management Medica
Page 113 and 114: Health Care Options Prepaid Medical
Page 115 and 116: Health Care Options Member ID Cards
Page 117 and 118: Health Care Options Blue Cross and
Page 119 and 120: Health Care Options Double Gold Dou
Page 121 and 122: Health Care Options Medicare Basic
Page 123 and 124: Health Care Options Platinum Blue S
Page 125 and 126: Health Care Options MedicareBlue PP
Page 127 and 128: Health Care Options Inquiries and C
Page 129 and 130: Health Care Options Additional info
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Page 135 and 136: Health Care Options BlueLinkTPA Blu
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Page 139 and 140: Health Care Options Prime Therapeut
Page 141 and 142: Health Care Options Workers' Compen
Page 143 and 144: Health Care Options HICF 1500 Form
Page 145 and 146: Health Care Options Networks Blue C
Page 147 and 148: Blue Plus Member Information Introd
Page 149 and 150: Blue Plus Member Rights and Respons
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Page 153 and 154: Blue Plus Member Benefits Members
Page 155 and 156: Blue Plus Quality of Care Complaint
Page 157 and 158: Blue Plus Referral Points Remember
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Blue Plus Standing Referral Minneso
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Blue Plus Clarifications of Terms (
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Blue Plus [Date] [Name of patient]
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Blue Plus Special Member Benefits O
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Blue Plus OB/GYN Open Access Diagno
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Blue Plus OB/GYN Open Access Diagno
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BlueCard® Claim Status Inquiry ...
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BlueCard® Identifying BlueCard ®
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BlueCard® Identifying BlueCard ®
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BlueCard® BlueCard Service Claims
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BlueCard® Prior Authorization and
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BlueCard® Electronic Data Intercha
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BlueCard® Claims Processed by the
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BlueCard® Overview (continued) 3.
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BlueCard® Claim Payment Guidelines
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BlueCard® Calls from Members and O
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BlueCard® Guidelines (continued) W
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BlueCard® Types of Medicare Advant
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BlueCard® Medicare Advantage Claim
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BlueCard® Reimbursement for Medica
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Claims Filing HCPCS/ Accommodation
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Claims Filing Administrative Simpli
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Claims Filing Claims with Attachmen
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Claims Filing Claims with Coordinat
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Claims Filing Claims with Coordinat
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Claims Filing 1500 HICF Form Profes
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Claims Filing Ordering Forms and Ma
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Claims Filing Site of Service (cont
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Claims Filing Institution (837I) /F
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Claims Filing Treatment Room Blue C
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Claims Filing Single facility claim
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Claims Filing Present on Admission
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Claims Filing Medicare Crossover Bl
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Claims Filing Cancel/Void and Repla
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Claims Filing Verifying Patient Eli
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Claims Filing Basic Character Set V
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Claims Filing Rural Health Clinics
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Claims Filing Coordination of Benef
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Claims Filing TEFRA The 1982 Tax Eq
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Claims Filing Employment As defined
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Claims Filing Surgical Technicians
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Reimbursement / Reconciliation Reim
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Reimbursement / Reconciliation Comp
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Reimbursement / Reconciliation Remi
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Reimbursement / Reconciliation Ques
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Reimbursement / Reconciliation Ques
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Reimbursement / Reconciliation Acco
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Reimbursement / Reconciliation Fiel
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Appeals Provider Appeals Introducti
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Appeals Submitting Requests for Pos
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Appeals Coding Appeals (continued)
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Appeals Supporting Documentation (c
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Coding Policies and Guidelines (Cod
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Coding Policies and Guidelines (Mod
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Chapter 11 Coding Policies and Guid
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Part-time (Medically Directed) Anes
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Electroconvulsive Treatments Blue C
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Moderate (Conscious) Sedation Monit
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Coding Policies and Guidelines (Beh
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Coding Restrictions Code Restrictio
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CTSS Skills Training and Developmen
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Intensive Residential Treatment Ser
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IRTS Member Eligibility IRTS Access
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Adult Non-Residential Crisis Servic
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MH-TCM Services to Minnesota Health
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Dialectical Behavioral Therapy/DBT
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Autism Spectrum Disorder/EIBI (cont
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Autism Spectrum Disorder/EIBI (cont
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Psychiatric Consultation to Primary
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Psychiatry and Chemical Dependency
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Medication Management M0064 and 908
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Nutritional Counseling/Medical Nutr
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Practitioner Key MD = Psychiatrist
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Clinical Supervision Under Minnesot
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DIAMOND Initiative (continued) Reim
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Missed Appointments (continued) Cou
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Guidelines for Court Ordered Evalua
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Guidelines for Court Ordered Evalua
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Behavioral Health Quality Improveme
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Pre-certification and Concurrent Re
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Coding Policies and Guidelines (Den
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Coding Policies and Guidelines (Den
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Prior Authorization Requirements Co
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Coding Policies and Guidelines (Dur
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Waivers and Upgraded/Deluxe DME Wai
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Hearing Aids (continued) Website Co
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Portable Oxygen Billing (continued)
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DME/Supply Internet Purchases Codin
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Coding Policies and Guidelines (Hom
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Elderly Waiver Program (continued)
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Referrals and Prior Authorization (
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Referrals and Prior Authorization (
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Adult Day Care Bath Services Coding
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Home Infusion (continued) Coding Po
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Coding Policies and Guidelines (Hom
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Rules and Regulations (continued) H
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Hospice Billing for Medicare Produc
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Coding Policies and Guidelines (Hos
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Coding Policies and Guidelines (Lab
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Papanicolaou Smears (continued) Dia
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Coding Policies and Guidelines (Mat
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Coding Policies and Guidelines (Opt
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Coding Policies and Guidelines (Pha
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Drugs Coding Policies and Guideline
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Drug Programs Coding Policies and G
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Coding Policies and Guidelines (Pub
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Coding Policies and Guidelines (Rad
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Physical Therapy Evaluation Codes C
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Hot and Cold Pack Exclusion TMJ Ort
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Massage and Manual Therapy Exclusio
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MHCP PT, OT, ST Authorization Proce
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Bilateral Services (continued) Codi
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Coding Policies and Guidelines (Sur
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Acne Treatment/ Skin Rejuvenation a
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Liposuction Edit Change Coding Poli
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Assistant Surgeons (continued) Assi
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