Name of Manual - Blue Cross and Blue Shield of Minnesota

Coding Policies and Guidelines (Behavioral Health)
Extended Care and
Halfway House Room
and Board (Medicaid
Government Programs
Only) (continued)
11-92
Blue Plus
Product Name Group Numbers
Blue Advantage –
PMAP
Blue Advantage –
GA/GAMC
Blue Advantage –
MSC+
PP011, PP012, PP014, PP015, PP016,
PP017, PP021, PP022, PP024, PP025,
PP026, PP027, PP031, PP032, PP034,
PP035, PP036, PP037
PP081, PP082, PP084, PP091, PP092, PP094
PP041, PP042, PP044, PP051, PP052,
PP054, PP055, PP056, PP057, PP061,
PP062, PP064, PP071, PP072, PP075,
PP076, PP077
MinnesotaCare PP161, PP162, PP163, PP164, PP121,
PP122, PP131, PP132, PP141, PP142,
PP111, PP112, PP151, PP152
SecureBlue PP200, PP201, PP202, PP210, PP220,
PP221, PP222, PP230, PP240, PP245,
PP250, PP255, PP260, PP261, PP262,
PP270, PP280, PP281, PP282, PP290, PP215
Fax a copy of the completed Rule 25 Assessment and Placement
Summary, available on line at dhs.state.mn.us admitting
diagnosis code for member, admitting physician/provider (if
applicable) and provider’s address.
Fax this information to:
Integrated Health Management-Chemical Dependency
Utilization Management (CD UM) (651) 662-0718.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual 06/19/12