How do I know if I have BCBSM coverage or if I have coverage under a self-funded health care plan administered by BCBSM?
Many large employers provide health coverage for its’ employees by creating self-funded health care plans. The employers then contract with entities such as insurance companies to administer the self-funded health care plan. BCBSM is an administrator of many self-funded health plans including the health care plans for employees of Ford, Daimler/Chrysler, General Motors and the State of Michigan. The Human Resources Department of your employer can advise you if your coverage is provided under a self-funded health care plan if it is not clear in the coverage information already provided to you. Also, BCBSM can advise you whether your coverage is a self-funded health care plan if you call the customer service staff and provide your group and contract number. OFIS does not have authority over self-funded health care plans created by employers but we have authority over the administrators of such plans.

I have coverage through the Michigan Farm Bureau with BCBSM and have a problem. Can OFIS help me?
If you purchased health coverage through BCBSM as a member of Michigan Farm Bureau and are under age 65, your coverage is provided by BCS Life Insurance Company and not BCBSM. BCBSM does issue its card and administers the claims for these contracts but you do not have coverage with BCBSM. BCS Life Insurance Company is licensed in Michigan and is under the authority of OFIS. If you are over age 65 and have purchased a Medicare Supplement contract through Michigan Farm Bureau, your coverage is provided by BCBSM. OFIS can handle your complaint. (http://www.michigan.gov/documents/cis_ofis_comp_all_25074_7.pdf)

I have coverage through Blue Cross Blue Shield in another state can OFIS help me?
If you have Blue Cross Blue Shield coverage issued through a plan in another state, OFIS does not have authority over the Blue Cross Blue Shield plan in the other state. You should pursue the matter with the state insurance department where the coverage was issued. Link to NAIC page to access other state insurance departments: http://www.naic.org/state_contacts/sid_websites.jsp

I have coverage under the Federal Employee Program that is administered by BCBSM and have a problem. Can OFIS help me?
OFIS does not have authority over the Federal Employee Program. If you have a complaint regarding your coverage under the Federal Employee Program, you should contact the Federal Office of Personnel Management, Office of Insurance Programs at 202-606-0755 to pursue the matter.

I am a subscriber, how do I file a complaint against BCBSM?
OFIS can handle your complaint against BCBSM <http://www.michigan.gov/documents/cis_ofis_comp_all_25074_7.pdf>.

I am a subscriber, how do I file a written grievance with BCBSM?
The internal grievance process of BCBSM should be explained in your coverage documents. The internal grievance process and your appeal options are also explained on the backside of page one of your Explanation of Benefits forms from BCBSM. Further information on the grievance process is available at http://www.michigan.gov/cis/0,1607,7-154-10555_12902_35510_35694---,00.html.

I am a provider dealing with BCBSM, how do I file a complaint?
Participating providers having problems with BCBSM should refer to their contract with BCBSM and follow the appeal options mentioned in the contract. If the problem cannot be resolved and does not involve contractual issues, OFIS may be able to provide assistance. (http://www.michigan.gov/documents/cis_ofis_comp_all_25074_7.pdf).

I’m a health care provider and participate with Blue Cross Blue Shield on either a formal or per case basis. Blue Cross Blue Shield of Michigan (BCBSM) recently audited me. I’m not happy with BCBSM’s findings. What kind of appeal rights do I have?
BCBSM maintains a contract appeals process to handle audit and claim disputes. Information on this appeals process can be found in the provider participation agreement, in the provider manual, or in BCBSM’s publication of the Record.

The first step in the appeals process is to submit a written complaint to BCBSM’s Provider Ombudsman Unit. BCBSM will provide a written explanation to the complaint within 30 days.

If the health care provider does not agree with BCBSM’s explanation, the health care provider may request, in writing, an informal conference to discuss the matters in dispute. This conference needs to be requested within 60 days of receipt of BCBSM’s explanation. BCBSM shall contact the health care provider within 30 days of receipt of the request to schedule such a meeting. At the health care provider’s request, the conference may be held by telephone. BCBSM must provide its proposed resolution and the facts supporting its determination to the health care provider within 10 days, along with a statement explaining the provider’s options to further appeal its decision.

The third step in the appeals process allows the health care provider to choose one of three options for an independent third party determination. The first option is to request binding arbitration. A request for binding arbitration must be sent to BCBSM’s Arbitration Department within 30 days of receipt of BCBSM’s informal conference findings. The second option is to have the dispute decided by any appropriate state or federal court. The third option is to request a review and determination by the Commissioner of Financial and Insurance Services. Requests for a review and determination should be mailed to the Commissioner within 120 days from receipt of BCBSM’s informal conference findings to the following address:

Commissioner of Financial and Insurance Services
C/O Health Plans Division
P. O. Box 30220
Lansing, MI 48909

Depending on the complexity of the complaint, the review and determination will either be conducted through a written review or through scheduling an informal meeting at the Office of Financial and Insurance Services (OFIS). After a determination is issued by OFIS, either the health care provider or BCBSM may ask the Commissioner to hear the matter as a contested case hearing under the Michigan Administrative Procedures Act. A contested case must be requested within 60 days of receipt of OFIS’ determination. Contested case results may be appealed by either party to Ingham County Circuit Court.

How do I find out if a doctor is a participating provider with BCBSM?
BCBSM should be able to advise you if a provider participates or is in your PPO. This information may also be available on the BCBSM website: www.bcbsm.com The provider may be able to advise you of his/her participation status with BCBSM. OFIS cannot advise you on the participation status of a provider.

What happens if I see a doctor or specialist that does not participate with BCBSM?
You should refer to your certificate of coverage. However, most often if the provider or specialist does not participate with BCBSM he/she may not accept the BCBSM payment as payment in full and you may be responsible for the difference in the amount billed by the provider or specialist and the amount paid by BCBSM.

What happens to my BCBSM coverage if I move outside of Michigan?
If you are no longer a Michigan resident and your coverage is not provided under a group plan, BCBSM may require that you transfer your BCBSM coverage to the Blue Cross Blue Shield plan in the state where you are living. Contact BCBSM if you are planning to relocate outside of Michigan.

Does BCBSM sell Medicare Supplemental coverage?
Yes, BCBSM sells both a Medicare Supplement Plan A and Plan C. Further information on Medicare Supplement coverage is available at http://www.michigan.gov/cis/0,1607,7-154-10555_12902_35510_36775---,00.html.

Does BCBSM provide coverage under HIPAA?
BCBSM is the alternative mechanism for individuals in Michigan who no longer have access to group health coverage. BCBSM will write an individual (non-group) policy for Michigan residents if they meet all of the following:

• Must be HIPAA eligible by having at least 18 months of continuous group health coverage
• Have accepted and exhausted all COBRA coverage they are entitled to.
• Most recent coverage was group employment related.
• Cannot have more than a 62-day gap in coverage.

If the above criteria is met and the person provides BCBSM with the certificate of creditable coverage from their last group health plan the 180-day waiting period for pre-existing conditions will be waived. Further information on HIPAA is available at http://www.michigan.gov/cis/0,1607,7-154-10555_12902_35510_35540---,00.html.

• Nonprofit Health Care Corporation Reform Act: Nonprofit Health Care Corporation Reform Act
• Nonprofit Health Care Corporation Reform Act: Diabetes Coverage: BCBSM Diabetes Coverage
• Patient’s Right to Independent Review Act: Patient's Right to Independent Review Act
• BCBSM Web Page - http://www.bcbsm.com/