Web-DENIS and CAREN IVR

Provider Delivered Care Management (PDCM) Eligibility

DeterminationMay 2014

Disclaimer

• The information provided on web-DENIS and CAREN IVR is based on current membership data and finalized claim data and is not a guarantee of payment.

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Web-DENIS-NASCO ExampleWhen the member is not eligible for MiPCT/PDCM

Once you log into web-DENIS, enter the members contract number, select “Med”, select General Practice and click “GO”:

This is what you will see on web-DENIS, under “MESSAGES” when the member is not eligible for PDCM.

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Web-DENIS-NASCO ExampleWhen the member is eligible for MiPCT/PDCM

This is what you will see on web-DENIS when the member is eligible for PDCM.

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Web-DENIS-NASCO ExampleHigh Deductible Health Plan with HSA Reference

When the member is enrolled in a High Deductible Health Plan with an HSA

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Web-DENIS-NASCO ExampleNo High Deductible Health Plan Reference

When the member is not enrolled in a High Deductible Health Plan

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Web-DENIS-MOS ExampleWhen the member is not eligible for MiPCT/PDCM

This is what you will see when you access the member’s medical/surgical benefit on web-Denis through Benefit Explainer and enter any one of the 12 procedure codes payable for PDCM if they are not enrolled in the program.

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Web-DENIS-MOS ExampleWhen the member is eligible for MiPCT/PDCM

This is what you will see when you access the member’s medical/surgical benefit in web-DENIS Explainer and enter any one of the 12 procedure codes payable for PDCM and they are eligible for PDCM.

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Web-DENIS-MOS ExampleHigh Deductible Health Plan with HSA

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Once you determine that any of the PDCM codes are payable, scroll down to “Maximums”, “Dollar Assignment Rules” to determine if the deductible will apply. If it applies like this example, the member has a HDHP with an HSA.

Web-DENIS-MOS Example No High Deductible Health Plan Reference

Once you determine that any of the PDCM codes are payable, scroll down to “Maximums”, “Dollar Assignment Rules” to determine if the deductible will apply. If it does not apply like this example, the member does not have a HDHP with an HSA.

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FEDERAL EMPLOYEE PROGRAM (FEP) HAS OPTED INTO PROVIDER DELIVERED CARE MANAGEMENT (PDCM)

Effective August 1, 2013. These members will NOT be on a patient list; rather, they will be identifiedby their unique identification number. Their identification number will start with “R”.

FEP members who are enrolled in Medicare (A&B or just B) are not eligible for the PDCM program through Blue Cross Blue Shield of Michigan.

FEP Identification Card

• An example of the Member Identification card is below.

CAREN IVR

• CAREN, our automated and interactive voice response telephone system (Call CAREN at 800-344-8525) allows you to check eligibility and benefits.

• Access availability is 24 hours, 7 days a week• You have five choices when calling CAREN:

The mailing address for claim submission Receive a fax of the member’s eligibility and benefits Hear the member’s eligibility and benefits Inquire on another member on the same contract Inquire about another contract

Once you enter/say the members’ information you may say fax or email. You do not have to listen to all the eligibility information.

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CAREN IVRWhen the member is eligible for MiPCT/PDCM

This is what you will see on the CAREN/IVR fax or hear when the member is eligible for PDCM and when the member is enrolled in a High Deductible Health Plan with an HSA.

The member may have Healthy Blue HSA/HRA/FSA or PCA funds available to cover some or all of the subscriber liability.

This member participates in the Provider Delivered Care Management Program (PDCM). PDCM services will be subject to their annual deductible; however, BCBSM will not impose the copayment or coinsurance required under the members contract.

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CAREN IVRWhen the member is eligible for MiPCT/PDCM

This is what you will see on the CAREN/IVR fax or hear when the member is eligible for PDCM.

This member participates in the Provider Delivered Care Management Program (PDCM). PDCM services will not be subject to their annual deductible and BCBSM will not impose the copayment or coinsurance required under the members contract.

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CAREN IVRWhen the member is not eligible for MiPCT/PDCM

You will not see on the fax or hear on the phone:

This member participates in the Provider Delivered Care Management Program (PDCM). PDCM services will not be subject to their annual deductible and BCBSM will not impose the copayment or coinsurance required under the members contract.

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Reference Materials

Access through bcbsm.com:

• CAREN IVR - http://www.bcbsm.com/providers/help/other-resources.html

• Web-DENIS - http://www.bcbsm.com/providers/help/faqs/web-denis-faq.html

Access through web-DENIS directly (requires access):

• CAREN IVR - https://egateway5.bcbsm.com/http://edenis.bcbsm.com:7195/therecord/other_stuff/CAREN_Professional.pdf

• Web-DENIS - https://egateway5.bcbsm.com/http://edenis.bcbsm.com:7195/therecord/provider_training.html 17