For Providers

Medical Policy Terms & Conditions

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These policies were written to guide MedicareBlue PPO in making coverage determinations and are technical in nature. They are designed to be for reference purposes only and do not guarantee coverage. These policies are used for making coverage determinations for persons with a specific condition. They should not be construed as medical advice. MedicareBlue PPO will consider each enrollee's condition, unique circumstances and the terms of the enrollee's contract when making coverage determinations. MedicareBlue PPO reserves the right to revise, update and/or add to these policies at any time without notice. If enrollees or providers have questions about a policy, they should feel free to contact MedicareBlue PPO.

A list of services for which prior authorization is recommended is provided. The fact that a particular service is not included on this list does not mean that the service is a covered service or benefit. MedicareBlue PPO guarantees payment for prior authorized services if the policy is in force on the date the enrollee receives care, premiums have been paid, lifetime or benefit maximums have not been exceeded, and the procedure that is authorized is the service that is billed by the provider. Deductibles, coinsurance, allowed amount, and copay provisions will continue to apply. For prior authorization forms, see the Forms section of the Provider Guide or contact customer service.

Receipt of benefits is subject to all of the terms and conditions of the enrollee’ Evidence of Coverage. Enrollees should refer to their Evidence of Coverage to review the provisions relating to a specific coverage determination, including exclusions and limitations. Providers should understand their rights and responsibilities under their contract. If there is a conflict between these policies and the contract or plan documents, the contract or plan documents shall govern.

These guidelines in no way imply that enrollees should not receive specific services based on the recommendation of the provider. Providers are responsible for medical advice and treatment of patients. Enrollees with specific health care needs should consult the appropriate health care professional.

This information is not an offer of coverage, solicitation of coverage, summary of benefits or guarantee of coverage. All products and coverage guidelines are subject to applicable laws and regulations. Reimbursement or coverage is subject to all of the applicable terms, conditions, limitations and exclusions of the enrollee's Evidence of Coverage or to the terms and conditions of the applicable provider agreement.

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July 03, 2009

Important Information

This page last updated and accepted by CMS June, 2009.

MedicareBlue PPO is a regional Medicare Advantage Plan with a Medicare contract. MedicareBlue Rx is a regional Medicare Prescription Drug Plan with a Medicare contract. MedicareBlue PPO or MedicareBlue Rx coverage is separately issued by one of the following plans: Wellmark Blue Cross and Blue Shield of Iowa,* Blue Cross and Blue Shield of Minnesota,* Blue Cross and Blue Shield of Montana,* Blue Cross and Blue Shield of Nebraska,* Blue Cross Blue Shield of North Dakota,* Wellmark Blue Cross and Blue Shield of South Dakota,* and Blue Cross Blue Shield of Wyoming.*

*Independent licensees of the Blue Cross and Blue Shield Association.