The Record - for physicians and other health care providers to share with their office staffs
October 2010

Urgent care center network being created

Recent studies show that patients sometimes seek emergency room care for an illness or injury when other settings might be more appropriate and cost-effective.

Blue Cross Blue Shield of Michigan is developing a Traditional urgent care center network to increase access to care, particularly after normal business hours, for the treatment of nonemergent patient conditions.

The creation of an urgent care center network and provider class plan means that:

  • We will designate urgent care centers as a unique provider type.
  • We will formally contract with freestanding, nonhospital-owned and hospital-owned urgent care centers for the Traditional program.
  • We can identify urgent care centers in a provider directory on bcbsm.com and the Blue Cross and Blue Shield Association website.
  • Urgent care centers will be reimbursed for –
    • All medical-surgical codes currently billable in a primary care physician’s office setting
    • The same range of laboratory tests billable in the primary care physician office setting
    • All radiology tests currently billable in the PPO physician office setting, plus four additional codes (related to hip X-rays)

All participating urgent care centers will be considered to be in-network for PPO members, and out-of-network sanctions will be waived.

Billing information
Urgent care centers must bill all services electronically on a CMS-1500 professional claim. Centers will not be reimbursed facility charges.

If a participant wants to conduct business as both a clinic and an urgent care center, BCBSM will need a separate NPI for each provider type. The existing clinic NPI can be changed to represent the urgent care center, but one NPI cannot represent two different provider types.

Urgent care center definition
An urgent care center is a medical setting distinct from a hospital emergency room whose purpose is to diagnose and treat illness or injury for unscheduled, nonroutine, ambulatory patients seeking immediate medical attention for conditions that are not life-threatening. This includes, but is not limited to, nonhospital-owned facilities, facilities that are partially owned by a hospital and facilities that are 100 percent owned by a hospital but not physically attached to the hospital. This does not include primary care physician or specialist office sites offering after-hours, extended hours or weekend care.

This may include facilities that are 100 percent owned by a hospital and physically attached to the hospital, if they elect to participate under the terms and conditions of the agreement for all urgent care services.

If you are interested in joining this network, enrollment materials will be available electronically on bcbsm.com as early as late October.

Creation of the urgent care center network is contingent upon approval by Blue Cross Blue Shield of Michigan’s Board of Directors and filing with the Michigan Office of Financial and Insurance Regulation.

Look for more information in the November Record. We’ll announce the start of the enrollment period on web-DENIS.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2009 American Medical Association. All rights reserved.