Web-DENIS and CAREN IVR
Provider Delivered Care
Management (PDCM) Eligibility
Determination
May 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 Example
When 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 Example
When 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 Example
High 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 Example
No High Deductible Health Plan Reference
When the member is not enrolled in a High Deductible Health Plan
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Web-DENIS-MOS Example
When 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 Example
When 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 Example
High Deductible Health Plan with HSA
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.
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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 IVR
When 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 IVR
When 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 IVR
When 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-denisfaq.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
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