You can join our Physician Group Incentive Program as an organized system of care

We encourage our participating network physicians and organized systems of care to get involved in the Physician Group Incentive Program, which has been improving the quality and efficiency of health care in Michigan for more than a decade. Here’s the criteria:

Network primary and specialty care physicians

• Can only join as part of a PGIP physician organization, and must be affiliated with a PGIP physician organization to be a member of an organized system of care
• Should contact a PGIP-participating physician organization directly to discuss specific membership criteria. Here’s a current list of the more than 40 PGIP physician organizations. (Each physician organization has its own criteria for membership. A physician can only be a member of one physician organization for the purposes of PGIP.)

To participate in PGIP, a network physician must:

• Participate in the Blue Cross PPO, TRUST or Traditional lines of business
• Be in good standing with the network
• Be a medical doctor, doctor of osteopathy, doctor of chiropractic or doctor of podiatric medicine. Fully licensed psychologists are also eligible to participate in the program.

If you’re a physician with questions about PGIP, contact your provider consultant at bcbsm.com/providers in the Contact Us section.

OSCs

• Blue Cross will accept applications from new OSCs through April 30, 2018.
• OSCs that apply before the April 30, 2018, deadline will be eligible to participate in PGIP’s new PPO risk program for OSCs starting in 2019. Check out future editions of The Record for more information on the new PPO risk program for OSCs.

If you represent an OSC and would like to join PGIP, send an email to valuepartnerships@bcbsm.com. Want more details? Check out the following webpages.

• Physicians: How to participate in PGIP
• Organized systems of care: Models of Care

To learn more about PGIP, check out our bcbsm.com and valuepartnerships.com websites.

Annual CAHPS^® survey goes out soon

An important measure of patient satisfaction is the annual Consumer Assessment of Healthcare Providers and Systems, or CAHPS, survey. This standardized survey of the patient’s care experience will be sent to a random sampling of our members — your patients — in early March.

Administered by the Centers for Medicare & Medicaid Services, the survey helps assess quality of care from a health plan member’s perspective. The survey measures patient experiences over the past six months in such areas as:

• Getting needed care
• Getting care quickly
• How well doctors communicate
• Health plan customer service
• How people rate their health plan

CAHPS focus areas

Based on results of the 2017 survey, here are three key areas we need to focus on going forward:

• Administering the annual flu vaccine during flu season
• Working to ensure that patients see the doctor or other health care practitioner within 15 minutes of an appointment time
• Sharing test results with patients promptly

 A collaborative effort

At Blue Cross Blue Shield of Michigan, we recognize that your ability to provide a high-quality care experience for your patients depends in part on our performance as a health plan. We’re listening to what you’re saying and are working to increase member and provider satisfaction, with a focus on:

• Helping members understand their health care plan so they’re more knowledgeable when they arrive at the doctor’s office
• Giving you access to the information you need when you need it
• Streamlining our administrative processes so they’re easier and less time-consuming
• Sharing best practices with you through our newsletters, blogs and Physician Group Incentive Program quarterly meetings so you can glean insight from other health care practitioners

Both Blue Cross and providers have a similar goal: highly satisfied patients. Here are some ways that practices with a high level of patient satisfaction benefit:

• Patients who are highly satisfied are more loyal.
• Patients who are highly satisfied are more likely to adhere to treatment plans.
• Practices with high patient satisfaction have higher levels of employee satisfaction and less employee turnover.

Feedback?
If you have any suggestions for how we can improve the patient experience of care, send an email to Laurie Latvis at LLatvis@bcbsm.com.

Battling the opioid epidemic

We’re continuing our efforts to combat the opioid epidemic through an array of initiatives and increased communications about the latest news and research. Check out the items below.

9 organizations receive more than $570,000 in grants to address opioid crisis
Nine community coalitions throughout Michigan will receive a total of $570,400 in funding through the Taking Action on Opioid and Prescription Drug Abuse in Michigan by Supporting Community Responses initiative, courtesy of Blue Cross Blue Shield of Michigan, the Blue Cross Blue Shield of Michigan Foundation, the Michigan Health Endowment Fund, the Community Foundation for Southeast Michigan and the Superior Health Foundation. The partnership provides one-time grants to begin new projects, or to enhance or expand existing projects aimed at reducing opioid and prescription drug abuse and harm. For more details, see the blog on MI Blues Perspectives.

Blue Cross works with policymakers to address epidemic
In late December, Lt. Gov. Brian Calley signed an opioid bill package into law (Public Acts 246-255 of 2017). Among other actions, the new law will increase use of the Michigan Automated Prescription System, limit new prescriptions to a seven-day supply and increase communications efforts for patients who are prescribed an opioid. Blue Cross Blue Shield of Michigan advocated for this legislation, serving on the original task force that recommended the changes. In addition, CEO Dan Loepp issued a public statement in support of the new law.

U of M offers online class on solving the opioid crisis
Based on a request from Blue Cross Blue Shield of Michigan, the University of Michigan is rerunning one of its online “Teach-Out” classes called “Teach-Out: Solving the Opioid Crisis.” Teach-Outs are short online courses that are open to everyone. In this class, experts from the fields of medicine, pharmacy, public health and dentistry will examine the affects of this national epidemic and answer such key questions as: What are opioids? How did we get to the current crisis? How can we recognize opioid abuse and what can we do about it? What makes the crisis so complex? The course opens March 5 and is available for three weeks. For more information and to enroll, click here.

Blue Cross limits supplies of opioid pain relievers
As part of our efforts to prevent opioid abuse, Blue Cross has changed how we manage opioids for our commercial members as follows:

• All fills of opioid pain relievers will be limited to a 30-day supply.
• Initial fills will be limited to a five-day supply for members who haven’t recently filled a prescription for opioid therapy and have been prescribed a short-acting agent.

For more details, see the January Record article.

Five steps to avoid prescription medication abuse in teens
A nationwide survey of eighth-, 10th- and 12th-graders shows that teens perceive less risk in trying prescription drugs like Vicodin and OxyContin than in previous years. As the opioid crisis continues to affect communities across the country, it’s important to keep in mind that changing attitudes toward substance abuse often precedes changes in reported use. We encourage health care providers to remind adult patients receiving any treatment that requires the use of a prescription pain medication to take the following steps to prevent abuse of these medications:

• Discuss the danger of legal prescription drugs misuse and how it compares closely to the use of illegal street drugs.
• Monitor dosage and quantities to ensure all pills are accounted for in the household.
• Keep prescription drugs in a secure location that isn’t readily accessible to teens.
• Dispose of any unused prescriptions at a safe collection site near you.
• Talk with families, friends and neighbors about how teens are misusing prescription drugs and what can be done to prevent teens from becoming victims of drug abuse.

For more details, see the blog on MI Blues Perspectives by Dr. Gary Vance, dental director with Blue Cross Specialty Products.

Tell us what you think about our provider manuals and you could win a prize

We want our provider manuals to be easy for you to use, so you can find the information you need quickly. As part of our continuing effort to improve our communications, we would like your opinion on our provider manuals. Can you spare five minutes to take an online survey? Your input will give us insight into which manuals you use and how we can improve them.

If you complete the online survey by April 30, you could win a $25 gift certificate.

Participation in the survey is not necessary to win. The drawing is open to all active Blue Cross or Blue Care Network providers. Enter by completing the survey no later than April 30, 2018, by sending an e-mail with your name, phone number and “Survey drawing” in the subject line to ProviderOutreach@bcbsm.com by April 30, 2018.

All entries must be received by April 30, 2018. One winner will be selected in a random drawing from among all eligible entries. The winner will receive a $25 gift card. The drawing will take place by May 4, 2018. The winner will be notified by telephone or email following the drawing.

Blue Cross Blue Shield of Michigan and BCN have several provider manuals. Here’s how to find them:

1. Go to bcbsm.com and log in to Provider Secured Services.
2. Click on Provider Manuals (lower right side of page).

You can also click on Provider Manuals within web-DENIS.

Updated Provider Training webpage offers all the learning resources you need

We’ve updated our Provider Training webpage on web-DENIS to make it easier for you to find the help you need online. Here’s what you’ll find when you visit:

• At the top of the page, we list upcoming webinars and registration options.
• On the right, you’ll find our New Provider Guide.
• The Quick Access section offers links to the four main areas on the page:
• Job aids, FAQs, brochures and flyers
• E-learning, including online training, presentations and videos
• Provider event presentations
• User guides
• Featured Links shows some of the top training materials available.

Here’s how to find the Provider Training webpage.

• Go to bcbsm.com and log in to Provider Secured Services.
• Click on BCBSM Provider Publications and Resources on the right side of the page, or click on web-DENIS and then click on BCBSM Provider Publications and Resources.
• Click on Newsletters & Resources.
• Click on Provider Training.

There’s a wealth of information available on this page, including videos that:

• Explain Provider Secured Services
• Offer tips on patient communications and cultural sensitivity
• Describe the e-referral tool

There are also flyers and frequently asked question documents on how to file replacement and void claims; physician assistant re-enrollment; and online health care. User guides are also available for the e-referral tool, along with presentations from provider forums.

If you’re looking for general Blue Cross Blue Shield of Michigan policies, don’t forget to also look in the Blue Cross PPO Provider Manual. From Provider Secured Services or web-DENIS, click on Provider Manuals and then click on Blue Cross PPO Provider Manual.

Changes coming to the way we handle provider audits

Starting June 1, 2018, Blue Cross Blue Shield of Michigan will change how we finalize provider audits.

• We will adjust billing and compliance audit findings at the claim level and at the time of the audit. Disputed claims will be eligible for a one-step internal appeal for reconsideration.
• We will offer a two-step process for medical necessity audits. It will consist of an internal review and independent external review. Adjustments will be done at the claim level and will be taken after the second appeal is complete.
• For all audits, Blue Cross will no longer accept checks or accounts receivable for finalizing the audit.

Look for more information about these changes in future issues of The Record.

Coding corner: Vascular disease

Vascular disease includes conditions involving the blood vessels. Some affect the arteries, such as peripheral vascular disease, while others affect the veins, such as deep vein thrombosis. There are many risk factors for vascular disease, including age, family history, diabetes, high cholesterol, hypertension, smoking, inactivity, injury and obesity.

Here are some important things to consider when coding for vascular disease:

• Has the condition resolved because of surgical intervention or otherwise, and no longer requires any form of treatment?
• Is the condition chronic and does it require ongoing treatment, monitoring or assessment? State the status and management plan.
• Is the vascular disease considered a complication of another chronic condition, such as diabetic angiopathy?
• Are there any complications resulting from the vascular disease, such as gangrene or skin ulcer?
• Is there a reason for long-term anticoagulant therapy, such as chronic deep venous thrombosis or chronic pulmonary embolism?

Peripheral vascular disease

Sometimes referred to as peripheral arterial disease or peripheral angiopathy, PVD is a circulatory condition that affects the arteries resulting in reduced blood flow to the extremities, typically in the legs.

The most common symptom is intermittent claudication, which is pain while walking that resolves after a few minutes of rest. The location of the pain depends on the site of the narrowed or blocked artery.

If you document PVD without further specificity, use ICD-10 code I73.9, PVD, unspecified. This code also includes intermittent claudication, peripheral angiopathy, and spasm of artery.

Documentation of PVD is extremely important in patients with diabetes mellitus as coders can assume the cause-and-effect relationship between the two conditions. See examples below:

• E11.51 Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene
• E10.51 Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene

NOTE: According to the 2016 second quarter AHA Coding Clinic — an official coding source recognized by the Centers for Medicare & Medicaid Services — instructions have been released on the assumed cause-and-effect relationship between diabetes and certain diseases of the kidneys, nerves and circulatory system. The following example shows the ICD-10-CM index format for certain conditions linked to Type 2 diabetes:

Diabetes, diabetic (mellitus)(sugar)
      Type 2 E11.9
          With
              Amyotrophy E11.44                             (Relationship assumed)
              Chronic kidney disease E11.22
              Circulatory complications E11.59
              Peripheral angiopathy E11.51

Within a date of service, if a provider has documented diabetes and peripheral angiopathy — or any condition following ‘with’ in the index — the conditions are assumed to be related even if the doctor doesn’t specifically document the relationship.

Deep Vein Thrombosis - DVT
This condition occurs when the blood thickens and clumps together forming a clot. This can take place within one or more deep veins and is most prevalent within veins of the legs.

Common symptoms of DVT can include pain, redness or discoloration, swelling or warmth of the affected leg. The location of these symptoms depends on the location of the clot.

When coding DVT, acuity of the condition is very important and the physician should reflect it in their documentation:

• Acute DVT refers to a new thrombosis that requires the initiation of anticoagulant therapy
• Chronic DVT is an old or established thrombus that requires long term and sometimes life-long anticoagulation therapy.

It’s important to remember that specific code assignment is based solely on physician documentation. It may be necessary to query the physician for clarification if acuity cannot be determined.

Coding PVD and DVT

To code PVD or DVT to the highest specificity, look for these key components:

• Location of affected artery or vein
• Laterality — left, right or bilateral
• The cause, if known
• Acuity
• Symptoms, including intermittent claudication or rest pain
• Complications such as ulceration or gangrene

Blue Cross and BCN will no longer cover Alvesco^®

To address the high cost of drugs and provide the best value for our members, Blue Cross Blue Shield of Michigan and Blue Care Network commercial plans will no longer cover Alvesco, starting March 1, 2018. Alvesco is a drug used to treat asthma. If members continue to use Alvesco on or after this date, they will be responsible for the full cost.

There are lower-cost prescription alternatives available. The covered alternatives are listed below.

Amerigroup not affiliated with Blue Cross Blue Shield of Michigan or Blue Care Network

If you recently received an invitation from Amerigroup Michigan Inc., an Anthem Inc. company, to participate in Amerigroup’s Medicare Advantage provider network, please note the following:

• While Amerigroup is a subsidiary of Anthem Inc., it does not offer Blue Cross or BCN products or services.
• Amerigroup’s Medicare Advantage offering and provider network aren’t affiliated in any way with Blue Cross, nor are they part of the Blue Cross and Blue Shield Association’s BlueCard Program.
• Amerigroup claims, provider inquiries and member servicing aren’t handled by Blue Cross or BCN.

HCPCS, CPT updates and early release codes

2018 Annual HCPCS maintenance
Medicine/Professional Miscellaneous/Data Gathering Codes

2018 early release CPT* code updates – Category III surgery/cardiovascular system arteries and veins transcatheter procedures and radiology and medicine codes

2018 annual CPT* maintenance – pathology and laboratory proprietary laboratory analysis codes

Billing chart: Blues highlight medical, benefit policy changes

You’ll find the latest information about procedure codes and Blue Cross Blue Shield of Michigan billing guidelines in the following chart.

This billing chart is organized numerically by procedure code. Newly approved procedures will appear under the New Payable Procedures heading. Procedures for which we have changed a billing guideline or added a new payable group will appear under Updates to Payable Procedures. Procedures for which we are clarifying our guidelines will appear under Policy Clarifications. New procedures that are not covered will appear under Experimental Procedures.

You will also see that descriptions for the codes are no longer included. This is a result of recent negotiations with the AMA on use of the codes.

We will publish information about new BCBS groups or changes to group benefits under the Group Benefit Changes heading.

For more detailed descriptions of the BCBSM policies for these procedures, please check under the Medical/Payment Policy tab in Explainer on web-DENIS. To access this online information:

• Log in to web-DENIS.
• Click on BCBSM Provider Publications & Resources.
• Click on Benefit Policy for a Code.
• Click on Topic.
• Under Topic Criteria, click on the drop-down arrow next to Choose Identifier Type and then click on HCPCS Code.
• Enter the procedure code.
• Click on Finish.
• Click on Search.

Blue Cross and BCN changing professional provider consultant model

Blue Cross Blue Shield of Michigan and Blue Care Network will be changing the way we assign our professional provider consultants in the next few months. Our new professional consultant model will have fewer office visits. However, it will maintain our commitment to serving the provider community with continued education, provider forums, online tools and telephone support. Watch for more information in upcoming issues of BCN Provider News and The Record.

As a reminder, we told you back in June you can obtain claims information 24 hours per day through our automated telephone system. In September, we gave you tips for navigating through the automated phone system. Here are the key phone numbers to call:

Provider forums coming to a town near you

As you read this article, we’re planning and scheduling the next set of Blue Cross Blue Shield of Michigan and Blue Care Network provider forums. As we work through the details, be sure to check next month’s issue of The Record for dates, times, registration information and topics.

This year, the morning sessions will have content specifically geared toward physician office staff who are responsible for closing quality measures and coding gaps. These sessions will also look at the overall patient experience. Topics will include:

• Patient experience
• Coding and documentation
• HEDIS^® measures

Afternoon sessions will be suited toward all office personnel and will cover topics like:

• New provider service model
• eviCore and prior authorizations
• eReferral
• The opioid epidemic
• Behavioral Health
• Updates for Provider Enrollment and Data Management and PARS (provider automated response system)

These forums are well received and provide valuable information to keep your staff up to date on the latest information. If you haven’t been to one yet be sure to check your April issue of The Record and plan to attend. We look forward to seeing you.

Caution: Antibiotics don’t cure viruses

Antibiotic resistance is a growing problem, both in the United States and across the world. The driving factors behind antibiotic resistance are their overuse and misuse.

Antibiotics can’t treat viruses and are therefore inappropriate for viral infections. However, there are times when patients may have a compromising comorbid condition or a competing bacterial diagnosis. In situations like these, an antibiotic is appropriate and necessary.

In the outpatient setting, at least 30% of antibiotic courses prescribed are unnecessary, according to the Centers for Disease Control and Prevention. Most of this unnecessary use is for acute respiratory conditions such as colds, bronchitis, sore throats caused by viruses and even some sinus and ear infections. Prescribing antibiotics for these conditions put patients at risk for harmful side effects and antibiotic resistant infections. It’s important to only order antibiotics for bacterial infections.

The CDC also estimates that nearly 50 percent of all outpatient antibiotic use is inappropriate. This includes unnecessary use plus inappropriate selection, dosing and duration.

Doctors should prescribe antibiotics only when needed, striving to use the right drug at the right dose and for the right amount of time.

For more information, visit cdc.gov/getsmart/index.html**.

**Blue Cross does not control the content of this website.

6 drugs added to commercial PPO 15-Day Specialty Drug Limitation Program

To match Blue Care Network’s HMO program, Blue Cross Blue Shield of Michigan’s commercial PPOs are adding six medications to its 15-Day Specialty Drug Limitation Program.

Starting April 1, 2018, instead of a 30-day supply, we’ll limit all fills of these drugs to a 15-day supply per fill. This includes first fills and refills. Members pay half of their copayment for a 15-day supply.

Blue Cross limits the day-supply quantity of a medication that a pharmacy can dispense to:

• Help save members money on copayments
• Reduce drug waste

We’ll add more drugs to the 15-day program throughout the year. The full list, including the six new drugs, follows:

There’s no change to the BCN commercial HMO 15-Day Specialty Drug Limitation Program. Its full drug list for 2018 follows:

The 15-Day Specialty Drug Limitation Program doesn’t apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

FEP programs help members manage chronic conditions

The Blue Cross and Blue Shield Federal Employee Program^® offers initiatives that encourage members with diabetes or high blood pressure to make healthier choices that can reduce complications related to the disease.

To manage high blood pressure

The Hypertension Management Program provides eligible members 18 and older with a free blood pressure monitor through CVS Caremark^®. Members are automatically enrolled in the program following three qualifications:

• They complete the FEP Blue Health Assessment.
• Members report a diagnosis of high blood pressure.
• At least one medical claim has been processed during the past 12 months with a diagnosis of hypertension.

To manage diabetes

The Diabetes Management Incentive Program is designed to encourage members to achieve and maintain control of their blood sugar and help manage or slow the progression of complications related to diabetes. Through this program, eligible members can earn a maximum of $100 toward a health account to be used for most qualified medical expenses.

The Diabetes Meter Program allows members with diabetes to receive, at no cost, one glucometer kit each calendar year. Members will still need to obtain a prescription for test strips and lancets for the new meter from their doctor.

FEP members

Members with hypertension or diabetes are encouraged to participate in these programs. They are voluntary, free and confidential. The self-monitoring tools provided by these programs support members’ efforts to manage their chronic conditions.

For more information about these and other health care programs, contact FEP Customer Service at 1-800-482-3600 or visit fepblue.org.

Direct reimbursement available to eligible therapists and psychologists, beginning June 1

Limited licensed psychologists and licensed marriage and family therapists will have the opportunity to participate in Blue Cross Blue Shield of Michigan’s Traditional network, starting June 1, 2018. Participating LLPs and LMFTs will receive direct reimbursement for covered mental health services within the scope of their licensure.

Covered mental health services within the LLP and LMFT scope of licensure will be reimbursed at 80 percent of the Traditional practitioner fee schedule, less any member deductibles and copayments.

This change affects Blue Cross benefit plans that cover mental health services that LLPs and LMFTs are licensed to provide.

Note: Not all plans will cover LLP and LMFT services, or services billed directly by an LLP or LMFT. To find out if a patient has coverage, check web-DENIS for member benefits and eligibility, or call CAREN at 1-800-344-8525.

If an LLP or LMFT registers as a nonparticipating provider for Traditional plans, we’ll send payment for covered services to the member.

Starting in March, LLPs and LMFTs can find the Traditional practitioner agreements and enrollment forms on bcbsm.com. Click on Providers, then Join the Blues Network and Enrollment and Changes to find enrollment information. Specific qualification requirements are identified within each agreement. Qualified LLPs and LMFTs may apply for a Blue Cross provider identification number by completing the enrollment applications available on the same web section.

For more information, please contact Provider Inquiry or your Blue Cross provider consultant.

Reimbursement policy update coming in behavioral health

Beginning June 1, Blue Cross will update our reimbursement policy for services billed by supervising providers of limited license behavioral health providers.

Services rendered by a Limited Licensed Professional Counselor (LLPC), Limited Licensed Master Social Worker (LLMSW), Temporary Limited Licensed Psychologist (TLLP), and Limited Licensed Marriage & Family Therapist (LLMFT) and billed by the supervising MD, DO, or Fully Licensed Psychologist, should include the appropriate modifier to identify the level of the rendering provider. Modifiers HO and AJ are required on the claim for proper reimbursement (see chart below).

Payable services billed with the appropriate modifier will be processed for reimbursement at 80% of the Traditional Fee Schedule (minus applicable member copay).

Per the Centers for Medicare & Medicaid Services, to qualify as “incident to,” services must be part of your patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment.

Blue Cross defines direct supervision (which is required for “incident to” billing) as services rendered in the office setting with the physician present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure.

For more information about billing for services, see your online provider manuals.

Starting April 2, 2018, non-emergency air ambulance services require authorization for commercial members

Effective for dates of service on or after April 2, 2018, all non-emergency air ambulance transports for Blue Cross Blue Shield of Michigan commercial PPO and Blue Care Network HMO^SM commercial members require authorization. Requests for authorization must be submitted to and approved by Alacura Medical Transportation Management LLC before the flight.

Alacura, an independent company working with Blue Cross and BCN, will use the Blue Cross and BCN medical policy titled Air Ambulance Services to determine the appropriateness of non-emergency flights.

Blue Cross defines non-emergency, or non-emergent, as services in which the ordering physician has determined and attested that the patient’s condition is such that transport may safely wait at least six hours from the time the service is requested.

There are no changes to member benefits related to air ambulance services. Non-emergency air ambulance services are eligible for reimbursement if the member has the benefit and if Alacura authorizes the flight.

How to request an authorization

To contact Alacura for a non-emergency flight request, call 844-608-3676. This requirement applies to both in-state and out-of-state air ambulance transports. If you’re required to submit documentation, fax it to Alacura at 844-608-3572.

Reason for this change

Air ambulance transports that aren’t medically necessary or that are flown by noncontracted providers expose Blue Cross and BCN members to significantly greater out-of-pocket costs and are much costlier for the plan. The requirement for authorization before non-emergency flights is expected to lower costs for Blue Cross and BCN members and customers.

Billing air ambulance claims

Instructions for billing emergency and non-emergency air ambulance services for dates of service on or after Jan. 1, 2017, are available.

These instructions apply to both Blue Cross and BCN air ambulance claims. The Blue Cross PPO and BCN provider manuals are being updated with links to this document.

To obtain the instructions, complete the following steps:

1. Visit bcbsm.com/providers.
2. Click Login.
3. Log in to Provider Secured Services.
4. Click BCN Provider Publications and Resources.
5. Click Billing/Claims.
6. Click Air ambulance services.

The instructions document is also available on the BCBSM Provider Publications and Resources page titled Clinical criteria and other resources. Look under the Clinical criteria heading.

In line with standard Blue Cross and BCN claims auditing policies, all air ambulance claims are subject to post-payment audit, to ensure the appropriateness of claims payment.

Reminder: Blue Cross’ concierge medicine policy

We would like to remind heath care providers who want to use a concierge medicine model in their practices that they must ensure that its requirements are permitted by their affiliation agreements with Blue Cross Blue Shield of Michigan.

In a concierge, or retainer, practice, patients pay membership fees to a health care provider or third-party vendor for enhanced services or amenities. As a benefit of paying this fee, members typically receive:

• Easy appointment access
• Extended office visits
• Enhanced email and telephone communication with doctors
• Care coordination (including referrals) between the concierge practice and specialists
• Wellness programs and plans, genetic and nutritional counseling, and risk appraisals

Providers may charge a concierge fee if:

• Patients aren’t required to pay the concierge fee to become or continue to be a patient in the practice.
• Patients aren’t required to pay the concierge fee to obtain access to the provider. Patients are only permitted access to ancillary providers (such as physician assistants or nurse practitioners) if they don’t pay the concierge fee.
• The services or products being offered as part of the concierge fee aren’t considered covered services under our affiliation agreements, but instead aren’t covered under a member’s benefit plan. Because benefit structures vary significantly among our members, providers are expected to understand each member’s benefit structure to ensure that covered services aren’t included in the concierge fee.
• Patients who don’t pay the concierge fee continue to receive the same level of access and services as they previously received.
• Providers continue to meet Blue Cross and Blue Care Network performance standards regarding access and service.
• The concierge level of service is clearly over and above usual practice in Michigan. Complaints from members who experience a decline in service level may result in Blue Cross concluding that the practice is noncompliant with the nondiscrimination clause of our affiliation agreements.

If you have any questions about the concierge medicine policy or need clarification, contact your provider consultant.

Chorionic Gonadotropin and Novarel^® changing tiers on March 1; cost-effective alternative available

Blue Cross Blue Shield of Michigan and Blue Care Network are moving Chorionic Gonadotropin and Novarel to the nonpreferred tier of all HMO and PPO drug lists; this change will be effective on March 1. Instead of taking Gonadotropin and Novarel, Blue Cross and BCN members can save money by switching to the lower cost alternative, Pregnyl^®.

Patients who are prescribed Gonadotropin and Novarel after March 1 will have to pay a higher copayment and these drugs may not be covered for members with a 3-tier closed-benefit plan.

Here is an overview of where these drugs sit within our various pharmacy plans:

We’ve sent letters to affected Blue Cross and BCN members, notifying them of this change and encouraging them to contact their physicians to discuss switching to the lower-cost alternative. This change does not apply to BCN Advantage or Blue Cross Medicare Part D members.

All of our drugs lists can be found online at bcbsm.com.

Blue Cross, BCN no longer covering hyaluronic acids, starting April 1

To give the best value to our members, Blue Cross Blue Shield of Michigan and Blue Care Network commercial plans won’t cover hyaluronic acids starting on April 1, 2018.** Blue Cross and BCN will continue to cover first-line alternative therapies based on guideline recommendations for treatment of pain in knee osteoarthritis. To get information on the types of covered drug therapy for pain management, refer to our approved drug list.

If you’ve prescribed hyaluronic acid therapy, be sure to complete all regimens by March 31, 2018. Starting April 1, 2018, we won’t cover these injections:

About hyaluronic acids
Hyaluronic acids, also known as viscosupplements, are used to treat osteoarthritis of the knee. A large body of evidence from randomized controlled trials and national guidelines have examined the effect of hyaluronic acids on pain and function. The data shows that there’s insufficient evidence of hyaluronic acid therapy improving the net health outcome in patients with knee osteoarthritis due to:

• A lack of defined meaningful clinical improvements over placebo
• Well-characterized biases among trials
• Publication bias
• Missing study results

**These changes don’t apply to Medicare, Medicaid and Federal Employee Program members.

Prevent unnecessary delays: Include key information for oncology pharmacy prior authorization drug requests

Help deliver effective therapy to your patients and ensure proper use of medications by providing key information with your oncology pharmacy prior authorization drug requests.

Prevent oncology medication claim processing delays
Send all oncology pharmacy prior authorization drug requests with:

• Recent chart notes
• Diagnosis
• Documentation of trials and failures of alternatives

If you don’t include chart notes with your oncology pharmacy prior authorization drug requests, your request may be denied. Chart notes are:

• Useful for verifying dosing regimens and patient usage
• Required if a patient continues therapy that began in a hospital setting
• Especially important for cancer patients on chemotherapy

Documentation of diagnosis, as well as trials and failures of alternatives ensure that you’re following the most up to date oncology prescribing guidelines.

For more information about our utilization management criteria for oncology medications, visit the Prior Authorization and Step Therapy Guidelines web pages for Blue Cross Blue Shield of Michigan PPO or Blue Care Network HMO plans.

Most immune globulin infusions will not be covered at outpatient hospital facilities starting April 1, 2018

Beginning April 1, 2018, Blue Cross Blue Shield of Michigan will require prior authorization for members who seek infusions or are currently receiving infusions in a hospital outpatient facility for select immune globulin medical drugs prior to being administered. Members must receive their infusions in a professional office setting, a professional infusion center or in the member’s home.

All drugs included in this program already require prior authorization for payment. Approved authorizations will be payable at professional settings and through home infusion with no further action required.

If your patient currently receives IVIG infusions at a hospital outpatient facility:

• Submit a prior approval request for your patient to Blue Cross for a hospital outpatient facility. If this request isn’t submitted and approved, the patient will be responsible for the full cost of the medicine.
• Check the directory of participating home infusion therapy providers and infusion centers where your patient may be able to continue infusion therapy.
• Tell your patient to contact any of the listed infusion therapy providers. If they’re able to accommodate your patient, they will work with your patient and you to make this change easy. We’re also sending this information to your patient.
• Help your patient switch infusion therapy to your office, infusion center or home infusion therapy provider by April 1.

For the ordering provider:
If a member must receive IVIG infusion in a hospital outpatient facility, please follow the normal steps for a prior authorization request and include:

• The authorization number previously approved
• Rationale that clearly describes the reason the infusion must be administered in a hospital setting
• Supporting chart notes

The IVIG drugs subject to this requirement include:

Note: A new authorization is not required when a member changes to a different IVIG product and an active prior authorization is already approved for the location where the infusion will be administered.

For more information about hospital outpatient infusion therapy, view the previous articles in the October and December issues of The Record.

Guidelines for timely member access to health care professionals

Blue Cross has established guidelines to ensure members have appropriate and timely access to their health care providers; we’ll conduct annual provider surveys to assess compliance with these quality indicators.

Primary care

• Regular and routine care – within 30 business days of member request
• Urgent care – within 48 hours of member request
• After-hours care – 24 hours a day, seven days a week through at least one of the following methods:

• Answering service (with live operator rather than a messaging system)
• On-call pager (call must be returned within 30 minutes)
• Call forwarding to a number where the covering practitioner can be reached
• Recorded telephone message that directs member to a physician for after-hours care

Behavioral health care

• Not life-threatening emergency – within six hours of member request
• Urgent care – within 48 hours of member request
• Initial visit for routine care – within 10 business days of member request
• Follow-up routine care – within 30 days of member request

Specialty care

• High-volume specialist: Obstetrician-gynecologist
• Regular and routine care – within 30 business days of member request
• Urgent care – within 48 hours of member request
  
  
• High-impact specialist: Oncology
• Regular and routine care – within 30 business days of member request
• Urgent care – within 48 hours of member request
  

For more detailed information, see the Access Standards in the PPO Policies chapter of your provider manual on web-DENIS, or contact your provider consultant.

Reminder: Procedure codes G0422 and G0423 are experimental for all groups, except FEP

Blue Cross Blue Shield of Michigan considers procedure codes G0422 and G0423 for intensive cardiac rehabilitation experimental for all groups, except Federal Employee Program^®. Our medical policy has been updated to show there is insufficient evidence in the medical literature that it improves clinical outcomes over standard cardiac rehabilitation programs.

Most immune globulin infusions will not be covered at outpatient hospital facilities starting April 1, 2018

Beginning April 1, 2018, Blue Cross Blue Shield of Michigan will require prior authorization for members who seek infusions or are currently receiving infusions in a hospital outpatient facility for select immune globulin medical drugs prior to being administered. Members must receive their infusions in a professional office setting, a professional infusion center or in the member’s home.

All drugs included in this program already require prior authorization for payment. Approved authorizations will be payable at professional settings and through home infusion with no further action required.

If your patient currently receives IVIG infusions at a hospital outpatient facility:

• Submit a prior approval request for your patient to Blue Cross for a hospital outpatient facility. If this request isn’t submitted and approved, the patient will be responsible for the full cost of the medicine.
• Check the directory of participating home infusion therapy providers and infusion centers where your patient may be able to continue infusion therapy.
• Tell your patient to contact any of the listed infusion therapy providers. If they’re able to accommodate your patient, they will work with your patient and you to make this change easy. We’re also sending this information to your patient.
• Help your patient switch infusion therapy to your office, infusion center or home infusion therapy provider by April 1.

For the ordering provider:
If a member must receive IVIG infusion in a hospital outpatient facility, please follow the normal steps for a prior authorization request and include:

• The authorization number previously approved
• Rationale that clearly describes the reason the infusion must be administered in a hospital setting
• Supporting chart notes

The IVIG drugs subject to this requirement include:

Note: A new authorization is not required when a member changes to a different IVIG product and an active prior authorization is already approved for the location where the infusion will be administered.

For more information about hospital outpatient infusion therapy, view the previous articles in the October and December issues of The Record.

Guidelines for timely member access to health care professionals

Blue Cross has established guidelines to ensure members have appropriate and timely access to their health care providers; we’ll conduct annual provider surveys to assess compliance with these quality indicators.

Primary care

• Regular and routine care – within 30 business days of member request
• Urgent care – within 48 hours of member request
• After-hours care – 24 hours a day, seven days a week through at least one of the following methods:

• Answering service (with live operator rather than a messaging system)
• On-call pager (call must be returned within 30 minutes)
• Call forwarding to a number where the covering practitioner can be reached
• Recorded telephone message that directs member to a physician for after-hours care

Behavioral health care

• Not life-threatening emergency – within six hours of member request
• Urgent care – within 48 hours of member request
• Initial visit for routine care – within 10 business days of member request
• Follow-up routine care – within 30 days of member request

Specialty care

• High-volume specialist: Obstetrician-gynecologist
• Regular and routine care – within 30 business days of member request
• Urgent care – within 48 hours of member request
  
  
• High-impact specialist: Oncology
• Regular and routine care – within 30 business days of member request
• Urgent care – within 48 hours of member request
  

For more detailed information, see the Access Standards in the PPO Policies chapter of your provider manual on web-DENIS, or contact your provider consultant.

Reminder: Procedure codes G0422 and G0423 are experimental for all groups, except FEP

Blue Cross Blue Shield of Michigan considers procedure codes G0422 and G0423 for intensive cardiac rehabilitation experimental for all groups, except Federal Employee Program^®. Our medical policy has been updated to show there is insufficient evidence in the medical literature that it improves clinical outcomes over standard cardiac rehabilitation programs.

6 drugs added to commercial PPO 15-Day Specialty Drug Limitation Program

To match Blue Care Network’s HMO program, Blue Cross Blue Shield of Michigan’s commercial PPOs are adding six medications to its 15-Day Specialty Drug Limitation Program.

Starting April 1, 2018, instead of a 30-day supply, we’ll limit all fills of these drugs to a 15-day supply per fill. This includes first fills and refills. Members pay half of their copayment for a 15-day supply.

Blue Cross limits the day-supply quantity of a medication that a pharmacy can dispense to:

• Help save members money on copayments
• Reduce drug waste

We’ll add more drugs to the 15-day program throughout the year. The full list, including the six new drugs, follows:

There’s no change to the BCN commercial HMO 15-Day Specialty Drug Limitation Program. Its full drug list for 2018 follows:

The 15-Day Specialty Drug Limitation Program doesn’t apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

Chorionic Gonadotropin and Novarel^® changing tiers on March 1; cost-effective alternative available

Blue Cross Blue Shield of Michigan and Blue Care Network are moving Chorionic Gonadotropin and Novarel to the nonpreferred tier of all HMO and PPO drug lists; this change will be effective on March 1. Instead of taking Gonadotropin and Novarel, Blue Cross and BCN members can save money by switching to the lower cost alternative, Pregnyl^®.

Patients who are prescribed Gonadotropin and Novarel after March 1 will have to pay a higher copayment and these drugs may not be covered for members with a 3-tier closed-benefit plan.

Here is an overview of where these drugs sit within our various pharmacy plans:

We’ve sent letters to affected Blue Cross and BCN members, notifying them of this change and encouraging them to contact their physicians to discuss switching to the lower-cost alternative. This change does not apply to BCN Advantage or Blue Cross Medicare Part D members.

All of our drugs lists can be found online at bcbsm.com.

Blue Cross, BCN no longer covering hyaluronic acids, starting April 1

To give the best value to our members, Blue Cross Blue Shield of Michigan and Blue Care Network commercial plans won’t cover hyaluronic acids starting on April 1, 2018.** Blue Cross and BCN will continue to cover first-line alternative therapies based on guideline recommendations for treatment of pain in knee osteoarthritis. To get information on the types of covered drug therapy for pain management, refer to our approved drug list.

If you’ve prescribed hyaluronic acid therapy, be sure to complete all regimens by March 31, 2018. Starting April 1, 2018, we won’t cover these injections:

About hyaluronic acids
Hyaluronic acids, also known as viscosupplements, are used to treat osteoarthritis of the knee. A large body of evidence from randomized controlled trials and national guidelines have examined the effect of hyaluronic acids on pain and function. The data shows that there’s insufficient evidence of hyaluronic acid therapy improving the net health outcome in patients with knee osteoarthritis due to:

• A lack of defined meaningful clinical improvements over placebo
• Well-characterized biases among trials
• Publication bias
• Missing study results

**These changes don’t apply to Medicare, Medicaid and Federal Employee Program members.

Prevent unnecessary delays: Include key information for oncology pharmacy prior authorization drug requests

Help deliver effective therapy to your patients and ensure proper use of medications by providing key information with your oncology pharmacy prior authorization drug requests.

Prevent oncology medication claim processing delays
Send all oncology pharmacy prior authorization drug requests with:

• Recent chart notes
• Diagnosis
• Documentation of trials and failures of alternatives

If you don’t include chart notes with your oncology pharmacy prior authorization drug requests, your request may be denied. Chart notes are:

• Useful for verifying dosing regimens and patient usage
• Required if a patient continues therapy that began in a hospital setting
• Especially important for cancer patients on chemotherapy

Documentation of diagnosis, as well as trials and failures of alternatives ensure that you’re following the most up to date oncology prescribing guidelines.

For more information about our utilization management criteria for oncology medications, visit the Prior Authorization and Step Therapy Guidelines web pages for Blue Cross Blue Shield of Michigan PPO or Blue Care Network HMO plans.