Statin therapy important for patients with cardiovascular disease and diabetes

The Centers for Disease Control and Prevention estimates that adults with diabetes are 1.7 times more likely to die from cardiovascular disease than adults without diabetes. Additionally, almost two out of five people with diabetes who could benefit from statin therapy to lower their risk of future heart attack, stroke and related death weren’t prescribed one, according to the Journal of the American College of Cardiology.

The Centers for Medicare & Medicaid Services focuses three of its star measures on the use of statin therapy, highlighting its importance.

Review the measures described below and consider prescribing statins for your patients diagnosed with atherosclerotic cardiovascular disease and diabetes.

To learn more about statin therapy and why it’s important for people with cardiovascular disease, read our July 2018 article.

Changes to the PGIP allocation will support Organized Systems of Care efforts

Using the same approach that has created the largest Patient-Centered Medical Home program in the country, Blue Cross is focused on helping organized systems of care (or OSCs) build infrastructure and integrated care processes. The goal is that by doing this, these systems can offer more efficient, coordinated care to the population of patients they serve. From the beginning, the Physician Group Incentive Program’s long-term goal has been to encourage primary care doctors, specialists, hospitals and other providers to create high-functioning, comprehensive OSCs, and to support them in their efforts.

As we announced in the April 2018 issue of The Record, the PGIP allocation increased from 5 to 7 percent of the allowed amount in July 2018 to help fund the new PGIP OSC initiatives.

Blue Cross is now taking the next step in its journey by creating the 2019 PGIP Risk-Bearing OSC Program. Starting Jan. 1, 2019, the 7 percent PGIP allocation will be directed as follows:

• Blue Cross will direct 2 percent to fund the 2019 PGIP Risk-Bearing OSC program. This new program rewards OSCs for managing the benefit cost trend of their attributed Blue Cross PPO patient population and is the first step in our pathway to risk strategy.
• The remaining 5 percent will continue to reward eligible POs and OSCs for improving the quality of patient care, system and practice transformation, and reducing costs.

In addition, the PGIP allocation will apply to most professional procedure codes regardless of the billed provider charge effective Jan. 1, 2019.

Providers contractually agree in their participation agreements to allocate a portion of their reimbursement to the PGIP fund. All funds allocated are distributed to physician organizations and OSCs that participate in PGIP to support physician practice and system transformation. No money is retained by Blue Cross for administrative costs.

For more information about PGIP, go to bcbsm.com/provider/value_partnerships/pgip.

Note: Claims for Federal Employee Program^® members are excluded from the PGIP allocation.

ICD-10-CM and PCS 2019 code updates are now available

The 2019 code updates for ICD-10-CM and ICD-10-PCS codes are now available on the Centers for Medicare & Medicaid Services website. These codes will be effective with dates of service on and after Oct. 1, 2018.

This year’s updates include 671 new diagnosis and inpatient procedure codes being added, 151 code revisions and 267 codes deleted.

To check for the code updates go to the CMS website.

Coding Corner: Myocardial infarction

It’s estimated that 1.5 million people are affected by a myocardial infarction (or MI) every year in the United States. Updates to the 2018 ICD-10-CM now require MI to be coded by type. MI codes have now been expanded to reflect clinical classifications, as defined by the Task Force for the Universal Definition of Myocardial Infarction.

The five types of MI classifications and corresponding codes:

• Type 1 Acute myocardial infarction (AMI) represented by codes from I21.0-I21.4, is spontaneous myocardial necrosis caused by a blockage of blood flow in the heart for a prolonged period. This most frequently occurs due to a plaque rupture or thrombotic occlusion.
• Myocardial infarction type 2 is represented by code I21.A1, pertains to a demand ischemia or ischemic imbalance that is “supply-demand mismatch”, an imbalance between oxygen demand and supply (e.g., coronary spasm, anemia or hypotension). Since a type 2 MI is always caused by an underlying condition or disease process a “code also” note is included, instructing you to code this condition as well, if it’s known and applicable.
• Types 3-5, represented by code I21.A9, generally apply to an MI associated with a revascularization procedure and are all “other myocardial infarction type.” They are described as follows:
• Type 3 - MI that results in sudden cardiac death (when biomarker values are unavailable)
• Type 4a - MI associated with percutaneous coronary intervention (PCI)
• Type 4b - MI associated with stent thrombosis
• Type 4c - MI due to restenosis > 50% after an initially successful PCI
• Type 5 - MI related to coronary artery bypass graft (CABG)

Clarification related to coding these new classifications (1-5) of MI can be found in ICD-10-CM guideline I.C.9.e, Acute Myocardial Infarction (AMI). Subsequently, you’ll find the official guidelines we were accustomed to using now only apply to a type 1 MI.

The guideline includes the following directions for coding MI:

• Don’t assign code I22 for subsequent myocardial infarctions other than type 1 or unspecified
• For subsequent type 2 AMI assign only code I21.A1
• For subsequent type 4 or type 5 AMI, assign only code I21.A9

Specificity within provider documentation is essential when choosing the correct MI code to represent the patient’s condition. Only when the documentation doesn’t specify the type of MI, the code I21.9, Acute myocardial infarction, unspecified, should be assigned. If further clarification is needed on a patient’s condition the physician should be queried.

Some important points when coding an MI:

• AMI described as acute or with duration of 4 weeks (28 days) or less, is classified and coded as an acute myocardial infarction.
• For encounters after the four week time frame, with the patient still receiving care related to the myocardial infarction, the appropriate aftercare code should be assigned, not a code from category I21.
• If an AMI is documented as non-transmural or subendocardial, but the site is provided, it’s still coded as a subendocardial AMI.
• For old or healed myocardial infarctions not requiring further care, code I25.2, old myocardial infarction, may be assigned.**
• Old myocardial infarction is a history code and should be reported to identify a “healed or old MI” whether the patient is currently experiencing problems or not. This history code for a myocardial infarction is significant because an old, or “healed” MI, typically requires ongoing monitoring to address any long-term complications or new symptoms that can arise as a result of the damage caused by the myocardial infarction.

**Important-The note under the code I25.2 mentioning “currently presenting no symptoms” refers to symptoms specifically related to the old/healed MI, not cardiac symptoms in general (AHA Coding Clinic for ICD Detail; Year: 2003; Second Quarter).

Remind your patients about the importance of getting a flu vaccine

Most people who get the flu will experience a mild illness but won’t need medical care or antiviral drugs and will recover in less than two weeks. Some people, however, with chronic conditions such as asthma and congestive heart failure can experience complications leading to pneumonia or bronchitis that can result in hospitalization and sometimes death.

The Centers for Disease Control and Prevention recommends a three-step approach to fighting the flu:

1. The flu vaccine is the first and most important step in protecting against flu viruses. The vaccine protects against the viruses that research indicates will be most common.
2. Everyday preventative actions include avoiding close contact with sick people, covering your nose and mouth when you cough or sneeze and washing your hands often with soap and water.
3. Antiviral drugs may be prescribed to treat the flu and shorten sick time. They work best when started in the first two days of symptoms.

If patients become sick with the flu, they should stay home and avoid contact with other people, except to seek medical care.

While you should encourage patients to call you with any concerns, most people can recover at home without medical care. During flu season, people should keep physician recommended over-the-counter medicines, alcohol-based hand rubs and tissues in their home.

Remind Medicare Advantage members to get mammograms every two years

Breast cancer is one of the most common cancers among women in the U.S., according to the American Cancer Society. Yet 20 percent of female Medicare Plus Blue PPO members ages 50 to 74 haven’t had a mammogram in two years.

It’s important to remind your patients to have this preventive service done, and guide them through the procedure.

Recommended care

The HEDIS^® measure breast cancer screening is also used by the Centers for Medicare & Medicaid Services as a star rating measure to drive improvements in patient health.

Per CMS and HEDIS guidelines, routine mammograms are recommended every 24 months for women ages 50 to 74.

Communicating with patients

• Provide patients with a prescription for a mammogram and phone number to a local imaging center.
• Follow-up with patients to make certain they completed their screenings.
• Patients who have had bilateral mastectomies are excluded from the breast cancer screening measure.
• When you submit an office visit claim for patients with exclusions, please include the following ICD–10–CM diagnosis codes as appropriate:
• Z90.13 — Acquired absence of bilateral breasts and nipples
• Z90.12 — Acquired absence of left breast and nipple
• Z90.11 — Acquired absence of right breast and nipple
• Document completed mammogram date and exclusion criteria in the medical record.
• Send all eligible women a reminder card with information about the importance of routine mammograms and stress that it’s a covered preventive screening.

3D mammograms

Blue Cross Blue Shield of Michigan will now cover digital breast tomosynthesis - more commonly known as 3D mammography. It may be used as a screening or diagnostic modality in the assessment and management of breast cancer for individuals meeting certain criteria.

Coverage criteria

1. 3D mammograms may be used for screening when one of these criteria is met:
• It’s used in combination with digital screening mammography in high risk individuals
• An ordering provider or radiologist determines it should be the primary mammographic study
2. 3D mammograms may be used for screening or diagnostic purposes when:
• Digital mammography alone is inadequate or insufficient to support clinical decision-making, based on the radiologist reviewer’s opinion

Exclusions: Those not meeting the above criteria

HEDIS^® is a registered trademark of the National Committee for Quality Assurance.

Physician assistants required to re-enroll earlier this year

Physician assistants were required to re-enroll with Blue Cross Blue Shield of Michigan and Blue Care Network so they could be reimbursed for services within their scope of license for services that occurred on or after Feb. 1, 2018. Re-enrollment began Oct. 1, 2017 and required physician assistants to:

• Re-enroll and be credentialed with Blue Cross and BCN, including our Medicare Advantage programs.
• Complete our attestation form, indicating that they have a legally required practice agreement with a physician, along with other required documents.
• Enroll as part of an existing contracted group or request participation via a new group practice (for BCN).
• Complete a CAQH ProView credentialing application within 14 calendar days of submitting enrollment requests.

Previous reimbursement arrangements were terminated for dates of service after Jan. 31, 2018.

For services that occur on or after Feb. 1:

• PAs who re-enrolled by Jan. 31 will be eligible for reimbursement for services within their scope of license either directly or under a group for all lines of business. PAs who have not will have their claims denied.
• PAs may choose to continue to be affiliated with physician groups and bill under the groups. If so, PAs should ensure they indicate the group information when they contract and re-enroll.
• PAs will continue to be reimbursed at 85 percent of the physician fee schedule.
• BCN authorization and referral requirements did not change and will continue to apply.
• If billing indirect/incident to, please make sure you are following this criteria:
• The physician delivered any component of the service.
• The physician provided specific clinical direction or consultation on an individual case basis to the PA prior to or during the service billed on that specific date.
• The PA presented pertinent clinical findings and obtained approval of evaluation and management by the physician prior to the end of the day following the service. (Specific clinical direction does not include the application of general protocols or care pathways.)

For more information, see your provider manual on web-DENIS.

Updates to PPO professional and outpatient claim editing process coming in December

Starting in December 2018, Blue Cross Blue Shield of Michigan will update its professional and outpatient facility PPO claim editing processes for select groups. We’re doing this to promote correct coding.

These improvements will make our claims payment system easier for you and your billing staff to navigate. Unique clinical editing reason codes will appear on the 835 response files or provider vouchers.

As a reminder, when billing PPO claims, you should follow guidelines from:

• The American Medical Association’s Current Procedural Terminology, or CPT, code set regarding:

• Correct modifier usage
• Evaluation and Management reporting guidelines
• National bundling edits

• National specialty societies, such as:

• American College of Surgeons
• American College of Radiology
• American Association of Neuromuscular and Electrodiagnostic Medicine
• American Cancer Society

As part of your contract with us, health care providers affiliated with the PPO network agree to supply services to Blue Cross members and bill according to guidelines and requirements set by the American Medical Association and select specialty societies.

If you have questions about the Blue Cross’ claim editing process, contact Provider Inquiry. Professional providers should call 1-800-344-8525, while facility providers should call 1-800-249-5103.

Prolia^® and Xgeva^® won’t be covered in outpatient hospitals without approval, starting Oct. 1

Blue Cross Blue Shield of Michigan is adding two injectable drugs, Prolia and Xgeva, to the site of care requirement for members, beginning Oct. 1, 2018. These drugs won’t be covered at outpatient hospital facilities without prior authorization for the approved location, starting Oct. 1.

The authorization requirement only applies to groups currently participating in the commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit.

Approved locations for Prolia and Xgeva injections

• Doctor’s office – Members must receive their injections in the doctor’s office.
• Home infusion therapy – They’re only approved if received at the same time as an infusion by a home infusion therapy provider.
• Outpatient hospital facility – Members must receive a prior authorization for this location.

Both drugs in this program already require prior authorization for payment. Approved authorizations will be payable for professional locations such as physician’s offices and home infusions with no further action required.

Help your patient switch his or her injection therapy to your office by October 1.

If a member must receive one of these injections in a hospital outpatient facility, the ordering provider must follow the normal steps for a prior authorization request and include:

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

If this request isn’t submitted and approved, the patient will be responsible for the full cost of the medicine Oct. 1 or later.

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

If you have questions, contact provider inquiry.

Reminder: Follow these guidelines when billing medical drugs that haven’t been purchased

Some health care providers have questioned what to do when billing certain medical drugs that were administered by a medical professional but supplied by our specialty pharmacy.

Here are guidelines to follow in professional and hospital settings:

• When professional providers administer a drug they didn’t purchase, they should bill for the administration code only and not include the drug or NDC code on the claim.
• When professional providers administer a medical drug that was purchased, notes should be documented and a copy of the purchase order included in the member’s chart.
• Identical NDC codes billed within 14 days of a specialty pharmacy claim will be recovered and the provider will need proof of purchase to have the claim repaid.

• When a hospital administers a drug in an outpatient setting that isn’t purchased by the hospital, the hospital should bill for the administration. However, the hospital should include the revenue code and corresponding procedure code for the medical drug with total charges of $.01.

For more information, see the May 2016 and July 2016 Record articles.

Remember these guidelines when coding for Medicare Plus Blue^SM PPO members

Use of Modifier 25

When Blue Cross pays for medical procedures, the payments include certain evaluation and management (or E&M) services that are necessary before you perform a procedure. Additional payments for these E&M services performed by a provider on the same day as a procedure are not allowed according to the Global Surgery Package Policies.

Modifier 25 is used when a provider performs an E&M service on the same day as a procedure that is significant, separately identifiable, and above and beyond the usual pre- and post-operative care associated with the procedure. Using modifier 25 in these situations allows additional payment for the separate E&M service.

An E&M service isn’t needed and shouldn’t be reported at every patient encounter. While the use of modifier 25 does not require different diagnosis codes, when patients have repeated visits and procedures for the same conditions, our system won’t allow a modifier 25 to override the visit edit and allow payment for the E&M without a record review. This helps us ensure that the E&M being reported is separate from the procedure and the prior visit.

Anesthesia for pain management procedures

We are in the process of reviewing and enhancing clinical editing related to anesthesia provided for pain management procedures. Anesthesia and moderate sedation services (CPT codes *00300, *00400, *00600, *01935-01936, *01991-01992, *99152-99153, *99156-99157) will be subject to a clinical edit when reported with a pain management service, but without a surgical procedure, for patients 18 years of age or older.

In 2016, the American Society of Anesthesiologists noted that while there are select indications for patients to receive anesthesia with interventional pain procedures, many patients are able to undergo these procedures without receiving anesthesia. Our enhancement of the clinical editing is in line with the ASA statement and should be in effect this month.

There are no changes to authorization rules for pain management procedures. Please refer to authorization guidelines if you have questions.

Reporting laser treatment

CPT codes *96920-96922 are laser treatments that are specific to the inflammatory skin disease (psoriasis). In accord with the code description, we will apply an edit for any claims reported without a diagnosis of psoriasis or parapsoriasis. This change will be effective for dates of service beginning Aug. 1, 2018.

In line with this change, please ensure that your documentation and coding supports the services rendered to minimize and hopefully eliminate edits. As always, if you receive an edit that you believe is incorrect, you can file an appeal through the clinical editing appeal process.

We’re using updated utilization management criteria for behavioral health

On Aug. 6, 2018, Medicare Plus Blue^SM PPO, Blue Cross Blue Shield of Michigan’s Medicare Advantage plan, and Blue Care Network’s commercial and Medicare Advantage plans (BCN HMO^SM and BCN Advantage^SM) began using the 2018 InterQual^® criteria for behavioral health utilization management determinations.

We first communicated about this in June 2018 in a web-DENIS message and a news item at ereferrals.bcbsm.com. These communications indicated that the move to the 2018 criteria would take place on Aug.1, but the date was subsequently changed to Aug. 6.

In addition, certain types of determinations are based on modifications to InterQual criteria or on medical policies, as shown in the table below:

Note: Determinations on Blue Cross PPO (commercial) behavioral health services are handled by New Directions.**

Links to the updated versions of the modified criteria, local rules and medical policies are available on the Blue Cross Behavioral Health page and the BCN Behavioral Health page at ereferrals.bcbsm.com.

**New Directions is an independent company that manages behavioral health services for Blue Cross Blue Shield of Michigan.

2018 InterQual criteria implemented

Blue Cross Blue Shield of Michigan implemented InterQual^®acute care, rehabilitation, long-term acute care, skilled nursing and home health criteria, beginning Aug. 6, 2018.

On this date, certain modifications to InterQual criteria took effect and all previous modifications and criteria were replaced with these new guidelines. We alerted health care providers about the implementation date in a web-DENIS message posted Aug. 2, 2018.

We also reported that precertification requests must be submitted via e-referral, effective Aug. 6, 2018. (As reported in an article in the April 2017 Record, we moved from the prenotification system to e-referral, effective July 31, 2017.)

The Blue Cross modifications to InterQual criteria can be accessed from web-DENIS as follows:

• From the home page of web-DENIS, click on BCBSM Provider Publications and Resources in the left column.
• Click on Newsletters & Resources.
• Click on Clinical Criteria & Resources and scroll down to the BCBSM modifications to InterQual criteria section of the page.

Note: 2018 InterQual criteria is also now being used for behavioral health. For details, see the article, We’re using updated utilization management criteria for behavioral health.

Michigan Carpenters’ Health, Saginaw Plumbers and Pipe Fitters U.A. Local 85 join Medical Drug Prior Authorization Program, starting Oct. 1

Starting on Oct. 1, 2018, Michigan Carpenters’ Health, Saginaw Plumbers and Pipe Fitters U.A. Local 85 groups will join the Medical Drug Prior Authorization Program.

Use web-DENIS to learn more about the program:

1. Log in to web-DENIS.
2. Click BCBSM Provider Publications and Resources.
3. Select Newsletters and Resources.
4. Click Forms (within the Other Resources menu on the left side of the screen).
5. Click on Physician administered medications.

Keep in mind that the prior-authorization requirement doesn’t apply to Federal Employee Program^® members.

Current drugs in the medical drug prior authorization program, include:

Register for AIM Specialty Health Prior Authorization Program webinar

We invite you to take part in the Blue Cross Blue Shield of Michigan, Blue Care Network and AIM Specialty Health^® Prior Authorization Program webinar at 10 a.m. Oct. 10, 2018. AIM handles our commercial PPO, Medicare Plus Blue^SM and BCN outpatient prior authorizations for high-tech radiology and echo cardiology. AIM also handles Blue Cross’ in-lab sleep therapy for commercial members and select programs for URMBT (medical and radiation oncology).

This webinar will give you an overview of the AIM prior authorization program, and it’ll help you understand program enhancements since 2017. Some topics include:

• Services affected by the program
• Prior authorization guidelines
• How to register on AIM’s provider website
• An overview of AIM's provider website for verifying authorizations

Click here to register. After registering, you'll receive a confirmation email and instructions for joining the WebEx webinar.

The webinar won’t include any programs managed by eviCore healthcare, and the training isn’t available on Mac operating systems.

CIOX to retrieve medical records for risk adjustment services

Blue Cross Blue Shield of Michigan and Blue Care Network will use CIOX Health to perform medical record retrieval for risk adjustment services for our commercial (non-Medicare) members beginning in October 2018.

Blue Cross and BCN request medical records every year to meet the Centers for Medicare & Medicaid Services’ standards for data submission and coding accuracy and CMS’ and Health and Human Services’ regulations and quality standards for patient care.

CIOX is contractually bound to preserve the confidentiality of members’ protected health information obtained from medical records, in accordance with the Health Insurance Portability and Accountability Act of 1996.

You won’t need to submit patient-authorized information releases to comply with medical records requests when both the provider and health care plan have a relationship with the patient, and the information relates to this relationship [45 CFR 164.506(c)(4)]. For more information about privacy rules, go to the U.S. Department of Health and Human Services website*.

If you have any questions, contact your provider outreach consultants.

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

We’ve added ‘All Cases’ search field to e-referral; tips for reviewing the results of medical drug authorization requests

On Aug. 6, 2018, we added an “All Cases” search box to e-referral. By checking the “All Cases” box, health care providers can search beyond the provider set to see any case the member has in the e-referral system. That includes vendor-created cases.

Previously, providers could only search for cases within their provider set.

This search field is for all lines of business but doesn’t apply to behavioral health services.

The screenshot below shows search results when the “All Cases” box (outlined in blue) isn’t checked.

The screenshot below shows search results when the “All Cases” box is checked. [Kyle, please blur the following on the screenshot below: Patient ID; Reference ID (1st column); Patient (3rd column); Date of Birth (5th column)]

An advantage of this change is that if a provider can’t find a case under the NPI, then he or she can now search under the member’s name.

If you’re looking up a specialty medical drug prior authorization for a case you’re not associated with, simply click the “All Cases” box.

Medical drug authorization requests

In the e-referral system, authorization request results for drugs covered under the medical benefit for Blue Cross PPO members are different from other types of authorization request results. To help you navigate these differences, we put together a tip sheet titled Reviewing e-referral results: Medical drug authorization requests. The tip sheet is located on the Medical Benefit Drugs – Pharmacy page in the Blue Cross section of our ereferrals.bcbsm.com website.

Changes coming to the e-referral system

Starting Nov. 23, 2018, the e-referral application (also known as CareAdvance Provider) will now support the use of these places of service when entering authorizations:

• Off Campus-Outpatient Hospital (POS 19 – New)
• On Campus-Outpatient Hospital (POS 22 – renamed from Outpatient Hospital)

We will update the e-referral user guide to reflect these changes.

For more information about e-referral, go to ereferrals.bcbsm.com.

Medicare Advantage non-compliance audits to begin Oct. 1, 2018

Blue Cross Blue Shield of Michigan is changing our audit policy on pursuing the submission of Additional Documentation Requests (also known as ADRs). Beginning Oct. 1, 2018, Blue Cross will implement existing Medicare policy to ensure program compliance for letters requesting medical records. Previously, we did not pursue remedies on non-responses to these letters.

Providers who do not respond to the request in the allotted time frame or by the extension time frame can have their entire claim or service denied as not reasonable or necessary. Providers will be notified that Blue Cross has issued a non-compliance denial for a claim or service and the claim will be recovered from future payments.

If Blue Cross receives the requested ADR after a denial has been issued, but within 30 calendar days after the last denial date, we will re-open the claim and make a medical record determination. In these situations, you can follow the two-step appeal process as outlined in the Medicare Plus Blue^SM PPO manual. If the determination is overturned after the record review, we will repay the amount recovered. Otherwise, the recovery will stand.

If you have questions, check your provider manual.

Register for a medical specialty drug prior-authorization web tool refresher course

What’s in it for you?
In this course, you’ll refresh your skills with the NovoLogix^® web tool, and learn how to create prior-authorization requests for provider or outpatient facility-administered specialty medical drugs.**

Register for one of the following Blue Cross Medicare Plus Blue^SM PPO webinars:

• Wednesday, Oct. 3, 2018, 1 to 2 p.m.
• Friday, Oct. 5, 2018, 10 to 11 a.m.

Once the host approves your registration, you’ll receive a confirmation email with instructions for joining the session.

**In July 2017, Blue Cross Medicare Plus Blue PPO launched a prior-authorization program for select provider-administered specialty medical drugs.

Battling the opioid epidemic: A roundup of recent news and information

Opioid laws hit physicians, patients in unintended ways
New state laws on opioids that were intended to save lives have some physicians concerned about unintended consequences, according to article in Crain’s Detroit Business on July 29. None of the doctors interviewed by Crain's objected to the laws' intent: Reducing misuse of the powerful painkillers that have contributed to rising deaths and addictions. But they say regulations have added unnecessary administrative headaches, led to a climate of fear for doctors and left some patients unable to get medications when they really need them. To read more, see the article in Crain's.

Michigan pharmacies filled more orders for drug that reverses opioid overdoses
Michigan pharmacies filled twice as many orders for naloxone, the drug that reverses opioid overdoses, during the second quarter of the year than it did the first, according to report from Lt. Gov. Brian Calley, the Detroit Free Press reported July 20. “While we have made great progress [in addressing the addiction epidemic], we have a long way to go and equipping people with naloxone is a great step,” Calley said. To read more, click here.

Number of deaths involving fentanyl and fentanyl analogs rise
MSMS reported that a Health Alert Network Update indicated a rising number of deaths involving fentanyl and fentanyl analogs (i.e., compounds that are chemically related to fentanyl.) To read more, see the MSMS website.

Heroin deaths surpass gun homicides for first time
Deaths from heroin, an opioid, spiked in 2015, rising by more than 2,000 cases, according to CDC data, as reported in The Washington Post. For the first time since at least the 1990s, there were more deaths due to heroin than traditional opioid painkillers such as hydrocodone and oxycodone. To read more, click here.

Blue plans make progress in addressing opioid epidemic
In July, the Blue Cross and Blue Shield Association issued an update to last year’s report on the opioid epidemic. The report titled, The Opioid Epidemic in America: An Update, indicated that Michigan is making significant progress in efforts to combat the epidemic. Last year’s report, titled America’s opioid epidemic and its effect on the nation’s commercially-insured population, examined opioid prescription rates, opioid use patterns and opioid use disorder among commercially insured Blue plan members.

Blue Cross plans working to improve addiction treatment
Dan Loepp, Blue Cross Blue Shield of Michigan president and CEO, details how Blue Cross is expanding its efforts to connect members to effective addition treatment in a MI Blues Perspectives blog. To read more, click here.

Grants to address opioid epidemic helping Michigan communities
MI Blues Perspectives, a source for Blue Cross and Michigan health news, is highlighting how $570,000 in grants to address the opioid crisis are affecting communities across the state. For details, see the following blogs:

• Taking Action: Prevention Driving U.P. Coalition Efforts to Combat Opioids
• Taking Action: Multi-pronged Approach Fighting Opioids in Northern Michigan
• Taking Action: The Power of Putting “Hope Before Handcuffs”

What’s happening with the Provider Inquiry automated response system?

Over the past year, we’ve been updating Provider Inquiry’s automated response system to better serve you. With the increase in usage, we’ve also received a lot of great feedback and suggestions. Based on your feedback, we’ve made several updates.

Inquiries about eligibility
As of early August, when you call for eligibility and benefits, and the system doesn’t find any active coverage, you’ll hear the following:

1. The date the policy became inactive
2. You’ll be asked if your inquiry is about a claim:
• If your response is “yes,” the system will ask for more information related to the claim so the call can be handled appropriately and routed correctly.
• If the response is “no,” the system will tell you to check with the member to determine their medical coverage.
3. The option to request information on another contract

Updates coming in September

We always appreciate your feedback. Please contact Provider Servicing if you have any suggestions or questions about the automated response system.

Our Medicare Advantage Private Fee-For-Service plan to end as of Dec. 31

In 2017, Blue Cross offered a new Private Fee-For-Service (or PFFS) product to our members so they had an additional product option for their health care. We originally built the CMS-required PFFS network using our existing statewide Medicare Advantage PPO network of providers, by amending their contracts to include the PFFS product. Starting Jan. 1, 2017, providers joined the PFFS network separately from the PPO network by signing the Medicare Advantage PFFS agreement.

Due to low enrollment, Blue Cross will no longer offer the PFFS plan to members starting in 2019. The existing PFFS provider network will be closed to new providers as of Oct. 1, 2018 and the network will no longer be active as of Jan. 1, 2019.

The combined Medicare Advantage PPO and PFFS contract will be amended to remove references to the PFFS network. As a result, the contract will include only the Medicare Advantage PPO network effective Jan. 1, 2019. The amended Medicare Advantage PPO-only contract is available at bcbsm.com Provider Enrollment. We will terminate the Medicare Advantage PFFS agreements effective Dec. 31, 2018.

If you have questions, please contact provider inquiry.

Discrimination against inmates is prohibited

The Blue Cross Blue Shield of Michigan provider community has an obligation to render services to all Blue Cross members. Discrimination against any group is strictly prohibited.

This includes prison inmates with health care coverage under Blue Cross. Providers aren’t allowed to refuse services based on their inmate status. If an individual has a Blue Cross plan ID card, he or she is eligible for care.

Blue Cross stipulated discrimination rules in its provider network contract, the Trust Network Practitioner Affiliation Agreement. Providers who aren’t in accordance with the agreement’s provisions are in violation of their contract.

The agreement reads:

“Trust Practitioner will not discriminate against Members based upon race, color, age, gender, marital status, religion, national origin, or sexual orientation nor may TRUST PRACTITIONER refuse to render Covered Services to Members based upon BCBSM's payment level, benefit or reimbursement policies. Nor shall Trust Practitioner discriminate against Members on the basis of physical or mental handicap. Trust Practitioner shall provide Covered Services to Members in the same manner, quality and promptness as services are provided to Trust Practitioner’s other patients. Trust Practitioner shall not intentionally segregate Members in any way or treat Members in a manner or location different from other persons receiving health care services.”

The parties involved in inmate care recognize the challenges, which is why they offer flexibility. Providers can see inmates before and after normal business hours or schedule visits on alternative days.

For more information, contact Yvonne Moore of Prison Health Services at ymoore@bcbsm.com.

Check to see if you have a new provider consultant

Professional providers
Professional provider consultants have been reassigned as part of the Provider Outreach reorganization you read about in The Record previously.

As a result, your consultant may have changed. We’ve posted new contact lists to help you find the correct person. There are two lists and you can access them as follows:

• Primary care physicians and medical care groups — click here
  
  
• Specialists and other professional providers — To find your list:
• Go to bcbsm.com/providers.
• Click on Contact Us in the upper right corner.
• Under Physicians and professionals, click on either Blue Cross Blue Shield of Michigan provider contacts or Blue Care Network provider contacts.
• Click on Provider consultants and select your geographic region to find the consultants for various provider types. (If you don’t know which region you’re in, you can view our map.)

Remember: The first point of contact for claims questions is still Provider Inquiry:

• 1-800-344-8525 for medical providers
• 1-800-482-4047 for vision and hearing providers

If your issue isn’t satisfactorily resolved, ask the customer service representative to escalate your inquiry to a manager. By directing issues through standard methods, such as Provider Inquiry, we can better identify problems, prioritize efforts and fix problems affecting many providers simultaneously versus one practice at a time.

The Blue Cross and BCN resource guides include contacts for questions related to laboratory, pharmacy, behavioral health and other areas. Note: The Blue Cross resource guide is on the first page and the BCN guide is on the second page.

With current investments being made in our standard processes, we expect you’ll see incremental improvements over time. We hope these improvements will result in higher levels of provider satisfaction when you reach out to us for information or assistance.

Hospitals and other facility providers
There have only been minor changes to the provider consultant assignments for hospitals and facilities. Here’s how you can find the hospital and facility consultant lists:

• Go to bcbsm.com/providers.
• Click on Contact Us in the upper right corner.
• Under Hospitals and facilities, click on either Blue Cross Blue Shield of Michigan provider contacts or Blue Care Network provider contacts. Both take you to the same location.
• Click on Provider consultants and select the provider’s geographic region. (If you’re not sure of the region, view our map for facility providers.)

If you have any questions regarding claims, call Provider Inquiry. The number for facilities is 1-800-249-5103.

We’re continuing to work out specific details of our reorganization efforts to help serve you better. If you have specific comments or suggestions for improvement, contact us at provideroutreach@bcbsm.com.

We’re adding Pulmozyme to the drug prior authorization program, beginning Oct. 1

Effective Oct. 1, 2018, Blue Cross Blue Shield of Michigan and Blue Care Network will add Pulmozyme (dornase alfa) to the pharmacy benefit drug prior authorization program for commercial PPO and HMO members.

Pulmozyme is used to improve lung function in people with cystic fibrosis, in conjunction with standard therapies.

Members should have their prescribers submit a request for authorization from us before payment is approved for this medication.

Members who have an existing prior authorization for any of the following drugs are not required to get a prior authorization for Pulmozyme:

• Orkambi^®
• Symdeko^®
• Kalydeco^®

If we don’t authorize this drug in advance, it may cost more or we may not cover it at all.

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.

Utilization management programs summary now available

Do you ever get confused as to which products require authorization? We’ve put together a handy document that helps you find out whether a service you’re providing requires an authorization and how to get it.

The document for Michigan providers includes all lines of business for Blue Cross Blue Shield of Michigan and Blue Care Network and lists who manages the authorizations. It will be updated from time to time.

The utilization management programs summary document has been posted online at these locations –

• On ereferrals.bcbsm.com -
• The BCN Authorization Requirements & Criteria page
• The Blue Cross Authorization Requirements & Criteria page in both the Blue Cross PPO and Medicare Plus Blue PPO sections
• On the Blue Cross Clinical Criteria & Resources page within Provider Secured Services

The document is not an all-inclusive list of procedures and services that require authorization, but we hope it’s a way to help you keep straight the requirements for some of the most frequently performed services. MESSA is excluded from all eviCore healthcare authorization programs.

Information updated for the use of some Rx vaccines

Below we’ve included some guidelines and information about various vaccines covered under the pharmacy benefit and their use for our members. This information applies to PPO and HMO members.

Flu vaccines

• FluMist^®, also called live attenuated influenza vaccine, has been approved for use in nonpregnant individuals, ages 2 through 49. The following people with some medical conditions should not receive the nasal spray flu vaccine:
• Children younger than age 2
• Adults ages 50 and older
• Pregnant women
• People with a history of severe allergic reaction to any component of the vaccine or to a previous dose of any influenza vaccine
• Children ages 2 through 17 who are receiving aspirin or salicylate-containing medications
• People with weakened immune systems (immunosuppression)
• Children ages 2 through 4 who have asthma or who’ve had a history of wheezing in the past 12 months
• People who’ve taken influenza antiviral drugs within the previous 48 hours
• Caretakers for severely immunocompromised people who require a protected environment (Otherwise, avoid contact with those people for seven days after getting the nasal spray vaccine)

Quantity limits

Quantity limits will be placed on the following vaccines, effective Sept. 1, 2018, unless otherwise noted. These limits will help prevent billing vaccines for greater quantities than recommended. The dosage for each vaccine is based on the recommended standard.

• Menactra^®
• Pneumovax^® 23
• Boostrix^® and Boostrix^® TDAP
• Gardasil^® and Gardasil^® 9
• Havrix^® (Adolescent dose)
• Vaqta^® (Adolescent dose)
• Havrix^® (Adult dose)
• Vaqta^® (Adult dose)
• Prevnar^®
• Menveo^® (effective Aug. 1, 2018)

Drug exclusions will take effect Oct. 1, 2018

Our goal at Blue Cross Blue Shield of Michigan and Blue Care Network is to provide our members with safe, high-quality prescription drug therapies. We continuously review prescription drugs to provide the best value for our members, control costs and make sure our members are using the right medication for the right situation.

We’ve made some changes to the drugs we cover as detailed below:

Acne drugs
We’ll stop covering the acne drugs listed below, and their generic equivalents, because there are safe, effective and less-expensive choices available.

Migraine and pain drugs
We’ll stop covering the various drugs listed below, and their generic equivalents, because there are safe, effective and less-expensive choices available.

Cough and cold drugs not approved by the FDA
We’ll also stop covering the cough and cold drugs listed below for members under the age of 18. These contain codeine or hydrocodone and haven’t been approved by the U.S. Food and Drug Administration for use in members under the age of 18.

Michigan Carpenters’ Health, Saginaw Plumbers and Pipe Fitters U.A. Local 85 join Medical Drug Prior Authorization Program, starting Oct. 1

Starting on Oct. 1, 2018, Michigan Carpenters’ Health, Saginaw Plumbers and Pipe Fitters U.A. Local 85 groups will join the Medical Drug Prior Authorization Program.

Use web-DENIS to learn more about the program:

1. Log in to web-DENIS.
2. Click BCBSM Provider Publications and Resources.
3. Select Newsletters and Resources.
4. Click Forms (within the Other Resources menu on the left side of the screen).
5. Click on Physician administered medications.

Keep in mind that the prior-authorization requirement doesn’t apply to Federal Employee Program^® members.

Current drugs in the medical drug prior authorization program, include:

Medical Drug Prior Authorization and Site of Care programs to expand

Blue Cross Blue Shield of Michigan and Blue Care Network are expanding our medical drug management programs for commercial members. We encourage proper utilization of high-cost specialty medications administered by a health care provider.

Beginning Oct. 1, 2018, Trogarzo™ and Zilretta^® will be added to the Medical Drug Prior Authorization program for HMO and PPO commercial lines of business. Trogarzo will also be added to the Site of Care program for HMO members, effective Oct. 1, 2018.

Trogarzo is used to treat human immunodeficiency virus type-1 infection for heavily treatment-experienced adults with multi-drug resistant HIV-1 infection failing their current antiretroviral regimen. Zilretta is a single dose intra-articular injection. It’s FDA-approved for the management of osteoarthritis knee pain.

Members currently on Trogarzo don’t have to do anything.

Members currently on Zilretta need a prior authorization on or after Oct. 1, 2018.

A prior authorization approval isn’t a guarantee of payment. Health care practitioners must verify eligibility and benefits for members. Members are responsible for the full cost of medications not covered under their medical benefit coverage.

Refer to the opt-out list for the groups that don’t require members to participate in the programs. To access the list, follow these steps:

1. Log in to Provider Secured Services.
2. Click BCBSM Provider Publications and Resources.
3. Click Newsletters & Resources.
4. Click Forms.
5. Click Physician administered medications.
6. Click BCBSM Medical Drug Prior Authorization Program list of groups that have opted out.

These changes don’t apply to BCN Advantage^SM, Blue Cross Medicare Plus Blue^SM PPO or Federal Employee Program^® members.

For a full list of drugs in the prior authorization program:

BCN

1. Go to ereferrals.bcbsm.com.
2. Select BCN at the top
3. Click BCN-Authorizations/Referrals
4. Click on the link for Medical Benefit Drugs – Pharmacy
5. Click Requirements for drugs covered under the medical benefit – BCN HMO underneath For BCN HMO (commercial) members.

Blue Cross

1. Log in as a provider at bcbsm.com/providers.
2. Click BCBSM Provider Publications and Resources on the lower right side of the page.
3. Click Newsletters and Resources.
4. Click the Forms link in the left navigation.
5. Click Physician administered medications.

Information updated for the use of some Rx vaccines

Below we’ve included some guidelines and information about various vaccines covered under the pharmacy benefit and their use for our members. This information applies to PPO and HMO members.

Flu vaccines

• FluMist^®, also called live attenuated influenza vaccine, has been approved for use in nonpregnant individuals, ages 2 through 49. The following people with some medical conditions should not receive the nasal spray flu vaccine:
• Children younger than age 2
• Adults ages 50 and older
• Pregnant women
• People with a history of severe allergic reaction to any component of the vaccine or to a previous dose of any influenza vaccine
• Children ages 2 through 17 who are receiving aspirin or salicylate-containing medications
• People with weakened immune systems (immunosuppression)
• Children ages 2 through 4 who have asthma or who’ve had a history of wheezing in the past 12 months
• People who’ve taken influenza antiviral drugs within the previous 48 hours
• Caretakers for severely immunocompromised people who require a protected environment (Otherwise, avoid contact with those people for seven days after getting the nasal spray vaccine)

Quantity limits

Quantity limits will be placed on the following vaccines, effective Sept. 1, 2018, unless otherwise noted. These limits will help prevent billing vaccines for greater quantities than recommended. The dosage for each vaccine is based on the recommended standard.

• Menactra^®
• Pneumovax^® 23
• Boostrix^® and Boostrix^® TDAP
• Gardasil^® and Gardasil^® 9
• Havrix^® (Adolescent dose)
• Vaqta^® (Adolescent dose)
• Havrix^® (Adult dose)
• Vaqta^® (Adult dose)
• Prevnar^®
• Menveo^® (effective Aug. 1, 2018)

Drug exclusions will take effect Oct. 1, 2018

Our goal at Blue Cross Blue Shield of Michigan and Blue Care Network is to provide our members with safe, high-quality prescription drug therapies. We continuously review prescription drugs to provide the best value for our members, control costs and make sure our members are using the right medication for the right situation.

We’ve made some changes to the drugs we cover as detailed below:

Acne drugs
We’ll stop covering the acne drugs listed below, and their generic equivalents, because there are safe, effective and less-expensive choices available.

Migraine and pain drugs
We’ll stop covering the various drugs listed below, and their generic equivalents, because there are safe, effective and less-expensive choices available.

Cough and cold drugs not approved by the FDA
We’ll also stop covering the cough and cold drugs listed below for members under the age of 18. These contain codeine or hydrocodone and haven’t been approved by the U.S. Food and Drug Administration for use in members under the age of 18.

Updates to PPO professional and outpatient claim editing process coming in December

Starting in December 2018, Blue Cross Blue Shield of Michigan will update its professional and outpatient facility PPO claim editing processes for select groups. We’re doing this to promote correct coding.

These improvements will make our claims payment system easier for you and your billing staff to navigate. Unique clinical editing reason codes will appear on the 835 response files or provider vouchers.

As a reminder, when billing PPO claims, you should follow guidelines from:

• The American Medical Association’s Current Procedural Terminology, or CPT, code set regarding:

• Correct modifier usage
• Evaluation and Management reporting guidelines
• National bundling edits

• National specialty societies, such as:

• American College of Surgeons
• American College of Radiology
• American Association of Neuromuscular and Electrodiagnostic Medicine
• American Cancer Society

As part of your contract with us, health care providers affiliated with the PPO network agree to supply services to Blue Cross members and bill according to guidelines and requirements set by the American Medical Association and select specialty societies.

If you have questions about the Blue Cross’ claim editing process, contact Provider Inquiry. Professional providers should call 1-800-344-8525, while facility providers should call 1-800-249-5103.

Prolia^® and Xgeva^® won’t be covered in outpatient hospitals without approval, starting Oct. 1

Blue Cross Blue Shield of Michigan is adding two injectable drugs, Prolia and Xgeva, to the site of care requirement for members, beginning Oct. 1, 2018. These drugs won’t be covered at outpatient hospital facilities without prior authorization for the approved location, starting Oct. 1.

The authorization requirement only applies to groups currently participating in the commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit.

Approved locations for Prolia and Xgeva injections

• Doctor’s office – Members must receive their injections in the doctor’s office.
• Home infusion therapy – They’re only approved if received at the same time as an infusion by a home infusion therapy provider.
• Outpatient hospital facility – Members must receive a prior authorization for this location.

Both drugs in this program already require prior authorization for payment. Approved authorizations will be payable for professional locations such as physician’s offices and home infusions with no further action required.

Help your patient switch his or her injection therapy to your office by October 1.

If a member must receive one of these injections in a hospital outpatient facility, the ordering provider must follow the normal steps for a prior authorization request and include:

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

If this request isn’t submitted and approved, the patient will be responsible for the full cost of the medicine Oct. 1 or later.

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

If you have questions, contact provider inquiry.

Reminder: Follow these guidelines when billing medical drugs that haven’t been purchased

Some health care providers have questioned what to do when billing certain medical drugs that were administered by a medical professional but supplied by our specialty pharmacy.

Here are guidelines to follow in professional and hospital settings:

• When professional providers administer a drug they didn’t purchase, they should bill for the administration code only and not include the drug or NDC code on the claim.
• When professional providers administer a medical drug that was purchased, notes should be documented and a copy of the purchase order included in the member’s chart.
• Identical NDC codes billed within 14 days of a specialty pharmacy claim will be recovered and the provider will need proof of purchase to have the claim repaid.

• When a hospital administers a drug in an outpatient setting that isn’t purchased by the hospital, the hospital should bill for the administration. However, the hospital should include the revenue code and corresponding procedure code for the medical drug with total charges of $.01.

For more information, see the May 2016 and July 2016 Record articles.

Remember these guidelines when coding for Medicare Plus Blue^SM PPO members

Use of Modifier 25

When Blue Cross pays for medical procedures, the payments include certain evaluation and management (or E&M) services that are necessary before you perform a procedure. Additional payments for these E&M services performed by a provider on the same day as a procedure are not allowed according to the Global Surgery Package Policies.

Modifier 25 is used when a provider performs an E&M service on the same day as a procedure that is significant, separately identifiable, and above and beyond the usual pre- and post-operative care associated with the procedure. Using modifier 25 in these situations allows additional payment for the separate E&M service.

An E&M service isn’t needed and shouldn’t be reported at every patient encounter. While the use of modifier 25 does not require different diagnosis codes, when patients have repeated visits and procedures for the same conditions, our system won’t allow a modifier 25 to override the visit edit and allow payment for the E&M without a record review. This helps us ensure that the E&M being reported is separate from the procedure and the prior visit.

Anesthesia for pain management procedures

We are in the process of reviewing and enhancing clinical editing related to anesthesia provided for pain management procedures. Anesthesia and moderate sedation services (CPT codes *00300, *00400, *00600, *01935-01936, *01991-01992, *99152-99153, *99156-99157) will be subject to a clinical edit when reported with a pain management service, but without a surgical procedure, for patients 18 years of age or older.

In 2016, the American Society of Anesthesiologists noted that while there are select indications for patients to receive anesthesia with interventional pain procedures, many patients are able to undergo these procedures without receiving anesthesia. Our enhancement of the clinical editing is in line with the ASA statement and should be in effect this month.

There are no changes to authorization rules for pain management procedures. Please refer to authorization guidelines if you have questions.

Reporting laser treatment

CPT codes *96920-96922 are laser treatments that are specific to the inflammatory skin disease (psoriasis). In accord with the code description, we will apply an edit for any claims reported without a diagnosis of psoriasis or parapsoriasis. This change will be effective for dates of service beginning Aug. 1, 2018.

In line with this change, please ensure that your documentation and coding supports the services rendered to minimize and hopefully eliminate edits. As always, if you receive an edit that you believe is incorrect, you can file an appeal through the clinical editing appeal process.

We’re using updated utilization management criteria for behavioral health

On Aug. 6, 2018, Medicare Plus Blue^SM PPO, Blue Cross Blue Shield of Michigan’s Medicare Advantage plan, and Blue Care Network’s commercial and Medicare Advantage plans (BCN HMO^SM and BCN Advantage^SM) began using the 2018 InterQual^® criteria for behavioral health utilization management determinations.

We first communicated about this in June 2018 in a web-DENIS message and a news item at ereferrals.bcbsm.com. These communications indicated that the move to the 2018 criteria would take place on Aug.1, but the date was subsequently changed to Aug. 6.

In addition, certain types of determinations are based on modifications to InterQual criteria or on medical policies, as shown in the table below:

Note: Determinations on Blue Cross PPO (commercial) behavioral health services are handled by New Directions.**

Links to the updated versions of the modified criteria, local rules and medical policies are available on the Blue Cross Behavioral Health page and the BCN Behavioral Health page at ereferrals.bcbsm.com.

**New Directions is an independent company that manages behavioral health services for Blue Cross Blue Shield of Michigan.

2018 InterQual criteria implemented

Blue Cross Blue Shield of Michigan implemented InterQual^®acute care, rehabilitation, long-term acute care, skilled nursing and home health criteria, beginning Aug. 6, 2018.

On this date, certain modifications to InterQual criteria took effect and all previous modifications and criteria were replaced with these new guidelines. We alerted health care providers about the implementation date in a web-DENIS message posted Aug. 2, 2018.

We also reported that precertification requests must be submitted via e-referral, effective Aug. 6, 2018. (As reported in an article in the April 2017 Record, we moved from the prenotification system to e-referral, effective July 31, 2017.)

The Blue Cross modifications to InterQual criteria can be accessed from web-DENIS as follows:

• From the home page of web-DENIS, click on BCBSM Provider Publications and Resources in the left column.
• Click on Newsletters & Resources.
• Click on Clinical Criteria & Resources and scroll down to the BCBSM modifications to InterQual criteria section of the page.

Note: 2018 InterQual criteria is also now being used for behavioral health. For details, see the article, We’re using updated utilization management criteria for behavioral health.