Reminder: Providing services to patients in an out-of-state MA PPO plan

Each year, we like to remind our health care providers about Medicare Advantage PPO network sharing for Blue Cross Blue Shield plans. Network sharing allows patients to see any Medicare Advantage PPO provider across the country and obtain in-network benefits.

If you’re a Blue Cross Blue Shield of Michigan-contracted MA PPO provider and see a Medicare Advantage PPO member from another Blue plan, they’ll have the same access to care as a Blue Cross Blue Shield of Michigan member. You’ll also receive reimbursement according to your agreement with Blue Cross.

If you’re not contracted with Blue Cross Blue Shield of Michigan for our MA PPO plan and you provide services for any Blue Medicare Advantage member, you’ll receive the Medicare-allowed amount for covered services. (Note: For urgent or emergency care, you’ll be reimbursed at the member’s in-network benefit level. Other services will be reimbursed at the out-of-network benefit level.)

Here are answers to a few frequently asked questions:

How will I know that a patient is covered under the MA PPO network sharing program?

You’ll see a Blue Cross Blue Shield ID card with this logo on it:

How do I verify benefits and eligibility?

Check web-DENIS or call BlueCard Eligibility at 1-800-676-BLUE (2583) and provide the member’s prefix that’s located on the ID card.

How do I get more information?
For more information, access the Medicare Plus Blue PPO manual by clicking here.

Providers must get appropriate consent to share patient information

Sharing an individual’s health information is an important part of delivering quality health care. Individuals and their health care providers share information with each other to diagnose health issues, make decisions on treatments and coordinate care.

Providers may share many kinds of health information with other providers for the purposes of payment, treatment and health care operations. However, providers must receive consent from patients to share an individual’s health record when it contains certain types of information. This applies even if the record is being shared for payment or treatment purposes.

Federal and state laws require providers to receive consent to share such information as mental health records or information on treatment or referrals for alcohol and substance use disorder. Blue Cross Blue Shield of Michigan participation agreements require providers to comply with all federal and state laws, including data privacy laws.

Providers must ensure they’re securing appropriate consents from patients that permit them to share necessary information with Blue Cross for use in payment and health care operations activities. These include case management and care coordination activities with New Directions, a company that provides behavioral health services for many of our members.

State of Michigan group to carve in behavioral health and substance use disorder services

As communicated in a web-DENIS message posted July 1, New Directions Behavioral Health will manage behavioral health and substance use disorder benefits on behalf of Blue Cross Blue Shield of Michigan for State of Michigan enrollees (group number 007000562), effective Oct. 1, 2019.

Their services were previously managed by Magellan Health. This change affects services provided on or after Oct. 1, 2019.

New Directions will be responsible for prior authorizations, as well as approvals and denials of all behavioral health and substance use disorder admissions, including outpatient services for applied behavioral analysis, or ABA, and intensive outpatient, or IOP, services. New Directions will also provide case management services. In addition, enrollees will be able to access Blue Cross Online Visits^SM, beginning Oct. 1, 2019.

Claims for behavioral health and substance use disorder services provided on or after Oct. 1, 2019, should be submitted to Blue Cross. Prior authorization requests for services provided on or after Oct. 1, 2019, should be submitted to New Directions.

Both Blue Cross and New Directions will provide customer service support and answer questions related to behavioral health and substance use disorder services. Blue Cross will respond to benefit or claims inquiries.

We’ll issue State of Michigan enrollees new ID cards throughout September.

State of Michigan enrollees will have access to Blue Cross’ broad PPO network, and services will be provided using the associated reimbursement fee schedule.

We’ll have more details in a future Record article.

Blue Cross expands pilot program to promote pain control through limiting post-operative opioid dispensing

In August 2018, Blue Cross Blue Shield of Michigan announced an initiative for select surgeries aimed at promoting effective pain control through care processes that limit opioid dispensing.

To recap, the payment policy was modified to allow surgeons to report modifier 22 for an additional 35% reimbursement when pain control optimization protocols are used to support the surgery. The initial period of the pilot program included the following surgical categories:

• Laparoscopic cholecystectomy
• Inguinal hernia repair
• Thyroidectomy
• Endoscopic sinus surgery and septoplasty
• Prostatectomy
• Bariatric surgery

Due to the success of the pilot program, we’ve expanded the program to also include the following surgical groupings:

• Adrenalectomy
• Appendectomy (adult)
• Carpel tunnel release
• Carotid endarterectomy
• Endovascular aneurism repair
• Parathyroidectomy
• Pediatric appendectomy
• Umbilical hernia repair
• Ureteroscopy
• Vasectomy
• Ventral hernia repair

Using modifier 22
To submit your attestation statement indicating that appropriate protocols were included as part of the surgery, follow the process for submitting medical records and other claim attachments when appending modifier 22 to a qualifying procedure. For details, see the Claims chapter of the provider manual.

Also, to bill modifier 22 for adherence with the Pain Control Optimization Pathway, the physician agrees to follow the prescribing recommendations of the Michigan Opioid Prescribing Engagement Network, or Michigan-OPEN. For information, click here.**

The physician also agrees to the following guidelines:

• No additional pills are prescribed after the initial discharge prescription.
• No opioid prescriptions have been filled within 30 days before surgery, with certain exceptions.
• For procedures with limited opioids recommended after surgery, Blue Cross will allow up to 10% to have an additional fill for an opioid within 30 days after surgery to accommodate unexpected excessive pain.
• This pilot program is expected to last one to two years, based on results. We’ll announce further details in future Record articles.

To read more about efforts to battle the opioid epidemic, see “Battling the opioid epidemic: A roundup of recent news and information.”

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.

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

Articles on the following topics were included in the July/August issue of Hospital and Physician Update:

Statewide partners commit $5 million for programs to treat opioid addition
Gov. Gretchen Whitmer and the Michigan Opioid Partnership announced in June that a combination of public and private funds totaling $5 million in grants will support programs for people with opioid use disorder. Grants will fund the planning, training and coordination of treatment for opioid use disorder, including the use of medication-assisted treatment.

Two hospital systems across the state will receive grants to pilot projects designed to help change the culture in hospitals to better combat the opioid epidemic: Beaumont Hospital and Munson Medical Center. The hospitals will receive grants of more than $1.3 million for projects that utilize medication-assisted treatment in partnership with outpatient treatment providers. Additional hospital grants are expected to be announced in the coming months.

For complete details, see the MI Blues Perspectives blog.

2019 Opioid Progress Report released
The American Medical Association has released its 2019 Opioid Progress Report — the third year that the AMA has reported on actions that physicians have taken to help end the nation's opioid epidemic. The report shows significant decreases in opioid prescribing as well as increases in the use of prescription drug monitoring programs and naloxone prescriptions. Here are some key findings:

• Opioid prescriptions decreased 33% between 2013 through 2018 from 251.8 million to 168.8 million.
• Health care professionals made more than 462 million PDMP queries in 2018, up from 61.4 million in 2014.
• More than 66,000 physicians and other health care professionals have a federal waiver to prescribe buprenorphine in-office for the treatment of opioid use disorder — an increase of more than 28,000 since 2016.

In addition to the national data, the AMA also released state-level data for opioid prescribing and PDMP use.

Nonopioid directive form now available online
In response to the state law that allows patients to refuse opioid medications by placing a form in their medical file, the Michigan Department of Health and Human Services recently made the Nonopioid Directive form available to the public on its website.** Blue Cross has also made it available on our website so members can easily print it, sign it and give it to their doctors for placement in their medical records. You can tell your patients to log in to the member portal at bcbsm.com, click on Forms and look under Managing My Account to find the Nonopioid Directive form.

The state law was signed last year and went into effect in late March. There are exceptions in the law, including a provision that a prescriber or a nurse under the order of a prescriber may administer an opioid if it’s deemed medically necessary for treatment.

Preliminary results pilot opioid use treatment program show relapse rate decreases

Results of the CLIMB pilot program for members with opioid use disorders show that people do better when they take full advantage of the recommended interventions, including medication-assisted treatment. In fact, the relapse rate has decreased from 36% to 14% for program participants. CLIMB, which stands for Community-based, Life-changing, Individualized Medically-assisted and evidence-Based treatment, launched in May 2018 for Blue Care Network and BCN Advantage^SM members and was rolled out to fully insured Blue Cross Blue Shield of Michigan PPO members earlier this year. For more details, see the article that ran in Hospital and Physician Update.

To subscribe... To subscribe to Hospital and Physician Update or The Record — and have the newsletters come directly to your inbox — click here.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.

Medicare Plus Blue will begin reporting qualified Medicare beneficiaries’ eligibility on applicable claim lines

Certain billing prohibitions apply to dual-eligible beneficiaries who meet the requirements for the Qualified Medicare Beneficiary program. As a result, Medicare now flags remittance advices for these beneficiaries because their cost sharing for deductibles, copayments and coinsurance is zero.

All Medicare and Medicaid payments received for furnishing services to a QMB are considered payment in full, even if Medicaid covers nothing. Providers must refund any money collected from a QMB for cost sharing, or recall any bills sent to a QMB or turned over to collections for these charges. Providers may bill subsequent payers for said cost-sharing amounts.

Medicare Plus Blue^SM wants to assist providers with not allowing QMB members to be charged for cost sharing applicable to services that fall within QMB eligibility. That’s why Medicare Plus Blue will adapt the Centers for Medicare & Medicaid Services’ standards of reporting members’ QMB eligibility on applicable claim lines.

When a claim comes in for an active QMB member (Dual Status Code 01 or 02), a new event code mapped to the CMS-recommended claims adjustment group code, claims adjustment reason code or remittance advice remark code combination will be applied to the claim line. Where the claim will be mapped will depend on whether the member pays a deductible, coinsurance, copayment, blood deductible, or deductible or coinsurance for professional services received in an institutional setting.

It will also be displayed on the provider explanation of payment or electronic 835 as well as the member’s explanation of benefits.

Background

• QMB program — Helps pay premiums, deductibles, coinsurance and copayments for Part A, Part B, or both programs
• Specified Low-Income Medicare Beneficiary Program — Helps pay Part B premiums
• Qualifying Individual Program — Helps pay Part B premiums
• Qualified Disabled Working Individual Program — Pays the Part A premium for certain disabled and working beneficiaries

Dual-eligible beneficiaries include those who are enrolled in Medicare Part A or Part B, and receiving full Medicaid benefits or assistance with Medicare premiums or cost sharing. The beneficiaries are receiving benefits or assistance through one of these Medicare Savings Program categories:

Federal law (Sections 1902(n)(3)(B) and 1866(a)(1)(A) of the Act, as modified by Section 4714 of the Balanced Budget Act of 1997) prohibits all Medicare providers from billing QMBs for all Medicare deductibles, coinsurance or copayments.

Providers are subject to sanctions if they bill a QMB for amounts above the total of all Medicare and Medicaid payments (even when Medicaid pays nothing). For more information on prohibited billing of QMBs, see Prohibition on Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program** and Section 1902 of the Act.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.

NaviNet handling Blue Cross Complete eligibility and claims inquiries beginning in August

Starting in August, Blue Cross Complete of Michigan will no longer use Blue Exchange for its eligibility and claims inquiries. If you're using the Provider Secured Services portal to access Blue Exchange for this information, use NaviNet instead.

Register for a NaviNet account here.

Consult the Blue Cross Complete Provider Resource Guide for more information.

HCPCS update: New codes added

The Centers for Medicare & Medicaid Services has added several new codes as part of its quarterly Healthcare Common Procedure Coding System updates. The codes, effective dates and Blue Cross Blue Shield of Michigan’s coverage decisions are below.

Outpatient prospective payment system

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.

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.

We’re making changes to the Medicare Advantage SNF post‑payment audit, recovery process

Blue Cross Blue Shield of Michigan and Blue Care Network are making changes to the post-payment audit and recovery process for its skilled nursing facilities. The changes will apply to Medicare Plus Blue^SM PPO and BCN Advantage^SM members.

Here’s what you need to know:

• Since June 1, HMS^® no longer performs post-payment SNF audits for dates of service for Medicare Plus Blue claims. (BCN Advantage SNF claims haven’t been subject to post-payment audits.)
• naviHealth will authorize Resource Utilization Group levels during the patient’s stay from preservice through discharge. This will be for SNF admissions with dates of service through Sept. 30, 2019. The company will work with SNFs to ensure that the biller submits the appropriate RUG level for reimbursement.
• To align with the Centers for Medicare & Medicaid payment methodology, naviHealth will authorize Patient-Driven Payment Model, or PDPM, levels during the patient’s stay from preservice through discharge. This will be for SNF admissions with service dates on or after Oct. 1, 2019. The company will work with SNFs to ensure the biller submits the appropriate PDPM level for reimbursement.
• On a quarterly basis, Blue Cross and BCN will review paid SNF claims to ensure that RUG or PDPM levels in the claims match the RUG or PDPM levels on the authorizations. If we find overpayments because levels on the claims don’t match those on the authorizations, we’ll pursue payment recoveries as necessary.
• Providers won’t need to submit medical records during the quarterly post-payment review process.

Working with naviHealth

To ensure that SNF claims reflect the authorized RUG or PDPM level, work closely with naviHealth throughout the patient’s stay.

Keep the following in mind:

• Before discharge, a naviHealth care coordinator will work with your biller to verify that the authorized RUG or PDPM levels are submitted for reimbursement.
• If you have questions about the RUG or PDPM level that naviHealth authorized, contact naviHealth during the patient’s stay to resolve those questions.
• When you submit SNF Medicare Advantage claims, make sure the RUG or PDPM levels on the claims match the levels on the authorization connected to the stay.

Additional information

As we communicated in an April Record article, naviHealth started managing authorization requests for Medicare Plus Blue and BCN Advantage members admitted to post-acute care on or after June 1, 2019. For more details, see Post-acute care services: Frequently asked questions by providers.

We’ll be starting Medicare Plus Blue readmission audits in September

Blue Cross Blue Shield of Michigan is implementing post-pay audits related to inpatient readmissions for all Medicare Plus Blue^SM PPO members.

Beginning with service dates on or after Sept. 1, 2019, we won’t reimburse for a readmission to the same facility occurring less than or equal to 30 days from the date the patient was released from the hospital if the readmission is related to the prior medical condition. This applies to both contracted and non-contracted hospitals that are reimbursed at a diagnosis-related group case rate. Hospitals can no longer rebill Medicare Part B services from the denied admission.

Medical records from each admission will be requested by HMS, an audit company that works with Blue Cross. Hospitals are required to provide their records for review. If the audit reveals that the medical conditions appear to be related, HMS will review the charts further to help ensure that appropriate discharge and completion of care procedures were followed.

The audit findings will be provided to the hospitals. If HMS finds the care isn’t related, the hospital will receive a no-findings letter. If HMS finds the care for both hospital visits is related, the case summaries and the rationale used in the decision to deny the readmission will be provided to the hospitals.

Hospitals can appeal the vendor decision by following the appeals process described in the Medicare Plus Blue PPO manual.

Hospitals are responsible for all costs pertaining to readmissions denied under the Medicare Plus Blue PPO Readmissions Reimbursement Policy. They aren’t allowed to charge or balance bill Medicare Plus Blue PPO members for the denied stay.

Exclusions

The following are exclusions to this policy:

• Professional services related to the readmission
• Admissions for chemotherapy or immunotherapy treatment
• Admissions to a substance abuse unit or facility
• Admissions to an inpatient rehabilitation unit
• Readmission after a patient is discharged from the hospital against medical advice
• Admissions for covered transplant services during the global case rate period for the transplant

Questions?

If you need to speak to an HMS vendor representative during an audit, call 1‑866‑875‑1749.

Commercial audits of DME, HIT and HCD claims taking place

SCIO Health Analytics^®, an independent company that provides auditing support for Blue Cross Blue Shield of Michigan, began audits for durable medical equipment, home infusion therapy and high-cost drug claims on July 1, 2019.

Blue Cross conducts audits to ensure that billed and paid services were ordered, medically necessary, documented, reported and covered under the patient’s contract according Blue Cross’ compliance and policy guidelines. Specifically, audits are conducted to:

• Confirm compliance with ICD-10 guidelines and diagnostic codes that are in effect on the date of service
• Confirm compliance with CPT^® guidelines and codes
• Confirm proper use of HCPCS codes
• Detect, prevent and correct waste and abuse
• Facilitate accurate claim payment

You’ll need to provide medical charts for review at the time of an audit.

Durable medical equipment and diabetic supplies
Documentation for DME and diabetic supplies must support all items billed on the claim form. It should include:

• Prescription or order form from the referring physician
• Certificate of Medical Necessity, if applicable
• Physician chart notes, if applicable
• Orthotist or prosthetist evaluation notes, if applicable
• Delivery ticket
• Pickup ticket, if applicable
• Blue Cross’ authorization for treatment, if applicable
• For diabetic supplies, proof of member contact must be documented for each refill.

SCIO will confirm you’ve properly documented requirements for:

• Duplicate therapies and inappropriate equipment for diagnosis
• Purchase versus rental
• Multiple providers billing for same services
• Multiple purchases of same items
• Capitation arrangement with additional fee-for-service item
• Capped rental items

Home infusion therapy and high cost drug claims
HIT and HCD claims will be audited to ensure injections and infusions were ordered by the physician, billed appropriately by the provider and paid accurately by the payer. Considerations include:

• Duplication of therapies by different providers
• Waste
• Correct dosages administered
• Various billing and processing errors
• Validation of drug pricing
• Medical record reviews to verify compliance of dosage, method of administration and other criteria

More information
After an audit, SCIO will send you a finding letter with instructions on how to request an appeal in case you decide to do so.

If you have questions, call your Blue Cross provider consultant. Or, to speak with a SCIO representative, call 1‑866‑628‑3488, ext. 7411.

We’re changing categorization process for physical therapy

We’re changing the categorization process for physical therapy. Beginning in January 2020, physical therapists will be assigned to one category — A, B or C — for all four networks: Blue Cross Blue Shield of Michigan, Medicare Plus Blue^SM, Blue Care Network and BCN Advantage^SM. Categories are based on the physical therapy paid claims data for all four networks.

We hope that having one assigned category covering all Blue Cross and BCN networks will make it easier for you to manage therapy requests.

The categorization process will be completed by eviCore healthcare, an independent company. They’ll also continue to generate the Provider Performance Summaries, or profile reports, and post them on the eviCore website.

Due to the upcoming changes in the categorization process, you won’t be receiving profile reports that were originally scheduled for July 2019 for Blue Cross and for November 2019 for BCN. You’ll maintain your current provider categories and current program requirements until you receive the new combined categories.

The new combined categorizations will be sent by eviCore in February 2020. You’ll still have 15 days from receipt of your categorization report to request reconsideration if you have additional information not captured in the claims data. Going forward, the combined profile reports will be available in February and August, with notifications from eviCore going out to providers in late January and July.

We’ll include more detailed information about the categorization merger in the upcoming months.

Save the date: You’re invited to a Stars Premiere event near you

This year, Blue Cross Blue Shield of Michigan’s Quality and Provider Education team and the Customer Experience team are inviting you to a special production called the Stars Premiere.

Don’t miss this opportunity to join us to hear about and experience the latest and greatest ideas for providing exceptional patient experiences. The event will include information about the Medicare Star Rating System, HEDIS^® measures,** the Health Outcomes Survey and much more.

The Stars Premiere will be held in theaters around the state. When you attend, you can earn Continuing Education Unit credits and participate in a highly engaging 90 minutes of conversation and activities. We’ll also include important information about closing gaps in care immediately following the event. Plus, you’ll be able to take away tools and tips designed to help your office improve patient satisfaction.

What to expect

You’ll be able to choose from either the 8 a.m. or 11 a.m. session, depending on your area of interest. There will be morning refreshments and movie popcorn. The schedule of events is:

• 8 a.m. session
• 8 to 9:30 a.m.: Patient experience and satisfaction session for physicians, office managers and other patient experience leaders
• 9:30 to 10:45 a.m.: HEDIS, HOS and Star Rating System update session for physicians, office managers and other staff who work to close gaps in care
• Note: Arrive at 7:30 a.m. for refreshments.

• 11 a.m. session
• 11 a.m. to noon: ICD–10 for coders, billers and others interested in coding
• Note: Arrive at 10:45 a.m. for refreshments.

It will also be displayed on the provider explanation of payment or electronic 835 as well as the member’s explanation of benefits.

Locations and registration

Tentative dates and locations (subject to change) are below. To register, click on the links. The theater names and addresses will be included in the September Record. Note: You won’t be able to register until Aug. 1.

• Tuesday, Sept. 17: Lansing
• 8 a.m. session
• 11 a.m. session
• Wednesday, Sept. 18: Grand Rapids
• 8 a.m. session
• 11 a.m. session
• Thursday, Sept. 19: Traverse City
• 8 a.m. session
• 11 a.m. session
• Tuesday, Sept. 24: Sterling Heights
• 8 a.m. session
• 11 a.m. session
• Wednesday, Sept. 25: Frankenmuth
• 8 a.m. session
• 11 a.m. session
• Thursday, Sept. 26: Ann Arbor
• 8 a.m. session
• 11 a.m. session

**HEDIS^®, which stands for Healthcare Effectiveness Data and Information Set, is a registered trademark of the National Committee for Quality Assurance.

HEDIS measure tip sheets updated for 2019

As part of our ongoing collaborative efforts with our participating physicians to improve health care quality, we’ve updated our HEDIS^® measure tip sheets for 2019.

The tip sheets highlight specific measures that are included in the Healthcare Effectiveness and Data Information Set, commonly called HEDIS.** The 26 tip sheets cover areas as diverse as antidepressant medication management, avoidance of antibiotic treatment in adults with bronchitis and use of imaging studies for low back pain.

By focusing on evidence-based measures, including HEDIS measures, we can help prevent and control diseases and chronic conditions. According to the Centers for Disease Control and Prevention’s National Center for Chronic Disease Prevention and Health Promotion, 90% of the nation’s $3.3 trillion in annual health care expenditures are for people with chronic and mental health conditions.

Our HEDIS tip sheets are part of a portfolio of efforts launched over the past few years to give health care providers the tools they need to improve their performance on HEDIS measures. The tip sheets also support our Provider Recognition Program.

As you’ve read before, physicians who participate in the Physician Group Incentive Program can receive higher levels of reimbursement for meeting key HEDIS measures.

The tip sheets have been posted on both the BCBSM Provider Publications and Resources section of web-DENIS as well as on BCN Provider Publications and Resources. Here’s one way to access them:

1. From the homepage of web-DENIS, click on BCBSM Provider Publications and Resources in the left column.
2. Click on Newsletters & Resources.
3. Click on Clinical Quality Corner on the left-hand side of the page under Other Resources.

**HEDIS^® is a registered trademark of the National Committee for Quality Assurance, or NCQA.

Blue Cross, BCN offering innovative insulin management program to qualifying members

Blue Cross Blue Shield of Michigan and Blue Care Network are offering the d-Nav^® Insulin Guidance Service to patients who have Type 2 diabetes. We’re the first U.S. health plans to offer this service, which was recently featured by the American Diabetes Association on ADA TV** and in The Lancet.** In addition, a study has shown that the d-Nav service improves the use of insulin therapy for patients who have Type 2 diabetes.

Participants receive the d-Nav^® Phone App, which was approved by the U.S. Food and Drug Administration, and a connected glucose meter. The d-Nav app provides insulin dose recommendations before each injection of insulin. Based on glucose patterns, d-Nav automatically adjusts the recommended doses when needed so that the patient’s blood sugar remains under control.

Here are additional details:

• Members receive blood glucose test strips, control solution and lancets at no extra cost (no copays).
• Members must visit a d-Nav Care Center to initiate the service.
• The d-Nav service from Hygieia is free for commercial HMO and PPO members who have Type 2 diabetes.
• The service includes individual meetings, follow-up calls and remote dose adjustments to help patients make proper use of insulin.

Participants in a nine-month health economic study reported a significant improvement to their health and well-being. Average HbA1c declined from a baseline of 9.4% to 7.1%; over 96% achieved HbA1c less than 9%; and patient satisfaction increased from 2.2 at baseline to 3.7 on a 4-point scale.

Hygieia informs members’ primary care physicians about their patients’ outcomes or any significant changes to the treatment plan. A secure physician portal allows doctors to follow the progress of their patients at any time.

Addition background information

Clinical studies suggest effective insulin treatment requires dose adjustment once or twice per week. However, dose adjustments happen much less frequently in practice, at best every eight to 12 weeks. The result is that most insulin users are exposed to the risk of hypoglycemia without benefiting from insulin’s unlimited ability to address hyperglycemia.

The d-Nav service addresses this need for frequent dose adjustments. It collaboratively supports primary care physicians and their patients by providing on-demand dose adjustment as needed between clinic visits.

For more information:

• Contact Dr. Shyla Khatiwala, Hygieia medical director, at shyla.Khatiwala@hygieia.com or call the d-Nav Care Center at 734-743-2838.
• Review a related Record article published in February.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.

Sign up for additional training webinars

Provider Experience is continuing its series of training webinars for health care providers and staff. The webinars are designed to help you work more efficiently with Blue Cross Blue Shield of Michigan and Blue Care Network

Here’s how to register for two upcoming training webinars:

Blues 201 provides in-depth learning opportunities for providers and builds on information shared in our Blues 101: Understanding the Basics webinar. This session focuses on AIM.

As additional training webinars become available, we’ll communicate about them through web-DENIS or The Record.

Commercial audits of DME, HIT and HCD claims taking place

SCIO Health Analytics^®, an independent company that provides auditing support for Blue Cross Blue Shield of Michigan, began audits for durable medical equipment, home infusion therapy and high-cost drug claims on July 1, 2019.

Blue Cross conducts audits to ensure that billed and paid services were ordered, medically necessary, documented, reported and covered under the patient’s contract according Blue Cross’ compliance and policy guidelines. Specifically, audits are conducted to:

• Confirm compliance with ICD-10 guidelines and diagnostic codes that are in effect on the date of service
• Confirm compliance with CPT^® guidelines and codes
• Confirm proper use of HCPCS codes
• Detect, prevent and correct waste and abuse
• Facilitate accurate claim payment

You’ll need to provide medical charts for review at the time of an audit.

Durable medical equipment and diabetic supplies
Documentation for DME and diabetic supplies must support all items billed on the claim form. It should include:

• Prescription or order form from the referring physician
• Certificate of Medical Necessity, if applicable
• Physician chart notes, if applicable
• Orthotist or prosthetist evaluation notes, if applicable
• Delivery ticket
• Pickup ticket, if applicable
• Blue Cross’ authorization for treatment, if applicable
• For diabetic supplies, proof of member contact must be documented for each refill.

SCIO will confirm you’ve properly documented requirements for:

• Duplicate therapies and inappropriate equipment for diagnosis
• Purchase versus rental
• Multiple providers billing for same services
• Multiple purchases of same items
• Capitation arrangement with additional fee-for-service item
• Capped rental items

Home infusion therapy and high cost drug claims
HIT and HCD claims will be audited to ensure injections and infusions were ordered by the physician, billed appropriately by the provider and paid accurately by the payer. Considerations include:

• Duplication of therapies by different providers
• Waste
• Correct dosages administered
• Various billing and processing errors
• Validation of drug pricing
• Medical record reviews to verify compliance of dosage, method of administration and other criteria

More information
After an audit, SCIO will send you a finding letter with instructions on how to request an appeal in case you decide to do so.

If you have questions, call your Blue Cross provider consultant. Or, to speak with a SCIO representative, call 1‑866‑628‑3488, ext. 7411.

We’re changing categorization process for physical therapy

We’re changing the categorization process for physical therapy. Beginning in January 2020, physical therapists will be assigned to one category — A, B or C — for all four networks: Blue Cross Blue Shield of Michigan, Medicare Plus Blue^SM, Blue Care Network and BCN Advantage^SM. Categories are based on the physical therapy paid claims data for all four networks.

We hope that having one assigned category covering all Blue Cross and BCN networks will make it easier for you to manage therapy requests.

The categorization process will be completed by eviCore healthcare, an independent company. They’ll also continue to generate the Provider Performance Summaries, or profile reports, and post them on the eviCore website.

Due to the upcoming changes in the categorization process, you won’t be receiving profile reports that were originally scheduled for July 2019 for Blue Cross and for November 2019 for BCN. You’ll maintain your current provider categories and current program requirements until you receive the new combined categories.

The new combined categorizations will be sent by eviCore in February 2020. You’ll still have 15 days from receipt of your categorization report to request reconsideration if you have additional information not captured in the claims data. Going forward, the combined profile reports will be available in February and August, with notifications from eviCore going out to providers in late January and July.

We’ll include more detailed information about the categorization merger in the upcoming months.

List top locations when updating your information with CAQH

Blue Cross Blue Shield of Michigan and Blue Care Network have updated their systems, in collaboration with CAQH, to allow health care providers to list up to three active locations where members are being seen for display in our online directories.

Follow these guidelines when updating your information in CAQH:

• Make sure you list accurate locations where you see members on a regular basis.
• Indicate how many days you practice at each location (for example, weekly, if you practice there once a week).

Limiting your addresses to three active locations for our directory won’t affect claims processing since Blue Cross and BCN services aren’t address-specific. Instead, it will help direct members to appropriate locations for services.

As your location patterns change, you’ll still be able to change the addresses as necessary.

If you have any questions, contact Provider Enrollment Customer Service at 1‑800‑822‑2761.

We’ll add more vaccines to pharmacy benefit Aug. 1

Starting Aug. 1, 2019, eligible Blue Cross Blue Shield of Michigan and Blue Care Network commercial non-Medicare members will have coverage for additional vaccines under their pharmacy benefits plan. This allows participating pharmacies to bill through the pharmacy claims processing system.

We’ve added the following vaccines to the pharmacy benefit:

• Tetanus, diphtheria
• Polio
• Measles, mumps, rubella
• Meningococcal B
• Varicella (chickenpox)

The program will cover the same vaccines that are offered under the Vaccine Affiliation program, which are currently billed under the medical benefit. Listed below are the vaccines and age requirements covered under the pharmacy benefits plan:

Vaccines for Blue Cross members can be processed under both pharmacy benefits and medical plans, but only one plan can be billed per claim. Both plans require a qualified administrator at a Blue Cross‑participating pharmacy or medical office to give the vaccine.

Qualified pharmacists giving the vaccine can bill either the member’s pharmacy benefits plan or the member’s medical plan when the pharmacy participates in the medical Vaccine Affiliation Program.

Participating medical offices giving the vaccine should bill the member’s medical plan.

Most Blue Cross commercial members with prescription drug coverage are eligible. Most of the vaccines will be covered with no cost share to members if their benefits meet the coverage criteria.

Grandfathered and retiree opt-out groups won’t be part of this program. These groups will maintain their current vaccine coverage under their medical benefit.

Most Blue Cross and BCN members can search for a participating retail pharmacy by logging in to their member account at bcbsm.com. After logging in:

• Hover the mouse over My Coverage in the blue bar at the top of the page.
• Select Prescription from the drop-down menu.
• Scroll down to Where to go for care and click on Find a pharmacy. The link will take you directly to Express Scripts^®. You won’t have to log in again.

Immune, subcutaneous globulin dosing strategy changing

Blue Cross Blue Shield of Michigan and Blue Care Network currently include immune globulin products in the prior authorization program under pharmacy and medical benefits for commercial members. Intravenous and subcutaneous immune globulin products available for the medical benefit are also included in the site of care program.

Immune globulin replacement therapy is indicated for many labeled and off-label indications and is traditionally dosed using a patient’s actual body weight. IVIG and SCIG products (see the list below) have insignificant distribution into fat tissue and are only present in the intravascular space and extracellular fluids. Clinical literature supports alternative dosing strategies that provide comparable drug exposure without altering the clinical outcomes of treatment.

To minimize drug waste, reduce unnecessary drug exposure and decrease the risk of adverse events, we’ll update our dosing strategy for intravenous and subcutaneous immune globulin therapy.

Effective Oct. 1, 2019, we’ll calculate doses using adjusted body weight for members whose:

• Body mass index is 30 kg/m2 or greater, or
• Actual body weight is 20% to 30% higher than their ideal body weight.

This applies to all members starting therapy on or after Oct. 1. Members currently receiving immune globulin will continue to receive their current dose until their prior authorizations expire.

This change doesn’t apply to the following:

• Blue Cross PPO or BCN HMO^SM commercial pediatric members, defined as:
  • Less than or equal to 15 years of age, or
  • Less than or equal to 18 years old and less than or equal to 50 kg.
• BCN Advantage^SM members
• Medicare Plus Blue^SM PPO members
• Federal Employee Program^® members

We’ll contact members currently on IVIG and SCIG therapy to let them know about this change.

Kenalog Spray and oral inhalers will have new quantity limits starting Sept. 1

On Sept. 1, 2019, Blue Cross Blue Shield of Michigan will implement quantity limits for Kenalog^® Spray and oral inhalers. To see a list of quantity limits for these products, click here.

This change is part of our overall efforts to provide members with safe, high-quality prescription drugs. It only affects our commercial (non-Medicare) members who have Blue Cross and Blue Care Network pharmacy benefits.

On July 17, we sent letters to members who may be affected by these quantity limit changes. The letters encourage members to discuss treatment options with their physicians.

If necessary, you can request an override of the quantity limits for your patients. For more information, call the Pharmacy Services Clinical Help Desk at 1‑800‑437‑3803.

Coding corner: Coding and documentation for COPD

Did you know?
Approximately 16 million Americans have chronic obstructive pulmonary disease, or COPD.

Here’s an overview of COPD and tips for documenting and coding it appropriately.

About COPD

COPD is a chronic inflammatory lung disease that results in the obstruction of smaller airways within the lungs. Symptoms may be mild at first, beginning with a cough and shortness of breath with exertion. As it progresses, shortness of breath worsens and may be present at rest. Abnormal levels of oxygen and carbon dioxide in the blood may also be found in patients with advanced COPD. Ultimately, progression of the disease leads to chronic respiratory failure.

COPD is a collective term that includes three specific diseases:

• Chronic bronchitis
• Emphysema
• Asthma with chronic obstruction

Emphysema is characterized by the slow progressive destruction of lung tissue, mainly the small air sacs in the lungs known as alveoli. This interferes with outward air flow from the lungs.

Chronic bronchitis mainly causes inflammation of the bronchial tubes, which allows mucus to build up and obstruct the airways. It also causes some constriction and narrowing of the airways. Patients with longstanding asthma may develop chronic obstruction of the airways and chronic inflammation, similar to chronic bronchitis.

Most patients with COPD have a combination of both emphysema and chronic bronchitis features. Emphysema features will be predominant in some patients, while chronic bronchitis features will be predominant in others.

Symptoms of COPD can vary from one patient to the next, but common symptoms are:

• Shortness of breath
• Frequent coughing, with or without mucus production
• Fatigue
• Wheezing
• Tightness in the chest

Stages of COPD

The stages of COPD are based on the forced expiratory volume, or FEV1. This is the maximal amount of air someone can forcefully exhale in one second. It is then converted to a percentage of normal. The lower the FEV1, the more severe the disease.

• Stage I (early or mild) — FEV1 about 80% or more of normal
• Stage II (moderate) — FEV1 between 50% and 80% of normal
• Stage III (Severe) — FEV1 between 30% and 50% of normal
• Stage IV (very severe or end stage) — FEV1 less than 30%, or people with low blood oxygen levels and a Stage III FEV1

Treatments for COPD

• Bronchodilators to open airways — Most come in the form of inhalers. Both short- and long-acting bronchodilators are available.
• Steroids — These reduce inflammation, swelling and mucus production. Less swelling allows more space through which air can travel. Steroids can be inhaled, taken orally or injected.
• Immunization — Centers for Disease Control and Prevention recommends that individuals with COPD get flu and pneumococcal vaccinations to help protect against complications of COPD.
• Oxygen therapy — Because COPD can lower blood oxygen levels, this treatment provides the body the extra oxygen it needs.

Documentation and coding tips

Always document and code COPD to the highest specificity. The term “COPD” is less specific than the individual diseases it includes. If a patient predominantly exhibits features of one specific disease over another, such as emphysema, chronic obstructive asthma or chronic bronchitis, then this should be documented rather than COPD.

Since conditions under the COPD umbrella can be coded in a variety of ways, the final code selection must consider all the specific details of a patient’s condition as documented by the provider.

With the increased specificity in documentation required by ICD-10-CM guidelines, here are some key points to remember:

• Specify the acuity: acute, chronic, intermittent, or chronic with an acute exacerbation
• Describe the severity: mild, moderate or severe
• Document clinical signs and symptoms: coughing, wheezing, sputum production, shortness of breath
• List any history of tobacco use, environmental exposure or occupational exposure
• Note any diagnostics test: ABGs (arterial blood gas test), PFTs (pulmonary function test), chest X-rays
• Document any treatment: oxygen, bronchodilators, steroids, pulmonary rehabilitation

Some examples of COPD codes are given in the chart below:

Sources:

• copdfoundation.com**
• mayoclinic.org**
• 2019 ICD-10-CM Professional for Physicians

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.

Study identifies barriers to statin therapy adherence

Statin therapy plays a key role in preventing cardiovascular events, but many patients don’t comply with statin therapy recommendations. According to a five-year study** from the National Center for Biotechnology Information, 50% of patients don’t adhere to the recommended statin therapy, with the highest level of discontinuation happening during the first year.

The NCBI study found the following:

• Patients younger than 50 and 70 or older are more likely not to adhere.
• Women are less likely to take statins as prescribed.
• Some patients reported not understanding the reason behind or the importance of statin therapy.
• Some patients reported having trouble remembering to take their statin.
• Some patients preferred lifestyle changes, such as diet, to lower cholesterol.

By understanding the reasons for nonadherence, barriers can be addressed, and treatment plans can be tailored to meet a patient’s individual needs.

An FEP^® reminder
The Federal Employee Program^® encourages you to remind patients who are FEP members that that they have no copay for generic statin drugs when filled at a preferred pharmacy. If your FEP patients have questions about their benefits, they can contact Customer Service at 1‑800‑482‑3600 or visit www.fepblue.org.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.

We’ll add more vaccines to pharmacy benefit Aug. 1

Starting Aug. 1, 2019, eligible Blue Cross Blue Shield of Michigan and Blue Care Network commercial non-Medicare members will have coverage for additional vaccines under their pharmacy benefits plan. This allows participating pharmacies to bill through the pharmacy claims processing system.

We’ve added the following vaccines to the pharmacy benefit:

• Tetanus, diphtheria
• Polio
• Measles, mumps, rubella
• Meningococcal B
• Varicella (chickenpox)

The program will cover the same vaccines that are offered under the Vaccine Affiliation program, which are currently billed under the medical benefit. Listed below are the vaccines and age requirements covered under the pharmacy benefits plan:

Vaccines for Blue Cross members can be processed under both pharmacy benefits and medical plans, but only one plan can be billed per claim. Both plans require a qualified administrator at a Blue Cross‑participating pharmacy or medical office to give the vaccine.

Qualified pharmacists giving the vaccine can bill either the member’s pharmacy benefits plan or the member’s medical plan when the pharmacy participates in the medical Vaccine Affiliation Program.

Participating medical offices giving the vaccine should bill the member’s medical plan.

Most Blue Cross commercial members with prescription drug coverage are eligible. Most of the vaccines will be covered with no cost share to members if their benefits meet the coverage criteria.

Grandfathered and retiree opt-out groups won’t be part of this program. These groups will maintain their current vaccine coverage under their medical benefit.

Most Blue Cross and BCN members can search for a participating retail pharmacy by logging in to their member account at bcbsm.com. After logging in:

• Hover the mouse over My Coverage in the blue bar at the top of the page.
• Select Prescription from the drop-down menu.
• Scroll down to Where to go for care and click on Find a pharmacy. The link will take you directly to Express Scripts^®. You won’t have to log in again.

Immune, subcutaneous globulin dosing strategy changing

Blue Cross Blue Shield of Michigan and Blue Care Network currently include immune globulin products in the prior authorization program under pharmacy and medical benefits for commercial members. Intravenous and subcutaneous immune globulin products available for the medical benefit are also included in the site of care program.

Immune globulin replacement therapy is indicated for many labeled and off-label indications and is traditionally dosed using a patient’s actual body weight. IVIG and SCIG products (see the list below) have insignificant distribution into fat tissue and are only present in the intravascular space and extracellular fluids. Clinical literature supports alternative dosing strategies that provide comparable drug exposure without altering the clinical outcomes of treatment.

To minimize drug waste, reduce unnecessary drug exposure and decrease the risk of adverse events, we’ll update our dosing strategy for intravenous and subcutaneous immune globulin therapy.

Effective Oct. 1, 2019, we’ll calculate doses using adjusted body weight for members whose:

• Body mass index is 30 kg/m2 or greater, or
• Actual body weight is 20% to 30% higher than their ideal body weight.

This applies to all members starting therapy on or after Oct. 1. Members currently receiving immune globulin will continue to receive their current dose until their prior authorizations expire.

This change doesn’t apply to the following:

• Blue Cross PPO or BCN HMO^SM commercial pediatric members, defined as:
  • Less than or equal to 15 years of age, or
  • Less than or equal to 18 years old and less than or equal to 50 kg.
• BCN Advantage^SM members
• Medicare Plus Blue^SM PPO members
• Federal Employee Program^® members

We’ll contact members currently on IVIG and SCIG therapy to let them know about this change.

Kenalog Spray and oral inhalers will have new quantity limits starting Sept. 1

On Sept. 1, 2019, Blue Cross Blue Shield of Michigan will implement quantity limits for Kenalog^® Spray and oral inhalers. To see a list of quantity limits for these products, click here.

This change is part of our overall efforts to provide members with safe, high-quality prescription drugs. It only affects our commercial (non-Medicare) members who have Blue Cross and Blue Care Network pharmacy benefits.

On July 17, we sent letters to members who may be affected by these quantity limit changes. The letters encourage members to discuss treatment options with their physicians.

If necessary, you can request an override of the quantity limits for your patients. For more information, call the Pharmacy Services Clinical Help Desk at 1‑800‑437‑3803.

Commercial audits of DME, HIT and HCD claims taking place

SCIO Health Analytics^®, an independent company that provides auditing support for Blue Cross Blue Shield of Michigan, began audits for durable medical equipment, home infusion therapy and high-cost drug claims on July 1, 2019.

Blue Cross conducts audits to ensure that billed and paid services were ordered, medically necessary, documented, reported and covered under the patient’s contract according Blue Cross’ compliance and policy guidelines. Specifically, audits are conducted to:

• Confirm compliance with ICD-10 guidelines and diagnostic codes that are in effect on the date of service
• Confirm compliance with CPT^® guidelines and codes
• Confirm proper use of HCPCS codes
• Detect, prevent and correct waste and abuse
• Facilitate accurate claim payment

You’ll need to provide medical charts for review at the time of an audit.

Durable medical equipment and diabetic supplies
Documentation for DME and diabetic supplies must support all items billed on the claim form. It should include:

• Prescription or order form from the referring physician
• Certificate of Medical Necessity, if applicable
• Physician chart notes, if applicable
• Orthotist or prosthetist evaluation notes, if applicable
• Delivery ticket
• Pickup ticket, if applicable
• Blue Cross’ authorization for treatment, if applicable
• For diabetic supplies, proof of member contact must be documented for each refill.

SCIO will confirm you’ve properly documented requirements for:

• Duplicate therapies and inappropriate equipment for diagnosis
• Purchase versus rental
• Multiple providers billing for same services
• Multiple purchases of same items
• Capitation arrangement with additional fee-for-service item
• Capped rental items

Home infusion therapy and high cost drug claims
HIT and HCD claims will be audited to ensure injections and infusions were ordered by the physician, billed appropriately by the provider and paid accurately by the payer. Considerations include:

• Duplication of therapies by different providers
• Waste
• Correct dosages administered
• Various billing and processing errors
• Validation of drug pricing
• Medical record reviews to verify compliance of dosage, method of administration and other criteria

More information
After an audit, SCIO will send you a finding letter with instructions on how to request an appeal in case you decide to do so.

If you have questions, call your Blue Cross provider consultant. Or, to speak with a SCIO representative, call 1‑866‑628‑3488, ext. 7411.