Changes to all Blue Cross Blue Shield of Michigan practitioner participation agreements announced

We’re making changes to the amendment provisions for all Blue Cross professional practitioner agreements and the Blue Cross Medicare Advantage PPO agreement. Effective Jan. 1, 2020, in addition to the language currently in the amendment provisions, these provisions will also state the following.

Blue Cross professional practitioner agreements:

“Notwithstanding the foregoing, if PRACTITIONER is employed by a physician group, physician organization, hospital or system, or other such entity (generally “Entity”), then PRACTITIONER acknowledges that he/she has authorized and empowered Entity to contract on PRACTITIONER’s behalf and bind PRACTITIONER to the terms and conditions of any arrangement Entity may enter into with BCBSM. If PRACTITIONER is not employed but has otherwise confirmed to BCBSM his/her affiliation with an Entity through a signed affiliation attestation, then PRACTIONER acknowledges that he/she has read and agrees to be bound to the terms of said Entity’s arrangement with BCBSM. Whether employed or affiliated, as set for above, PRACTITIONER acknowledges and agrees that BCBSM may, without notice of any kind, modify the terms of this Agreement to the extent necessary to effectuate and operationalize the arrangement between Entity and BCBSM. Such modifications may include, but are not limited to, modification to fee schedules or rates, application of withholds on payments to PRACTITIONER, or modifications to incentive programs. If a conflict exists between this Agreement and an arrangement between BCBSM and the Entity, the arrangement between BCBSM and the Entity shall control for disputes arising thereunder.”

Blue Cross MA PPO agreement:

7.3 General Modifications. BCBSM may amend this Agreement by providing ninety (90) days prior notice, written or electronic, of such amendment. Electronic notice shall include, but not be limited to, publication on web-DENIS. Written notice may include publication in The Record. Provider’s signature is not required to make the amendment effective. However, should the Provider no longer wish to continue affiliation in the MA PPO Program because of an amendment, then Provider may terminate this Agreement by providing forty-five (45) days written notice to BCBSM except during the initial term of the Agreement.

Otherwise, this Agreement, or any part, article, section, Exhibit, or Attachment hereto, may be amended, altered, or modified only in writing as duly executed by both parties.

Notwithstanding the foregoing, if Provider is employed by a physician group, physician organization, hospital or system, or other such entity (generally “Entity”), then Provider acknowledges that he/she has authorized and empowered Entity to contract on Provider’s behalf and bind Provider to the terms and conditions of any arrangement Entity may enter into with BCBSM.  If Provider is not employed but has otherwise confirmed to BCBSM his/her affiliation with an Entity through a signed affiliation attestation, then Provider acknowledges that he/she has read and agrees to be bound to the terms of said Entity’s arrangement with BCBSM.  Whether employed or affiliated, as set for above, Provider acknowledges and agrees that BCBSM may, without notice of any kind, modify the terms of this Agreement to the extent necessary to effectuate and operationalize the arrangement between Entity and BCBSM, to the extent the terms of such modifications are in accordance with the Medicare Advantage program rules pertaining to physician incentive plans. Such modifications may include, but are not limited to, modification to fee schedules or rates, application of withholds on payments to Provider, or modifications to incentive programs. If a conflict exists between any provision of this Agreement and an arrangement between BCBSM and the Entity, the arrangement between BCBSM and the Entity shall control, except for such provisions of this Agreement which are required by Medicare Advantage program rules, regulations, or CMS sub-regulatory guidance, in which case such provisions of this Agreement shall control.

Mandated changes to Blue Cross Medicare Advantage PPO agreement announced

Blue Cross Blue Shield of Michigan is adding the following provision to the Medicare Advantage PPO Provider Agreement. This is in accordance with the requirements of Centers for Medicare & Medicaid Services regulations 42 C.F.R. § 422.2 and 42 C.F.R. § 422.222:

CMS Preclusion List. Medicare Advantage Organizations are not permitted to make payment for a health care item, service, or drug that is furnished, ordered or prescribed by an individual or entity that is included in the CMS Preclusion List 42 C.F.R. § 422.2. Should Provider be added to the CMS Preclusion List, it agrees to immediately notify BCBSM so that BCBSM may notify its impacted members. Provider understands and agrees that beginning 60 days after the notification to the member, Provider will no longer be eligible for payment from BCBSM and will be prohibited from pursuing payment from the member for any service furnished, ordered, or prescribed after that date. Provider also understands and agrees that it will hold financial liability for services, items, and drugs that are furnished, ordered, or prescribed after the 60-day period. Provider asserts that it does not now, nor will it in the future, employ or contract with providers or prescribers who are listed on the CMS Preclusion List. Provider understands that the Preclusion List will be regularly updated by CMS and agrees that it will monitor the Preclusion List and ensure that none of its employees, contractors, or prescribers are included on it. Should Provider discover that one of its employees, contractors, or prescribers has been added to the preclusion list, Provider agrees to immediately notify BCBSM. Provider shall ensure that payments are not made to providers or prescribers included on the CMS Preclusion List. To the extent that Provider contracts with other providers to provide services to BCBSM members pursuant to this agreement, it will require such other providers to comply with the requirements of 42 C.F.R. § 422.2 and 42 C.F.R. § 422.222.

Since the above provision is a CMS mandated change, it will amend the agreement 30 days after publication of this article. This is in accordance with Paragraph 7.1 of the Blue Cross Medicare Advantage PPO agreement.

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 on Oct. 9 from 10 to 11:30 a.m. AIM handles our commercial PPO, Medicare Plus Blue^SM and BCN outpatient prior authorizations for several programs, including high-tech radiology and cardiology.

AIM also handles Blue Cross’ in-lab sleep therapy for both commercial and Medicare Plus Blue members, as well as select programs for URMBT (medical and radiation oncology).

This webinar will give you an overview of the AIM prior authorization program provider portal and provide you with information and links to program enhancements since 2018. Some topics include:

• 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 webinar.

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

Additional webinars are scheduled for October, including one titled AIM Specialty Medicare Advantage Medical Oncology. See Sign up for additional training webinars, also in this issue, for details.

Sign up today: New training webinars for providers and staff

Provider Experience is continuing its series of training webinars for health care providers and staff. The webinars are designed to help you better understand how Blue Cross Blue Shield of Michigan and Blue Care Network operate, and how we can work more efficiently together.

Sign up today
Here’s the upcoming schedule. Click a link below to register for dates and times that work for you.

As additional training webinars become available, we’ll update you via web-DENIS or The Record.

Here’s when to bill for an originating site facility fee

Providers have expressed some confusion about when and how to bill for the telehealth originating site facility fee (HCPCS code Q3014).

Providers should only bill the originating site facility fee when telehealth technology is used to connect the patient to a provider at a distant location. If the patient is in the same location of the provider who is rendering a professional service, the originating site code isn’t required and, therefore, is not payable.

Blue Cross Blue Shield of Michigan follows the Centers for Medicare & Medicaid Services originating site requirements and allows for reimbursement when the patient is in the following locations:

• Physician or practitioner’s office
• Outpatient hospital
• Critical access hospital, or CAH
• Rural health clinic
• Federally qualified health center
• Community mental health center
• Skilled nursing facility
• Hospital-based or CAH-based renal dialysis center

The originating site facility fee isn’t considered an actual service provided. Rather, the fee is for the use of the telehealth technology at one of the above-named locations. The technology provides a service for a patient receiving service from a provider at a distant location.

Changes to reimbursement policy for board-certified behavior analysts take place Jan. 1

Effective Jan. 1, 2020, the following two reimbursement policy changes affecting board-certified behavior analysts will occur.

1. Regarding Blue Cross Blue Shield of Michigan’s Board Certified Behavior Analyst Participation Agreement, Addendum C (Reimbursement Methodology), the payment policy will change to reflect that BCBSM will pay the lesser of the billed charge or 80% of the published maximum payment... The current methodology calls for 60% of the published maximum payment.

   According to Section 6.6 of the Participation Agreement, the provider’s signature isn’t required to make an amendment to the agreement effective. However, if the provider no longer wishes to continue his or her participation in the network because of an amendment, the provider may terminate the agreement by providing 45 days written notice to Blue Cross.

   The revised agreement will be available on Jan. 1, 2020, in the Participation chapter of the online provider manual on web-DENIS.

2. In addition to the modification to the agreement outlined above, approved amounts for adaptive behavior assessment and treatment codes also will change Jan. 1, 2020. Revised amounts will be available for viewing on web-DENIS on Oct. 1, 2019. To find fee schedule information, go to the homepage of web-DENIS and follow these steps:
   1. Click on BCBSM Provider Publications and Resources.
   2. Click on Entire Fee Schedules and Fee Changes. (After clicking on this, you’ll be asked to accept the End User Agreement.).

Blue Cross updates medical record requirements for applied behavior analysis services

Blue Cross Blue Shield of Michigan updated the medical record documentation requirements for applied behavior analysis services. The updates clarify documentation requirements for services involving tutors and technicians.

These requirements apply to the following plans:

• Blue Cross PPO commercial
• BCN HMO^SM (commercial)

View the updated medical record requirements here. You can also find them at ereferrals.bcbsm.com. Click BCN or Blue Cross and then Behavioral Health. Once on the Behavioral Health page, select the document title, which is Behavioral health medical record documentation requirements for applied behavior analysis services.

Save time, submit prior authorization requests electronically for pharmacy benefit drugs

Providers can now use their electronic health record or CoverMyMeds^®** to submit prior authorizations for Blue Cross Blue Shield of Michigan and Blue Care Network commercial members with commercial pharmacy benefits.

Electronic prior authorization, or ePA, replaces faxing and phone calls so providers can focus less on administrative tasks and more on patient care. Other benefits of ePA include:

• Automatic approvals for select drugs.
• Turnaround time is improved for reviews and decisions.
• Easy to use for prescribers, nurses and office staff.
• All documentation and requests are kept conveniently in one place.

Here are some answers to frequently asked questions about ePA:

Why should I use ePA?
You’ll save time. You can send 11 ePAs in the time it takes to fax just one (based on Comcast and Verizon broadband rates and fax speed of 33.6 kilobits per second), and patients can receive medications faster.

The process is easy and intuitive, and providers and authorized personnel can use the electronic health record tool or log in online.

What is the cost of ePA?
Some electronic health record vendors charge an additional fee for this added functionality. There’s no cost to use online portals.

What makes ePA better?
Both the online portals and ePA within your electronic health record make it easy to submit fully electronic requests and give you:

• Clear direction on clinical requirements
• The ability to attach documentation if required
• Secure and efficient prior authorization administration all in one place
• The capability to proactively renew existing prior authorizations up to 60 days before they expire
• Streamlined questions, asking only those needed for the prior authorization, unlike fax forms.

How do I get started?
Electronic prior authorization can integrate into your current electronic health record workflow. Check with your vendor to ensure you have the latest software version enabling ePA.

If ePA in your electronic health record tool is currently unavailable, create a free account online for the tool that works best for your office. Registration is free and takes only a couple of minutes.

To complete an ePA, follow these steps:

1. Go to covermymeds.com/epa/express-scripts.***

• Create a free account if you don’t already have one.

2. Start a prior authorization.

• Click New Request, and enter the patient’s state and medication.
• Type Blue Cross Blue Shield of Michigan into the Plan, PBM and Form Name field.
• Select the appropriate form, and click Start Request.

3. Complete the ePA.

• Enter all demographic fields marked Required, and click Send to Plan.
• Complete the returned list of patent-specific, clinical questions marked Required.

4. Confirm the ePA process has been completed.

• Click Send to Plan again to complete the ePA request.
• After Blue Cross or BCN has reviewed your submitted prior authorization, the determination will appear in your CoverMyMeds account.

Approval decisions are often returned within moments of submission, depending on the complexity or need for further review.

For more information

• If you have questions, contact the Pharmacy Help Desk at 1-800-437-3803.
• Click here for a flyer detailing the benefits of ePA.

**Other free ePA services include Surescripts^® and ExpressPAth^®.
***Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.

We’ll be adding Evenity to the Medicare Part B medical drug prior authorization list

We’re adding Evenity^® (J3111) to the Medicare Plus Blue^SM PPO and BCN Advantage^SM Part B medical drug prior authorization list for dates of service on or after Nov.1, 2019. 

Medicare Plus Blue PPO
For Medicare Plus Blue, we’ll require prior authorization for this medication for the following sites of care when you bill the medication electronically through an 837P transaction or on a professional CMS-1500 claim form:

• Physician office (place of service code 11)
• Outpatient facility (place of service code 19, 22 or 24)

BCN Advantage
For BCN Advantage, we’ll require prior authorization for this medication for the following sites of care when you bill the medication as a professional service or as an outpatient facility service, and when you bill electronically through an 837P transaction or on a professional CMS-1500 claim form:

• Physician office (place of service code 11)
• Outpatient facility (place of service code 19, 22 or 24)
• Home (place of service code 12)

We’ll also require prior authorization when you bill electronically through an 837I transaction or use a UB04 claim form for a hospital outpatient type of bill 013x.

Use NovoLogix to submit requests
The NovoLogix^® online tool offers real-time status checks and immediate approvals for certain medications.

To gain access:

• For BCN Advantage, access to Provider Secured Services gives you automatic access to NovoLogix. There’s nothing more you need to do.
• For Medicare Plus Blue, if you have a Type 1 (individual) NPI and you checked the “Medical Drug PA” box when you completed the Provider Secured Services Application, you have access to NovoLogix. If you didn’t check that box, complete Addendum P and fax it to the number on the form.

If you need access to Provider Secured Services, complete the Provider Secured Services Application and fax it to the number on the form.

To access NovoLogix through Provider Secured Services:

1. Visit bcbsm.com/providers.
2. Click Login.
3. Log in to Provider Secured Services.
4. Click one of the following on the Provider Secured Services homepage.
   • BCN Medical Benefit – Medication Prior Authorization
   • Medicare Advantage PPO Medical Benefit – Medication Prior Authorization
5. Enter or select your NPI and click Go.

If you can’t log in to Provider Secured Services, call 1-877-258-3932 from 8 a.m. to 8 p.m. Eastern time Monday through Friday.

If you have questions about authorizations, call the Pharmacy Help Desk at 1‑800‑437‑3803 from 9 a.m. to 4 p.m. Eastern time Monday through Friday.

We’ll cover hemophilia drugs under the pharmacy benefit for most commercial members, starting Jan. 1

We’re changing how we cover hemophilia drugs for most of our commercial, non-Medicare members. Starting Jan. 1, 2020, if a member has Blue Cross Blue Shield of Michigan or Blue Care Network pharmacy coverage, all hemophilia drugs should be billed under their pharmacy benefits.

However, this change doesn’t affect all commercial members. For example, if a member has pharmacy coverage through a company other than Blue Cross or BCN, hemophilia drugs will continue to be covered under the medical benefit.

To determine whether this change applies to a specific member:

• Review Blue Cross PPO member benefits in Benefit Explainer.
• Review BCN HMO^SM member benefits in web-DENIS.

We’ll notify affected members about these changes. Members don’t have to do anything. Their medication and treatment won’t change.

Here are answers to some frequently asked questions.

What changes will occur on Jan. 1, 2020?
For affected members, hemophilia drugs that are currently covered under the medical benefit will be covered under the pharmacy benefit. In addition:

• Members will be limited to a 30-day supply of hemophilia drugs.
• The hemophilia drug Hemlibra^® will continue to require authorization.

When will the changes go into effect?
The changes will go into effect for dates of service on or after Jan. 1, 2020.

Which groups and members are affected?
This change affects most commercial Blue Cross PPO and BCN HMO members who have pharmacy coverage, including those covered by individual plans and those covered through groups with administrative service contracts.

ASC groups can opt out of the program. Groups that opt out will continue to use the medical benefit for hemophilia drugs.

The following groups and members aren’t affected:

• HMO and PPO members with a carved-out pharmacy benefit
• Medicare and Medicaid members
• Groups with pharmacy benefits that involve limited and religious accommodations that cover only the pharmacy benefits mandated by the Affordable Care Act

How will this change affect members who are currently undergoing hemophilia therapy?
There won’t be any change to a member’s therapy. Drug selection, dosage and frequency will remain the same. Members will continue to receive care from their current providers.

We’re adding hemophilia drugs to the formulary as branded, nonspecialty medications. Depending on a member’s pharmacy benefits, copayments may increase for some members.

How will providers and specialty pharmacies know to bill the pharmacy benefit starting Jan. 1, 2020?
We’ll send letters to providers and specialty pharmacies about billing Blue Cross and BCN members under the pharmacy benefit, unless the members’ group has opted out of the hemophilia program.

If a hemophilia drug is processed under the pharmacy benefit and the group has opted out, a point-of-sale message will let the specialty pharmacy know immediately that the place of service isn’t covered. The provider or specialty pharmacy will be instructed to bill the medical benefit, as they did previously.

Why are we making this change?

Quality of care: We provide our members with access to the best health care at the lowest cost. By adding this drug class to the pharmacy benefit, we can continue to offer hemophilia therapy to our members while increasing the quality of care and possibly reducing the cost to the plan and to our members.

Better data: We’ll be able to get real-time data regarding units dispensed, dosing and the dates on which each member receives medication. This data isn’t always available under the medical benefit. In addition, we can see where the member is receiving therapy and direct him or her to higher-quality centers with better pricing.

We’ll stop covering 500 mg Zytiga tablets starting Nov. 1

We’ll no longer cover 500 mg Zytiga^® (abiraterone) tablets starting Nov. 1, 2019. However, members can continue to fill their prescriptions for 500 mg Zytiga until Jan. 1, 2020. If they fill prescriptions for 500 mg Zytiga tablets on or after this date, they’ll be responsible for the full cost.

Note: Members can continue their current treatment with generic Zytiga 250 mg tablets and may pay less for this prescription than what they pay currently.

The following table includes some information to compare the available strengths of Zytiga.

We’ll let members know about this change and encourage them to speak with their doctor about getting a prescription for 250 mg generic Zytiga tablets and discuss any concerns they may have.

For a complete list of covered drugs, go to bcbsm.com/pharmacy and click Drug lists.

If you have questions, call the Pharmacy Services Clinical Help Desk at 1-800-437-3803 and select Option 1.

Save time, submit prior authorization requests electronically for pharmacy benefit drugs

Providers can now use their electronic health record or CoverMyMeds^®** to submit prior authorizations for Blue Cross Blue Shield of Michigan and Blue Care Network commercial members with commercial pharmacy benefits.

Electronic prior authorization, or ePA, replaces faxing and phone calls so providers can focus less on administrative tasks and more on patient care. Other benefits of ePA include:

• Automatic approvals for select drugs.
• Turnaround time is improved for reviews and decisions.
• Easy to use for prescribers, nurses and office staff.
• All documentation and requests are kept conveniently in one place.

Here are some answers to frequently asked questions about ePA:

Why should I use ePA?
You’ll save time. You can send 11 ePAs in the time it takes to fax just one (based on Comcast and Verizon broadband rates and fax speed of 33.6 kilobits per second), and patients can receive medications faster.

The process is easy and intuitive, and providers and authorized personnel can use the electronic health record tool or log in online.

What is the cost of ePA?
Some electronic health record vendors charge an additional fee for this added functionality. There’s no cost to use online portals.

What makes ePA better?
Both the online portals and ePA within your electronic health record make it easy to submit fully electronic requests and give you:

• Clear direction on clinical requirements
• The ability to attach documentation if required
• Secure and efficient prior authorization administration all in one place
• The capability to proactively renew existing prior authorizations up to 60 days before they expire
• Streamlined questions, asking only those needed for the prior authorization, unlike fax forms.

How do I get started?
Electronic prior authorization can integrate into your current electronic health record workflow. Check with your vendor to ensure you have the latest software version enabling ePA.

If ePA in your electronic health record tool is currently unavailable, create a free account online for the tool that works best for your office. Registration is free and takes only a couple of minutes.

To complete an ePA, follow these steps:

1. Go to covermymeds.com/epa/express-scripts.***

• Create a free account if you don’t already have one.

2. Start a prior authorization.

• Click New Request, and enter the patient’s state and medication.
• Type Blue Cross Blue Shield of Michigan into the Plan, PBM and Form Name field.
• Select the appropriate form, and click Start Request.

3. Complete the ePA.

• Enter all demographic fields marked Required, and click Send to Plan.
• Complete the returned list of patent-specific, clinical questions marked Required.

4. Confirm the ePA process has been completed.

• Click Send to Plan again to complete the ePA request.
• After Blue Cross or BCN has reviewed your submitted prior authorization, the determination will appear in your CoverMyMeds account.

Approval decisions are often returned within moments of submission, depending on the complexity or need for further review.

For more information

• If you have questions, contact the Pharmacy Help Desk at 1-800-437-3803.
• Click here for a flyer detailing the benefits of ePA.

**Other free ePA services include Surescripts^® and ExpressPAth^®.
***Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.

Physical, occupational and speech therapy claims require appropriate modifier

Blue Cross Blue Shield of Michigan is updating the claims processing system to require all outpatient physical, occupational and speech therapy claims to be billed with one of the following therapy modifiers:

• GN
• GO
• GP

Once the update is complete, the claims processing system will reject all professional outpatient therapy services submitted without an appended modifier. Therapy providers are encouraged to begin billing with the modifiers as soon as possible.

The system update is expected to be completed in early 2020. We’ll notify you of the effective date through web-DENIS and a future issue of The Record.

2019 third-quarter CPT code updates

Pathology and laboratory

Proprietary laboratory analysis codes

CPT Category II codes

Composite measures
Physical examination

CPT Category II codes

Performance measures
Diagnostic/screening processes or results

Categorization for outpatient physical therapy services changing in 2020

As previously announced in an article in the August 2019 Record, Blue Cross Blue Shield of Michigan and Blue Care Network are changing the use management categorization process for physical therapy. Beginning Jan. 1, 2020, profile reports for categorization will include physical therapy claims from Blue Cross commercial PPO, Medicare Plus Blue^SM PPO, BCN commercial and BCN Advantage^SM HMO.

Having one assigned category covering all four networks should make it easier for you to manage therapy requests.

About the program
The program:

• Applies to in-state, outpatient services
• Includes independent, outpatient, hospital outpatient and occupational therapy services
• Includes the current preauthorization program for three of the four networks
• Will be based on a single categorization score across the plans

About the new category assignments

• Category assignments will be determined by 12 months of combined independent, outpatient and hospital outpatient paid claims data.
• Categories will be based on risk-adjusted visits by age, gender and diagnosis.
• Visits will be appropriately weighted through eviCore healthcare’s process to develop a combined peer average, and will be tiered into three categories:

A — Up to 80% of the peer average
B — Greater than 80 to120% of the peer average
C — Greater than 120% of the peer average

• IPT services will be categorized individually by their type 1 NPI, based on all rendered services, not as a group.
• Physical therapists must have at least 10 episodes of service to be categorized.
• Providers with less than 10 episodes will default to category B.
• New providers with 10 or more episodes will no longer default to category B but will be categorized into their appropriate tier based on their average risk-adjusted visits or episodes.
• When multiple therapists in a practice treat the same patient and bill therapy services for a distinct member episode using a common tax ID, eviCore uses visit attribution (a method to avoid under-reporting utilization) and will attribute all PT utilization to the provider who billed the most visits for that episode of care. 
• Provider Performance Summary TREND reports will be available on eviCore’s website in November 2019.

Next steps
In late January 2020, eviCore will mail letters identifying your provider category based on your combined claims data. Physical therapists will continue to have the option to request a reconsideration of category status within 15 days from the date of the category notification letter if they have additional information that may change their category.

Preauthorization process
Preauthorization will continue for BCN, BCN Advantage and Medicare Plus Blue PPO based on your combined category. There’s no change to the preauthorization program for M.D.s, D.O.s, speech and language therapists and occupational therapists. And you’ll continue to receive a Provider Performance Summary if you received one previously.

Corrective Action Plan
CAP will continue for Blue Cross’ commercial PPO.

• If a provider in category C has more than 50% of the total number of patients categorized as commercial PPO patients:
• Warning letters will be sent by Blue Cross to providers who remain in category C for three consecutive categorization periods
• Disaffiliation letters will be sent by Blue Cross to providers in category C for four consecutive categorization periods
• A first- and second-level appeal process will be available to providers receiving a disaffiliation letter.
• All providers previously on a CAP will continue to be monitored by Blue Cross but will have additional time to comply before any disaffiliation will be implemented because this is a new program.
• Blue Cross will continue to work with all providers to comply with standards.

If you have questions regarding the change, contact Physical Therapy Inquiry at 313-448-6371.

PCMH practices with care management services now identified in provider search tool

Primary care providers who meet a specific threshold for delivering in-office care management and are designated as Patient-Centered Medical Homes are now included in the Find a Doctor search tool on bcbsm.com.

To find care management service providers, Blue Cross Blue Shield of Michigan members can enter their search parameters as they normally would for a primary care physician. Once the results load, members can filter the list to see physicians who offer Provider-Delivered Care Management. Under the Area of Focus section, they can select PCMH with Care Management.

To be included in the filter, physicians must be:

• PCMH-designated for the Sept. 1, 2019, through Aug. 31, 2020, program year
• Providing care management using a care team
• Using the 12 care management codes for 1% of eligible members on at least two different days during calendar year 2018

These criteria are less stringent than the criteria to receive value-based reimbursement for Provider-Delivered Care Management, which requires care management delivered to 3% of eligible members on at least two different days. In other words, a provider who’s included in the search functionality on bcbsm.com isn’t guaranteed to receive value-based reimbursement for Provider-Delivered Care Management.

Information about which physicians provide PCMH with care management will be updated annually in the fall.

If you’re a PGIP-participating physician organization, you may submit questions after logging in to the PGIP PO collaboration site. If you are a primary care physician, you may submit questions to your PGIP physician organization.

New, updated questionnaires have started opening in e-referral system

New and updated questionnaires started opening in the e‑referral system for certain procedures on Aug. 25 and Sept. 29, 2019. In addition, new and updated preview questionnaires, authorization criteria and medical policies are available on the ereferrals.bcbsm.com website.

We use our authorization criteria, medical policies and your answers to the questionnaires when making utilization management determinations about your authorization requests.

New questionnaires

Effective Aug. 25, questionnaires started opening for the first time in the e-referral system for authorization requests for BCN HMO^SM and BCN Advantage^SM for the procedures listed below, which already require authorization.

Updates to existing questionnaires

In addition, updated questionnaires started opening in the e-referral system on the dates specified below for BCN HMO, BCN Advantage and Medicare Plus Blue^SM PPO authorization requests (unless otherwise noted), for the following services:

• Cervical spine surgery — Aug. 25; opens only for BCN HMO and BCN Advantage
• Cervical spine surgery with artificial disc replacement — Sept. 29
• Cholecystectomy (laparoscopic) — Aug. 25; opens only for BCN HMO and BCN Advantage
• Endovascular intervention, peripheral artery — The updated questionnaire for this service was originally scheduled to open starting on July 28 for Medicare Plus Blue requests but actually started opening on Aug. 25.
• Ethmoidectomy — Aug. 25
• Hammertoe correction surgery — Aug. 25
• Hip arthroplasty, total, revision — Aug. 25
• Knee arthroplasty, total, revision — Aug. 25
• Noncoronary vascular stents — Sept. 29
• Sacral nerve neuromodulation/stimulation — Aug. 25
• Sinusotomy, frontal, endoscopic — Aug. 25
• Sleep studies, outpatient facility or clinic-based setting — Aug. 25; opens only for BCN HMO and BCN Advantage
• Vascular embolization or occlusion of hepatic tumors (TACE/RFA) — Aug. 25

Preview questionnaires

For all of these services, you can access preview questionnaires at ereferrals.bcbsm.com. The preview questionnaires show the questions you’ll need to answer in the actual questionnaires that open in the e-referral system. This can help you prepare your answers ahead of time.

To find the preview questionnaires:

• For BCN: Click BCN and then click Authorization Requirements & Criteria. Scroll down and look under the Authorization criteria and preview questionnaires heading.
• For Medicare Plus Blue: Click Blue Cross and then click Authorization Requirements & Criteria. In the Medicare Plus Blue PPO members section, look under the Authorization criteria and preview questionnaires — Medicare Plus Blue PPO heading.

Authorization criteria and medical policies

We also posted links to the pertinent authorization criteria and medical policies on the Authorization Requirements & Criteria pages.

We’re discontinuing Reference Based Benefits offering Dec. 31

Effective Dec. 31, 2019, Blue Cross Blue Shield of Michigan is closing the Reference Based Benefits, or RBB, offering. RBB allows employers to set a maximum (reference) price for their employees’ select inpatient, outpatient and imaging services. It has been available to large, national, self-funded employers since 2017.

RBB is being discontinued due to limited employer savings, declining employer interest and changing market dynamics.

Update your Provider Authorization form when changes occur

Blue Cross Blue Shield of Michigan is dedicated to safeguarding the protected health information of our members. These safeguards include completion of a Trading Partner Agreement and Provider Authorization form as part of the electronic data interchange setup process. All EDI trading partners must complete a TPA and Provider Authorization form before they can exchange PHI with Blue Cross.

Terms of the TPA require you to notify Blue Cross of any changes in your trading partner information. If you switch service bureaus (clearinghouses), software vendors, billing services or the recipient for your 835 files, you must update your Provider Authorization form. Updating the form ensures information is routed to the appropriate destination. You don’t need to update the Provider Authorization form if your submitter and trading partner IDs don’t change. 

Keep these items in mind when changes occur. You should review your Provider Authorization information if you’ve:

• Joined a new group practice
• Left a group practice and now bill using your own NPI
• Hired a new billing service
• Started submitting claims through a clearinghouse or you’ve changed clearinghouses
• Decided you no longer want to receive 835 remittance files
• Selected a new destination for your 835s

You must update your Provider Authorization if you’ll be sending claims using a different submitter ID or routing your 835s to a different unique receiver or trading partner ID. To make changes to your EDI setup, visit bcbsm.com/providers and follow these steps:

• Click on Quick Links.
• Click on Electronic Connectivity (EDI).
• Click on How to use EDI to exchange information with us electronically.
• Click on Update your Provider Authorization Form under EDI Agreements.

If you have any questions about EDI enrollment, contact the EDI Help Desk at 1-800-542-0945. For assistance with the TPA and Provider Authorization form, select the TPA option.

Remind patients to get the flu vaccine

Most healthy people who get the flu experience a mild to moderate illness but won’t need medical care or antiviral drugs. Most will recover in less than two weeks without treatment. But because of the potential for serious complications, the Centers for Disease Control and Prevention recommends flu vaccinations for everyone age 6 months and older, and especially for those at higher risk of complications. This group includes:

• Adults age 65 and older
• Children younger than age 2
• Pregnant women and women up to two weeks after the end of pregnancy
• American Indians and Alaska natives
• People who live in nursing homes and other long-term care facilities

Additionally, certain chronic conditions, such as heart disease, asthma, diabetes and chronic obstructive pulmonary disease, increase a patient’s risk of complications due to the flu.

There are also other health conditions that put patients at a higher risk for complications. Some of these include:

• Blood disorders such as sickle cell disease
• Cystic fibrosis
• Kidney disorders
• Liver disorders
• Patients with a body mass index of 40 or higher
• Patients with a weakened immune system due to a condition or medications
• Neurologic and neurodevelopment conditions

An FEP^® reminder

There’s no out-of-pocket cost for Federal Employee Program^® members when they receive the flu vaccine. FEP members can call the 24/7 Nurse Line at 1-888-258-3432 with questions about the flu and treatments to manage their symptoms. For more information, FEP members can go to www.fepblue.org or call the Customer Service number on the back of their member ID card.

Coding corner: Documentation and coding for rheumatoid arthritis

Nearly 1.5 million people in the United States – 70% of whom are women – have rheumatoid arthritis, or RA. Symptoms usually begin between the ages of 30 and 60, but may occur later in life for men. A family history increases the odds of having RA; however, most people with RA have no family history. Although the exact cause of RA is unknown, scientific evidence shows that genes, hormones and environmental factors play a role in the abnormal response of the immune system.

Documentation and coding tips

• Information about coding for RA can be found in Chapter 13 (“Diseases of the Musculoskeletal System and Connective Tissue”) of the ICD-10-CM coding book. Look under “Inflammatory polyarthropathies (M05-M14).”
• Involvement of any joints, body systems and organs should be specified in order to code RA to the highest specificity.
• Most codes have site and laterality designations. Site represents the joint or organ involved.
• For categories where no “multiple site” codes are provided, and more than one joint or organ is involved, multiple codes should be used to represent the different sites involved.
• Rheumatoid factor test results and interpretation should be documented to code to the highest specificity. 

The chart below gives some examples of rheumatoid arthritis with or without rheumatoid factor, and with or without organ and systems involvement:

Sources:

• arthritis.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.

Mandated changes to Blue Cross Medicare Advantage PPO agreement announced

Blue Cross Blue Shield of Michigan is adding the following provision to the Medicare Advantage PPO Provider Agreement. This is in accordance with the requirements of Centers for Medicare & Medicaid Services regulations 42 C.F.R. § 422.2 and 42 C.F.R. § 422.222:

CMS Preclusion List. Medicare Advantage Organizations are not permitted to make payment for a health care item, service, or drug that is furnished, ordered or prescribed by an individual or entity that is included in the CMS Preclusion List 42 C.F.R. § 422.2. Should Provider be added to the CMS Preclusion List, it agrees to immediately notify BCBSM so that BCBSM may notify its impacted members. Provider understands and agrees that beginning 60 days after the notification to the member, Provider will no longer be eligible for payment from BCBSM and will be prohibited from pursuing payment from the member for any service furnished, ordered, or prescribed after that date. Provider also understands and agrees that it will hold financial liability for services, items, and drugs that are furnished, ordered, or prescribed after the 60-day period. Provider asserts that it does not now, nor will it in the future, employ or contract with providers or prescribers who are listed on the CMS Preclusion List. Provider understands that the Preclusion List will be regularly updated by CMS and agrees that it will monitor the Preclusion List and ensure that none of its employees, contractors, or prescribers are included on it. Should Provider discover that one of its employees, contractors, or prescribers has been added to the preclusion list, Provider agrees to immediately notify BCBSM. Provider shall ensure that payments are not made to providers or prescribers included on the CMS Preclusion List. To the extent that Provider contracts with other providers to provide services to BCBSM members pursuant to this agreement, it will require such other providers to comply with the requirements of 42 C.F.R. § 422.2 and 42 C.F.R. § 422.222.

Since the above provision is a CMS mandated change, it will amend the agreement 30 days after publication of this article. This is in accordance with Paragraph 7.1 of the Blue Cross Medicare Advantage PPO agreement.

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 on Oct. 9 from 10 to 11:30 a.m. AIM handles our commercial PPO, Medicare Plus Blue^SM and BCN outpatient prior authorizations for several programs, including high-tech radiology and cardiology.

AIM also handles Blue Cross’ in-lab sleep therapy for both commercial and Medicare Plus Blue members, as well as select programs for URMBT (medical and radiation oncology).

This webinar will give you an overview of the AIM prior authorization program provider portal and provide you with information and links to program enhancements since 2018. Some topics include:

• 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 webinar.

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

Additional webinars are scheduled for October, including one titled AIM Specialty Medicare Advantage Medical Oncology. See Sign up for additional training webinars, also in this issue, for details.

Sign up today: New training webinars for providers and staff

Provider Experience is continuing its series of training webinars for health care providers and staff. The webinars are designed to help you better understand how Blue Cross Blue Shield of Michigan and Blue Care Network operate, and how we can work more efficiently together.

Sign up today
Here’s the upcoming schedule. Click a link below to register for dates and times that work for you.

As additional training webinars become available, we’ll update you via web-DENIS or The Record.

Here’s when to bill for an originating site facility fee

Providers have expressed some confusion about when and how to bill for the telehealth originating site facility fee (HCPCS code Q3014).

Providers should only bill the originating site facility fee when telehealth technology is used to connect the patient to a provider at a distant location. If the patient is in the same location of the provider who is rendering a professional service, the originating site code isn’t required and, therefore, is not payable.

Blue Cross Blue Shield of Michigan follows the Centers for Medicare & Medicaid Services originating site requirements and allows for reimbursement when the patient is in the following locations:

• Physician or practitioner’s office
• Outpatient hospital
• Critical access hospital, or CAH
• Rural health clinic
• Federally qualified health center
• Community mental health center
• Skilled nursing facility
• Hospital-based or CAH-based renal dialysis center

The originating site facility fee isn’t considered an actual service provided. Rather, the fee is for the use of the telehealth technology at one of the above-named locations. The technology provides a service for a patient receiving service from a provider at a distant location.

Blue Cross updates medical record requirements for applied behavior analysis services

Blue Cross Blue Shield of Michigan updated the medical record documentation requirements for applied behavior analysis services. The updates clarify documentation requirements for services involving tutors and technicians.

These requirements apply to the following plans:

• Blue Cross PPO commercial
• BCN HMO^SM (commercial)

View the updated medical record requirements here. You can also find them at ereferrals.bcbsm.com. Click BCN or Blue Cross and then Behavioral Health. Once on the Behavioral Health page, select the document title, which is Behavioral health medical record documentation requirements for applied behavior analysis services.

We’ll be adding Evenity to the Medicare Part B medical drug prior authorization list

We’re adding Evenity^® (J3111) to the Medicare Plus Blue^SM PPO and BCN Advantage^SM Part B medical drug prior authorization list for dates of service on or after Nov.1, 2019. 

Medicare Plus Blue PPO
For Medicare Plus Blue, we’ll require prior authorization for this medication for the following sites of care when you bill the medication electronically through an 837P transaction or on a professional CMS-1500 claim form:

• Physician office (place of service code 11)
• Outpatient facility (place of service code 19, 22 or 24)

BCN Advantage
For BCN Advantage, we’ll require prior authorization for this medication for the following sites of care when you bill the medication as a professional service or as an outpatient facility service, and when you bill electronically through an 837P transaction or on a professional CMS-1500 claim form:

• Physician office (place of service code 11)
• Outpatient facility (place of service code 19, 22 or 24)
• Home (place of service code 12)

We’ll also require prior authorization when you bill electronically through an 837I transaction or use a UB04 claim form for a hospital outpatient type of bill 013x.

Use NovoLogix to submit requests
The NovoLogix^® online tool offers real-time status checks and immediate approvals for certain medications.

To gain access:

• For BCN Advantage, access to Provider Secured Services gives you automatic access to NovoLogix. There’s nothing more you need to do.
• For Medicare Plus Blue, if you have a Type 1 (individual) NPI and you checked the “Medical Drug PA” box when you completed the Provider Secured Services Application, you have access to NovoLogix. If you didn’t check that box, complete Addendum P and fax it to the number on the form.

If you need access to Provider Secured Services, complete the Provider Secured Services Application and fax it to the number on the form.

To access NovoLogix through Provider Secured Services:

1. Visit bcbsm.com/providers.
2. Click Login.
3. Log in to Provider Secured Services.
4. Click one of the following on the Provider Secured Services homepage.
   • BCN Medical Benefit – Medication Prior Authorization
   • Medicare Advantage PPO Medical Benefit – Medication Prior Authorization
5. Enter or select your NPI and click Go.

If you can’t log in to Provider Secured Services, call 1-877-258-3932 from 8 a.m. to 8 p.m. Eastern time Monday through Friday.

If you have questions about authorizations, call the Pharmacy Help Desk at 1‑800‑437‑3803 from 9 a.m. to 4 p.m. Eastern time Monday through Friday.

Physical, occupational and speech therapy claims require appropriate modifier

Blue Cross Blue Shield of Michigan is updating the claims processing system to require all outpatient physical, occupational and speech therapy claims to be billed with one of the following therapy modifiers:

• GN
• GO
• GP

Once the update is complete, the claims processing system will reject all professional outpatient therapy services submitted without an appended modifier. Therapy providers are encouraged to begin billing with the modifiers as soon as possible.

The system update is expected to be completed in early 2020. We’ll notify you of the effective date through web-DENIS and a future issue of The Record.

2019 third-quarter CPT code updates

Pathology and laboratory

Proprietary laboratory analysis codes

CPT Category II codes

Composite measures
Physical examination

CPT Category II codes

Performance measures
Diagnostic/screening processes or results

Categorization for outpatient physical therapy services changing in 2020

As previously announced in an article in the August 2019 Record, Blue Cross Blue Shield of Michigan and Blue Care Network are changing the use management categorization process for physical therapy. Beginning Jan. 1, 2020, profile reports for categorization will include physical therapy claims from Blue Cross commercial PPO, Medicare Plus Blue^SM PPO, BCN commercial and BCN Advantage^SM HMO.

Having one assigned category covering all four networks should make it easier for you to manage therapy requests.

About the program
The program:

• Applies to in-state, outpatient services
• Includes independent, outpatient, hospital outpatient and occupational therapy services
• Includes the current preauthorization program for three of the four networks
• Will be based on a single categorization score across the plans

About the new category assignments

• Category assignments will be determined by 12 months of combined independent, outpatient and hospital outpatient paid claims data.
• Categories will be based on risk-adjusted visits by age, gender and diagnosis.
• Visits will be appropriately weighted through eviCore healthcare’s process to develop a combined peer average, and will be tiered into three categories:

A — Up to 80% of the peer average
B — Greater than 80 to120% of the peer average
C — Greater than 120% of the peer average

• IPT services will be categorized individually by their type 1 NPI, based on all rendered services, not as a group.
• Physical therapists must have at least 10 episodes of service to be categorized.
• Providers with less than 10 episodes will default to category B.
• New providers with 10 or more episodes will no longer default to category B but will be categorized into their appropriate tier based on their average risk-adjusted visits or episodes.
• When multiple therapists in a practice treat the same patient and bill therapy services for a distinct member episode using a common tax ID, eviCore uses visit attribution (a method to avoid under-reporting utilization) and will attribute all PT utilization to the provider who billed the most visits for that episode of care. 
• Provider Performance Summary TREND reports will be available on eviCore’s website in November 2019.

Next steps
In late January 2020, eviCore will mail letters identifying your provider category based on your combined claims data. Physical therapists will continue to have the option to request a reconsideration of category status within 15 days from the date of the category notification letter if they have additional information that may change their category.

Preauthorization process
Preauthorization will continue for BCN, BCN Advantage and Medicare Plus Blue PPO based on your combined category. There’s no change to the preauthorization program for M.D.s, D.O.s, speech and language therapists and occupational therapists. And you’ll continue to receive a Provider Performance Summary if you received one previously.

Corrective Action Plan
CAP will continue for Blue Cross’ commercial PPO.

• If a provider in category C has more than 50% of the total number of patients categorized as commercial PPO patients:
• Warning letters will be sent by Blue Cross to providers who remain in category C for three consecutive categorization periods
• Disaffiliation letters will be sent by Blue Cross to providers in category C for four consecutive categorization periods
• A first- and second-level appeal process will be available to providers receiving a disaffiliation letter.
• All providers previously on a CAP will continue to be monitored by Blue Cross but will have additional time to comply before any disaffiliation will be implemented because this is a new program.
• Blue Cross will continue to work with all providers to comply with standards.

If you have questions regarding the change, contact Physical Therapy Inquiry at 313-448-6371.

We’re discontinuing Reference Based Benefits offering Dec. 31

Effective Dec. 31, 2019, Blue Cross Blue Shield of Michigan is closing the Reference Based Benefits, or RBB, offering. RBB allows employers to set a maximum (reference) price for their employees’ select inpatient, outpatient and imaging services. It has been available to large, national, self-funded employers since 2017.

RBB is being discontinued due to limited employer savings, declining employer interest and changing market dynamics.

Update your Provider Authorization form when changes occur

Blue Cross Blue Shield of Michigan is dedicated to safeguarding the protected health information of our members. These safeguards include completion of a Trading Partner Agreement and Provider Authorization form as part of the electronic data interchange setup process. All EDI trading partners must complete a TPA and Provider Authorization form before they can exchange PHI with Blue Cross.

Terms of the TPA require you to notify Blue Cross of any changes in your trading partner information. If you switch service bureaus (clearinghouses), software vendors, billing services or the recipient for your 835 files, you must update your Provider Authorization form. Updating the form ensures information is routed to the appropriate destination. You don’t need to update the Provider Authorization form if your submitter and trading partner IDs don’t change. 

Keep these items in mind when changes occur. You should review your Provider Authorization information if you’ve:

• Joined a new group practice
• Left a group practice and now bill using your own NPI
• Hired a new billing service
• Started submitting claims through a clearinghouse or you’ve changed clearinghouses
• Decided you no longer want to receive 835 remittance files
• Selected a new destination for your 835s

You must update your Provider Authorization if you’ll be sending claims using a different submitter ID or routing your 835s to a different unique receiver or trading partner ID. To make changes to your EDI setup, visit bcbsm.com/providers and follow these steps:

• Click on Quick Links.
• Click on Electronic Connectivity (EDI).
• Click on How to use EDI to exchange information with us electronically.
• Click on Update your Provider Authorization Form under EDI Agreements.

If you have any questions about EDI enrollment, contact the EDI Help Desk at 1-800-542-0945. For assistance with the TPA and Provider Authorization form, select the TPA option.

Skilled nursing facilities must follow CMS guidelines for issuing NOMNC forms to Medicare Advantage members

BCN Advantage^SM and Medicare Plus Blue^SM PPO members sometimes remain in skilled nursing facilities for days beyond the service end date on the Notice of Medicare Non-Coverage form. Sometimes the extended stay is due to a provider’s failure either to deliver a completed NOMNC form in a timely manner or failure to comply with Centers for Medicare & Medicaid Services guidelines for responding to requests from Livanta LLC. This results in days added to the member’s stay that may not be medically necessary.

Livanta is the quality improvement organization assigned to Medicare Advantage members in Michigan.

On behalf of Blue Cross Blue Shield of Michigan, naviHealth will issue an administrative denial for these days if they occur because the SNF provider didn’t handle the NOMNC in accordance with CMS guidelines. In an administrative denial, the authorization is approved but the reimbursement for the extra days is denied.

Examples of improper handling and delivery of the NOMNC include:

• Late delivery of the NOMNC. Members must receive the NOMNC 48 hours before the planned discharge date.
  Note: naviHealth completes as much of the NOMNC as possible and tells the provider when to issue the NOMNC.
• Failure to fill out the NOMNC in its entirety. All fields in the NOMNC must be completed, including all date and signature fields. For more information, see the Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123.**
• Not submitting the requested medical information to the QIO in a timely manner when the member appealed the service end date with the QIO.
  
  Note: To view CMS instructions about appropriate delivery of the NOMNC, see sections 260.2 to 260.4.5 of the CMS Manual System: Pub 100-04 Medicare Claims Processing, Transmittal 2711.**

When SNF providers have repeated difficulties handling the NOMNC according to CMS guidelines, their naviHealth care coordinators will reach out to provide education about CMS guidelines and health plan requirements. If, after receiving education, an SNF provider continues to have difficulties, naviHealth will deliver an administrative denial letter to the provider when members stay beyond the end date stated on the NOMNC.

The administrative denial letter will include details on the specific CMS guideline violations. Blue Cross and Blue Care Network will hold the provider responsible for the additional days the member stayed in the SNF. Per CMS guidelines, providers can’t bill members for the additional days.

You can find information about CMS guidelines and Medicare Plus Blue and BCN Advantage requirements in the following locations:

• Medicare Claims Processing Manual, Chapter 30:** See sectio*n “260.3.6 — Financial Liability for Failure to Deliver a Valid NOMNC.”
• Medicare Plus Blue PPO Manual: See the Utilization Management section. Look under the “Post-acute care skilled nursing, inpatient rehabilitation and long-term acute care facilities” heading.
• BCN Provider Manual: See the BCN Advantage chapter. Look in the “BCN Advantage provider appeals” section.

As a reminder, naviHealth manages authorization requests for Medicare Plus Blue and BCN Advantage members admitted to post-acute care on or after June 1, 2019. For details, see the Post-acute care services: Frequently asked questions by providers document.

**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.

HMS concluded Medicare Plus Blue audits of skilled nursing facilities May 31

HMS^®, an independent company that performs audits for Blue Cross Blue Shield of Michigan, stopped conducting skilled nursing facility audits for Medicare Plus Blue^SM members after May 31, 2019, admissions.

As you read in the April Record article, authorizations for Medicare Plus Blue PPO members who require a transfer from acute inpatient hospitals to skilled nursing facilities are managed by naviHealth, an independent company that handles care transitions, effective June 1, 2019.

For more information on the prior authorization request process, see the Medicare Plus Blue PPO Manual.

We’re resuming Medicare Plus Blue PPO place-of-service audits

Blue Cross Blue Shield of Michigan is resuming inpatient place-of-service audits for all Medicare Plus Blue^SM claims.

Beginning with service dates on or after Sept. 1, 2019, we won’t reimburse for inpatient hospitalizations where the medical record doesn’t support the inpatient setting that was billed. Denials will be based on whether the patient’s level of hospital care was billed correctly, not on medical necessity. Providers can avoid possible recovery of funds during claims processing and post-payment audits by closely following rules for documentation, coding and billing set by the Centers for Medicare & Medicaid Services and Blue Cross.

Hospitals are liable for the denied claims and aren’t allowed to charge or balance bill Medicare Advantage members. However, they can rebill Medicare Part B services.

Process 

HMS^® will perform Medicare Plus Blue place-of-service audits on behalf of Blue Cross. Hospitals must submit medical records to HMS for audit, upon request. If the inpatient care is documented in the medical record, the hospital will receive a no-findings letter. If HMS finds the inpatient level of care isn’t supported in the medical record, hospitals will receive case summaries that include the rationale used in determining the denial. To appeal the decision, hospitals must follow the appeals process described in the Medicare Plus Blue PPO manual.

If you have questions during an audit, call 1-866-875-1749 to talk with an HMS representative.

Medicare Plus Blue PPO audits to use Sepsis-3 criteria

HMS^® began auditing Medicare Plus Blue^SM reimbursed diagnosis-related group claims for clinical and coding validation in September, as announced in the September Record. HMS is an independent company working for Blue Cross Blue Shield of Michigan.

The audits will review medical records to ensure that:

• Claims were billed in accordance with coding guidelines
• Diagnoses were supported by documentation in the medical record.

Regarding a sepsis diagnosis, Blue Cross will use Sepsis-3 as the evaluation criteria for payment purposes. Sepsis-3 is the most recent evidence-based definition of sepsis, defined as a life-threatening organ dysfunction caused by a dysregulated host response to infection.

Learn more about Sepsis-3 criteria by reviewing the article titled Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3),** published in JAMA.

Be ready to share medical charts for review during an audit. After an audit, HMS will send the findings and information on how you can ask for an appeal, if necessary.

If you have questions during an audit, call 1-866-875-1749 to speak with an HMS representative.

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

Tell patients about possible noncoverage before providing service, treatment or item

If you and your patient decide that the best course of care for him or her may not be covered by Medicare Plus Blue^SM PPO, you’re required to inform the patient of possible noncoverage before performing the service or treatment or obtaining the item. If the patient decides to pursue the noncovered course of care knowing it won’t be covered by the benefit plan, you must first submit a preservice organization determination (also known as an advance coverage determination) to the plan.

Here’s why
If you don’t provide the patient with notice of possible noncoverage by the plan, and the patient proceeds with the course of care, you may not bill the patient for such noncovered items, treatments or services.
Note: This doesn’t pertain to any of the outlined services that require precertification or prior authorization.

Here’s how
Review the provider responsibilities for noncovered services and referrals for noncovered services in the “Billing Members” section of the Medicare Plus Blue PPO Manual on Page 5. It details the steps recommended for providers to follow when ordering services or procedures that may not be covered by the benefit plan, including how to get an advance coverage determination and when to request an expedited determination. This process resolves any uncertainties for both the provider and patient.

Thank you for your continued support as we strive for excellence in both the provider and the member experience.

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

Initiatives reduce opioids after surgery without increasing pain
What if you could slash the number of opioids prescribed to patients undergoing nine common surgeries by nearly 30% without increasing a patient’s pain? It’s happening now in Michigan, thanks to the Michigan Surgical Quality Collaborative and Michigan Opioid Prescribing Engagement Network, two Value Partnerships initiatives. The number of opioid pills for patients sent home after surgery from the more than 40 participating Michigan hospitals dropped from an average of 26 per patient to an average of 18, according to the University of Michigan news release.**

Executive order creates Michigan Opioids Task Force
Gov. Gretchen Whitmer signed executive order 2019-18, creating the Michigan Opioids Task Force, MSMS** reported Aug. 28. The task force will bring together leaders from across state government to tackle the opioid epidemic.

In the news

• Purdue Pharma offers up to $12 billion to settle opioid claims
  The maker of OxyContin, Purdue Pharma, and its owners, the Sackler family, are offering to settle more than 2,000 lawsuits against the company for $10 billion to $12 billion, nbcnews.com** reported Aug. 27. The lawsuits allege the company and the Sackler family are responsible for starting and sustaining the opioid crisis.

• Johnson & Johnson ordered to pay $572 million in opioid trial
  A judge in Oklahoma ruled that Johnson & Johnson had intentionally played down the dangers and oversold the benefits of opioids, The New York Times** reported Aug. 26.

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

Oct. 10 is National Depression Screening Day

Oct. 10 is National Depression Screening Day,** a time for shining the spotlight on the importance of depression screening and treatment — and eliminating some of the stigma surrounding depression and other mental health issues.

Oct. 10 is also World Mental Health Day** and Oct. 6 through 12 is Mental Health Awareness Week.**

More than 16 million adults in the U.S. suffer from major depression,** according to the Substance Abuse and Mental Health Services Administration. In fact, depression is the leading cause of disability worldwide.

“Depression is a chronic illness that often comes on so slowly that people may not even know they have it,” said Dr. William Beecroft, medical director of behavioral health for Blue Cross Blue Shield of Michigan and Blue Care Network. “Screening for the condition, like screening for diabetes, is simple but people need to be aware of the signs of depression so they can seek help if needed. That’s why awareness campaigns like National Depression Screening Day and Mental Health Awareness Week are so important. Screening for depression is a good first step on the journey to good overall health.”

New Directions, a company that provides behavioral health services for many Blue Cross members, has posted a series of depression guidelines** on its website.

Here are some other resources suitable for sharing with your patients:

• A recent blog by Dr. Duane DiFranco, M.D., on MI Blues Perspectives
• A flyer offering tips for dealing with someone who is struggling with depression and another that looks at the signs of depression
• Materials posted in the Mental Health Awareness section of the Blue Cross Engage page
• For more mental health-related content, subscribe to our blogs, A Healthier Michigan and MI Blues Perspectives.

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

Updates to 2020 ICD-10 codes available

The fiscal year 2020 ICD-10-CM and ICD-10-PCS code updates that will be effective with dates of service on or after Oct. 1, 2019, are now available on the Centers for Medicare & Medicaid Services website. This year’s updates include 1,007 new CM and PCS (diagnosis and inpatient procedure) codes, 160 CM and PCS code revisions, and 2,077 CM and PCS deletions.

To access the code updates, click here.**

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

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’ll be adding Evenity to the Medicare Part B medical drug prior authorization list

We’re adding Evenity^® (J3111) to the Medicare Plus Blue^SM PPO and BCN Advantage^SM Part B medical drug prior authorization list for dates of service on or after Nov.1, 2019. 

Medicare Plus Blue PPO
For Medicare Plus Blue, we’ll require prior authorization for this medication for the following sites of care when you bill the medication electronically through an 837P transaction or on a professional CMS-1500 claim form:

• Physician office (place of service code 11)
• Outpatient facility (place of service code 19, 22 or 24)

BCN Advantage
For BCN Advantage, we’ll require prior authorization for this medication for the following sites of care when you bill the medication as a professional service or as an outpatient facility service, and when you bill electronically through an 837P transaction or on a professional CMS-1500 claim form:

• Physician office (place of service code 11)
• Outpatient facility (place of service code 19, 22 or 24)
• Home (place of service code 12)

We’ll also require prior authorization when you bill electronically through an 837I transaction or use a UB04 claim form for a hospital outpatient type of bill 013x.

Use NovoLogix to submit requests
The NovoLogix^® online tool offers real-time status checks and immediate approvals for certain medications.

To gain access:

• For BCN Advantage, access to Provider Secured Services gives you automatic access to NovoLogix. There’s nothing more you need to do.
• For Medicare Plus Blue, if you have a Type 1 (individual) NPI and you checked the “Medical Drug PA” box when you completed the Provider Secured Services Application, you have access to NovoLogix. If you didn’t check that box, complete Addendum P and fax it to the number on the form.

If you need access to Provider Secured Services, complete the Provider Secured Services Application and fax it to the number on the form.

To access NovoLogix through Provider Secured Services:

1. Visit bcbsm.com/providers.
2. Click Login.
3. Log in to Provider Secured Services.
4. Click one of the following on the Provider Secured Services homepage.
   • BCN Medical Benefit – Medication Prior Authorization
   • Medicare Advantage PPO Medical Benefit – Medication Prior Authorization
5. Enter or select your NPI and click Go.

If you can’t log in to Provider Secured Services, call 1-877-258-3932 from 8 a.m. to 8 p.m. Eastern time Monday through Friday.

If you have questions about authorizations, call the Pharmacy Help Desk at 1‑800‑437‑3803 from 9 a.m. to 4 p.m. Eastern time Monday through Friday.

We’ll cover hemophilia drugs under the pharmacy benefit for most commercial members, starting Jan. 1

We’re changing how we cover hemophilia drugs for most of our commercial, non-Medicare members. Starting Jan. 1, 2020, if a member has Blue Cross Blue Shield of Michigan or Blue Care Network pharmacy coverage, all hemophilia drugs should be billed under their pharmacy benefits.

However, this change doesn’t affect all commercial members. For example, if a member has pharmacy coverage through a company other than Blue Cross or BCN, hemophilia drugs will continue to be covered under the medical benefit.

To determine whether this change applies to a specific member:

• Review Blue Cross PPO member benefits in Benefit Explainer.
• Review BCN HMO^SM member benefits in web-DENIS.

We’ll notify affected members about these changes. Members don’t have to do anything. Their medication and treatment won’t change.

Here are answers to some frequently asked questions.

What changes will occur on Jan. 1, 2020?
For affected members, hemophilia drugs that are currently covered under the medical benefit will be covered under the pharmacy benefit. In addition:

• Members will be limited to a 30-day supply of hemophilia drugs.
• The hemophilia drug Hemlibra^® will continue to require authorization.

When will the changes go into effect?
The changes will go into effect for dates of service on or after Jan. 1, 2020.

Which groups and members are affected?
This change affects most commercial Blue Cross PPO and BCN HMO members who have pharmacy coverage, including those covered by individual plans and those covered through groups with administrative service contracts.

ASC groups can opt out of the program. Groups that opt out will continue to use the medical benefit for hemophilia drugs.

The following groups and members aren’t affected:

• HMO and PPO members with a carved-out pharmacy benefit
• Medicare and Medicaid members
• Groups with pharmacy benefits that involve limited and religious accommodations that cover only the pharmacy benefits mandated by the Affordable Care Act

How will this change affect members who are currently undergoing hemophilia therapy?
There won’t be any change to a member’s therapy. Drug selection, dosage and frequency will remain the same. Members will continue to receive care from their current providers.

We’re adding hemophilia drugs to the formulary as branded, nonspecialty medications. Depending on a member’s pharmacy benefits, copayments may increase for some members.

How will providers and specialty pharmacies know to bill the pharmacy benefit starting Jan. 1, 2020?
We’ll send letters to providers and specialty pharmacies about billing Blue Cross and BCN members under the pharmacy benefit, unless the members’ group has opted out of the hemophilia program.

If a hemophilia drug is processed under the pharmacy benefit and the group has opted out, a point-of-sale message will let the specialty pharmacy know immediately that the place of service isn’t covered. The provider or specialty pharmacy will be instructed to bill the medical benefit, as they did previously.

Why are we making this change?

Quality of care: We provide our members with access to the best health care at the lowest cost. By adding this drug class to the pharmacy benefit, we can continue to offer hemophilia therapy to our members while increasing the quality of care and possibly reducing the cost to the plan and to our members.

Better data: We’ll be able to get real-time data regarding units dispensed, dosing and the dates on which each member receives medication. This data isn’t always available under the medical benefit. In addition, we can see where the member is receiving therapy and direct him or her to higher-quality centers with better pricing.

We’ll stop covering 500 mg Zytiga tablets starting Nov. 1

We’ll no longer cover 500 mg Zytiga^® (abiraterone) tablets starting Nov. 1, 2019. However, members can continue to fill their prescriptions for 500 mg Zytiga until Jan. 1, 2020. If they fill prescriptions for 500 mg Zytiga tablets on or after this date, they’ll be responsible for the full cost.

Note: Members can continue their current treatment with generic Zytiga 250 mg tablets and may pay less for this prescription than what they pay currently.

The following table includes some information to compare the available strengths of Zytiga.

We’ll let members know about this change and encourage them to speak with their doctor about getting a prescription for 250 mg generic Zytiga tablets and discuss any concerns they may have.

For a complete list of covered drugs, go to bcbsm.com/pharmacy and click Drug lists.

If you have questions, call the Pharmacy Services Clinical Help Desk at 1-800-437-3803 and select Option 1.

Save time, submit prior authorization requests electronically for pharmacy benefit drugs

Providers can now use their electronic health record or CoverMyMeds^®** to submit prior authorizations for Blue Cross Blue Shield of Michigan and Blue Care Network commercial members with commercial pharmacy benefits.

Electronic prior authorization, or ePA, replaces faxing and phone calls so providers can focus less on administrative tasks and more on patient care. Other benefits of ePA include:

• Automatic approvals for select drugs.
• Turnaround time is improved for reviews and decisions.
• Easy to use for prescribers, nurses and office staff.
• All documentation and requests are kept conveniently in one place.

Here are some answers to frequently asked questions about ePA:

Why should I use ePA?
You’ll save time. You can send 11 ePAs in the time it takes to fax just one (based on Comcast and Verizon broadband rates and fax speed of 33.6 kilobits per second), and patients can receive medications faster.

The process is easy and intuitive, and providers and authorized personnel can use the electronic health record tool or log in online.

What is the cost of ePA?
Some electronic health record vendors charge an additional fee for this added functionality. There’s no cost to use online portals.

What makes ePA better?
Both the online portals and ePA within your electronic health record make it easy to submit fully electronic requests and give you:

• Clear direction on clinical requirements
• The ability to attach documentation if required
• Secure and efficient prior authorization administration all in one place
• The capability to proactively renew existing prior authorizations up to 60 days before they expire
• Streamlined questions, asking only those needed for the prior authorization, unlike fax forms.

How do I get started?
Electronic prior authorization can integrate into your current electronic health record workflow. Check with your vendor to ensure you have the latest software version enabling ePA.

If ePA in your electronic health record tool is currently unavailable, create a free account online for the tool that works best for your office. Registration is free and takes only a couple of minutes.

To complete an ePA, follow these steps:

1. Go to covermymeds.com/epa/express-scripts.***

• Create a free account if you don’t already have one.

2. Start a prior authorization.

• Click New Request, and enter the patient’s state and medication.
• Type Blue Cross Blue Shield of Michigan into the Plan, PBM and Form Name field.
• Select the appropriate form, and click Start Request.

3. Complete the ePA.

• Enter all demographic fields marked Required, and click Send to Plan.
• Complete the returned list of patent-specific, clinical questions marked Required.

4. Confirm the ePA process has been completed.

• Click Send to Plan again to complete the ePA request.
• After Blue Cross or BCN has reviewed your submitted prior authorization, the determination will appear in your CoverMyMeds account.

Approval decisions are often returned within moments of submission, depending on the complexity or need for further review.

For more information

• If you have questions, contact the Pharmacy Help Desk at 1-800-437-3803.
• Click here for a flyer detailing the benefits of ePA.

**Other free ePA services include Surescripts^® and ExpressPAth^®.
***Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.

L codes payable to DME providers

Retroactive to July 1, 2018, the listed L codes have been updated to pay to all durable medical equipment providers. These codes — L8000, L8015, L8020, L8030 and L8501 — have been added to the off-the-shelf HCPCS codes list as payable to all DME, prosthetics, orthotics and medical supplier providers without any special accreditation requirement.

Off-the-shelf L codes