Tricia A. Keith to succeed Daniel J. Loepp as president and CEO of Blue Cross Blue Shield of Michigan

On May 15, 2024, Blue Cross Blue Shield of Michigan’s Board of Directors appointed Tricia A. Keith to succeed Daniel J. Loepp as president and CEO on Jan. 1, 2025, following his retirement.

Keith, a Michigan native and lifelong resident, will become the company’s first female chief executive. She has been with Blue Cross Blue Shield of Michigan since 2006 and currently serves as executive vice president, chief operating officer and president of Emerging Markets.

“She has the energy, experience and innovative spirit our company needs as health care continues to change,” Loepp said. “She is the right leader at the right time for Blue Cross Blue Shield of Michigan.”

Loepp has had many achievements during two decades of leadership at Blue Cross, including transforming the company from a large single-state health insurance plan to a diversified multi-company enterprise of national scale.

For more information, visit mibluesperspectives.com.

Reminder: Follow guidelines established for processing Medicare primary claims

Medicare primary claims must be submitted to Medicare for processing. Medicare is then responsible for forwarding the claims to Blue Cross Blue Shield of Michigan via a crossover arrangement for secondary payment determinations.

Blue Cross requires, at minimum, a 30-day waiting period after the Medicare remittance date before we can accept and process a provider-submitted Medicare supplemental claim that is eligible for crossover.

Professional and facility electronic provider-submitted claims received before the 30-day waiting period will obtain the following Blue Cross front-end edit:

• Professional = AS0246 Supplemental Claim Received Within 30 Days of Medicare Processing Date.
• Facility = AS0248 Supplemental Claim Received Within 30 Days of Medicare Processing Date.

In our provider portal, Availity, check your response files (acknowledgments and reports) and payer (277CA) reports for front-end edits. Edited claims can’t be resubmitted until 30 days after the Medicare remittance date has lapsed.

You should only bill Blue Cross directly before the 30-day remittance date for a patient with Medicare primary coverage when the service provided is statutorily excluded from Medicare coverage.

For statutorily excluded services, it’s important to note:

• Providers who offer statutorily excluded services must indicate these services by using a GY modifier at the claim line level.
• Submit statutorily excluded service lines on a separate claim. Don’t combine those lines with other services.
• Providers will no longer have to first submit known statutorily excluded services to Medicare for consideration.

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal and electronic data interchange services.

How to protect yourself against health care fraud

Health care fraud is a serious crime that increases health care costs for everyone and causes potential safety issues for many patients. Our Corporate and Financial Investigations Unit has put together the following tips to help protect you against health care fraud:

• Verify requests for patient information

  Health care provider offices may receive fraudulent requests for patient information, national provider identifier numbers and provider signatures by standard mail, email or fax. Always verify requests before sending responses.

• Verify patient ID

  Ask for a picture ID to ensure that the person presenting the Blue Cross Blue Shield of Michigan or Blue Care Network subscriber card is the owner of that card.

• Use proper billing codes

  Consult the CPT and ICD-10 codebooks and other resources to verify that the codes used are appropriate and accurate.

• Check patient history

  To help prevent prescription drug fraud, ask patients if they’re seeing or have obtained prescriptions from other doctors. Check reports from the Michigan Automated Prescription System, or MAPS.

• Safeguard prescription pads

  Prescription pads shouldn’t be accessible to patients. Prescription fraud schemes are often perpetrated by using stolen prescription pads or compromised e-prescribing passwords.

• Make patient agreements

  Enter into controlled substance or narcotics contracts with patients to express the importance of limiting usage of medications as well as evaluating potential for addictive behaviors.

If you suspect a request may be fraudulent, don’t respond to it

When we conduct mass requests for medical records or patient information, we often notify you through a provider newsletter article or a provider alert. If you’re suspicious of a request that you receive, you can call our Fraud Hotline at 1-844-STOP-FWA (1-844-786-7392) or send an email to StopFraud@bcbsm.com. We may ask you to share the request so we can check its legitimacy.

For more useful information, check out the Victimized Provider Project section** of the Centers for Medicare & Medicaid Services website. The Victimized Provider Project helps keep providers from being held liable for overpayment for claims paid that are the result of identity theft.

By working together, we can help eliminate fraud, which will improve patient safety and reduce costs.

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

Blue Cross, BCN provide updated clinical editing billing tips

Blue Cross Blue Shield of Michigan and Blue Care Network publish clinical editing billing tips to help our health care providers avoid claim delays and denials.

We use nationally recognized clinical editing programs that compare procedure codes billed against nationally accepted coding and billing standards to check for clinical appropriateness and data accuracy.

We communicate new clinical editing policies and provide reminders for some clinical edits that are already in place, so providers can correctly report performed procedures, and we can pay claims accurately and timely with minimal delays.

This Clinical editing billing tips document includes the following tips:

• CLIA-waived tests for Medicare Plus Blue℠ claims
• Critical care in the ER when patient is discharged to home in the same encounter
• ICD-10-CM 7th character and therapy codes clinical editing update for Medicare Advantage claims
• Outpatient services during an inpatient stay are not separately reimbursable
• Procedure not carried out reminder
• Prostate specimen re-bundle
• Robotic/computer assistance and 3D imaging
• Sexually transmitted infection testing to be bundled
• More information about clinical editing

AllianceRx Walgreens Pharmacy to become Walgreens Specialty Pharmacy on Aug. 1

AllianceRx Walgreens Pharmacy, a provider of specialty pharmacy services, will become Walgreens Specialty Pharmacy on Aug. 1, 2024.

Its web address will change to WalgreensSpecialtyRx.com on Aug. 1.

Walgreens Specialty Pharmacy will continue to provide Blue Cross Blue Shield of Michigan and Blue Care Network commercial, Medicare Plus Blue℠ and BCN Advantage℠ members with specialty medications used to treat chronic, complex or rare conditions.

We started notifying members of the name change in May through prescription orders. Members can continue to call 1-866-515-1355 should they have any questions about their specialty medications.

Prescriptions can be sent to Walgreens Specialty Pharmacy by:

• Phone: 1-866-515-1355
• Fax: 1-866-515-1356
• Electronically to e-prescribing name: Walgreens Specialty Pharmacy – MICHIGAN

New on-demand training available: Check out our latest learning path

Provider Experience continues to offer training resources for health care providers and staff. Our on-demand courses are designed to help you work more efficiently with Blue Cross Blue Shield of Michigan and Blue Care Network. As part of our ongoing efforts, we recently added another learning path.

Our newest learning path contains courses for the behavioral health community. This is our latest in the approach for helping providers and staff determine the right courses to take. We’ll keep updating the courses as new ones are created that cover behavioral health topics. This will ensure you have the latest information that’s easy to find in one spot.

The behavioral health learning path will feature a brand-new course, Behavioral Health Basics. The course is designed to close knowledge gaps in several areas of behavioral health to give a well-rounded view of behavioral health coverage at Blue Cross and BCN. It addresses potential provider challenges, reviews current resources, walks through scenarios, and challenges the learner’s knowledge along the way. You can also find upcoming courses in the learning path such as a mini-module on the Behavioral Health portal. 

Professional providers and facilities should encourage those in the behavioral health field to view the new path. Simply open the Course Catalog on the provider training website and click on Learning Paths.
We also added the following learning opportunities:

• Blue High Performance Network℠ mini module:  Providers at acute care and children's hospitals can learn about the criteria for joining the Blue Cross Blue Shield of Michigan Blue High Performance Network℠ in Southeast Michigan.
• Diabetes, HEDIS^®/Stars and More in 2024: View this recorded webinar that describes the NCQA changes to diabetes-related quality measures.
• Provider Quick Guides: We have updated two toolkits:
• Serious illness toolkit
• Chronic kidney disease toolkit

To access the training site, follow these steps:

1. Log in to the provider portal at availity.com.**
2. Click on Payer Spaces on the menu bar and then click on the BCBSM and BCN logo.
3. Under Applications, click on the Provider Training Site tile.
4. Click on Submit on the Select an Organization page.
5. Existing users who used the same email address as their provider portal profile email will be directed to the training site. If you used a different email address, contact ProviderTraining@bcbsm.com to update your profile.

If you’re a new training site user, complete the one-time registration by entering your role and creating a password. This allows you to access the training site outside of the provider portal if needed.

If you need assistance navigating the provider training site, email ProviderTraining@bcbsm.com.

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

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal and electronic data interchange services.

Keep patients’ information secure

Unauthorized access to patients’ protected health information is a serious threat to all health care providers. In addition to personal health details, patient PHI often contains other valuable information such as Social Security numbers, dates of birth and account details. For these reasons, office administrators must do everything they can to minimize the risks associated with unauthorized access.

To help safeguard patient PHI and comply with federal law, office administrators are encouraged to incorporate the following steps as best practices:

• Account management

Support a centralized tool for user account creation, modification and termination.

- Define, review and update access permissions to align with job roles and responsibilities.
- Provide clear instructions for employees to report any issues or concerns.
- Provide a clear policy outlining employee access rights and privileges, such as executing suitable member inquires.

• Access review frequency

Initiate access reviews when employees change roles or departments; revoke access promptly.

- Schedule quarterly or biannual audits of access levels to ensure compliance.
- Update employee access and roles to align with current job functions.

• Termination procedures

Set up procedures for promptly revoking access upon employee termination.

- Coordinate with the Human Resources department to ensure access termination aligns with employee departure dates.
- Conduct post-termination access audits to verify access removal.

For more useful tips, refer to the Keep Office Information Secure document on ereferrals.bcbsm.com.

Billing chart: Blue Cross highlights 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.

We'll publish information about new Blue Cross groups or changes to group benefits under the Group Benefit Changes heading.

For more detailed descriptions of the Blue Cross' policies for these procedures, check under the Commercial Policy tab in Benefit Explainer on Availity^®. To access this online information:

1. Log in to availity.com.
2 .Click on Payer Spaces on the Availity menu bar.
3. Click on the BCBSM and BCN logo.
4. Click on Benefit Explainer on the Applications tab.
5. Click on the Commercial Policy tab.
6. Click on Topic.
7. Under Topic Criteria, click on the circle for Unique Identifier and click the drop-down arrow next to Choose Identifier Type, then click on HCPCS Code.
8. Enter the procedure code.
9. Click on Finish.
10. Click on Search.

Click here to view the July Billing Chart.

Register now for our virtual Behavioral Health Summit

Professional behavioral health providers and billers are invited to our virtual Behavioral Health Summit on Thursday, Aug. 8.

Attendees can interact with Provider Engagement & Transformation consultants, receive tailored presentations from various behavioral health-specific departments and network with peers and industry leaders.

For more information about the summit, send an email to providerengagement@bcbsm.com.

Webinars for physicians, coders focus on risk adjustment, coding

We’re offering webinars about documentation and coding of common challenging diagnoses. These live, lunchtime educational sessions will also include opportunities to ask questions. 

Below is our schedule and the tentative topics for the sessions. All sessions start at noon Eastern time and generally last for 30 minutes. Register for the session that best works with your schedule on the provider training website.

Provider training website access

Provider portal users with an Availity^® Essentials account can access the provider training website by logging in to availity.com,** clicking on Payer Space in the top menu bar and then clicking on the BCBSM and BCN logo. Then click on the Applications tab, scroll down to the Provider Training Site tile and click on it.

You can also directly access the training website if you don’t have a provider portal account: Provider training website.

After logging in to the provider training website, look in Event Calendar to sign up for your desired session. You can also quickly search for all the sessions with the keyword “lunchtime" and then look under the results for Events.You can listen to the previously recorded sessions too. Check out the following:  

Questions?

• For more information about the sessions, contact April Boyce at aboyce@bcbsm.com.
• For more information about registration or using the provider training website, contact the provider training team at ProviderTraining@bcbsm.com.
• For more information on accessing the provider training website through the provider portal see the “Access our training site from our provider portal; new learning path available” article in the December 2023 Record.

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

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal and electronic data interchange services.

Changes coming for select weight loss drugs for some commercial members

Blue Cross Blue Shield of Michigan and Blue Care Network are changing how we approach coverage of glucagon-like peptide-1 receptor agonist, known as GLP-1, drugs indicated for weight loss for our fully insured large group commercial members. These drugs include:

• Saxenda^® (liraglutide)
• Wegovy^® (semaglutide) 
• Zepbound^® (tirzepatide) 

Here’s what will change:

• Aug. 1, 2024 – Current prior authorizations for these drugs will end at midnight July 31. New prior authorization requests will be required, and new prior authorization criteria will be applied for these members for dates of service from Aug. 1 through Dec. 31, 2024. Some members will require new prescriptions to align with the new prior authorization criteria, if the original prescriber didn’t have an established relationship with the member or hasn’t seen the member in person. For members with a plan renewal date other than Jan. 1, their new prior authorizations will end before their renewal dates, instead of Dec. 31.
• Jan. 1, 2025 – Coverage for GLP-1 weight loss drugs for fully insured large group commercial members will end Jan. 1, 2025. For members with a plan renewal date other than Jan. 1, the coverage will end on the renewal date.

We’re notifying members affected by these changes and their prescribers.

We’re changing prior authorization criteria

For dates of service from Aug. 1 through Dec. 31, 2024, Saxenda, Wegovy and Zepbound will have new prior authorization criteria for fully insured large group commercial members.

The new criteria will not apply to MESSA group members. In addition, self-funded groups that cover GLP-1 drugs for weight loss may continue using their current prior authorization criteria.

All current authorizations for these medications for fully insured large group commercial members will expire July 31, 2024, and the following new criteria will apply:

• The member must be 18 years or older and have a body mass index of 35 or higher.
• The medication must be prescribed by a health care provider who has an established relationship with the member and has seen the member in person.
• The prescriber must document the member’s current baseline weight (within 30 days).
• The prescriber must document the member’s active participation in a lifestyle modification program (working with a coach, tracking food and exercising) for a minimum of six months before the prior authorization request. The prescriber will no longer be able to simply attest to a member’s participation. Without this documentation, the request will be denied.
• The member must enroll and participate in the Teladoc^® Health program for weight management. This program, at no cost to eligible members, offers easy-to-use tools and support. The prescriber must submit documentation of the member’s active participation, or the request will be denied.

In addition to the requirements above, Saxenda, Wegovy and Zepbound:

• Can’t be used in combination with other weight loss products or other products that contain GLP-1 agonists
• Aren’t covered for members with Type 2 diabetes

For more information on how to submit a prior authorization electronically:

1. Go to ereferrals.bcbsm.com.
2. Select Blue Cross for PPO members or BCN for HMO members.
3. Click on Pharmacy Benefit Drugs in the left navigation.
4. See the section, “How to submit an electronic prior authorization, or ePA, request.”

What you need to do

If you have Blue Cross or BCN commercial members with a current prior authorization for Saxenda, Wegovy or Zepbound, ask the members if they are affected by this change. Members will know they’re affected if they receive letters from Blue Cross and BCN. Members can also check their Blue Cross member accounts or call the Customer Service number on their ID cards.

If a member is affected, you’ll need to submit a new prior authorization request following the new requirements for dates of service beginning Aug. 1, 2024. Based on the new requirements, the member may require a new prescription. If the new coverage requirements aren’t met, or the documentation noted above is not included in the prior authorization request, the member will no longer qualify for coverage.

We’re changing coverage

Beginning Jan. 1, 2025, Blue Cross and BCN will no longer cover any GLP-1 drug for weight loss for fully insured large group commercial members. For group members with a plan renewal date other than Jan. 1, this change will go into effect on the renewal date.

This applies to all GLP-1 weight loss drugs, including Saxenda, Wegovy and Zepbound.

If you keep a member who is affected by this change on a GLP-1 drug for weight loss, that member will be responsible for the full cost of the drug.

We’ll update our drug criteria documents

The following documents will be updated to reflect these changes as they occur:

• Blue Cross PPO and BCN HMO prior authorization and step therapy coverage criteria
• Blue Cross PPO and BCN HMO prior authorization and step therapy coverage criteria for the Preferred Drug List

Why Blue Cross and BCN are making these changes

We’re making these changes in part because research has shown that a person’s chance of success in losing weight and maintaining that weight loss is greatly improved when medication is paired with lifestyle changes, including diet and exercise.^1,2 This is why we’re requiring that members on Saxenda, Wegovy or Zepbound participate in the weight management program through Teladoc Health.

In addition, prescription medications need to be effective as well as safe. Data published by the Blue Cross Blue Shield Association in May 2024 shows that most patients aren’t staying on GLP-1 drugs for weight loss long enough to see a benefit.³ Due to the high cost of these drugs and supply considerations, we want to ensure they are used for the most appropriate patients who can achieve clinical benefits. Additional research is needed to understand whether GLP-1 medications lead to lower medical costs in the long term.

Questions?

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

See the additional article in this issue about a change to coverage criteria for other GLP-1 drugs for Medicare Advantage members.

¹Jensen, S. B., Blond, M. B., Sandsdal, R. M., Olsen, L. M., Juhl, C. R., Lundgren, J. R., Janus, C., Stallknecht, B. M., Holst, J. J., Madsbad, S., & Torekov, S. S. (2024). Healthy weight loss maintenance with exercise, GLP-1 receptor agonist, or both combined followed by one year without treatment: A post-treatment analysis of a randomised placebo-controlled trial.**  eClinicalMedicine, 69, 102475.

²Dalle Grave, R. (2024). The benefit of healthy lifestyle in the era of new medications to treat obesity.**  Diabetes, Metabolic Syndrome and Obesity, 17, 227-230.

³Blue Cross Blue Shield Association, Blue Health Intelligence Issue Brief (May 2024). Real-World Trends in GLP-1 Treatment Persistence and Prescribing for Weight Management.** Retrieved from https://www.bcbs.com/sites/default/files/BHI_Issue_Brief_GLP1_Trends.pdf**

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

Medicare Advantage prior authorization criteria changed for some diabetes drugs

We’ve changed our prior authorization criteria for glucagon-like peptide 1 agonist, or GLP-1, drugs indicated for diabetes for Medicare Plus Blue℠ and BCN Advantage℠ members who are beginning treatment with the brand-name medications listed below:

• Bydureon^®
• Byetta^®
• Ozempic^®
• Rybelsus^®
• Trulicity^®
• Mounjaro^®

Our prior authorization criteria require GLP-1 drugs to be used for the treatment of Type 2 diabetes, an indication approved by the U.S. Food and Drug Administration. Members must have a diagnosis of Type 2 diabetes for prior authorization to be approved, effective May 10, 2024.

In the past, the clinical requirement could be met through either a Type 2 diabetes diagnosis or a failed trial of one other diabetes medication on our drug list.The criteria update won’t apply to members who have started GLP-1 treatment prior to May 10, 2024. Those members will be exempt from this prior authorization update and will be able to remain on their GLP-1 medications without needing new prior authorizations.

For information on how to submit prior authorization requests electronically, click here.

For a complete list of covered drugs and associated requirements, go to 2024 Drug Lists.

See the additional article in this issue about a change to coverage criteria for other GLP-1 drugs for commercial fully insured members.

Outpatient audits of Medicare Plus Blue professional claims to begin in October

An audit of Medicare Plus Blue℠ outpatient professional claims will be performed in October by EXL, an independent company that provides auditing support for Blue Cross Blue Shield of Michigan.  

The audit will include select professional claims that correspond to facility claims with CPT codes that range from *10004 through *69990.

The initial review performed by EXL will use the facility’s medical records to compare a facility surgery claim with the physician’s professional claim to identify any billing inconsistencies with CPT or HCPCS procedure codes. Medical records won’t be requested for the physician’s professional claim.

Once you receive a patient listing with an audit notice letter:

• No further adjustments can be made to the related claims.
• No rebilling is allowed to correct a billing mistake or other errors.
• Inform your billing and finance departments of the claims being audited.

After an audit, EXL will send a letter with findings and information about requesting an appeal, if applicable.

If you have questions, call EXL’s customer service number at 1-833-717-0378.

Keep this information in mind when it comes to therapeutic massage

Blue Cross Blue Shield of Michigan reimburses for therapeutic massage as a part of an overall physical medicine treatment plan if the following criteria are met:

• It’s provided as part of a formal course of physical therapy in addition to other therapeutic interventions on the same date of service, with the exception of manual therapy.
• It’s provided in the early, acute phase of therapy to address a musculoskeletal problem and is generally limited to two weeks of treatment.

Reminders

• Massage therapy alone, either as a one-time service or as a series of massages over time, isn’t a benefit included in Blue Cross health plans.
• All Blue Cross requirements related to the identification and qualifications of approved providers of physical therapy apply to the providers of massage therapy.
• All Blue Cross rules regarding orders and documentation of rehabilitation services apply to the provision of massage therapy.
• All Blue Cross rules and requirements related to “incident to” billing for physical therapy apply to massage therapy.

Medically necessary therapeutic massage may be delivered by participating providers when it’s within their scope of practice. Chiropractors may perform this service as a part of a complete physical medical plan; they may not supervise other provider types in the performance of therapeutic massage.

Blue Cross doesn’t reimburse for therapeutic massage and physical medicine services provided by massage therapists, therapy aides, exercise physiologists or kinesiotherapists, even under the supervision of an eligible provider type.

For Michigan Education Special Services Association members, massage therapy services are payable when supervised and billed by a chiropractor. Chiropractors can delegate massage therapy to another person. The chiropractor isn’t required to provide them directly.

A physician (M.D. or D.O.) agreement or signature isn’t required on a treatment plan for MESSA members.

Be sure to verify the contract benefits of a member before performing therapeutic massage.

Help patients manage chronic conditions

This is part of an ongoing series of articles focusing on the tools and resources available to help FEP^® members manage their health.

Patients who manage their chronic conditions are less likely to have emergency room visits, hospital admissions or hospital readmissions. This article contains resources for health care providers and patients about managing chronic conditions.

For providers

The Michigan Quality Improvement Consortium Committee of the Michigan Association of Health Plans** has guidelines for managing chronic conditions. Here are some of those resources:

• Medical Management of Adults with Hypertension**
• Management of Type 2 Diabetes Mellitus**
• Lipid Screening and Management**
• Opioid Prescribing in Adults Excluding Palliative and End-of-Life Care**
• Primary Care Diagnosis and Management of Adults with Depression**

For patients

Here are a few resources to help your patients manage chronic conditions:

• My Blood Pressure Log:** Patients can track their blood pressures based on their treatment plans.
• My Diabetes Care Record:** Patients can keep track of goals, track checkups and lab test results.
• The Scoop on Statins: What Do You Need to Know?:** Patients can learn about statins and how to address medication concerns.
• What to Ask Your Doctor Before Taking Opioids:** Patients can learn about the side effects of opioids and what to discuss with a health care professional.
• Commonly prescribed antidepressants and how they work:** Patients can read about the common types of antidepressants.

Sometimes flare-ups of a chronic condition can occur and require hospital services. When patients are seen by their provider within seven days after discharge, an additional emergency room visit, hospital admission or hospital readmission may be avoided.

For more information on FEP programs or benefits visit fepblue.org** or call Customer Service at 1-800-482-3600.

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

We’ll use 2024 InterQual criteria, starting Aug. 1

On Aug. 1, 2024, Blue Cross Blue Shield of Michigan and Blue Care Network will start using 2024 InterQual^® criteria to make determinations on prior authorization requests for the medical – non-behavioral health – services we manage for these members:

• Blue Cross commercial
• Medicare Plus Blue℠
• BCN commercial
• BCN Advantage℠

If InterQual criteria are updated to correct known issues or errors, we’ll use the updated criteria as soon as they’re available.

Blue Cross and BCN also use local rules for prior authorization requests for post-acute care that include inpatient rehabilitation, skilled nursing facility and long-term acute care. These local rules are modifications of InterQual criteria that we use in making determinations. You can access the local rules on the Services that need prior authorization page on bcbsm.com. We’ve updated that page to include the most current version of the local rules.

Refer to the table below for more specific information about which criteria we use in making determinations for various types of non-behavioral health prior authorization requests.

When clinical information is requested for a medical or surgical admission or for other services, we require health care providers to submit specific components of the medical record that show that the request meets the criteria. We review this information when making determinations on prior authorization requests.

Note: The information in this article applies to members whose authorizations are managed by Blue Cross or BCN directly and not by independent companies that provide services to Blue Cross or BCN.

Select one PO with affiliated MCG to support all Blue Cross, BCN business

Blue Cross Blue Shield of Michigan and Blue Care Network are asking primary care providers to align with one physician organization, and that PO’s affiliated medical care group, to receive support for all Blue Cross and BCN lines of business in which the primary care provider chooses to participate. This includes Blue Cross and BCN commercial and Medicare Advantage plans.

This alignment needs to occur before Jan. 1, 2026, but we’re encouraging primary care providers to consider their options and make any necessary changes now. Working with a Blue Cross physician organization and its related BCN medical care group will maximize efficiency for Blue Cross and BCN reporting, incentives and value-based contracting. We expect this change to reduce the administrative burden on primary care providers and result in more time for patient care.

What primary care providers need to do

Review the list of POs and their corresponding MCGs.

• If the primary care provider is already part of a PO and MCG that align, there is no action needed. If you have any questions, contact your PO.
• If the primary care provider is not already part of a PO or MCG, review the list of POs and their corresponding MCGs and reach out to ask about participation requirements, including the benefits and services they offer.
• If the primary care provider is with one PO for Blue Cross contracts and an MCG that doesn’t align to that same PO for BCN contracts, determine which entity you will align with going forward. Talk to both entities to ensure you make an informed choice.
• If the primary care provider is in the Upper Peninsula, there is no need to align with a BCN MCG. There is currently no corresponding MCG to the Upper Peninsula Health Group PO. 

What you should know

• We encourage primary care providers to join physician organizations or medical care groups to maximize value-based reimbursement, incentive opportunities and opportunities for a value-based contract.
• A primary care provider can participate in the Blue Cross networks without aligning to a PO. 
• In some cases, a primary care provider may be able to participate in the BCN and BCN Advantage networks without aligning to a PO or MCG entity, but participation is limited based on the needs of the network.

For more information

Here’s where you can learn more:

• Contact your Blue Cross PO or BCN MCG
• Reach out to PO or MCG contacts in the list of POs and their corresponding MCGs

Changes coming to prior authorization process for post-acute care services for Medicare Advantage members

In the fourth quarter of 2024, Home & Community Care (formerly known as naviHealth, Inc.) will no longer manage prior authorizations for post-acute care services for Medicare Plus Blue℠ and BCN Advantage℠ members.

Post-acute care services will continue to require prior authorizations, but they will be managed by Blue Cross Blue Shield of Michigan and Blue Care Network.

Watch for provider alerts and articles in The Record and BCN Provider News with additional information about this change, including:

• Training, which will include program requirements and more
• Updates to our provider communications and documents for this program

Home & Community Care is an independent company that manages prior authorizations for post-acute care services for Blue Cross Blue Shield of Michigan and Blue Care Network members who have Medicare Advantage plans.

Remember this information about reimbursement for manual therapy

Blue Cross Blue Shield of Michigan reimburses manual therapy (*97140) as a part of an overall physical therapy or medicine treatment plan.

Manual therapy is one of the main modalities of physical therapy. This type of treatment is performed by a physical therapy or medicine provider using hands-on techniques to help strengthen and stretch different aspects of the body to reduce pain and inflammation, eliminate swelling and increase range of motion.

CPT code *97140 is a constant timed procedure that requires direct one-on-one contact with the provider. It is billed in 15-minute increments and can’t be provided in the same visit as a therapeutic massage.

Keep the following in mind:

• All Blue Cross requirements related to the identification and qualifications of approved providers of physical therapy apply to the providers of massage therapy.
• Blue Cross rules regarding orders and documentation of rehabilitation services apply to the provision of manual therapy.
• All Blue Cross rules and requirements related to “incident to” billing for physical therapy and medicine apply.
• Manual therapy isn't a covered service when applied to the same area of the body as that of chiropractic manipulative therapy. They are considered duplicate services.

Medically necessary manual therapy may be delivered by participating providers when such a modality is within their scope of practice. Chiropractors may perform this service when performed as a part of a complete physical medical plan; they may not supervise other provider types in performance of manual therapy.

Blue Cross doesn’t reimburse for physical therapy or medicine services provided by massage therapists, therapy aides, exercise physiologists or kinesiotherapists, even under the supervision of an eligible provider type.

As always, be sure to verify the contract benefits of a member before performing therapeutic massage.

Requirements, codes changed for some medical benefit drugs

Blue Cross Blue Shield of Michigan and Blue Care Network encourage proper utilization of high-cost medications that are covered under medical benefits. As part of this effort, we maintain comprehensive lists of requirements for our members.

In April, May and June 2024, we added requirements for some medical benefit drugs. These requirements went into effect on various dates. In addition, some drugs were assigned new HCPCS codes.

Changes in requirements

For Blue Cross and BCN commercial members, we added prior authorization requirements for the following drugs:

For Medicare Plus Blue℠ and BCN Advantage℠ members, we added prior authorization requirements for the following drugs:

Code changes

The table below shows HCPCS code changes that were effective January 2024 for the medical benefit drugs managed by Blue Cross and BCN.

Drug lists

For additional details, see the following drug lists:

• For commercial members: Blue Cross and BCN utilization management medical drug list
• For Medicare Advantage members: Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members.

These lists are also available on the following pages of the ereferrals.bcbsm.com website:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

Additional information about these requirements

We communicated these changes previously through provider alerts. Those alerts contain additional details.

You can view the provider alerts on ereferrals.bcbsm.com and on our Provider Resources site, which is accessible through our provider portal (availity.com).***

Additional information for Blue Cross commercial groups

For Blue Cross commercial health plans, authorization requirements apply only to groups that participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under medical benefits.

To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List. A link to this list is also available on the Blue Cross Medical Benefit Drugs page of the ereferrals.bcbsm.com website.

Note: Blue Cross and Blue Shield Federal Employee Program^® members and UAW Retiree Medical Benefits Trust (non-Medicare) members don't participate in the standard prior authorization program.

Reminder

An authorization approval isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.

**May be assigned a unique code in the future

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

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal and electronic data interchange services.

Do you have time for a Quality Minute?

This is another article in our ongoing series of quick tips designed to be read in 60 seconds or less and provide your practice with information about performance in key areas.

Kidney health evaluation for patients with diabetes

To help close the diabetes care HEDIS^® measure, follow these tips for a kidney health evaluation:

• For patients 18 to 85 years of age with diabetes, complete both an eGFR (blood) and uACR (urine) test.
• The uACR component can be satisfied by ordering a quantitative urine albumin test (*82043) and a urine creatinine test (*82570) less than four days apart or a urine albumin creatine ratio (uACR) lab test. There isn’t a CPT code for uACR. This test is reported through LOINC codes.
• If your practice performs in-office testing, determine what kind of analyzer you use and the type of urine albumin test being performed. Some analyzers only measure semi-quantitative urine albumin, which are reported using different codes and will not close gaps.
• Chronic kidney disease is classified using both the eGFR and uACR to appropriately assign a stage. CKD can be diagnosed if there is evidence of decreased kidney function (eGFR), kidney damage (elevated uACR) or both for at least three months. It is important to use the appropriate ICD-10 code to classify CKD severity and avoid using CKD unspecified codes, when possible.

For more information, refer to the Kidney Health Evaluation for Patients with Diabetes tip sheet or 2024 Kidney Health Evaluation for Patients with Diabetes Network Performance Improvement presentation. Here’s how to find them.

1. Log in to our provider portal (availity.com).**
2. Click on Payer Spaces on the menu bar and then click on the BCBSM and BCN logo.
3. Click on the Resources tab.
4. Click on Secure Provider Resources (Blue Cross and BCN).
5. Click on Member Care on the menu bar and then click on Clinical Quality and Tip Sheets for the tip sheet or Clinical Quality Overview for the presentation.

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

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

Medicare implantable ambulatory event monitors questionnaire removed from e-referral system

On May 26, 2024, we removed the Medicare implantable ambulatory event monitors questionnaire from the e-referral system. This questionnaire no longer opens for Medicare Plus Blue℠ or BCN Advantage℠ members. However, procedure code *33285 continues to require prior authorization.  

We’ve updated the Authorization criteria and preview questionnaires document on the ereferrals.bcbsm.com website to reflect this change.

As a reminder, we use our authorization criteria, our medical policies and health care providers’ answers to the questionnaires in the e-referral system when making utilization management determinations on prior authorization requests.

Soliris, Ultomiris to require step therapy for commercial members

For dates of service on or after July 22, 2024, members must try and fail — or have a contraindication or intolerance for — Empaveli^® (pegcetacoplan), HCPCS code J3590, before we’ll approve prior authorization requests for the following drugs:

• Soliris (eculizumab), HCPCS code J1300
• Ultomiris (ravulizumab), HCPCS code J1303

This step therapy requirement applies to most Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members and is in addition to the other requirements that currently apply to Soliris and Ultomiris.

Prior authorization information:

• When you submit prior authorization requests for Soliris and Ultomiris, the NovoLogix^® online tool will prompt you to answer questions related to the step therapy requirement.
• Prior authorization is also required for Empaveli.

Some Blue Cross commercial groups aren’t subject to these requirements

For Blue Cross commercial, these requirements apply only to groups that participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under medical benefits. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list.

Blue Cross and Blue Shield Federal Employee Program^® members and UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans don’t participate in the standard prior authorization program.

Dapagliflozin, generic for Farxiga, isn’t covered for Medicare Advantage plans

Dapagliflozin, the authorized generic for Farxiga^®, is not included on the covered drug list for Medicare Plus Blue℠ and BCN Advantage℠ individual plans. Farxiga, the name brand, is the preferred product on our Medicare Advantage drug list.

Our Medicare Advantage group health care plans may use different drug lists with different benefits, so please refer to the patient’s benefits online for coverage information. For example, neither Farxiga nor dapagliflozin is covered for UAW Retiree Medical Benefits Trust members.

Note: To ensure the pharmacy dispenses the name brand and the member receives the lowest out-of-pocket costs, make sure Farxiga prescriptions have “DAW1” notated. The authorized generic isn’t on our drug list, and even if approved through a drug list exception, the member will pay more than for Farxiga.

This issue directly affects the medication adherence incentive measure. We are making every effort to prevent point-of-sale issues causing members to go without their medications. It's crucial to understand that any such issues will adversely affect your patient’s medication adherence and your incentive measure.

We've also shared this information with our major retail chain pharmacies. We're here to help you manage these medication coverage issues.

Hemlibra has a quantity limit requirement for most commercial members

We’ve added a quantity limit requirement for most Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members for Hemlibra^® (emicizumab-kxwh), HCPCS code J7170. The new quantity limit requirement, effective for dates of service on or after June 20, 2024, is in addition to the prior authorization and site-of-care requirements that apply to this drug.

Some Blue Cross commercial groups aren’t subject to these requirements

For Blue Cross commercial, these requirements apply only to groups that participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under medical benefits. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list.

Note: Blue Cross and Blue Shield Federal Employee Program^® members and UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans don’t participate in the standard prior authorization program.

List of requirements

For a full list of quantity limit requirements related to drugs covered under the medical benefit, see the document titled Blue Cross and BCN quantity limits for medical drugs.

Loqtorzi to have requirements for most members, starting Aug. 15

For dates of service on or after Aug. 15, 2024, Loqtorzi™ (toripalimab-tpzi), HCPCS code J3263, will have the following requirements through the Oncology Value Management program:

• For Blue Cross Blue Shield of Michigan and Blue Care Network commercial members: Loqtorzi will have both a prior authorization requirement and a site-of-care requirement.
• For Medicare Plus Blue℠ and BCN Advantage℠ members: Loqtorzi will have a prior authorization requirement.

The Oncology Value Management program is administered by Carelon Medical Benefits Management. These drugs are part of members’ medical benefits, not their pharmacy benefits.  

Prior authorization requirement

Prior authorization requirements apply when these drugs are administered in outpatient settings for:

• Blue Cross commercial
• All fully insured members (group and individual)
• Members who have coverage through self-funded groups that have opted in to the Oncology Value Management program. (Although UAW Retiree Medical Benefits Trust non-Medicare plans have opted into this program, these requirements may not apply; refer to their medical oncology drug list, which is linked below.)
  Note: This requirement doesn’t apply to members who have coverage through the Blue Cross and Blue Shield Federal Employee Program^®.
• Medicare Plus Blue members
• BCN commercial members
• BCN Advantage members

Site-of-care requirement

For the commercial members listed above, this drug may be covered only when administered at the following sites of care for dates of service on or after Aug. 15:

• Doctor’s or other health care provider’s office
• The member's home, administered by a home infusion therapy provider
• Ambulatory infusion center

Here’s what to do for commercial members who receive Loqtorzi at an outpatient hospital facility for dates of service before Aug. 15:

• Locate an in-network home infusion therapy provider or ambulatory infusion center at which the member may be able to continue infusion therapy.
• Discuss with the member how to facilitate receiving infusions at an allowed site of care.

For members who need to transition to a new infusion location, we’ll work with you and the member to facilitate the transition. We’ll notify members and encourage them to talk to you before changing their infusion location. We’ll also let them know that the change of location doesn’t affect the treatment you’re providing.

How to submit prior authorization requests

Submit prior authorization requests to Carelon using one of the following methods:

• Through the Carelon provider portal, which you can access by doing one of the following:
• Logging in to our provider portal (availity.com),** clicking on Payer Spaces and then clicking on the BCBSM and BCN logo. This takes you to the Blue Cross and BCN payer space, where you’ll click the Carelon ProviderPortal tile.
  Note: If you need to request access to our provider portal, see the Register for web tools webpage on bcbsm.com.
• Logging in directly to the Carelon provider portal at providerportal.com.**
• By calling the Carelon Contact Center at 1-844-377-1278

Drug lists

For additional information on requirements related to drugs covered under medical benefits, refer to the following drug lists:

• Blue Cross commercial and BCN commercial:
• Oncology Value Management program prior authorization list for Blue Cross and BCN commercial members
• Blue Cross and BCN utilization management medical drug list
• URMBT members with Blue Cross non-Medicare plans:
• Oncology Value Management program prior authorization list for UAW Retiree Medical Benefits Trust PPO non-Medicare members
• Medical Drug Management with Blue Cross for UAW Retiree Medical Benefits Trust PPO non-Medicare Members
• Medicare Plus Blue and BCN Advantage members:
• Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members

We’ll update the pertinent drug lists to reflect the information in this message prior to the effective date.

As a reminder, prior authorization isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.

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

Carelon Medical Benefits Management is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage prior authorizations for select services.

Step therapy requirement added for botulinum toxins for Medicare Advantage members, starting Aug. 5

For dates of service on or after Aug. 5, 2024, health care providers must show that Medicare Plus Blue℠ and BCN Advantage℠ members tried and failed Xeomin^® (incobotulinumtoxinA), HCPCS code J0588, when requesting prior authorization for the following drugs:

• Botox^® (onabotulinumtoxinA), HCPCS code J0585
• Dysport^® (abobotulinumtoxinA), HCPCS code J0586
• Daxxify^® (daxibotulinumtoxinA), HCPCS code J0589
• Myobloc^® (rimabotulinumtoxinB), HCPCS code J0587

Xeomin is the preferred botulinum toxin product for Blue Cross Blue Shield of Michigan and Blue Care Network’s Medicare Advantage members.

The following is additional important information:

• Step therapy with Xeomin won’t be required for requests to treat chronic migraines or urinary conditions such as overactive bladder.
• Xeomin doesn’t require prior authorization for dates of service after June 1, 2024. For dates of service before June 1, submit prior authorization requests through the NovoLogix^® online tool.
• Submit prior authorization requests for Botox, Dysport, Myobloc and Daxxify through NovoLogix.

These drugs are a part of members’ medical benefits, not their pharmacy benefits.

When prior authorization is required

These drugs require prior authorization, as applicable, when they are administered by a health care provider in sites of care such as outpatient facilities or physician offices and are billed in one of the following ways:

• Electronically through an 837P transaction or on a professional CMS-1500 claim
• Electronically through an 837I transaction or using the UB04 claim for a hospital outpatient type of bill 013X

How to submit prior authorization requests through NovoLogix

To access NovoLogix, log in to our provider portal at availity.com,** click on Payer Spaces in the menu bar and then click on the BCBSM and BCN logo. You’ll find links to the NovoLogix tools on the Applications tab. 

If you need to request access to our provider portal, follow the instructions on the Register for web tools page at bcbsm.com.

List of requirements

For a list of requirements related to drugs covered under medical benefits, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members.

We’ll update this list prior to the effective date.

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

NovoLogix is an independent company that provides an online prescription drug prior authorization tool for Blue Cross Blue Shield of Michigan and Blue Care Network.

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal and electronic data interchange services.

Step therapy requirement added for Saphnelo for Medicare Advantage members Sept. 1

For dates of service on or after Sept. 1, 2024, providers will have to show that our Medicare Plus Blue℠ and BCN Advantage℠ members tried and failed Benlysta^® (belimumab), HCPCS code J0490, when requesting prior authorization for Saphnelo^® (anifrolumab-fnia), HCPCS code J0491.

• Benlysta will continue to require prior authorization.
• Submit prior authorization requests through the NovoLogix^® online tool.

These drugs are a part of members’ medical benefits, not their pharmacy benefits.

When prior authorization is required

These drugs require prior authorization, as applicable, when they’re administered by a health care provider in sites of care such as outpatient facilities or physician offices and are billed in one of the following ways:

• Electronically through an 837P transaction or on a professional CMS-1500 claim
• Electronically through an 837I transaction or using the UB04 claim for a hospital outpatient type of bill 013X

Submit prior authorization requests through NovoLogix

To access NovoLogix, log in to our provider portal (availity.com),** click on Payer Spaces in the menu bar and then click on the BCBSM and BCN logo. You’ll find links to the NovoLogix tools on the Applications tab. 

Note: If you need to request access to our provider portal, follow the instructions on the Register for web tools webpage at bcbsm.com/providers.

List of requirements

For a list of requirements related to drugs covered under medical benefits, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members.

We’ll update this list before the effective date.

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

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal and electronic data interchange services.

Syfovre, Izervay, Elfabrio to have requirements for URMBT members with non-Medicare plans

For dates of service on or after Aug. 13, 2024, Syfovre^®, Izervay™ and Elfabrio^® will have the requirements outlined below for UAW Retiree Medical Benefits Trust members with Blue Cross Blue Shield of Michigan non-Medicare plans.  

These drugs are part of members’ medical benefits, not their pharmacy benefits.

Note: The requirements don’t apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714).

How to submit prior authorization requests

Submit prior authorization requests through the NovoLogix^® online tool. It offers real-time status checks and immediate approvals for certain medications.

To access NovoLogix, log in to our provider portal (availity.com),** click on Payer Spaces in the menu bar and then click on the Blue Cross and BCN logo. You’ll find links to the NovoLogix tools on the Applications tab.

Note: If you need to request access to our provider portal, see the Register for web tools webpage on bcbsm.com.

For drugs that have a site-of-care requirement, the NovoLogix online tool will prompt you to select a site of care when you submit prior authorization requests. If the request meets clinical criteria for the drug and is for one of the following sites of care, it will be approved automatically:

• Doctor’s or other health care provider’s office
• Ambulatory infusion center
• The member’s home, from a home infusion therapy provider

More about requirements for medical benefit drugs

For additional information on requirements related to drugs covered under medical benefits for URMBT members with Blue Cross non-Medicare plans, see:

• Oncology Value Management prior authorization list for UAW Retiree Medical Benefits Trust PPO non-Medicare members
• Medical Drug Management with Blue Cross for UAW Retiree Medical Benefits Trust PPO non-Medicare Members

We’ll update the drug lists to reflect the information in this message prior to the effective date.

As a reminder, prior authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

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

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan to offer provider portal services.

Article correction: Spevigo SC has requirements for most commercial members, starting April 25

Last month, we published an article about Spevigo SC in The Record. The HCPCS code for Spevigo SC was incorrect. The correct HCPCS code for that drug is J1747, which we’ve included in this updated article. All information below is correct.

For dates of service on or after April 25, 2024, we added prior authorization and site-of-care requirements for most Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members for the following drug covered under medical benefits:

Spevigo^® SC (spesolimab-sbzo), HCPCS code J1747

How to submit prior authorization requests

Submit prior authorization requests through the NovoLogix^® online tool. It offers real-time status checks and immediate approvals for certain medications.

To access NovoLogix, log in to our provider portal at availity.com,** click on Payer Spaces in the menu bar and then click on the BCBSM and BCN logo. You’ll find links to the NovoLogix tools on the Applications tab.

Note: If you need to request access to our provider portal, see the Register for web tools webpage on bcbsm.com.

The NovoLogix online tool will prompt you to select a site of care when you submit prior authorization requests for this drug. If the request meets clinical criteria for the drug and is for one of the following sites of care, it will be approved automatically:

• Doctor’s or other health care provider’s office
• Ambulatory infusion center
• The member’s home, from a home infusion therapy provider

Additional information or documentation may be required for requests to administer Spevigo in an outpatient hospital setting.

Some Blue Cross commercial groups aren’t subject to these requirements

For Blue Cross commercial, these requirements apply only to groups that participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under medical benefits. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List.

Blue Cross and Blue Shield Federal Employee Program^® members and UAW Retiree Medical Benefits Trust (non-Medicare) members don’t participate in the standard prior authorization program.

List of requirements

For a full list of requirements related to drugs covered under medical benefits, see the Blue Cross and BCN utilization management medical drug list for Blue Cross commercial and BCN commercial members. We’ve updated this list to reflect the changes.

You can access this list and other information about requesting prior authorization on the following pages of the ereferrals.bcbsm.com website:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

Prior authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

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

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal and electronic data interchange services.

Webinars for physicians, coders focus on risk adjustment, coding

We’re offering webinars about documentation and coding of common challenging diagnoses. These live, lunchtime educational sessions will also include opportunities to ask questions. 

Below is our schedule and the tentative topics for the sessions. All sessions start at noon Eastern time and generally last for 30 minutes. Register for the session that best works with your schedule on the provider training website.

Provider training website access

Provider portal users with an Availity^® Essentials account can access the provider training website by logging in to availity.com,** clicking on Payer Space in the top menu bar and then clicking on the BCBSM and BCN logo. Then click on the Applications tab, scroll down to the Provider Training Site tile and click on it.

You can also directly access the training website if you don’t have a provider portal account: Provider training website.

After logging in to the provider training website, look in Event Calendar to sign up for your desired session. You can also quickly search for all the sessions with the keyword “lunchtime" and then look under the results for Events.You can listen to the previously recorded sessions too. Check out the following:  

Questions?

• For more information about the sessions, contact April Boyce at aboyce@bcbsm.com.
• For more information about registration or using the provider training website, contact the provider training team at ProviderTraining@bcbsm.com.
• For more information on accessing the provider training website through the provider portal see the “Access our training site from our provider portal; new learning path available” article in the December 2023 Record.

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

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal and electronic data interchange services.

Diagnosis billing updated for facility lab claims

Blue Cross Blue Shield of Michigan has updated the outpatient facility lab claims process. Facilities should bill with a routine preventive diagnosis as the primary diagnosis when diagnoses for both routine preventive and medical diagnostic care are billed on the same claim.

This update will be effective July 1, 2024. Previously, claims were processed based on the primary diagnoses reported on outpatient facility lab claims.

Background

• Outpatient facility claims are billed with a claim-level string of diagnoses, including a primary diagnosis and multiple supporting diagnoses.
• Unlike professional claims, no pointers assign a specific diagnosis to a specific service line on a claim.
• Outpatient facility lab claims may include lab procedures that were done for routine preventive reasons or for medical diagnostic purposes.
• Some lab procedures are not payable as routine preventive and may reject as “not a benefit” if the primary diagnosis on the claim is routine preventive.
• Most routine preventative services are payable at 100% with no member out-of-pocket costs, but deductibles and copayments may apply when the primary diagnosis is medical diagnostic.

What does this mean to facilities?

Facilities will now bill the routine preventive diagnosis as the primary diagnosis when diagnoses for both routine preventive and medical diagnostic care are applied to the same claim. This allows us to identify services that are not payable as routine (highest benefit) and apply a payable medical diagnostic care diagnosis, if present.

Future process

Currently, we’re reviewing options for an automated, technical solution where we can process these codes based on the claim-level diagnosis billed, regardless of what diagnosis is listed as primary.

We’ll use 2024 InterQual criteria, starting Aug. 1

On Aug. 1, 2024, Blue Cross Blue Shield of Michigan and Blue Care Network will start using 2024 InterQual^® criteria to make determinations on prior authorization requests for the medical – non-behavioral health – services we manage for these members:

• Blue Cross commercial
• Medicare Plus Blue℠
• BCN commercial
• BCN Advantage℠

If InterQual criteria are updated to correct known issues or errors, we’ll use the updated criteria as soon as they’re available.

Blue Cross and BCN also use local rules for prior authorization requests for post-acute care that include inpatient rehabilitation, skilled nursing facility and long-term acute care. These local rules are modifications of InterQual criteria that we use in making determinations. You can access the local rules on the Services that need prior authorization page on bcbsm.com. We’ve updated that page to include the most current version of the local rules.

Refer to the table below for more specific information about which criteria we use in making determinations for various types of non-behavioral health prior authorization requests.

When clinical information is requested for a medical or surgical admission or for other services, we require health care providers to submit specific components of the medical record that show that the request meets the criteria. We review this information when making determinations on prior authorization requests.

Note: The information in this article applies to members whose authorizations are managed by Blue Cross or BCN directly and not by independent companies that provide services to Blue Cross or BCN.

Inpatient rehabilitation facility reviews resume for Medicare Plus Blue claims, starting Oct. 1

Cotiviti, an independent company that provides claim reviews for Blue Cross Blue Shield of Michigan, will resume auditing Medicare Plus Blue℠ PPO inpatient rehabilitation facility claims Oct. 1, 2024.

Audits will:

• Include a one-year look-back at claims.
• Check patient-met criteria for admission to inpatient rehabilitation facilities.
• Confirm billed case mix group codes.
• Detect, prevent and correct waste and abuse.
• Facilitate correct claim payment.

Be ready to share medical charts. After an audit, Cotiviti will send you a letter with the findings and information on how you can ask for an appeal, if necessary.

Medical criteria information

Inpatient rehabilitation facility level of care is reasonable and necessary if the patient meets all requirements. Cotiviti will confirm that you’ve properly documented the requirements for inpatient rehabilitation facility level of care, including the following:

• Physician order
• Patient supervision by a rehabilitation physician
• Physician visits
• Patient’s need for active and ongoing therapeutic intervention of multiple therapy disciplines

Questions?

Contact Cotiviti Provider Relations at 770-379-2009 from 8 a.m. to 5 p.m. Eastern time Monday through Friday.

Changes coming to prior authorization process for post-acute care services for Medicare Advantage members

In the fourth quarter of 2024, Home & Community Care (formerly known as naviHealth, Inc.) will no longer manage prior authorizations for post-acute care services for Medicare Plus Blue℠ and BCN Advantage℠ members.

Post-acute care services will continue to require prior authorizations, but they will be managed by Blue Cross Blue Shield of Michigan and Blue Care Network.

Watch for provider alerts and articles in The Record and BCN Provider News with additional information about this change, including:

• Training, which will include program requirements and more
• Updates to our provider communications and documents for this program

Home & Community Care is an independent company that manages prior authorizations for post-acute care services for Blue Cross Blue Shield of Michigan and Blue Care Network members who have Medicare Advantage plans.

Requirements, codes changed for some medical benefit drugs

Blue Cross Blue Shield of Michigan and Blue Care Network encourage proper utilization of high-cost medications that are covered under medical benefits. As part of this effort, we maintain comprehensive lists of requirements for our members.

In April, May and June 2024, we added requirements for some medical benefit drugs. These requirements went into effect on various dates. In addition, some drugs were assigned new HCPCS codes.

Changes in requirements

For Blue Cross and BCN commercial members, we added prior authorization requirements for the following drugs:

For Medicare Plus Blue℠ and BCN Advantage℠ members, we added prior authorization requirements for the following drugs:

Code changes

The table below shows HCPCS code changes that were effective January 2024 for the medical benefit drugs managed by Blue Cross and BCN.

Drug lists

For additional details, see the following drug lists:

• For commercial members: Blue Cross and BCN utilization management medical drug list
• For Medicare Advantage members: Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members.

These lists are also available on the following pages of the ereferrals.bcbsm.com website:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

Additional information about these requirements

We communicated these changes previously through provider alerts. Those alerts contain additional details.

You can view the provider alerts on ereferrals.bcbsm.com and on our Provider Resources site, which is accessible through our provider portal (availity.com).***

Additional information for Blue Cross commercial groups

For Blue Cross commercial health plans, authorization requirements apply only to groups that participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under medical benefits.

To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List. A link to this list is also available on the Blue Cross Medical Benefit Drugs page of the ereferrals.bcbsm.com website.

Note: Blue Cross and Blue Shield Federal Employee Program^® members and UAW Retiree Medical Benefits Trust (non-Medicare) members don't participate in the standard prior authorization program.

Reminder

An authorization approval isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.

**May be assigned a unique code in the future

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

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal and electronic data interchange services.

Soliris, Ultomiris to require step therapy for commercial members

For dates of service on or after July 22, 2024, members must try and fail — or have a contraindication or intolerance for — Empaveli^® (pegcetacoplan), HCPCS code J3590, before we’ll approve prior authorization requests for the following drugs:

• Soliris (eculizumab), HCPCS code J1300
• Ultomiris (ravulizumab), HCPCS code J1303

This step therapy requirement applies to most Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members and is in addition to the other requirements that currently apply to Soliris and Ultomiris.

Prior authorization information:

• When you submit prior authorization requests for Soliris and Ultomiris, the NovoLogix^® online tool will prompt you to answer questions related to the step therapy requirement.
• Prior authorization is also required for Empaveli.

Some Blue Cross commercial groups aren’t subject to these requirements

For Blue Cross commercial, these requirements apply only to groups that participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under medical benefits. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list.

Blue Cross and Blue Shield Federal Employee Program^® members and UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans don’t participate in the standard prior authorization program.

Dapagliflozin, generic for Farxiga, isn’t covered for Medicare Advantage plans

Dapagliflozin, the authorized generic for Farxiga^®, is not included on the covered drug list for Medicare Plus Blue℠ and BCN Advantage℠ individual plans. Farxiga, the name brand, is the preferred product on our Medicare Advantage drug list.

Our Medicare Advantage group health care plans may use different drug lists with different benefits, so please refer to the patient’s benefits online for coverage information. For example, neither Farxiga nor dapagliflozin is covered for UAW Retiree Medical Benefits Trust members.

Note: To ensure the pharmacy dispenses the name brand and the member receives the lowest out-of-pocket costs, make sure Farxiga prescriptions have “DAW1” notated. The authorized generic isn’t on our drug list, and even if approved through a drug list exception, the member will pay more than for Farxiga.

This issue directly affects the medication adherence incentive measure. We are making every effort to prevent point-of-sale issues causing members to go without their medications. It's crucial to understand that any such issues will adversely affect your patient’s medication adherence and your incentive measure.

We've also shared this information with our major retail chain pharmacies. We're here to help you manage these medication coverage issues.

Hemlibra has a quantity limit requirement for most commercial members

We’ve added a quantity limit requirement for most Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members for Hemlibra^® (emicizumab-kxwh), HCPCS code J7170. The new quantity limit requirement, effective for dates of service on or after June 20, 2024, is in addition to the prior authorization and site-of-care requirements that apply to this drug.

Some Blue Cross commercial groups aren’t subject to these requirements

For Blue Cross commercial, these requirements apply only to groups that participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under medical benefits. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list.

Note: Blue Cross and Blue Shield Federal Employee Program^® members and UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans don’t participate in the standard prior authorization program.

List of requirements

For a full list of quantity limit requirements related to drugs covered under the medical benefit, see the document titled Blue Cross and BCN quantity limits for medical drugs.

Loqtorzi to have requirements for most members, starting Aug. 15

For dates of service on or after Aug. 15, 2024, Loqtorzi™ (toripalimab-tpzi), HCPCS code J3263, will have the following requirements through the Oncology Value Management program:

• For Blue Cross Blue Shield of Michigan and Blue Care Network commercial members: Loqtorzi will have both a prior authorization requirement and a site-of-care requirement.
• For Medicare Plus Blue℠ and BCN Advantage℠ members: Loqtorzi will have a prior authorization requirement.

The Oncology Value Management program is administered by Carelon Medical Benefits Management. These drugs are part of members’ medical benefits, not their pharmacy benefits.  

Prior authorization requirement

Prior authorization requirements apply when these drugs are administered in outpatient settings for:

• Blue Cross commercial
• All fully insured members (group and individual)
• Members who have coverage through self-funded groups that have opted in to the Oncology Value Management program. (Although UAW Retiree Medical Benefits Trust non-Medicare plans have opted into this program, these requirements may not apply; refer to their medical oncology drug list, which is linked below.)
  Note: This requirement doesn’t apply to members who have coverage through the Blue Cross and Blue Shield Federal Employee Program^®.
• Medicare Plus Blue members
• BCN commercial members
• BCN Advantage members

Site-of-care requirement

For the commercial members listed above, this drug may be covered only when administered at the following sites of care for dates of service on or after Aug. 15:

• Doctor’s or other health care provider’s office
• The member's home, administered by a home infusion therapy provider
• Ambulatory infusion center

Here’s what to do for commercial members who receive Loqtorzi at an outpatient hospital facility for dates of service before Aug. 15:

• Locate an in-network home infusion therapy provider or ambulatory infusion center at which the member may be able to continue infusion therapy.
• Discuss with the member how to facilitate receiving infusions at an allowed site of care.

For members who need to transition to a new infusion location, we’ll work with you and the member to facilitate the transition. We’ll notify members and encourage them to talk to you before changing their infusion location. We’ll also let them know that the change of location doesn’t affect the treatment you’re providing.

How to submit prior authorization requests

Submit prior authorization requests to Carelon using one of the following methods:

• Through the Carelon provider portal, which you can access by doing one of the following:
• Logging in to our provider portal (availity.com),** clicking on Payer Spaces and then clicking on the BCBSM and BCN logo. This takes you to the Blue Cross and BCN payer space, where you’ll click the Carelon ProviderPortal tile.
  Note: If you need to request access to our provider portal, see the Register for web tools webpage on bcbsm.com.
• Logging in directly to the Carelon provider portal at providerportal.com.**
• By calling the Carelon Contact Center at 1-844-377-1278

Drug lists

For additional information on requirements related to drugs covered under medical benefits, refer to the following drug lists:

• Blue Cross commercial and BCN commercial:
• Oncology Value Management program prior authorization list for Blue Cross and BCN commercial members
• Blue Cross and BCN utilization management medical drug list
• URMBT members with Blue Cross non-Medicare plans:
• Oncology Value Management program prior authorization list for UAW Retiree Medical Benefits Trust PPO non-Medicare members
• Medical Drug Management with Blue Cross for UAW Retiree Medical Benefits Trust PPO non-Medicare Members
• Medicare Plus Blue and BCN Advantage members:
• Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members

We’ll update the pertinent drug lists to reflect the information in this message prior to the effective date.

As a reminder, prior authorization isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.

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

Carelon Medical Benefits Management is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage prior authorizations for select services.

Step therapy requirement added for botulinum toxins for Medicare Advantage members, starting Aug. 5

For dates of service on or after Aug. 5, 2024, health care providers must show that Medicare Plus Blue℠ and BCN Advantage℠ members tried and failed Xeomin^® (incobotulinumtoxinA), HCPCS code J0588, when requesting prior authorization for the following drugs:

• Botox^® (onabotulinumtoxinA), HCPCS code J0585
• Dysport^® (abobotulinumtoxinA), HCPCS code J0586
• Daxxify^® (daxibotulinumtoxinA), HCPCS code J0589
• Myobloc^® (rimabotulinumtoxinB), HCPCS code J0587

Xeomin is the preferred botulinum toxin product for Blue Cross Blue Shield of Michigan and Blue Care Network’s Medicare Advantage members.

The following is additional important information:

• Step therapy with Xeomin won’t be required for requests to treat chronic migraines or urinary conditions such as overactive bladder.
• Xeomin doesn’t require prior authorization for dates of service after June 1, 2024. For dates of service before June 1, submit prior authorization requests through the NovoLogix^® online tool.
• Submit prior authorization requests for Botox, Dysport, Myobloc and Daxxify through NovoLogix.

These drugs are a part of members’ medical benefits, not their pharmacy benefits.

When prior authorization is required

These drugs require prior authorization, as applicable, when they are administered by a health care provider in sites of care such as outpatient facilities or physician offices and are billed in one of the following ways:

• Electronically through an 837P transaction or on a professional CMS-1500 claim
• Electronically through an 837I transaction or using the UB04 claim for a hospital outpatient type of bill 013X

How to submit prior authorization requests through NovoLogix

To access NovoLogix, log in to our provider portal at availity.com,** click on Payer Spaces in the menu bar and then click on the BCBSM and BCN logo. You’ll find links to the NovoLogix tools on the Applications tab. 

If you need to request access to our provider portal, follow the instructions on the Register for web tools page at bcbsm.com.

List of requirements

For a list of requirements related to drugs covered under medical benefits, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members.

We’ll update this list prior to the effective date.

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

NovoLogix is an independent company that provides an online prescription drug prior authorization tool for Blue Cross Blue Shield of Michigan and Blue Care Network.

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal and electronic data interchange services.

Step therapy requirement added for Saphnelo for Medicare Advantage members Sept. 1

For dates of service on or after Sept. 1, 2024, providers will have to show that our Medicare Plus Blue℠ and BCN Advantage℠ members tried and failed Benlysta^® (belimumab), HCPCS code J0490, when requesting prior authorization for Saphnelo^® (anifrolumab-fnia), HCPCS code J0491.

• Benlysta will continue to require prior authorization.
• Submit prior authorization requests through the NovoLogix^® online tool.

These drugs are a part of members’ medical benefits, not their pharmacy benefits.

When prior authorization is required

These drugs require prior authorization, as applicable, when they’re administered by a health care provider in sites of care such as outpatient facilities or physician offices and are billed in one of the following ways:

• Electronically through an 837P transaction or on a professional CMS-1500 claim
• Electronically through an 837I transaction or using the UB04 claim for a hospital outpatient type of bill 013X

Submit prior authorization requests through NovoLogix

To access NovoLogix, log in to our provider portal (availity.com),** click on Payer Spaces in the menu bar and then click on the BCBSM and BCN logo. You’ll find links to the NovoLogix tools on the Applications tab. 

Note: If you need to request access to our provider portal, follow the instructions on the Register for web tools webpage at bcbsm.com/providers.

List of requirements

For a list of requirements related to drugs covered under medical benefits, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members.

We’ll update this list before the effective date.

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

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal and electronic data interchange services.

Syfovre, Izervay, Elfabrio to have requirements for URMBT members with non-Medicare plans

For dates of service on or after Aug. 13, 2024, Syfovre^®, Izervay™ and Elfabrio^® will have the requirements outlined below for UAW Retiree Medical Benefits Trust members with Blue Cross Blue Shield of Michigan non-Medicare plans.  

These drugs are part of members’ medical benefits, not their pharmacy benefits.

Note: The requirements don’t apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714).

How to submit prior authorization requests

Submit prior authorization requests through the NovoLogix^® online tool. It offers real-time status checks and immediate approvals for certain medications.

To access NovoLogix, log in to our provider portal (availity.com),** click on Payer Spaces in the menu bar and then click on the Blue Cross and BCN logo. You’ll find links to the NovoLogix tools on the Applications tab.

Note: If you need to request access to our provider portal, see the Register for web tools webpage on bcbsm.com.

For drugs that have a site-of-care requirement, the NovoLogix online tool will prompt you to select a site of care when you submit prior authorization requests. If the request meets clinical criteria for the drug and is for one of the following sites of care, it will be approved automatically:

• Doctor’s or other health care provider’s office
• Ambulatory infusion center
• The member’s home, from a home infusion therapy provider

More about requirements for medical benefit drugs

For additional information on requirements related to drugs covered under medical benefits for URMBT members with Blue Cross non-Medicare plans, see:

• Oncology Value Management prior authorization list for UAW Retiree Medical Benefits Trust PPO non-Medicare members
• Medical Drug Management with Blue Cross for UAW Retiree Medical Benefits Trust PPO non-Medicare Members

We’ll update the drug lists to reflect the information in this message prior to the effective date.

As a reminder, prior authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

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

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan to offer provider portal services.

Article correction: Spevigo SC has requirements for most commercial members, starting April 25

Last month, we published an article about Spevigo SC in The Record. The HCPCS code for Spevigo SC was incorrect. The correct HCPCS code for that drug is J1747, which we’ve included in this updated article. All information below is correct.

For dates of service on or after April 25, 2024, we added prior authorization and site-of-care requirements for most Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members for the following drug covered under medical benefits:

Spevigo^® SC (spesolimab-sbzo), HCPCS code J1747

How to submit prior authorization requests

Submit prior authorization requests through the NovoLogix^® online tool. It offers real-time status checks and immediate approvals for certain medications.

To access NovoLogix, log in to our provider portal at availity.com,** click on Payer Spaces in the menu bar and then click on the BCBSM and BCN logo. You’ll find links to the NovoLogix tools on the Applications tab.

Note: If you need to request access to our provider portal, see the Register for web tools webpage on bcbsm.com.

The NovoLogix online tool will prompt you to select a site of care when you submit prior authorization requests for this drug. If the request meets clinical criteria for the drug and is for one of the following sites of care, it will be approved automatically:

• Doctor’s or other health care provider’s office
• Ambulatory infusion center
• The member’s home, from a home infusion therapy provider

Additional information or documentation may be required for requests to administer Spevigo in an outpatient hospital setting.

Some Blue Cross commercial groups aren’t subject to these requirements

For Blue Cross commercial, these requirements apply only to groups that participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under medical benefits. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List.

Blue Cross and Blue Shield Federal Employee Program^® members and UAW Retiree Medical Benefits Trust (non-Medicare) members don’t participate in the standard prior authorization program.

List of requirements

For a full list of requirements related to drugs covered under medical benefits, see the Blue Cross and BCN utilization management medical drug list for Blue Cross commercial and BCN commercial members. We’ve updated this list to reflect the changes.

You can access this list and other information about requesting prior authorization on the following pages of the ereferrals.bcbsm.com website:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

Prior authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

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

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal and electronic data interchange services.