2018 HCPCS Update: Coverage decisions on 2018 procedure codes now available

Information about new or deleted Healthcare Common Procedural Coding System codes, including CPT codes, has been released. You may begin using the new codes starting Jan. 1, 2018.

We’ve posted the 2018 coverage decisions as a PDF on web-DENIS. You can access our annual HCPCS Update document as follows:

• From the home page of web-DENIS, click on BCBSM Provider Publications and Resources.
• Click on News & Resources.
• Look under What’s New to find the 2018 HCPCS Update.

Our claims processing systems use HCPCS codes to allow health care providers to report services they performed. HCPCS is a two-level coding system. Providers should use the following resources to find the code that best describes the service provided:

• Level I codes are published in the Physicians' Current Procedural Terminology, CPT 2018, maintained by the American Medical Association. For a comprehensive list of 2018 changes, refer to Appendix B.
• Level II codes are the Centers for Medicare & Medicaid Services codes and apply to professional services, procedures, items and supplies. For a comprehensive list of CMS Level II code changes, refer to the HCPCS Level II Code Book.

The 2018 CPT and HCPCS manuals may be purchased from various sources, including the following:

American Medical Association

To order by mail:

Order Department
American Medical Association
P.O. Box 930876
Atlanta, GA 31193-0876

To order online: amabookstore.com

To order by phone: 1-800-621-8335

Practice Management Information Corporation

To order by mail:

PMIC
200 W. 22nd Street, Suite 253
Lombard, IL 60148

To order online: pmiconline.com

To order by phone: 1-800-633-7467, ext. 2713

For more information about the 2018 HCPCS Update, send an email to ProvComm@bcbsm.com.

Battling the opioid epidemic

Blue Cross Blue Shield of Michigan and Blue Care Network are continuing our efforts to combat the opioid epidemic through an array of initiatives and increased communications about the latest news and research. Check out the following items.

Blue Cross limits opioid pain relievers to 30-day supply; first fills of short-acting opioids to 5 days

Opioid quantities permitted for acute pain often exceed the duration necessary for treatment, leaving unused pills in households that, potentially, could fall into the wrong hands. More than three out of four people who abuse prescription medications obtain them from friends or family.

As part of our effort to decrease accidental overdoses and minimize opioid diversion, Blue Cross is changing how we manage opioids for our commercial members. Starting Feb. 1, 2018:

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

The initial fill limits won’t apply to members with oncology diagnoses or in end-of-life care.

Studies show that taking opioids for only a matter of days can lead to unintended long-term use. That’s why it’s important to prescribe the shortest duration of opioids possible. The Centers for Disease Control and Prevention guideline recommends three days or fewer days of opioids for most cases of acute pain.

Health care providers and health plans can work together to ensure appropriate access to pain management and decrease the risk of opioid abuse. We encourage you to use the Michigan Automated Prescription System when prescribing opioid prescriptions. Go to MAPS to register, then you can request reports at any time.

CDC says doctors should communicate to patients about opioid use
The Centers for Disease Control and Prevention advises doctors to provide some education to patients about opioid use. Doctors and patients should talk about:

• How opioids can reduce pain during short-term use, but how there isn’t enough evidence to suggest that opioids control chronic pain effectively with long-term use
• Nonopioid treatments (such as exercise, nonopioid medications and cognitive behavioral therapy) that can be effective with less risk
• Importance of regular follow-up
• Precautions that can be taken to decrease risks, including checking drug monitoring databases, conducting urine drug testing and prescribing naloxone, if needed, to prevent fatal overdose
• Protecting your family and friends by storing opioids in a secure, locked location and safely disposing unused opioids

To see the CDC fact sheet on the topic, click here.

Opioids in the news
In the November – December issue of Hospital and Physician Update, we provided a roundup of some recent news stories about opioids. You can check it out by clicking here.

For more information on efforts to battle the opioid epidemic, see the article on Drug Take Back Day, also in this issue.

Reminder: CMS transitioning to new fraud-protected Medicare card

As you read in the September Record and the September/October BCN Provider News, the Centers for Medicare & Medicaid Services is taking steps to remove Social Security numbers from Medicare cards. This initiative will help CMS prevent fraud, fight identity theft and protect essential program funding, as well as the private health care and financial information of Medicare beneficiaries

CMS will issue new Medicare cards with a new unique, randomly assigned number called a Medicare Beneficiary Identifier to replace the existing Social Security-based Health Insurance Claim Number — both on the cards and in various CMS systems.
Keep in mind that your systems will need to be able to accept the new MBI format by April 2018.

CMS will start mailing cards to people with Medicare benefits in April 2018. All Medicare cards will be replaced by April 2019.

Provider ombudsman announced
CMS recently announced the appointment of Dr. Eugene Freund as the provider ombudsman for the new Medicare card. He will:

• Serve as a CMS resource for the provider community
• Ensure that CMS hears and understands any implementation problems experienced by clinicians, hospitals, suppliers and other providers
• Communicate about the new Medicare card to providers
• Help develop solutions to any implementation problems that may arise

To reach the ombudsman, contact NMCProviderQuestions@cms.hhs.gov.

For more information
Visit the CMS.gov** or check out the September Record article.

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

UAW Retiree Medical Benefits Trust members transition to Medicare Plus Blue^SM PPO

Many of your patients who receive coverage through the UAW Retiree Medical Benefits Trust are now enrolled in Blue Cross Blue Shield of Michigan’s Medicare Plus Blue PPO, effective Jan. 1, 2018.

This change offers several advantages to members:

• No monthly contributions to the Trust required
• Free fitness club membership in the Silver Sneakers fitness program
• Lower deductibles than their previous TCN plan
• No referrals required to visit the doctor, specialist or hospital of the member’s choice

While referrals are not required for Medicare Plus Blue, members may need authorization prior to receiving certain services. As we welcome new members, we’re asking them if they have any upcoming services early in the new year that might require prior authorization. You can request an authorization any time after Jan. 1, 2018, for a service. Please review the authorization guidelines and criteria on the e-referral site.

If you’re part of the Medicare Plus Blue PPO network, these members will be able to find your practice or facility in our online provider directory.

While most of our health care providers are familiar with Medicare Plus Blue, there are some differences in benefits and care management services between the previous TCN plan and the Medicare Plus Blue plan. Click here for more information about the plan.

As always, it’s important to always ask your patients about recent changes in insurance carriers and benefits — and request a copy of their ID card — when they come to your office for services. You can check member benefits and eligibility on web-DENIS.

Express Scripts retiring faxed prior authorizations

If you’ve been faxing prior authorizations for medications directly to Express Scripts, we want to let you know that Express Scripts is transitioning from faxed to electronic prior authorizations, or ePAs, starting Dec. 31, 2017. As a result of this change, Express Scripts is retiring the current prior authorization fax number, as well as more than 40 other numbers.

There are two ways to start using ePA:

1. Visit express-scripts.com/pa.**
2. Contact your electronic health record service to enable ePA in your system.

If you want to request a prior authorization by phone, call 1-844-600-0779.

This change only affects providers serving members who have pharmacy benefits directly with Express Scripts, such as members of the UAW Retiree Medical Benefits Trust, or URMBT. There’s no change to the Blue Cross Blue Shield of Michigan prior authorization process for medications for patients who have Blue Cross pharmacy benefits. (Patients with these benefits have an Rx logo at the bottom right corner of their Blue Cross card.)

To see the full list of fax numbers that are being retired — or for additional details — visit express-scripts.com/pa.**

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

Twice-yearly Drug Take Back Day events help combat opioid crisis

Americans nationwide did their part to reduce the opioid crisis as part of the 14th Prescription Drug Take Back Day on Oct. 28. The Drug Enforcement Administration announced that a record-setting 912,305 pounds — 456 tons — of potentially dangerous expired, unused, and unwanted prescription drugs was collected for disposal at more than 5,300 collection sites during Prescription Drug Take Back Day on Oct. 28.

That’s almost six tons more than what was collected at last spring’s event. This brings the total amount of prescription drugs collected by the DEA beginning in the fall of 2010 to 9,015,668 pounds, or 4,508 tons.

As the state’s largest health insurers, Blue Cross Blue Shield of Michigan and BCN started supporting the DEA’s Drug Take Back Day in 2011.

National Prescription Drug Take Back Day events continue to remove ever-higher amounts of opioids and other medicines from the country’s homes, where they could be stolen and abused by family members and visitors, including children and teens.

“More people start down the path of addiction through the misuse of opioid prescription drugs than any other substance,” said DEA Acting Administrator Robert W. Patterson. “The abuse of these prescription drugs has fueled the nation’s opioid epidemic, which has led to the highest rate of overdose deaths this country has ever seen.”

The DEA’s next Drug Take Back Day is April 28, 2018, so mark your calendar. We’ll bring you more information in the April Record.

Blue Cross updates online prescription drug lists

Blue Cross Blue Shield of Michigan recently updated its prescription drug lists. We periodically update these lists to help ensure patient safety and assist prescribers in selecting the most effective, affordable drug therapy for patients.

You can view the most recent prescription drug lists, including updates to the Custom Select Drug List, at bcbsm.com/rxinfo. These lists can help prescribers make prescribing decisions that lead to increased medication adherence for their patients.

Coding corner: Using a ‘history of cancer’ code vs. ‘active cancer’ code

Selecting the diagnosis code that best captures a patient’s condition at the time of his or her visit can be a challenge, but keeping some basic guidelines in mind helps. And to ensure best coding practices, providers can always refer to ICD-10-CM guidelines.

Here’s what you need to know about coding for cancer.

The documentation should always clearly indicate one of the following:

• The cancer is active and still being treated.
• The cancer is no longer active or is in remission and there’s no recurrence; i.e., no further treatment is necessary.

When coding for active malignancy versus coding for a person with a history of malignancy, ICD-10-CM coding guidelines are specific. Section I.C.2.m. states:

“When a primary malignancy has been excised but further treatment, such as an additional surgery for the malignancy, radiation therapy or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is completed.

“When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy, a code from category Z85, personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.”

Forms of active treatment include:

• Current hormonal therapy for the cancer or neoplasm (not for prophylactic purposes)
• Watchful waiting or active surveillance, meaning the malignant neoplasm has not been treated but is being closely monitored for progression
• A patient has a condition but isn’t being treated because he or she refuses treatment or is too frail

An exception to these rules occurs when coding multiple myeloma and leukemia. For these diagnoses, there are “in remission” codes that providers should use once treatment is completed and the patient achieves remission.

The following scenarios help differentiate between situations where providers should use “history of malignancy” codes and those in which the malignancy should be coded as active.

Scenario one:
A patient with a history of breast cancer who had chemotherapy, radiation and a mastectomy — and who currently has no evidence of recurrence — comes in for an office visit. The provider documents that the patient isn’t receiving active therapy for breast cancer. The code for personal history of malignant neoplasm of the breast (Z85.3) should be used.

Scenario two:
A female patient who was diagnosed with cancer of the central portion of the right breast returns to the office for a visit after a mastectomy and is currently receiving radiation therapy. Doctors should document current active treatment (radiation), and use a code for active breast cancer; e.g., C50.111 malignant neoplasm of central portion of right female breast.

Scenario three:
A patient who was diagnosed with cancer of the axillary tail of the left breast three years ago — and who had a mastectomy followed by radiation and chemotherapy — comes in for an office visit. She is currently taking Arimidex^® and undergoing adjuvant therapy, which is considered active treatment. Therefore, it’s inappropriate to use a “history of breast cancer” code. Providers should use active cancer codes for as long as the patient is still undergoing adjuvant therapy.

Scenario four:
A patient who was diagnosed with acute myeloblastic leukemia was treated with chemotherapy and successfully achieved remission. He returns to the office for a visit and has no evidence of recurrence. The code for acute myeloblastic leukemia in remission (C92.01) should be used.

In summary

• Clinical evidence needs to be documented to support an active cancer code. The documentation must clearly indicate that the cancer was either not treated or is being actively treated, including with adjuvant therapy.
• If the cancer has been eradicated and there’s no evidence of recurrence and no further treatment is needed, then it’s appropriate to use a “personal history of cancer” code.
• Multiple myeloma and leukemia have “in remission” codes that providers should use when a patient achieves remission following treatment.

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

Also, keep in mind that ICD-10-CM diagnosis codes and ICD-10-CM Official Guidelines for Coding and Reporting are subject to change. It’s the responsibility of the provider to ensure that current ICD-10-CM diagnosis codes and the current ICD-10-CM Official Coding Guidelines for Coding and Reporting are reviewed prior to the submission of claims.

Billing chart: Blues highlight medical, benefit policy changes

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

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

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

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

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

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

Northwood Inc. to manage DME/P&O and medical supply needs for Medicare Plus Blue^SM members

As reported in a web-DENIS message on Dec. 1, 2017, Blue Cross Blue Shield of Michigan will use Northwood Inc.’s network of providers to meet the durable medical equipment, prosthetics, orthotics and medical supply needs of Medicare Plus Blue PPO members, starting Jan. 1, 2018. Northwood is an independent company working for Blue Cross.

Blue Cross is leasing the Northwood provider network and contracted fees for durable medical equipment, prosthetics, orthotics and medical supplies. Blue Cross will process claims for these supplies and equipment for Medicare Plus Blue members.

Blue Cross will reimburse in-network providers for serving these members according to the vendor fee schedules. If there’s no fee schedule for a specific service, we’ll base our reimbursement on Medicare’s allowed amount for that service. Out-of-network claims for Medicare Plus Blue PPO members will be reimbursed using the Medicare fee schedule, with the potential of higher level of cost sharing being applied.

Northwood is contacting providers who serve Medicare Plus Blue members about becoming a Northwood-participating provider. If you’d like to join the Northwood network, you can get a provider enrollment application by contacting Debbie Skattebo, Northwood’s provider relations manager, at 586-755-3830 or 1-800-447-9559, extension 3703. You can also email provideraffairs@northwoodinc.com.

All Medicare Plus Blue plans include DME/P&O, medical supplies and Part B drugs that are covered under original Medicare.

J & B to provide diabetic supplies for Medicare Plus Blue^SM members

As of Jan. 1, 2018, J & B Medical Supply will be the in-network diabetic supplier for all Blue Cross Medicare Plus Blue^SM PPO members.

J & B provides mail-order diabetic supplies both in Michigan and out of state. This is the same diabetic supply company now used by Blue Care Network and BCN Advantage^SM members.

We’re encouraging our Medicare Plus Blue members to use J & B when they need diabetic supplies, such as continuous glucose monitors, pumps and diabetic testing mail-order supplies.

For questions about J & B Medical Supply, call the company at 1-888-896-6233 from 8 a.m. to 6 p.m. Monday through Friday. If you leave a message after hours or on the weekend, J & B will call you back the following business day. If you want more information about the services J & B provides, send an email to info@jandbmedical.com.

Online benefit information now available through Benefit Explainer

As you may have read on web-DENIS in November, we recently made it easier for you to look up benefits for your patients.

We added a tab in Benefit Explainer called Online Benefits Information. This tab will give you the option of viewing online benefit charts for our members (the same ones that members have access to).

The online benefit charts will display benefit information in clear, simple and non-technical language. The features of the Online Benefits Information tab include medical and hospital benefits, prescription drug information and dental, vision and hearing benefits.

Here’s how to find this information:

1. Log in to web-DENIS
2. Click on Subscriber Info and then on Eligibility/Coverage/COB.
3. Enter your patient’s contract information.
4. Click on the links in the detailed benefits section to launch Benefit Explainer.
5. Once Benefit Explainer opens, click on the BPR tab to populate your patient’s contract information in the dashboard.
6. When you click on Search, you’ll see the new Online Benefits Information tab (located to the right of the Quickview Report tab), with benefit information below.

Keep in mind that not all member benefit information will be available in the Online Benefits Information tab. For example, you won’t get results for members with inactive benefit packages, Medigap members, members who buy their insurance on the individual market and those who are part of groups that aren’t on the Michigan Operating System.

Also, the information in the OBI tab and benefit chart is a summary of benefits and doesn’t include the member’s legal certificates and riders.

All other features of Benefit Explainer haven’t changed and are still available.

If you have any questions, contact Provider Inquiry. You can also ask your provider consultant to train you on the new Online Benefits Information tab.

Reminder: Be sure to update Provider Authorization form when changes occur

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

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

Keep in mind that you should review your provider authorization information when you’ve:

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

You must update your provider authorization if you’ll be sending claims using a different submitter ID or routing your 835s to a different, unique receiver or trading partner ID.

To make changes to your EDI setup, follow these steps:

• Visit bcbsm.com/providers.
• Click on Quick Links.
• Click on Electronic Connectivity EDI.
• Click on How to use EDI to exchange information with us electronically.
• Under EDI agreements, click on Update your Provider Authorization Form.

If you have questions about EDI enrollment, call the EDI Help Desk at 1-800-542-0945. For assistance with the Trading Partner Agreement and Provider Authorization forms, select the “TPA” option.

Reminder: Physician assistants required to re-enroll with Blue Cross, BCN by Jan. 31

Physician assistants must re-enroll with Blue Cross Blue Shield of Michigan and Blue Care Network, including our Medicare Advantage programs, by Jan. 31, 2018. Physician assistant re-enrollments will be processed with an effective date of Feb. 1, 2018.

Current reimbursement arrangements will be terminated for dates of service after Jan. 31, 2018.

Please refer to the following documents for complete information:

• October 2017 Record article
• September-October 2017 BCN Provider News article

Re-enrolling physician assistants must go to bcbsm.com/providers and click on the following links:

• Enrollment and Changes
• Provider Enrollment
• Physicians and Professionals
• Change an existing provider
• Physician Assistant

The Required Documents Checklist indicates the additional information and documents required from the physician assistant.

The following required forms will appear:

• Physician Assistant Re-Enrollment Form
• Physician Assistant/Physician Practice Agreement Attestation Form
• BCBSM Physician Assistant Combined Signature Document

In addition, keep the following in mind:

• All physician assistants are encouraged to re-enroll as early as possible to ensure claims don’t reject inappropriately for dates of service on or after Feb. 1, 2018.
• Be sure your Council for Affordable Quality Healthcare data is current and consistent with the information you provide on the re-enrollment form.

How to contract and re-enroll

Physician assistants can find and use the Blue Cross and BCN practitioner agreements and enrollment forms on bcbsm.com.

Note: If a professional group is enrolling a new physician assistant, the group must enroll the PA in the Provider Enrollment and Change Self-Service application and then use the application to add the PA to the group.

Information about reimbursement for dates of service on or after Feb. 1, 2018

• Physician assistants who have re-enrolled by Jan. 31, 2018, will be eligible for reimbursement for services within their scope of license either directly or under a group for all lines of business.
• Physician assistants who haven’t re-enrolled will have their claims denied.

If you have any questions about physician assistant re-enrollments, contact Provider Inquiry.

Here’s what chiropractors need to know about physical medicine services and therapeutic massage

Here are some important reminders to keep in mind regarding physical medicine and therapeutic massage.

Physical medicine

• Blue Cross Blue Shield of Michigan doesn’t require an order from an M.D. or D.O. for the first physical medicine service provided to a member.

• We only pay chiropractic physicians for additional physical medicine services they provide to a member if the chiropractor sends a written physical medicine treatment plan to the member’s medical doctor or doctor of osteopathy and the physician agrees to the treatment plan and signs it.

• The physical medicine treatment plan must be signed by the member’s M.D. or D.O. before any additional covered physical medicine services provided to the patient will be paid.

• The signed treatment plan must be filed in the member’s medical records at the chiropractic physician’s office.

• For Blue Care Network, physical medicine services require authorization through Landmark. Authorization through Landmark is required of all health care providers performing physical medicine procedures, including M.D.s, D.O.s, doctors of chiropractic and physical therapists.

Therapeutic massage
Blue Cross Blue Shield 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.
• It’s provided in the early, acute phase of therapy to address a musculoskeletal problem and is generally limited to two weeks of treatment.

Keep the following in mind:

• Massage therapy alone, either as a one-time service or as a series of massages over time, isn’t a covered benefit.
• 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 massage therapy.
• All Blue Cross rules and requirements related to “incident to” billing for physical therapy apply.

Medically necessary therapeutic massage may be delivered by participating providers, when such massage 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 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, additional physical therapy procedure codes, including massage therapy, are payable when supervised and billed by a chiropractor. Chiropractors can delegate physical medicine services, including 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.

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

If you have any questions, contact your provider consultant.

Get ready for annual visits for your Medicare Advantage patients

Now that we’re embarking on a new year, you’ll start seeing new and existing Medicare Advantage patients for their “welcome to Medicare” visits, annual wellness visits or routine physical exams. To help you prepare, we want to share this important information about these different visits:

• New Medicare Advantage members should be scheduling their “welcome to Medicare” preventive visit, also known as the initial preventive examination, and their routine physical exams.
• Existing Medicare Advantage members should begin scheduling their annual wellness visit and their routine physical exams.

Welcome to Medicare visit
The “welcome to Medicare” preventive visit is sometimes referred to as the initial preventive examination. This is a one-time appointment for new Medicare patients to be scheduled within their first 12 months of enrollment. Medicare pays for one “welcome to Medicare” visit per member, per lifetime.

This visit is a great way to get up-to-date information on health screenings, shot records, family medical history and other preventive care services for your patients. These visits can be scheduled at the same time or coordinated with the patient’s routine physical exam to get the best picture of your patient’s health.

The “welcome to Medicare” visit will include a health risk assessment and self-reported information from your patient to be completed before or during the visit. For more information about health risk assessments, visit Framework for Patient-Centered Health Risk Assessments on the Centers for Disease Control and Prevention website.

During the “welcome to Medicare” visit, you should:

• Perform a health risk assessment
• Record your patient’s medical and social history (like alcohol or tobacco use, diet and activity level)
• Check height, weight and blood pressure
• Calculate body mass index
• Perform a simple vision test
• Review potential risk for depression and patient level of safety
• Offer to talk about creating advance directives
• Educate the patient on preventive services needed and prescribe appropriate services
• Create a screening schedule (checklist) for appropriate preventive services

Annual wellness visit
The annual wellness visit is a chance for you to develop or update your patient’s personalized prevention plan based on his or her current health situation and risk factors. Health risk assessments are also part of the annual wellness visit. The assessment consists of self-reported information from your patient to be completed before or during the visit.

Medicare will cover an annual wellness visit every 12 months for patients who’ve been enrolled in Medicare for longer than 12 months. Patients can schedule their annual wellness visit on the same day or coordinate it with their routine physical exam (see below) to help give you a complete view of their health.

Services at the annual wellness visit include:

• Health risk assessment
• Review of medical and family history
• Develop or update a list of current providers and prescriptions
• Height, weight, blood pressure and other routine measurements
• Detection of any cognitive impairment
• Personalized health advice
• A list of risk factors and treatment options
• Education on preventative services needed and prescribe appropriate services
• A review and update of the screening schedule (checklist) for appropriate preventive services

Routine physical exam
The routine physical exam is typically covered annually by the patient’s Medicare Advantage health care plan. These exams are part of preventive services that aren’t part of the welcome to Medicare visit or annual wellness visit.

Routine physical exams are used to get information about the patient’s medical history, family history and perform a head-to-toe assessment with a hands-on examination to assess your patient’s health, address any abnormalities or signs of disease. Routine physical exams should include the following:

• A visual inspection
• Palpitation
• Auscultation
• Manual examination

Care plans
These preventive visits are an excellent opportunity for you and your patients to plan their care for the year. Care plans should include a schedule for preventive services and health screenings, many of which are required annual services to meet Healthcare Effectiveness Data and Information Set, commonly known as HEDIS^® specifications.**

You’ll need to recommend and prescribe — or refer your patient for needed preventive services — that apply to his or her care plan. Some examples of preventive services include:

• Colon cancer screening
• FOBT yearly
• Sigmoidoscopy every five years
• Colonoscopy every 10 years
• Cologuard every three years
• Breast cancer screening
• Mammography every two years
• Osteoporosis testing in older women
• Bone mineral density testing in women ages 65-85 every two years
• Comprehensive diabetes care
• A1c blood sugar screening — two to four times per year
• Urine microalbumin screening — yearly
• Retinal eye exam — every other year if negative or every year if positive

These visits also provide a great opportunity to review or create a risk assessment for your patients, including a full list of their long-term chronic conditions. This will help your patients take advantage of disease and care management programs, as well as prevention initiatives.

This benefits both you and your patient by:

• Uncovering care management opportunities
• Identifying practice patterns
• Managing patient medications better
• Reducing avoidable hospital admissions

For more information on risk adjustment and HEDIS best practices, refer to our online provider manuals — and keep an eye out for more newsletter articles coming your way throughout the year.

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

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

Commercial professional and facility claim audits begin April 1

HMS^® and SCIO Health Analytics^®, independent companies working for Blue Cross Blue Shield of Michigan, will assist with auditing claims for all commercial professional and facility services, starting April 1, 2018.

The scope of the audits will be either claim-specific or project-based, and will ensure that billed and paid services were ordered, medically necessary, documented, reported and covered under the patient’s contract, according to Blue Cross’ policies and guidelines. This applies to all providers who bill procedure or revenue codes.

The audits will look back two years and confirm that you’ve properly billed and documented requirements for services billed.

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

The purpose of provider audits is to:

• Confirm compliance with HCPCS and CPT codes that are in effect on the date of service.
• Ensure services billed are medically necessary.
• Detect, prevent and correct waste and abuse.
• Facilitate accurate claim payment.

Questions?

Contact your provider consultant. During an audit, call 1-866-875-1749 to speak with an HMS representative, or 1-866-628-3488 to speak with an SCIO representative.

Audits of Medicare Plus Blue^SM PPO professional claims begin April 2018

On April 1, 2018, HMS^® and SCIO Health Analytics^®, independent companies supporting Blue Cross Blue Shield of Michigan, will begin auditing Medicare Plus Blue^SM PPO claims for professional services. This applies to all professional providers who bill CPT and HCPCS codes.

The auditors will look back two years and review specific claims or projects to confirm that you’ve properly billed and documented requirements for your billed services. Specifically, they’ll ensure that billed and paid services were ordered, medically necessary, documented, reported and covered under the patient’s contract, according to Centers for Medicare & Medicaid Services guidelines.

Besides ensuring that billed services were medically necessary, provider audits:

• Confirm compliance with HCPCS and CPT codes in effect on the date of service.
• Detect, prevent and correct waste and abuse.
• Support accurate claim payment.

Health care providers will be notified of upcoming audits through a medical chart request letter. In the letter, they’ll be informed of what claims are part of the review, what we’re reviewing for and the time frame during which they can respond to our request.

At the time of an audit, you’ll want to be prepared to share medical charts for review. After the audit, HMS or SCIO Health Analytics will send you a letter with the findings and information on how you can seek an appeal, if necessary.

During an audit, if you need to speak to a SCIO Health Analytics representative, call 1-866-628-3488. If you need to speak to a HMS representative, call 1-866-875-1749. If you have any general questions about the audit process, you can reach out to your provider consultant.

Update: Commercial Medical Drug Prior Authorization Program

The Commercial Medical Drug Prior Authorization Program encourages proper utilization of high-cost specialty medications administered by health care providers for many Blue Cross Blue Shield members. The list below includes all the specialty medications included in the program as of Jan. 1, 2018:

Keep in mind that prior authorization is a clinical review approval only, not a guarantee of payment. Blue Cross reserves the right to change the prior authorization list at any time.

We accept requests for prior authorization in three ways:

You can find prior authorization forms for all physician-administered medications on web-DENIS. After you log in, follow these steps:

1. Click on BCBSM Provider Publications and Resources.
2. Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
3. Click on Go to the Forms page.
4. Click on Physician administered medications.

Our standard processing time to review requests is 15 days. We’ll review urgent requests within 72 hours.

Note: The prior authorization requirement doesn’t apply to Federal Employee Program^® members.

We’re requiring prior authorization for some additional specialty drugs for MA PPO members

Additional specialty medications covered under the Medicare Part B medical benefit for Medicare Advantage PPO members will require prior authorization, beginning with dates of service on or after Feb. 12, 2018. These are medications that aren’t self-administered, but must be given by injection or infusion by a doctor or health care professional in the office setting.

The prior authorization requirement helps ensure that health care providers use the most effective therapies available, according to the Centers for Medicare & Medicaid Services coverage guidelines for medical necessity, safety and efficacy.

Doctors must obtain prior authorization and verify patient benefits to be eligible for payment for administering these services. Doctors can submit a request and obtain authorization within 90 days of the date of service. If prior authorization isn’t obtained, the claim will be denied.

Keep in mind that the patient must meet all the requirements and have the necessary coverage for the claim to be paid. Also, authorization isn’t a guarantee of payment. CMS benefit coverage rules and exclusions or limitations apply.

What specialty medications require prior authorization?
Listed below are the specialty drugs that have been added to the list for Medicare Part B prior authorization effective for dates of service on or after Feb. 12, 2018:

Our prior authorization program is evaluated on an ongoing basis, and we may add or remove drugs or procedures from our list of drugs that require prior authorization. When this happens, we’ll notify you through The Record or web-DENIS.

How do I initiate a prior authorization request?

See the July 2017 Record article for details.

HCPCS replacement codes established

The HCPCS procedure codes listed below are effective Jan. 1, 2018.

J0565 replaces J3490 and J3590 when billing for Zinplava^®
The Centers for Medicare & Medicaid Services has established a permanent procedure code for Zinplava^®.

All services through Dec. 31, 2017, will continue to be reported with code J3490 or J3590. All services performed on and after Jan. 1, 2018, must be reported with J0565.

J1428 replaces J3490 and J3590 when billing for Exondys51^®
CMS has established a permanent procedure code for Exondys51^®.

All services through Dec. 31, 2017, will continue to be reported with code J3490 or J3590. All services performed on and after Jan. 1, 2018, must be reported with J1428.

Prior authorization is still required for Exondys51 (eteplirsen) when reported with the new procedure code J1428.

J1555 replaces J1599, J3490 and J3590 when billing for Cuvitru^®
CMS has established a permanent procedure code for Cuvitru^®.

All services through Dec. 31, 2017, will continue to be reported with code J1599, J3490 or J3590. All services performed on and after Jan. 1, 2018, must be reported with J1555.

Prior authorization is still required for Cuvitru (immune globulin) when reported with the new procedure code J1555.

J1627 replaces J3490 when billing for Sustol^®
CMS has established a permanent procedure code for Sustol^®.

All services through Dec. 31, 2017, will continue to be reported with code J3490. All services performed on and after Jan. 1, 2018, must be reported with J1627.

Sustol continues to be covered for the Federal Drug Administration-approved indications as establisted on Aug. 9, 2016. Sustol (granisetron) is an extended-release injection, a serotonin-3 (5-HT3) receptor antagonist indicated in combination with other antiemetic’s in adults for the prevention of acute and delayed nausea and vomiting associated with initial and repeat courses of moderately emetogenic chemotherapy or anthracycline and cyclophosphamide combination chemotherapy regimens.

J1726 replaces Q9986 when billing for Makena^®
CMS has established a permanent procedure code for Makena^®.

All services through Dec. 31, 2017, will continue to be reported with code Q9986. All services performed on and after Jan. 1, 2018, must be reported with J1726.
Prior authorization is still required for Makena (hydroxyprogesterone caproate) when reported with the new procedure code J1726.

J1729 replaces Q9985 when billing for hydroxyprogesterone caproate
CMS has established a permanent procedure code for hydroxyprogesterone caproate.

All services through Dec. 31, 2017, will continue to be reported with code Q9985. All services performed on and after Jan. 1, 2018, must be reported with J1729.

Prior authorization is still required for the specialty medical Injection, hydroxyprogesterone caproate, not otherwise specified when reported with the new procedure code J1729.

J2326 replaces J3490 and J3590 when billing for Spinraza^®
CMS has established a permanent procedure code for Spinraza^®.

All services through Dec. 31, 2017, will continue to be reported with code J3490 or J3590. All services performed on and after Jan. 1, 2018, must be reported with J2326.

Prior authorization is still required for Spinraza (nusinersen) when reported with the new procedure code J2326.

J2350 replaces J3490 and J3590 when billing for Ocrevus^®
CMS has established a permanent procedure code for Ocrevus^®.

All services through Dec. 31, 2017, will continue to be reported with code J3490 or J3590. All services performed on and after Jan. 1, 2018, must be reported with J2350.

Prior authorization is still required for Ocrevus (ocrelizumab) when reported with the new procedure code J2350.

J3358 replaces Q9989 when billing for Stelara^®
CMS has established a permanent procedure code for Stelara^®.

All services through Dec. 31, 2017, will continue to be reported with code Q9989. All services performed on and after Jan. 1, 2018, must be reported with J3358.

Prior authorization is still required for Stelara (ustekinumab) when reported with the new procedure code J3358.

J7210 replaces J7199 when billing for Afstyla^®
CMS has established a permanent procedure code for Afstyla^®.

All services through Dec. 31, 2017, will continue to be reported with code J7199. All services performed on and after Jan. 1, 2018, must be reported with J7210.

Afstyla continues to be covered for the FDA-approved indication of hemophilia.
Pharmacy doesn’t require preauthorization of this drug.

For more information about HCPCS codes, see the article titled “HCPCS Update: Coverage decisions on 2018 procedure codes now available,” also in this issue.

Autism coverage changing for NASCO non-auto ASC groups

Blue Cross Blue Shield of Michigan recently sent a letter to members who are part of NASCO non-auto ASC groups and whose children currently are receiving applied behavioral analysis. The letter advised them of changes to their autism coverage beginning Jan. 1, 2018.

Among the most significant changes to the ABA coverage are the following:

• Must obtain preauthorization through New Directions for ABA services provided on or after Jan. 1, 2018.
• The preauthorization process begins with an evaluation by an approved autism evaluation center or an out-of-state equivalent.

The letter advised them that they must schedule the evaluation by Friday, Dec. 29, 2017. (While the evaluation can take place after this date, it needed to be scheduled no later than Dec. 29, 2017.) Once the appointment has been scheduled, members must advise New Directions of the date of the appointment so that the patient can continue to receive ABA therapy while waiting for the evaluation.

As always, be sure to check the benefits and eligibility of your patients with Blue Cross insurance by going to web-DENIS or calling PARS before providing services.

Here’s what you need to know about 2018 Skilled Nursing Facility Pay-for-Performance program

In 2018, Blue Cross Blue Shield of Michigan freestanding and hospital-based skilled nursing providers will have the opportunity to earn incentive rewards through the Skilled Nursing Facility Pay-for-Performance program. The SNF P4P is part of a health information exchange through the Michigan Health Information Network notification service.

The goal of the SNF P4P is to:

• Enhance the population-based model of health.
• Promote a team-based approach.
• Engage a strong commitment to the care continuum.
• Help ensure that a patient’s caregivers receive timely notification of an admission, discharge, transfer or emergency room visit.
• Improve coordination of care and outcomes.
• Reduce the likelihood of an unplanned readmission.

Program details and reward
Blue Cross will recognize SNFs that are successful in fully implementing the MiHIN admission, discharge and transfer process. We’ll also recognize facilities that implemented the process during previous program years and continue to meet participation expectations.

Providers achieving the program expectations and deadlines will be eligible to receive an additional 2 percent reward for either six or 12 months following the incentive’s effective date.

SNFs that don’t meet the SNF P4P program requirements or choose not to participate will forfeit the incentive opportunity.

Important dates

Additional information

SNF benefit available for FEP members with Standard Option and without Medicare Part A

Federal Employee Program^® members who have the Standard Option and no Medicare Part A coverage will have a skilled nursing facility benefit, beginning Jan. 1, 2018, for a maximum of 30 days annually. Precertification and signed consent for case management must be obtained before admission.

The FEP member must participate in all treatment and care planning activities, including discharge planning and transition to home, during the SNF admission.

If you have benefit questions, contact the FEP Customer Service line at 1-800-482-3600. If you have facility precertification questions, contact Precertification at 1-800-572-3413. If you have questions about Case Management services, call 1-800-325-6278.

Here are coverage changes to FEP Service Benefit Plan for 2018

Below is an overview of updates to the 2018 Federal Employee Program^® benefit plan.

Skilled nursing facility coverage — Standard Option only
We now provide benefits for skilled nursing facility admissions for members who don’t have Medicare Part A as their primary payor and have selected the Standard Option benefit coverage. Consent for case management must be signed before admission. Previously, benefits were limited to Standard Option members with primary Medicare Part A.

Residential treatment center coverage
We now require precertification for overseas admission to a residential treatment center. Benefits aren’t available if precertification isn’t obtained before admission. Previously, precertification wasn’t required.

Overseas admission changes
We now provide 100 percent coverage for inpatient services performed at a Preferred facility for overseas members when AXA Assistance has arranged direct billing or acceptance of a guarantee of benefits with the facility, and for services billed by a Department of Defense facility. Previously, member cost share wasn’t waived for services billed by a DoD facility.

Telehealth coverage
We now provide benefits for telehealth services delivered via phone or secure online video for the treatment of minor acute conditions, and counseling for behavioral health and substance use disorders.

Member incentive program changes

• The contract holder and spouse are eligible for the wellness incentive rewards for the Blue Health Assessment, Diabetes Management Incentive Program, Hypertension Management Program, Pregnancy Care Incentive Program, and Smoking and Tobacco Cessation Program. Previously, eligible members for the wellness incentive rewards were limited to two adults per contract, age 18 or older.
• Members are now entitled to receive the pregnancy care incentive of $75 toward their health account and the MyBlue Pregnancy Box when they complete the Blue Health Assessment indicating that they are pregnant and submit a copy of the provider’s medical record documenting the first trimester prenatal care visit. Previously, members had to complete the BHA and enroll in My Pregnancy Care Assistant.

Service allowances changes

• We now use the Local Plan Allowance as our plan allowance for inpatient services performed by non-member facilities. Previously, our allowance was based on the average amount paid nationally on a per-day basis to contracting and non-contracting facilities for covered room, board and ancillary charges for type of admission.
• We now use the allowance equal to the greater of one of the following:
• The Medicare participating fee schedule amount or the Medicare Part B drug average sale price, or ASP.
• 100 percent of the local plan allowance for services performed by non-participating professional providers. Previously, if there was no Medicare participating fee schedule or local plan UCR amount, our allowance was 60 percent of the billed charge.
• We now apply facility-billed claims for osteopathic and chiropractic manipulative treatment services to a member’s annual manipulative treatment visit maximum. Previously, only professional claims applied to a member’s annual visit maximum.

Human organ transplant coverage

• We now limit the coverage of blood and marrow stem cell transplants for autoimmune diagnoses to those listed on Page 75 of the Service Benefit Plan brochure. Previously, the listed diagnoses were presented as examples of covered diagnoses. Now those listed diagnoses serve as the complete list of covered diagnoses. Benefits aren’t available for diagnoses not on the list.
• We now limit the coverage of allogeneic blood or marrow stem cells to the following inherited metabolic disorders: Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy, Hurler’s syndrome and Maroteaux-Lamy syndrome variants. Previously, we also covered Hunter’s syndrome and Sanfilippo’s syndrome.
• We now provide coverage limited to the following diagnoses for autologous blood or marrow stem cell transplants, only when performed as part of a clinical trial: chronic lymphocytic leukemia/small lymphocytic lymphoma, chronic myelogenous leukemia, glial tumors, retinoblastoma, rhabdomyosarcoma, Wilm’s tumor and other childhood kidney cancers. Previously, we also covered breast cancer and epithelial ovarian cancer under the autologous blood or marrow stem cell clinical trial transplant benefit.

Reimbursement for Medicare Part B premiums — Basic Option only
We now provide a reimbursement account for Medicare Part B premiums to any member with Medicare Part A and Part B and who have selected the Basic Option coverage. The account must be used exclusively to pay Medicare Part B premiums. Previously, there was no reimbursement account benefit.

Screening coverage changes

• We now provide preventive care benefits for DNA analysis of stool samples as a technique for colorectal cancer screening, paid in full when billed by a preferred provider. Limited to one per calendar year. Previously, medical benefits were provided with a member cost share.
• We now provide preventive care benefits for the screening of latent tuberculosis infection in adults age 18 and older. Limited to once per calendar year. Previously, no preventive care benefits were available for this screening.

Family planning coverage
We now provide family planning benefits for vasectomy and related covered professional services, e.g., anesthesia, with no member cost share. Previously, this was a surgical benefit with member cost share.

Prescription drug benefit changes

• Standard Option prescription drug benefit changes
• Copayment for Tier 1 (generic) anti-hypertensive drugs obtained at Preferred retail pharmacies is now $3 (no deductible). Previously, cost share under Preferred retail pharmacies was 20 percent of the plan allowance (no deductible).
• Copayment for Tier 1 (generic) anti-hypertensive drugs obtained through the Mail Service Prescription Drug Program is now $3 (no deductible). Previously, copayment for the Mail Service Prescription Drug Program was $15 (no deductible).
• Copayment for Tier 2 preferred brand-name asthma drugs obtained at Preferred retail pharmacies is now 20 percent of the plan allowance (no deductible). Previously, copayment was 30 percent of the plan allowance (no deductible).
• Copayment for Tier 2 preferred brand-name asthma drugs obtained through the Mail Service Prescription Drug Program is now $65 (no deductible). Previously, copayment was $80 (no deductible).
• Cost share for Tier 3 non-preferred brand-name drugs is 50 percent (no deductible) of the plan allowance for Preferred retail pharmacies. Previously, cost share was 45 percent (no deductible) of the plan allowance.
• Copayment for Tier 3 non-preferred brand-name drugs will be $125 (no deductible) for the Mail Service Prescription Drug Program. Previously, copayment was $105.

• Basic Option prescription drug benefit changes
• Copayment for Tier 1 (generic) anti-hypertensive drugs obtained at Preferred retail pharmacies is now $5. Previously, cost share under Preferred retail pharmacies was $10 copayment for 30-day supply.
• When Medicare Part B is primary, copayment for Tier 1 (generic) anti-hypertensive drugs obtained through the Mail Service Prescription Drug Program is now $5. Previously, copayment for the Mail Service Prescription Drug Program was $20.
• Copayment for Tier 2 preferred brand-name asthma drugs obtained at a Preferred retail pharmacy is now $35 for each purchase of up to a 30-day supply ($105 copayment for a 90-day supply). Previously, copayment was $50 for each purchase of up to a 30-day supply ($150 copayment for 90-day supply).
• When Medicare Part B is primary, copayment for Tier 2 preferred brand-name asthma drugs obtained at a Preferred retail pharmacy is now $30 for each purchase of up to a 30-day supply ($90 copayment for a 90-day supply). Previously, copayment was $45 for each purchase up to a 30-day supply ($135 copayment for 90-day supply).
• When Medicare Part B is primary, copayment for Tier 2 preferred brand-name asthma drugs obtained through the Mail Service Prescription Drug Program is now a $75 copayment. Previously, copayment was $90.
• Cost share for Tier 3 non-preferred brand-name drugs obtained at a Preferred retail pharmacy is 60 percent of plan allowance ($75 minimum) for up to a 30-day supply ($210 minimum for a 90-day supply). Previously, cost share was 60 percent of the plan allowance ($65 minimum) for a 30-day supply ($195 minimum for a 90-day supply).
• When Medicare Part B is primary, cost share for Tier 3 non-preferred brand-name drugs obtained at a Preferred retail pharmacy is 50 percent of the plan allowance ($60 minimum) for up to a 30-day supply ($175 minimum for a 90-day supply). Previously, cost share was 50 percent of the plan allowance ($55 minimum) for a 30-day supply ($165 minimum for a 90-day supply).
• When Medicare Part B is primary, cost share for Tier 3 non-preferred brand-name drugs obtained through the Mail Service Prescription Drug Program is now a $125 copayment. Previously, copayment was $115.

• Standard and Basic Options prescription drug benefit changes
• Copayment for Tier 1 (generic) asthma drugs is now $5 for Preferred retail pharmacies and Mail Service Prescription Drug Program (with and without Medicare Part B). Previously, cost share was 20 percent of the plan allowance (no deductible) for Standard Option and $10 copayment for each purchase of up to a 30-day supply and a $30 copayment for 90-day supply for Basic Option.
• We now provide preventive care benefits for generic cholesterol-lowering statin drugs. Previously, pharmacy benefits were provided with a member cost share.
• We now provide preventive care benefits for aspirin to prevent cardiovascular disease and colorectal cancer for adults ages 50 through 59.
• If member chooses to get the brand-name drug and provider’s prescription allows for generic substitution, applicable cost share for a brand-name drug will be the drug tier cost share plus the difference in the costs of the brand-name and generic drugs. Member expenses for “dispense as written” prescriptions don’t count toward catastrophic protection out-of-pocket maximum. Previously, if the provider’s prescription allowed for generic substitution and member chose to get the brand-name drug, they were responsible only for the drug tier cost share.
• We now provide benefits for oral medical foods under the pharmacy benefit only. Prior approval is required. Previously, medical benefits were provided for oral medical foods.
• We now provide benefits for gonadotropin-releasing hormone antagonists and testosterones regardless of age. Previously, benefits were limited to members age 16 and older.

The enrollment codes for 2018 remain the same

For more information on FEP benefits, refer to the 2018 Blue Cross and Blue Shield Service Benefit Plan. If you have questions, call our Customer Service line at 1-800-482-3600.

Clarification: Injection kits not payable

Blue Cross Blue Shield of Michigan doesn’t pay for injection kits, which may contain a drug, bandages, alcohol swabs and other medical supplies. If a patient requires a drug within the kit, you should bill for it separately, using the appropriate HCPCS code. The associated supplies aren’t eligible for additional separate reimbursement.

Online benefit information now available through Benefit Explainer

As you may have read on web-DENIS in November, we recently made it easier for you to look up benefits for your patients.

We added a tab in Benefit Explainer called Online Benefits Information. This tab will give you the option of viewing online benefit charts for our members (the same ones that members have access to).

The online benefit charts will display benefit information in clear, simple and non-technical language. The features of the Online Benefits Information tab include medical and hospital benefits, prescription drug information and dental, vision and hearing benefits.

Here’s how to find this information:

1. Log in to web-DENIS
2. Click on Subscriber Info and then on Eligibility/Coverage/COB.
3. Enter your patient’s contract information.
4. Click on the links in the detailed benefits section to launch Benefit Explainer.
5. Once Benefit Explainer opens, click on the BPR tab to populate your patient’s contract information in the dashboard.
6. When you click on Search, you’ll see the new Online Benefits Information tab (located to the right of the Quickview Report tab), with benefit information below.

Keep in mind that not all member benefit information will be available in the Online Benefits Information tab. For example, you won’t get results for members with inactive benefit packages, Medigap members, members who buy their insurance on the individual market and those who are part of groups that aren’t on the Michigan Operating System.

Also, the information in the OBI tab and benefit chart is a summary of benefits and doesn’t include the member’s legal certificates and riders.

All other features of Benefit Explainer haven’t changed and are still available.

If you have any questions, contact Provider Inquiry. You can also ask your provider consultant to train you on the new Online Benefits Information tab.

Reminder: Be sure to update Provider Authorization form when changes occur

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

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

Keep in mind that you should review your provider authorization information when you’ve:

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

You must update your provider authorization if you’ll be sending claims using a different submitter ID or routing your 835s to a different, unique receiver or trading partner ID.

To make changes to your EDI setup, follow these steps:

• Visit bcbsm.com/providers.
• Click on Quick Links.
• Click on Electronic Connectivity EDI.
• Click on How to use EDI to exchange information with us electronically.
• Under EDI agreements, click on Update your Provider Authorization Form.

If you have questions about EDI enrollment, call the EDI Help Desk at 1-800-542-0945. For assistance with the Trading Partner Agreement and Provider Authorization forms, select the “TPA” option.

Reminder: Physician assistants required to re-enroll with Blue Cross, BCN by Jan. 31

Physician assistants must re-enroll with Blue Cross Blue Shield of Michigan and Blue Care Network, including our Medicare Advantage programs, by Jan. 31, 2018. Physician assistant re-enrollments will be processed with an effective date of Feb. 1, 2018.

Current reimbursement arrangements will be terminated for dates of service after Jan. 31, 2018.

Please refer to the following documents for complete information:

• October 2017 Record article
• September-October 2017 BCN Provider News article

Re-enrolling physician assistants must go to bcbsm.com/providers and click on the following links:

• Enrollment and Changes
• Provider Enrollment
• Physicians and Professionals
• Change an existing provider
• Physician Assistant

The Required Documents Checklist indicates the additional information and documents required from the physician assistant.

The following required forms will appear:

• Physician Assistant Re-Enrollment Form
• Physician Assistant/Physician Practice Agreement Attestation Form
• BCBSM Physician Assistant Combined Signature Document

In addition, keep the following in mind:

• All physician assistants are encouraged to re-enroll as early as possible to ensure claims don’t reject inappropriately for dates of service on or after Feb. 1, 2018.
• Be sure your Council for Affordable Quality Healthcare data is current and consistent with the information you provide on the re-enrollment form.

How to contract and re-enroll

Physician assistants can find and use the Blue Cross and BCN practitioner agreements and enrollment forms on bcbsm.com.

Note: If a professional group is enrolling a new physician assistant, the group must enroll the PA in the Provider Enrollment and Change Self-Service application and then use the application to add the PA to the group.

Information about reimbursement for dates of service on or after Feb. 1, 2018

• Physician assistants who have re-enrolled by Jan. 31, 2018, will be eligible for reimbursement for services within their scope of license either directly or under a group for all lines of business.
• Physician assistants who haven’t re-enrolled will have their claims denied.

If you have any questions about physician assistant re-enrollments, contact Provider Inquiry.

Commercial professional and facility claim audits begin April 1

HMS^® and SCIO Health Analytics^®, independent companies working for Blue Cross Blue Shield of Michigan, will assist with auditing claims for all commercial professional and facility services, starting April 1, 2018.

The scope of the audits will be either claim-specific or project-based, and will ensure that billed and paid services were ordered, medically necessary, documented, reported and covered under the patient’s contract, according to Blue Cross’ policies and guidelines. This applies to all providers who bill procedure or revenue codes.

The audits will look back two years and confirm that you’ve properly billed and documented requirements for services billed.

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

The purpose of provider audits is to:

• Confirm compliance with HCPCS and CPT codes that are in effect on the date of service.
• Ensure services billed are medically necessary.
• Detect, prevent and correct waste and abuse.
• Facilitate accurate claim payment.

Questions?

Contact your provider consultant. During an audit, call 1-866-875-1749 to speak with an HMS representative, or 1-866-628-3488 to speak with an SCIO representative.

Here’s what you need to know about 2018 Skilled Nursing Facility Pay-for-Performance program

In 2018, Blue Cross Blue Shield of Michigan freestanding and hospital-based skilled nursing providers will have the opportunity to earn incentive rewards through the Skilled Nursing Facility Pay-for-Performance program. The SNF P4P is part of a health information exchange through the Michigan Health Information Network notification service.

The goal of the SNF P4P is to:

• Enhance the population-based model of health.
• Promote a team-based approach.
• Engage a strong commitment to the care continuum.
• Help ensure that a patient’s caregivers receive timely notification of an admission, discharge, transfer or emergency room visit.
• Improve coordination of care and outcomes.
• Reduce the likelihood of an unplanned readmission.

Program details and reward
Blue Cross will recognize SNFs that are successful in fully implementing the MiHIN admission, discharge and transfer process. We’ll also recognize facilities that implemented the process during previous program years and continue to meet participation expectations.

Providers achieving the program expectations and deadlines will be eligible to receive an additional 2 percent reward for either six or 12 months following the incentive’s effective date.

SNFs that don’t meet the SNF P4P program requirements or choose not to participate will forfeit the incentive opportunity.

Important dates

Additional information

Northwood Inc. to manage DME/P&O and medical supply needs for Medicare Plus Blue^SM members

As reported in a web-DENIS message on Dec. 1, 2017, Blue Cross Blue Shield of Michigan will use Northwood Inc.’s network of providers to meet the durable medical equipment, prosthetics, orthotics and medical supply needs of Medicare Plus Blue PPO members, starting Jan. 1, 2018. Northwood is an independent company working for Blue Cross.

Blue Cross is leasing the Northwood provider network and contracted fees for durable medical equipment, prosthetics, orthotics and medical supplies. Blue Cross will process claims for these supplies and equipment for Medicare Plus Blue members.

Blue Cross will reimburse in-network providers for serving these members according to the vendor fee schedules. If there’s no fee schedule for a specific service, we’ll base our reimbursement on Medicare’s allowed amount for that service. Out-of-network claims for Medicare Plus Blue PPO members will be reimbursed using the Medicare fee schedule, with the potential of higher level of cost sharing being applied.

Northwood is contacting providers who serve Medicare Plus Blue members about becoming a Northwood-participating provider. If you’d like to join the Northwood network, you can get a provider enrollment application by contacting Debbie Skattebo, Northwood’s provider relations manager, at 586-755-3830 or 1-800-447-9559, extension 3703. You can also email provideraffairs@northwoodinc.com.

All Medicare Plus Blue plans include DME/P&O, medical supplies and Part B drugs that are covered under original Medicare.

J & B to provide diabetic supplies for Medicare Plus Blue^SM members

As of Jan. 1, 2018, J & B Medical Supply will be the in-network diabetic supplier for all Blue Cross Medicare Plus Blue^SM PPO members.

J & B provides mail-order diabetic supplies both in Michigan and out of state. This is the same diabetic supply company now used by Blue Care Network and BCN Advantage^SM members.

We’re encouraging our Medicare Plus Blue members to use J & B when they need diabetic supplies, such as continuous glucose monitors, pumps and diabetic testing mail-order supplies.

For questions about J & B Medical Supply, call the company at 1-888-896-6233 from 8 a.m. to 6 p.m. Monday through Friday. If you leave a message after hours or on the weekend, J & B will call you back the following business day. If you want more information about the services J & B provides, send an email to info@jandbmedical.com.

We’ve updated our policy on continuous glucose monitoring systems

The safety and effectiveness of U.S. Food and Drug Administration-approved continuous glucose monitoring systems has been established. Both the intermittent (72 hours or greater) and continuous basis systems may be considered useful therapeutic devices for patients meeting the relevant patient selection criteria.

Two additional procedure codes – K0553 and K0554 – are now covered when medically necessary. This policy was effective July 1, 2017.

Reminder: DME HCPCS payment policy is changing, effective March 1, 2018

As announced in the December 2017 Record, effective March 1, 2018, Blue Cross Blue Shield of Michigan is making changes to how we process durable medical equipment HCPCS codes for Blue Cross’ commercial PPO products. We’re adding four categories to explain how we’ll pay for DME.

Click on each category for a list of DME HCPCS codes:

• Capped rental
• Purchase only
• Rent forever
• Short-term rental

The DME capped rental period is expanding from 10 monthly payments to 13 monthly payments. After 13 monthly payments, the equipment will be considered purchased.

We’re also expanding the capped rental and reasonable useful lifetime time frame.
The reasonable useful lifetime for purchased DME is expanding from every three years to five years. This aligns with Centers for Medicare & Medicaid Services policy.

These changes will result in updates to the rental fees, specifically for the capped rental HCPCS codes. These changes will be incorporated into the newly published DME/P&O Fee Schedule, effective March 1, 2018.

You can access the fee schedule via web-DENIS.

• Log in to web-DENIS.
• Click on BCBSM Provider Publications and Resources.
• Click on Entire Fee Schedules and Fee Changes.