We’re enhancing our self-service tools to better meet your needs

We’re expanding our self-service offerings to help meet your business needs. This includes changes to the Provider Automated Response System, or PARs, and Provider Secured Services.

About PARS
PARS is a telephone system that provides patient eligibility, benefits and claims information for health care providers.

• Benefit information: PARS provides high-level benefit information that’s not specific to a procedure or revenue code.
• Claims information: PARS provides detailed claims data, including information about ICN number, date of service, charged amount, allowed amount, cost share applied, amount paid to provider, check number, check date and check status.

The system has both touchtone and voice recognition capabilities, including an option that allows you to request that a hard copy of the benefits or general claims information be sent to your fax or email address.

Using PARS is:

• Quick (inquiry answered within a few minutes)
• Convenient (available 24 hours a day, seven days a week)
• Personalized (caller controls the information they want to hear or skip)
• Accurate (receipt of a fax or email provides documentation of the information received on a given day)

PARS provides information for:

• Blue Cross Blue Shield of Michigan and Blue Care Network commercial
• Medicare Advantage
• Federal Employee Program^®
• Professional, facility, vision and hearing

When calling with questions about the determination of a claim, our customer service representatives will encourage you to use PARS to retrieve your information. They’ll help you navigate through the system or find the detailed information you need.

About Provider Secured Services
Provider Secured Services is a secure site on bcbsm.com/providers that gives you patient information and the resources you need to do business with us. Depending on the kind of provider (or facility) you are, you can:

• Get patient eligibility, benefits and claims status using web-DENIS.
• Sign up for electronic funds transfer for direct deposit of claims payments and view online vouchers.
• Get medical drug prior authorization if you're a doctor practicing in an office or a hospital.
• Use Health e-Blue^SM to generate reports about patient health. Primary care physicians can also use it to fill out Healthy Blue Living^SM HMO qualification forms.

Providers and facilities outside of Michigan may qualify for access based on the following two questions:

Do you only get payment from us for Medicare crossover claims?
You can use Provider Secured Services to:

• Register for EFT.
• View your online vouchers.

First you'll need to enroll with us using the Out-of-State/EFT New Provider Enrollment form (PDF). The form includes a section for signing up for access to Provider Secured Services.

You'll also need to fill out the Use and Protection Agreement (PDF).

Do you get payment from us for Medicare and non-Medicare claims?
If you're one of the allied provider types listed below, you can use secured services for EFT and online vouchers, plus patient eligibility, benefits and claims status.

• Clinical independent laboratory
• Durable medical equipment supplier
• Freestanding radiology center
• Hearing
• Independent diagnostic testing facility
• Physiological laboratory
• Vision

You need to be enrolled with us first to use Provider Secured Services even if you don't participate with Blue Cross.

Our enrollment forms have a section on them for signing up for Provider Secured Services, where you can also list staff members who need access and what they can access. Get started here.

Allied providers should fill out the Professional Secured Access Application if they:

• Already use Provider Secured Services and need to make changes such as adding or removing staff members
• Skipped the Provider Secured Services section on the Enrollment form:
  Provider Secured Access Application (PDF)

If you've never used Provider Secured Services before, you'll also need to fill out the Use and Protection Agreement (PDF).

If you have a change in staff and an ID that can be reassigned, fill out the Provider Secured Services ID Reassignment form (PDF).

If you need assistance, call the Web Support Help Desk at 1-877-258-3932 from 8 a.m. to 8 p.m. Monday through Friday.

Are you getting paid for following best practice guidelines for rheumatoid arthritis?

Disease-modifying anti-rheumatic drug therapy, or DMARD, for rheumatoid arthritis is one of the HEDIS^® measures used to determine Medicare star ratings. It assesses RA patients ages 18 and older who were diagnosed with RA at two separate visits and who filled at least one ambulatory prescription for DMARD in the measurement year.

Why DMARD therapy?
Several major studies have documented the benefits of aggressive early treatment, which is essential in helping prevent long-term damage and disability from RA. DMARD therapy increases the quality of life more effectively than other treatment strategies. According to the American College of Rheumatology, patients with a confirmed diagnosis should be treated with DMARD therapy regardless of severity or how long they’ve had RA unless contraindicated.

DMARD therapy is the only treatment that helps prevent further erosion and damage to joints. Managing providers should see their patients undergoing DMARD therapy treatment in follow-up visits at least four times a year to monitor the disease therapy effectiveness and any adverse events with the treatment.

Provider incentive for DMARD therapy
Blue Cross Blue Shield of Michigan provides $100 to participating primary care physicians for each Medicare Advantage member with RA who fills at least one prescription for DMARD therapy each calendar year. Blue Cross offers this incentive for DMARD treatment because it follows RA national guidelines.

Referring patients to a rheumatologist
Referral of patients to a rheumatologist is highly recommended to confirm and treat the disease because:

• Suspected and early onset of RA may resemble other forms of inflammatory arthritis.
• Patients with RA, when appropriately treated, can experience a reduction of disease progression, joint damage, long-term disability, elimination of surgery, lower disease activity and improved chances of disease remission.

Ensuring accurate diagnosis and coding
Be sure claims submitted are consistent with appropriate diagnosis coding guidelines. Confirm a diagnosis of RA, versus osteoarthritis or joint pain, before entering it on claims. Members’ RA claims are sometimes coded inaccurately when they also have joint pain or other signs and symptoms that must be addressed. RA claims shouldn’t be submitted unless the diagnosis has been confirmed.

Note these ICD-10 coding guidelines:

• Don’t code diagnoses using terms such as “probable, suspected, questionable, rule out, working diagnosis” or similar terms indicating uncertainty. Code conditions to the highest degree of specificity, including symptoms, signs, abnormal test results or other reasons for the visit.
• Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis hasn’t been confirmed by the provider.

DMARD medications
Excellent treatment responses can be achieved with a wide variety of nonbiologic and biologic DMARD therapies. Below are some examples:

**Tier 1 preferred generic drug that offers the lowest member cost sharing

Exclusions
Patients are excluded from the rheumatoid arthritis measure when claims in the measurement year support one of the following:

• Patient is in hospice.
• Patient is 66 or older and enrolled in an institutional Special Needs Plan, or I-SNP, or living long-term in an institutional setting.
• Patient is age 81 or older with frailty.
• Patient is pregnant.
• Patient was dispensed a dementia medication.
• Diagnosis of HIV any time in the patient’s history.

Also excluded are patients ages 66 through 80 with two advanced illness claims in the measurement year or the year prior to the measurement year and one frailty claim.

Note: If your patient can’t tolerate DMARD therapy, it’s important to include advanced illness and frailty diagnosis codes on your office visit claims when appropriate.

Following is a sample list of frailty ICD-10 codes recognized by HEDIS:

• R26.2 — Difficulty in walking, not otherwise classified
• R26.89 — Other abnormalities of gait and mobility
• R26.9 — Unspecified abnormalities of gait and mobility
• R41.81 — Age-related cognitive decline
• R53.1 — Weakness
• R53.81 — Other malaise
• R53.83 — Other fatigue
• R54 — Age-related physical debility
• Z73.6 — Limitation of activities due to disability
• Z74.09 — Other reduced mobility
• Z91.81 — History of falling
• Z99.81 — Dependence on wheelchair

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

Resources can help you promote suicide awareness and prevention

September was designated Suicide Prevention Awareness Month, but any time of the year is a good time to spread the word about the how we can help prevent suicide. As part of Blue Cross Blue Shield of Michigan and Blue Care Network’s ongoing focus on behavioral health, we created an array of materials to raise awareness about this important topic.

Suicide deaths have risen dramatically in the U.S. during the past 15 years — and across all ages, races, genders and ethnicities. Families, communities and workplaces can all play a role in reversing this dangerous trend.

Here are links to some resources you may find helpful:

• Column by Dr. William Beecroft, medical director of behavioral health for BCN, in Hospital and Physician Update
• Blog by Daniel J. Loepp, Blue Cross president and CEO, on MI Blues Perspectives.
• Blog on promoting suicide awareness and prevention in the workplace on MI Blues Perspectives
• Materials on suicide prevention and awareness on the Engage page at bcbsm.com/engage. Resources include posters and flyers on suicide facts, warning signs and how employers can help. Scroll down to the Mental health awareness section of the page to access them.

Also, people in distress or their colleagues or loved ones can get guidance through toll-free numbers such as the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).

Next Drug Take Back Day scheduled for Oct. 27

Drug Take Back Days are a key tool in our efforts to battle the opioid epidemic. They provide a convenient, responsible means of disposing of prescription drugs, while also educating people about the potential for abuse of medications. The U.S. Drug Enforcement Administration coordinates two National Prescription Drug Take Back Days each year, with the next one scheduled for Oct. 27.

As we’ve done previously, Blue Cross Blue Shield of Michigan supports Drug Take Back Day in various ways. For example, we’ll:

• Post new blogs on MI Blues Perspectives.
• Promote existing blogs, such as the one highlighting our efforts with Walgreens.
• Promote resources found on our Opioids 101 site.
• Host a Twitter chat during the week of Oct. 22.

You can subscribe to MI Blues Perspectives, a good source of Blue Cross and Michigan health news, and have blogs sent directly to your email inbox.

To find a drug disposal facility near you, use the DEA’s search tool** or Michigan OPEN’s Opioid Disposal Map.** For more information, visit the DEA Diversion Control Division website** or Michigan OPEN’s Opioid Disposal Information and Resources page.**

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

Blue Cross PPO members who live outside Michigan will need prior authorization for certain services

Beginning Jan. 1, 2019, Blue Cross Blue Shield of Michigan will require prior authorization for PPO members who need certain services managed by AIM, regardless of where they live.

The services that require prior authorization include high-tech radiology, in-lab sleep management, proton beam therapy and echocardiogram services. Currently, members who reside in the state of Michigan already need prior authorization for these services. Starting Jan. 1, the program will expand to include those PPO members who live outside of Michigan and seek care from a Michigan provider.

You can find procedure code requirements on Benefit Explainer in web-DENIS. Log in to the provider portal, go to web-DENIS and select BCBSM Provider Publications and Resources. You can look up benefit and medical policy for procedure codes by selecting Benefit Policy for a Code.

Health care providers can request authorization for these services through the AIM ProviderPortal^SM at aimspecialtyhealth.com or by contacting AIM at 1-800-728-8008.

2019 early release CPT code updates

Category III and medicine codes — Surgery, radiology, medicine, pathology and laboratory, vaccines/toxoids

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

Billing chart: Blues highlight medical, benefit policy changes

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

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

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

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

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

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

We’re simplifying provider appeals process

As part of our efforts to simplify administrative processes for health care providers, we’ve made some changes to the claim inquiry and appeals processes. Keep in mind that it’s no longer necessary to reach out to your provider consultant as part of the process. Here’s an overview of how the appeals process works.

Step one: To inquire about an adverse benefit or claim determination, contact Provider Inquiry.

• 1-800-344-8525 for medical providers
• 1-800-482-4047 for vision and hearing providers
• 1-800-249-5103 for facility providers

Step two: If your issue couldn’t be resolved after contacting Provider Inquiry and you have additional information to provide, you may file a written appeal request with Blue Cross Blue Shield of Michigan. Your written request must be received within 30 calendar days from the date you contacted Provider Inquiry.

Background: Providers may file a written appeal for an adverse benefit or claim determination within 30 days of completing the routine inquiry procedure and within 180 days from the date of claim determination.

The following are examples of reasons a provider may receive an adverse claim or benefit determination:

• Lack of benefits or reduction of benefits
• Services that are considered experimental or investigational
• Lack of medical necessity
• Lack of precertification (not obtained as required)
• Pricing disputes
• Sanctions due to cost containment programs
• Facility rejections related to length of stay or appropriateness of treatment setting

You may submit your written appeal request on your office letterhead or use the Provider Appeal Form. The form was recently revised and can be accessed from the Forms page of web-DENIS as follows:

• From the home page of web-DENIS, click on BCBSM Provider Publications and Resources.
• Click on Newsletters & Resources.
• Click on Forms in the left column.

In your appeal request, include the following:

• The documentation you referenced when you contacted Provider Inquiry
• The reason you’re appealing
• Supporting documentation
• The enrollee’s ID (including the three-character alpha-numeric prefix)
• The patient’s name and the date(s) of service

Send the written appeal request or the completed Provider Appeal Form and all supporting documentation by fax to 1-877-348-2210 or by mail to:

Blue Cross Blue Shield of Michigan
Provider Appeals — Mail Code CS3A
600 E. Lafayette Blvd.
Detroit, MI 48226

We’ll respond to your appeal within 30 calendar days.

Note: Your appeal will be returned if it’s missing information or doesn’t meet the time frames outlined above.

Physicians, Blue Cross and BCN agree that healthy lifestyles are key to living well

In October 2017, Blue Cross Blue Shield of Michigan commissioned an independent market research firm, Gongos Research, to conduct an online survey of Blue Cross and Blue Care Network physicians. The objective? To obtain their opinions about patient care, health and wellness programs, the health care industry and more. Over the next year, we’ll be running a series of articles that examine how we’re responding to their attitudes and concerns. This is the first article in the series.

Doctors want their patients to take steps toward a healthier lifestyle by making good decisions about nutrition, physical activity and overall wellness. That was a key finding of a recent survey conducted by Blue Cross. See the chart below for other findings related to health and wellness.

** Results show top-two box percent “agree” responses on a five-point scale.

“Blue Cross and Blue Care Network value our relationship with physicians and share in the belief that healthy lifestyles are important for everyone,” said Sherri Dansby, market research manager with Corporate Marketing and Customer Experience. “As part of that belief, Blue Cross strives to give our members the tools they need to succeed in living well.”

Health and wellness tools
Here’s an overview of some of these tools and programs:

• The Blue Cross^® Health and Wellness website, powered by WebMD^®, gives members 24-hour access to current health information and tools, including digital health assistant programs, health trackers and a personal health record.
• The Blue365^® program offers health and wellness deals and discounts exclusively to our members. Blue365 categories include healthy eating, fitness, lifestyle and wellness. Personal care and financial deals are also available to members. Members can access these deals at bcbsm.com and through the BCBSM mobile app.
• Blue365^® discounts on groceries and healthy meal programs give members nutritious food options, such as discounts at Better Health stores, Weight Watchers, Jenny Craig and Nutrisystem. Private weight-loss coaching, nutrition educational resources and discounts on vitamins and supplements are also available.
• Fitness Your Way™ by Tivity Health™ allows members the flexibility to work out at any of its locations nationwide for only $29 per month. More than 10,000 fitness locations participate, including LA Fitness, Snap Fitness and Anytime Fitness, as well as many local fitness centers. Deals are also offered on mindfulness courses, wearable health devices and fitness equipment.

In addition to providing wellness tools directly to members, Blue Cross and BCN provide health and wellness resources to employer groups through the Blue Cross^® Health and Wellness benefit. Examples of resources offered include:

• Lifestyle coaching and stress management tools designed to help improve health risks
• Smoking and tobacco cessation support programs
• Health assessments and coaching
• Wellness challenges for motivation to improve healthy behaviors

Nine in 10 physicians responding to the survey seek to help their patients live healthy lives. And nearly 8 in 10 physicians frequently recommend health and wellness tools to their patients.

Blue Cross and BCN encourage health care providers to consider our health and wellness programs when making lifestyle recommendations to their patients.

WebMD Health Services is an independent company supporting Blue Cross Blue Shield of Michigan and Blue Care Network members by providing health and wellness services.

Fit4D: New diabetes education program for eligible members

Fit4D is a new education program to help Medicare Plus Blue^SM PPO and BCN Advantage^SM HMO and HMO-POS members with diabetes achieve their health goals.

If a patient asks you about the Fit4D program, let him or her know that it provides them with personalized diabetes education and coaching services. Participation is voluntary and available at no extra cost to members.

Eligible patients must be identified as needing the service by Blue Cross Blue Shield of Michigan Care Management, and must:

• Be a fully insured Medicare Advantage PPO or HMO member.
• Be age 18 or older.
• Have an A1c equal to or greater than 8.0.

If patients would like to learn more about the Fit4D program, have them call the Fit4D 24-hour message line at 1-800-422-9875.

What your patients can expect
A Fit4D certified diabetes educator will coach your patients by telephone, text or email. Coaching is available in English and Spanish, and will include the following topics:

• Monitoring blood sugar
• Understanding how medication works
• Taking medication correctly
• Recognizing the importance of regular doctor visits
• Achieving healthy eating and exercise goals

Patients can opt out of the program by calling Fit4D’s 24-hour message line at 1-800-422-9875. TTY users can call 711.

Cancer screening saves lives: Here are some recommendations

Screening offers the best chance to find cancer and treat it successfully. Screening can also prevent many cancers by prompting treatment for abnormal cell changes or pre-cancers before they have a chance to turn into a cancer. And when detected early, cancer is, as you know, more easily treated.

The following provides an overview of American Cancer Society-recommended screenings for common cancers.

When is cervical cancer screenings recommended?

• All women should begin cervical cancer screening at age 21. Women ages 21 to 29 should have a Pap test every three years.
• Women ages 30 to 65 should be screened with a Pap test combined with an HPV test every five years.

When is a mammogram recommended?
According to new recommendations from the American Cancer Society:

• Women ages 40 to 44 should be given the choice to start annual breast cancer screening with mammograms if they want to.
• Women ages 45 to 54 should get mammograms every year.
• Women 55 and older should switch to mammograms every two years or continue yearly screening if desired.
• Regular screening should continue as long as a woman is in good health and is expected to live 10 more years or longer.

Note: Based on the patient’s family history and other clinical factors, different age ranges may be necessary.

When is prostate screening recommended?

• Men at average risk for prostate cancer should begin screening at age 50.
• Men at high risk for prostate cancer should begin at 45. High-risk men include:
• African-Americans
• Men who had a father, brother, son or other first-degree relative diagnosed with prostate cancer at an early age, which is younger than 65.
• Men with more than one first-degree relative who had prostate cancer at an early age should start screenings at 40.

For more information on cancer screening, visit the American Cancer Society website.**

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

Coding corner: Documenting ulcers of the skin

Clear and complete clinical documentation is crucial to coding ulcers, which are sores on the skin or a mucous membrane, accompanied by the disintegration of tissue.

Ulcers can result in complete loss of the epidermis and often other layers of the skin and even subcutaneous fat. They sometimes can be caused by lack of mobility, which causes prolonged pressure on tissue.

Code assignments are based on the type, location, laterality and the stage of severity. They’re also based on any associated underlying conditions, including:

• Diabetes
• Atherosclerosis
• Chronic venous hypertension

The coding guidelines and code assignments for these conditions can be found in Chapter 12 of the ICD-10-CM Official Guidelines for Coding and Reporting manual: Diseases of the Skin and Subcutaneous Tissue (L00-L99).

Here are some tips for coding pressure versus non-pressure ulcers.

Identifying and coding pressure ulcers

Pressure ulcers, also known as pressure sores, pressure injuries, bedsores and decubitus ulcers, are localized damage to the skin and underlying tissue. They usually occur over a bony prominence as a result of pressure or pressure in combination with shear friction.

• Pressure ulcer stages are classified by the severity or progression of the disease:
• Unspecified stage
• The stage of the ulcer isn’t documented.
• Stages 1-4 of pressure ulcer
• Stage 1 — Skin is intact with redness.
• Stage 2 — Shallow, open ulcer with red wound bed. The ulcer has partial thickness and loss of dermis, presenting as a shallow open ulcer with a red pink wound bed without slough.
• Stage 3 — Subcutaneous fat may be visible. Slough may be present at this stage but it doesn’t obscure the depth of tissue loss.
• Stage 4 — Bone, tendon or muscle is exposed. Slough or eschar may be present on some parts of the wound bed.

• Unstageable
• The ulcer is classified as unstageable if the stage of ulcer can’t be clinically determined. The ulcer is covered by slough, eschar or blister, for instance, or has been treated with a skin or muscle graft.
• Pressure ulcers documented as deep tissue injury rather than because of trauma is an example.

• ICD-10-CM contains combination codes to identify the site and the stage of pressure ulcers. Assign as many codes from category L89 as needed to identify all pressure ulcers for the patient.

Below are some examples with category ranges from L89000-L8995.

• Risk factors for pressure or decubitus ulcers include:
• Bedridden patients
• Chronic conditions, including diabetes or vascular disease
• Immobility due to brain or spinal injury
• Wheelchair dependent
• Documentation should be clearly noted on whether the wound is healed or healing.
• An ICD-10-CM code is not assigned when the documentation states the pressure ulcer is completely healed.
• The medical record documentation for healing ulcers should always include the appropriate stage.
• When unable to determine a stage for an ulcer, include a comment for the reason (e.g., eschar).
• Patients admitted to inpatient hospital stay with pressure ulcers
• Assign the code for the site and severity at the time of admission for ulcers that healed at the time of discharge.
• When a pressure ulcer evolves into another stage during the admission:
• Two separate codes should be assigned.
• One code for the site and stage on admission
• A second code for the same ulcer site and the highest stage reported during the stay

Non-pressure chronic ulcers

Official guidelines have been added to ICD-10-CM Official Guidelines for Coding and Reporting FY 2018, Section 1, Chapter 12.b.1.2.3.

Seventy-two codes were added to the categories L97 and L98 that involve muscle or bone without the presence of necrosis. See 2018 updates to ICD-10-CM codes on the Centers for Medicare & Medicaid Services website.**

Below are some examples of category ranges from L97101 through L98499.

• An ICD-10-CM code isn’t assigned when the documentation states the pressure ulcer is completely healed.
• When the condition is described as healing, assign the appropriate non-pressure ulcer code based on the documentation in the medical record.
• Use a code assignment for unspecified severity when the severity of the wound isn’t documented.
• Documentation should be clearly written to identify whether the patient has a new non-pressure ulcer from the one that’s healing. Document so it’s clear there’s another ulcer that’s different from the one the patient is already being treated for.
• Patients admitted to inpatient hospital with a non-pressure ulcer.
• For ulcers present at the time of admission but healed at the time of discharge, assign the code for the site and severity at the time of admission.
• When a non-pressure ulcer evolves into another stage during the admission, two separate codes should be assigned:
• One code for the site and severity level on admission
• A second code for the same ulcer site and the highest stage reported during the stay

Key points to keep in mind

• Clinical documentation should be clearly written for conditions such as wound, sore or skin breakdown so these conditions aren’t confused with ulcers of the skin.
• The associated ulcer diagnosis must be documented in the encounter note by the doctor, even if a nurse documented the pressure stages.
• The stage (1- 4) of progression of the ulcer is always required for pressure or decubitus ulcers.
• When documenting an ulcer, always identify the site, such as the back or lower limb and laterality, such as right or left.
• A completely healed ulcer isn’t coded.
• Documentation should clearly distinguish when an ulcer is healed versus in the healing process.
• Identify when an ulcer being treated is chronic and non-healing.
• Documentation of ulcers during an inpatient hospital stay include:
• The documentation of pressure ulcers if they were present on admission
• Two separate code assignments when an ulcer condition evolves into another stage during hospital stay
• Document all associated underlying conditions such as:
• Gangrene
• Atherosclerosis of the lower extremities
• Chronic venous hypertension
• Diabetes
• Postphlebitic syndrome
• Varicosity

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.

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

Most providers are missing out on medication reconciliation reimbursements. Are you?

It’s estimated that 85 percent of providers aren’t submitting reimbursement claims for conducting medication reconciliation with their attributed Blue Cross Blue Shield of Michigan members after hospital discharge.

To receive reimbursement, follow these steps when patients are discharged after a hospital stay:

• Schedule a post-discharge office visit as soon as possible.
• Perform medication reconciliation during the visit by reconciling the hospital discharge medications against the outpatient medication list.
• Document the following in the outpatient medical record: “Current and discharge medications were reconciled.”
• Submit *1111F with the post-discharge office visit claim within 30 days of the discharge.
• CPT II code *1111F states, “Discharge medications reconciled with the current medication list in outpatient medical record.”

When medication reconciliation is conducted by the prescribing primary care doctor or the ongoing care provider within 30 days of a hospital discharge and a claim is submitted for *1111F, Blue Cross will reimburse as follows:

• $10 for Medicare Plus Blue^SM
• $35 for Blue Cross commercial

About the HEDIS^® measure
Medication reconciliation post-discharge assesses patients age 18 and older who were discharged from an acute or non-acute inpatient stay between Jan. 1 and Dec. 1 of the measurement year. It looks at patients whose medications were reconciled from the date of discharge through 30 days after discharge (31 days total).

For more information

• Frequently asked questions: Reimbursement for medication reconciliation within 30 days of an inpatient discharge to home.
• “New Medicare star ratings measure: Medication reconciliation post-discharge”
• “Providers receive reimbursement for conducting medication reconciliation post-discharge for MA PPO members”

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

New user-friendly prompts coming to Pharmacy Prior Authorization Help Desk

Starting Dec. 14, 2018, you’ll hear something new when you call the Pharmacy Prior Authorization Help Desk toll-free number. New phone prompts will direct callers to the appropriate line of business for eligible Blue Cross Blue Shield of Michigan and Blue Care Network members.

The prompts are clear and simple to use. Here’s what you need to do:

1. Call 1-800-437-3803.
   
   
2. Enter a valid member contract number to authenticate and speak with a live representative.
   
   The automated system will find contracts by line of business. This will eliminate the need for you to provide an answer if the contract is commercial or Medicare. Without an eligible contract, you won’t be able to speak to a live agent.
   
   
3. Choose the pharmacy or medical drug benefit you’re calling about. You’ll hear the following prompt:
   
   
   “There are two options for drug prior authorizations. For medications that are taken by the patient themselves and billed to the pharmacy benefit, say ‘pharmacy.’ For infusions or injectable drugs given by a health care professional, billed to the medical benefit, say ‘medical.’”
   
   “Pharmacy” covers self-administered oral, topical or self-injected drugs the member picks up at a retail pharmacy.
   
   “Medical” covers drugs administered by a health care professional, often in a home, office or outpatient facility.
   
   
4. Choose the appropriate option for fast and accurate service.

Upcoming changes for home infusion therapy and ambulatory infusion center providers

Beginning Jan. 1, 2019, home infusion therapy and ambulatory infusion center providers can submit payable procedure codes for rendered services from the list below:

Select injectable medications will be payable in the home setting and ambulatory infusion centers without requiring medical IV therapy on the same day.

Note: The billing requirement to include the National Drug Code, or NDC, and quantity remains in place.

We no longer cover Clindagel^®

Our goal at Blue Cross Blue Shield of Michigan and Blue Care Network is to provide safe, high-quality prescription drug therapies while also controlling costs. To accomplish this, we’re making some changes to the drugs we cover.

Because there are safe, effective and less-expensive choices, we stopped covering Clindagel beginning Sept. 1, 2018. Clindagel is a topical product used for the treatment of acne.

Your patients currently using this drug can continue to fill their prescriptions through Nov. 14, 2018. If a patient fills his or her prescription on or after Nov. 15, he or she will be responsible for the full cost.

Here’s a look at the cost and available formulations of Clindagel as compared to available formulations of the generic alternative, which has similar effectiveness, quality and safety at a fraction of the cost.

Members can no longer receive prescriptions for DME/P&O items through telehealth visits

Blue Cross Blue Shield of Michigan is concerned that members are receiving durable medical equipment and prosthetic and orthotic items without clear demonstration of medical necessity or proper fitting.

Therefore, effective Nov. 1, 2018, health care providers won’t be able to prescribe or issue DME/P&O supplies during telehealth visits. A telehealth visit doesn’t meet the medical necessity requirements for prescribing these items. Prescription and issuance resulting from a telehealth visit may be subject to audit review and recovery.

A telehealth visit includes:

• Phone call
• Both email and postal mail
• Video chat

All telehealth formats are excluded from issuing DME and prosthetic and orthotic items.

URMBT to participate in medical drug prior authorization program

Beginning Jan. 1, 2019, members of the UAW Retiree Medical Benefits Trust will participate in the medical drug prior authorization program.

You can find information about this program by logging in to web-DENIS and following these steps:

1. From the web-DENIS home page, click on BCBSM Provider Publications and Resources.
2. Click on Newsletters and Resources.
3. Click on Forms.
4. Click on Physician administered medications.

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

The list below reflects all the medications that are part of the medical drug prior authorization program:

New utilization management programs beginning for URMBT members

Beginning Jan. 1, 2019, Blue Cross will implement two new utilization management programs for oncology services for UAW Retiree Medical Benefits Trust, or URMBT, non-Medicare members. With these programs, prior authorization must be obtained for some outpatient medical and radiation oncology treatments.

The programs, which promote evidenced-based, high-value care for our members, require prior authorization for radiation oncology and medical oncology services in outpatient settings. Prior authorization will be managed by AIM Specialty Health^®.

The benefits of these programs include:

• Synchronization with Blue Cross Blue Shield of Michigan’s medical policy
• 24/7 access to the AIM ProviderPortal^SM for automated clinical appropriateness review and access to the AIM contact center personnel, including oncology nurses and oncologists, during business hours
• Actionable information — Includes a comprehensive set of current, evidence-based AIM Cancer Treatment Pathways for more than 80 clinical scenarios (medical oncology program only)
• Enhanced reimbursement — By choosing an AIM Cancer Treatment Pathway regimen, when clinically appropriate, the ordering provider can receive enhanced reimbursement (to be billed using designated S-codes, only for the medical oncology program)

The affected codes for medical oncology and radiation oncology are on the Clinical Criteria & Resources page of the BCBSM Newsletters and Resources section of web-DENIS. Look in the AIM Specialty Health Resources section and click on URMBT Medical Oncology Prior Authorization List or URMBT Radiation Oncology Prior Authorization List.

Providers can also find procedure code preapproval requirements for members when checking benefits and eligibility on web-DENIS.

You can obtain authorization by going to the AIM ProviderPortal** or by calling AIM at 1-800-728-8008, beginning Dec. 24, 2018 (for services on or after Jan. 1, 2019).

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

Don’t forget to update your Provider Authorization Form when changes occur with your 835 (ERA) routing destination

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 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 us of any changes in your trading partner information. You must update your Provider Authorization Form if you send claims using a different submitter ID or route your 835s (Electronic Remittance Advice) to a unique receiver/Trading Partner ID. Updating the form ensures information is routed to the appropriate destination.

Any time you switch vendors, billing services or clearinghouses, you need to update your Provider Authorization Form. 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.

You should review the information on your Provider Authorization Form if you’ve:

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

If you have questions about EDI enrollment, contact the EDI help desk at 1-800-542-0945. For assistance with TPA and Provider Authorization forms, select the TPA option.

New user-friendly prompts coming to Pharmacy Prior Authorization Help Desk

Starting Dec. 14, 2018, you’ll hear something new when you call the Pharmacy Prior Authorization Help Desk toll-free number. New phone prompts will direct callers to the appropriate line of business for eligible Blue Cross Blue Shield of Michigan and Blue Care Network members.

The prompts are clear and simple to use. Here’s what you need to do:

1. Call 1-800-437-3803.
   
   
2. Enter a valid member contract number to authenticate and speak with a live representative.
   
   The automated system will find contracts by line of business. This will eliminate the need for you to provide an answer if the contract is commercial or Medicare. Without an eligible contract, you won’t be able to speak to a live agent.
   
   
3. Choose the pharmacy or medical drug benefit you’re calling about. You’ll hear the following prompt:
   
   
   “There are two options for drug prior authorizations. For medications that are taken by the patient themselves and billed to the pharmacy benefit, say ‘pharmacy.’ For infusions or injectable drugs given by a health care professional, billed to the medical benefit, say ‘medical.’”
   
   “Pharmacy” covers self-administered oral, topical or self-injected drugs the member picks up at a retail pharmacy.
   
   “Medical” covers drugs administered by a health care professional, often in a home, office or outpatient facility.
   
   
4. Choose the appropriate option for fast and accurate service.

New utilization management programs beginning for URMBT members

Beginning Jan. 1, 2019, Blue Cross will implement two new utilization management programs for oncology services for UAW Retiree Medical Benefits Trust, or URMBT, non-Medicare members. With these programs, prior authorization must be obtained for some outpatient medical and radiation oncology treatments.

The programs, which promote evidenced-based, high-value care for our members, require prior authorization for radiation oncology and medical oncology services in outpatient settings. Prior authorization will be managed by AIM Specialty Health^®.

The benefits of these programs include:

• Synchronization with Blue Cross Blue Shield of Michigan’s medical policy
• 24/7 access to the AIM ProviderPortal^SM for automated clinical appropriateness review and access to the AIM contact center personnel, including oncology nurses and oncologists, during business hours
• Actionable information — Includes a comprehensive set of current, evidence-based AIM Cancer Treatment Pathways for more than 80 clinical scenarios (medical oncology program only)
• Enhanced reimbursement — By choosing an AIM Cancer Treatment Pathway regimen, when clinically appropriate, the ordering provider can receive enhanced reimbursement (to be billed using designated S-codes, only for the medical oncology program)

The affected codes for medical oncology and radiation oncology are on the Clinical Criteria & Resources page of the BCBSM Newsletters and Resources section of web-DENIS. Look in the AIM Specialty Health Resources section and click on URMBT Medical Oncology Prior Authorization List or URMBT Radiation Oncology Prior Authorization List.

Providers can also find procedure code preapproval requirements for members when checking benefits and eligibility on web-DENIS.

You can obtain authorization by going to the AIM ProviderPortal** or by calling AIM at 1-800-728-8008, beginning Dec. 24, 2018 (for services on or after Jan. 1, 2019).

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

Don’t forget to update your Provider Authorization Form when changes occur with your 835 (ERA) routing destination

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 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 us of any changes in your trading partner information. You must update your Provider Authorization Form if you send claims using a different submitter ID or route your 835s (Electronic Remittance Advice) to a unique receiver/Trading Partner ID. Updating the form ensures information is routed to the appropriate destination.

Any time you switch vendors, billing services or clearinghouses, you need to update your Provider Authorization Form. 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.

You should review the information on your Provider Authorization Form if you’ve:

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

If you have questions about EDI enrollment, contact the EDI help desk at 1-800-542-0945. For assistance with TPA and Provider Authorization forms, select the TPA option.

We’re updating facility billing policy on multiple surgery reimbursement with nerve block procedure

Beginning Jan. 1, 2019, Blue Cross Blue Shield of Michigan will no longer apply the 125 percent multiple surgery reimbursement to the following hip and knee arthroplasty (performed in an outpatient surgical setting) procedure codes when billed in conjunction with a nerve block procedure:

• *27125
• *27130
• *27440
• *27441
• *27442
• *27443
• *27445
• *27446
• *27447

FEP billing guidelines for physical, speech and occupational therapy at skilled nursing facilities

Health plan benefits for Federal Employee Program^® members include physical, speech and occupational therapy that’s provided in a skilled nursing facility.

What you need to know when billing for this:

• The facility must bill each individual date of service.
• Services with a date range will cause the claim to reject and will delay the claim process.
• Visits will accumulate toward the physical therapy, speech therapy and occupational therapy maximum under the member’s Standard or Basic Option coverage.
• The Standard Option visit maximum is 75 visits per person, per calendar year.
• The Basic Option visit maximum is 50 visits per person, per calendar year.

If you have any benefits questions, call FEP Customer Service at 1-800-482-3600. To inquire about facility precertification, call 1-800-572-3413. If you have questions about case management, call 1-800-325-6278.

New user-friendly prompts coming to Pharmacy Prior Authorization Help Desk

Starting Dec. 14, 2018, you’ll hear something new when you call the Pharmacy Prior Authorization Help Desk toll-free number. New phone prompts will direct callers to the appropriate line of business for eligible Blue Cross Blue Shield of Michigan and Blue Care Network members.

The prompts are clear and simple to use. Here’s what you need to do:

1. Call 1-800-437-3803.
   
   
2. Enter a valid member contract number to authenticate and speak with a live representative.
   
   The automated system will find contracts by line of business. This will eliminate the need for you to provide an answer if the contract is commercial or Medicare. Without an eligible contract, you won’t be able to speak to a live agent.
   
   
3. Choose the pharmacy or medical drug benefit you’re calling about. You’ll hear the following prompt:
   
   
   “There are two options for drug prior authorizations. For medications that are taken by the patient themselves and billed to the pharmacy benefit, say ‘pharmacy.’ For infusions or injectable drugs given by a health care professional, billed to the medical benefit, say ‘medical.’”
   
   “Pharmacy” covers self-administered oral, topical or self-injected drugs the member picks up at a retail pharmacy.
   
   “Medical” covers drugs administered by a health care professional, often in a home, office or outpatient facility.
   
   
4. Choose the appropriate option for fast and accurate service.

Upcoming changes for home infusion therapy and ambulatory infusion center providers

Beginning Jan. 1, 2019, home infusion therapy and ambulatory infusion center providers can submit payable procedure codes for rendered services from the list below:

Select injectable medications will be payable in the home setting and ambulatory infusion centers without requiring medical IV therapy on the same day.

Note: The billing requirement to include the National Drug Code, or NDC, and quantity remains in place.

We no longer cover Clindagel^®

Our goal at Blue Cross Blue Shield of Michigan and Blue Care Network is to provide safe, high-quality prescription drug therapies while also controlling costs. To accomplish this, we’re making some changes to the drugs we cover.

Because there are safe, effective and less-expensive choices, we stopped covering Clindagel beginning Sept. 1, 2018. Clindagel is a topical product used for the treatment of acne.

Your patients currently using this drug can continue to fill their prescriptions through Nov. 14, 2018. If a patient fills his or her prescription on or after Nov. 15, he or she will be responsible for the full cost.

Here’s a look at the cost and available formulations of Clindagel as compared to available formulations of the generic alternative, which has similar effectiveness, quality and safety at a fraction of the cost.

URMBT to participate in medical drug prior authorization program

Beginning Jan. 1, 2019, members of the UAW Retiree Medical Benefits Trust will participate in the medical drug prior authorization program.

You can find information about this program by logging in to web-DENIS and following these steps:

1. From the web-DENIS home page, click on BCBSM Provider Publications and Resources.
2. Click on Newsletters and Resources.
3. Click on Forms.
4. Click on Physician administered medications.

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

The list below reflects all the medications that are part of the medical drug prior authorization program:

Overview of correct pharmacy benefit billing for Cimzia, Enbrel, Victoza

For accurate, quick reimbursement of your Cimzia^®, Enbrel^® and Victoza^® prescription benefit claims, be sure to bill the strengths, quantities and days’ supply per package as follows:

If you have questions, contact our claims processor, Express Scripts^®, at 1-800-922-1557. If you have any unresolved issues or other questions, contact our Pharmacy Services Clinical Help Desk at 1-800-437-3803.

Members can no longer receive prescriptions for DME/P&O items through telehealth visits

Blue Cross Blue Shield of Michigan is concerned that members are receiving durable medical equipment and prosthetic and orthotic items without clear demonstration of medical necessity or proper fitting.

Therefore, effective Nov. 1, 2018, health care providers won’t be able to prescribe or issue DME/P&O supplies during telehealth visits. A telehealth visit doesn’t meet the medical necessity requirements for prescribing these items. Prescription and issuance resulting from a telehealth visit may be subject to audit review and recovery.

A telehealth visit includes:

• Phone call
• Both email and postal mail
• Video chat

All telehealth formats are excluded from issuing DME and prosthetic and orthotic items.