|
May 2014
PGIP accepting applications from new Organized Systems of Care through June 30
The Physician Group Incentive Program will accept applications from newly formed Organized Systems of Care from May 1 through June 30. OSCs whose applications are approved will become PGIP-contracted OSCs, effective Jan. 1, 2015.
Participation in the PGIP Organized Systems of Care program provides the opportunity to earn financial rewards for developing OSC integrated care processes and infrastructure through OSC initiatives.
To receive the OSC application packet, contact Donna Saxton at dsaxton@bcbsm.com or 313-448-0969.
Note: OSCs currently contracted with PGIP should not submit a new application.
Check member benefits before billing for abortion services
Procedure codes for abortion procedures
Procedure codes identified as non-elective, regardless of diagnosis, include:
*59812
*59820
*59821
*59830
*59870
Procedure codes identified as elective or non-elective, based on diagnosis, include:
*59100
*59840
*59841
*59850
*59851
*59852
*59855
*59856
*59857
*59866
S0190
S0191
S0199
S2260
S2265
S2266
S2267
For BCBSM, follow correct coding guidelines; preauthorization is not required. For BCN, clinical review guidelines apply.
Blue Cross Blue Shield of Michigan and Blue Care Network are aligning the terminology used in our policies and certificates with Michigan’s Abortion Insurance Opt-Out Act, which became effective for plans that are new or renewed on or after March 13.
For BCN, all benefit language was updated March 13. BCBSM groups with plan years beginning January through March 2014, had their benefit language updated by March 31, 2014. BCBSM groups with plan years beginning April 2014 or later will have their benefit language updated on their plan year effective date.
This article will help you know what to look for when filing claims for abortion services.
The law establishes definitions of elective and non-elective abortion services. For providers, this means that some abortion procedures that were previously covered under the medical-surgical benefit are no longer payable unless the patient has a special rider for elective abortion coverage.
Under this new law, abortion coverage for the following circumstances is not available to members without an elective abortion rider:
- Congenital birth defects
- Preserve the health of the mother
- Cases of rape or incest
- An abortion for any other reason that is not a medical reason
- For individual plans only, "increase the probability of a live birth" is considered elective, according to state law. Please note that the Blues’ individual plans do not offer an elective abortion rider.
Elective abortion coverage may only be provided through a rider.
The procedure codes for abortions are listed above at right. Please note that certain procedure codes should not be submitted for reimbursement if the member doesn’t have elective coverage.
Keep in mind that it’s important to check benefits on web-DENIS or CAREN for BCN or Benefit Explainer for Blue Cross to verify whether a member has elective abortion coverage. For BCN, when checking eligibility and benefits on web-DENIS, click on Medical Benefits and scroll down to Elective Abortions to see if the member has coverage. If you do not see elective abortion coverage on web-DENIS or CAREN, you should call Provider Inquiry to determine if the patient has coverage for the specific circumstance. You can also check benefits by the 270/271 electronic standard transaction. For information about the 270/271 electronic standard transaction, send an email to EDICustmgmt@bcbsm.com.
The law only applies to underwritten group and individual plans. Underwritten groups have the opportunity to purchase elective abortion coverage through an optional rider. Elective abortion coverage is not available in plans sold to individuals.
Please see the March Record for background on the Abortion Insurance Opt-Out Act.
More information about the law and the penalties for not complying with it are available at the Michigan.gov** website.
**The Michigan Blues does not control this website or endorse its general content.
The information in this document is based on the Michigan Blues’ review of the applicable legislation and is not intended to impart legal advice. Interpretations of this legislation may vary, and efforts will be made to present accurate information and update it if necessary. This overview is intended as an educational tool only and does not replace a more rigorous review of the law’s applicability to individual circumstances and attendant legal counsel, and should not be relied upon as legal or compliance advice.
Prescription drug lists updated, available on our website
Blue Cross Blue Shield of Michigan updated its drug lists, sometimes called formularies, in early April.
We periodically update these lists to help ensure patient safety and assist prescribers in selecting the most effective and affordable drug therapy for patients.
You can view the most recent prescription drug list updates at bcbsm.com/rxinfo. You can also view BCBSM’s pharmacy management requirements and other prescription drug lists, such as the specialty product list, at the site.
Our prescription drug lists can help prescribers make better-informed prescribing decisions that can lead to increased medication adherence and help providers explain prescription drug coverage to our members.
Keep these coding tips in mind to improve medical record documentation
Lymphoma cancer is often coded incorrectly due to misconceptions about the nature of the condition. To be classified as lymphoma, the neoplasm must originate within the lymph nodes. This is different than a solid tumor that has spread to the lymph nodes.
Tips to consider when coding lymphoma
Proper documentation is the key to accurate code selection for lymphomas. If documentation is unclear, ask the physician for more explanation to ensure codes chosen are to the highest level of specificity. Coding for neoplasms classified as lymphomas can be found in ICD-9-CM categories 200-202.
- A malignant neoplasm must form within the lymph nodes to be classified as lymphoma.
- Neoplasms that form in the lymphatic and hematopoietic tissues do not spread to secondary sites. Rather, the malignant cells may travel and arise in other sites within the associated tissues. These are still classified as primary neoplasms.
- Lymphomas can be benign or malignant; this should be specifically identified in the physician’s documentation.
- When a physician documents that the lymphoma is "in remission," it is still reported using lymphoma codes 200-202. Although the condition is in remission, it is still classified as an active condition.
- If the lymphoma is documented as "history of," indicating the condition is completely cured, select a personal history code from category V10.7X. There are three different V codes based on the type of lymphoma documented.
- Solid tumors that have spread or metastasized to the lymph nodes are not considered lymphoma. They are considered secondary or unspecified malignant neoplasms of the lymph nodes and are reported with categories 140-199.
Types of lymphoma
Lymphoma is most commonly referenced by two specific types: Hodgkin lymphoma and non-Hodgkin lymphoma. The type of lymphoma is determined by how it behaves, spreads and responds to treatment.
- Hodgkin lymphoma
Hodgkin lymphoma is an uncommon form of lymphoma involving Reed-Sternberg Cells, large abnormal lymphocytes that may contain more than one nuclei. Most are of B-cell origin. Typically, this lymphoma begins in a single node and spreads to other nodes. Hodgkin lymphoma is commonly classified to the following codes. An "X" in the fifth place indicates a fifth digit is required.
201.0X - Hodgkin paragranuloma
201.1X - Hodgkin granuloma
201.2X - Hodgkin sarcoma
201.4X - Lymphocytic-histiocytic predominance
201.5X - Nodular sclerosis
201.6X - Mixed cellularity
201.7X - Lymphocytic depletion
201.9X - Hodgkin disease, unspecified
- Non-Hodgkin lymphoma
There are many different classifications and sub-types of non-Hodgkin lymphoma. To ensure the most specific code is reported, providers should document the most specific subtype of non-Hodgkin lymphoma. Listed below are a few of the more common codes for non-Hodgkin lymphoma. An X in the fifth place indicates a fifth digit is required.
200.0X - Reticulosarcoma
200.1X - Lymphocarcoma
200.2X - Burkitt’s tumor or lymphoma
200.3X - Marginal zone lymphoma
200.4X - Mantle cell lymphoma
200.5X - Primary central nervous system lymphoma
200.6X - Anaplastic large cell lymphoma
200.7X - Large cell lymphoma
202.0X - Nodular lymphoma
202.1X - Mycosis fungoides
202.2X - Sezary’s disease
202.7X - Peripheral T-cell lymphoma
202.8X - Other lymphomas
Locating lymphoma codes and digit clarification
Begin searching for the appropriate code in the alphabetical index under lymphoma. For benign lymphomas, the index will direct coders to the neoplasm table. In the table, reference the site of the neoplasm and select the code from the benign column.
When coding for a malignant neoplasm, reference the sub-term for the site or type, under lymphoma. Once a code is selected, reference the tabular list to ensure the code is correct.
A fifth digit is required for lymphomas, classifying the specific nodes and locations affected. When multiple lymph nodes are affected, the use of the fifth digit eight is utilized. The table below is a breakdown of required fifth digits.
0 - Unspecified site, extranodal and solid organ sites
1 - Lymph nodes of head, face and neck
2 - Intrathoracic lymph nodes
3 - Intra abdominal lymph nodes
4 - Lymph nodes of axilla and upper limb
5 - Lymph nodes of inguinal region and lower limb
6 - Intrapelvic lymph nodes
7 - Spleen
8 - Lymph nodes of multiple sites
Lymphomas need to be coded to the highest level of specificity. Refer to your ICD-9 guidelines for more specific information on the differences between benign and malignant.
HCPCS codes added
The Centers for Medicare & Medicaid Services has added 12 new HCPCS codes as part of its regular quarterly HCPCS updates.
The new codes are listed below.
Code* |
Change |
Coverage Comments |
Effective Date |
0364T |
Added |
Not covered by BCBSM |
July 1, 2014 |
0365T |
Added |
Not covered by BCBSM |
July 1, 2014 |
0366T |
Added |
Not covered by BCBSM |
July 1, 2014 |
0367T |
Added |
Not covered by BCBSM |
July 1, 2014 |
0368T |
Added |
Not covered by BCBSM |
July 1, 2014 |
0369T |
Added |
Not covered by BCBSM |
July 1, 2014 |
0370T |
Added |
Not covered by BCBSM |
July 1, 2014 |
0371T |
Added |
Not covered by BCBSM |
July 1, 2014 |
0372T |
Added |
Not covered by BCBSM |
July 1, 2014 |
0373T |
Added |
Not covered by BCBSM |
July 1, 2014 |
0374T |
Added |
Not covered by BCBSM |
July 1, 2014 |
G9361 |
Added |
Not covered by BCBSM |
Jan 1, 2014 |
Correction: Transfer days for electronic fund transfers
In an article in the April Record titled "Here are answers to more questions about electronic fund transfers, there was some incorrect information in a table that outlined the days of the week when funds are transferred to accounts. We have updated the article in our online Record archives. You can access the correct version of the article by clicking here.
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.
| Code* |
BCBSM Changes to:
Basic Benefit and Medical Policy, Group
Variations Payment Policy, Guidelines
|
| NEW PAYABLE PROCEDURES |
0245T-0248T |
Basic Benefit and Medical Policy
Open treatment of rib fractures using internal fixation
The safety and effectiveness of open reduction and internal
fixation of rib fractures has been established. It is a useful
therapeutic option for patients meeting select criteria. This policy is effective Nov. 1, 2013.
Group Variations
Payable for all groups.
Inclusionary Guidelines
Open reduction and internal fixation for rib fractures is appropriate for patients:
- With a confirmed diagnosis of flail chest and paradoxical chest movement and
- Inability to be weaned from ventilator (> 5 days post-injury) and
- Painful, displaced rib fractures with failure of narcotics or epidural pain catheter to control pain
Exclusionary Guidelines
- Unstable cardiopulmonary status
- Presence of pulmonary contusion
- Severe head injury with increased intracranial pressure
- Other severe associated organ injuries that would make general anesthesia unsafe
|
0330T-0334T |
Group Variations
Payable for Federal Employee Program® members only, effective July 1, 2013.
|
81321-81323 |
Basic Benefit and Medical Policy
The safety and effectiveness of genetic testing for a phosphatase and tensin homolog, or PTEN, mutation is established to confirm the diagnosis when a patient displays clinical signs of a PTEN hamartoma tumor syndrome or in a first-degree relative of a proband (typically the individual being studied or reported on) with a known PTEN mutation. It may be considered a useful diagnostic option when indicated.
Genetic testing for a PTEN mutation is considered experimental for all other indications, including, but not limited to, prenatal testing. The peer-reviewed medical literature has not demonstrated the clinical utility of genetic testing for a PTEN mutation for indications not listed in this policy.
This policy is effective Jan. 1, 2014.
Inclusionary Guidelines
- Genetic testing for a PTEN mutation to confirm the diagnosis of a PTEN hamartoma tumor syndrome when a patient displays clinical signs of any of the following suspected PTEN hamartoma tumor syndromes (see Policy Description section of the medical policy for detailed criteria):
- Bannayan-Riley-Ruvalcaba syndrome
- Cowden syndrome
- PTEN-related proteus syndrome
- Proteus-like syndrome
- Genetic testing for a PTEN mutation in a first-degree relative of a proband with a known PTEN mutation.
Exclusionary Guidelines
- Prenatal genetic testing for a PTEN mutation
- All other indications not listed in the inclusion section
Group Exclusions
- Chrysler, Ford, General Motors, Delphi or URMBT
- State of Michigan
- Michigan Public School Employees Retirement System
|
A7016 |
Basic Benefit and Medical Policy
Effective Sept. 1, 2013, procedure code A7016 is now payable. This procedure will pay for all accounts with the durable medical equipment benefit.
Group Variations
Includes Chrysler, Ford, General Motors and URMBT groups. |
J3590 |
Basic Benefit and Medical Policy
Varithena is established as safe and effective for its FDA approved indication for the treatment of incompetent great saphenous veins, accessory saphenous veins and visible varicosities of the great saphenous vein system above and below the knee. This policy is effective Nov. 26, 2013.
Varithena™ should be reported with NOC code J3590 until a permanent code is established.
This product is for intravenous use under ultrasound guidance only. Use up to 5 ml per injection and 15 ml per treatment session. S Treatments sessions should be separated by a minimum of five days.
Inclusionary Guidelines
- Indicated for the treatment of incompetent great saphenous veins, accessory saphenous veins and visible varicosities of the great saphenous vein system above and below the knee.
- Liquid or foam sclerotherapy is considered medically necessary as an adjunctive treatment of symptomatic saphenous veins, varicose tributaries, accessory and perforator veins 2.5 mm or greater in diameter for persons who meet medical necessity criteria for varicose vein treatment and who have previously been treated for incompetence (e.g., reflux) at the saphenofemoral junction or saphenopopliteal junction.
Exclusionary Guidelines
- Although sclerotherapy can be used to treat visible subcuticular veins (e.g., spider angiomas, and telangiectasias) less than 2.5 mm in size, these small veins do not cause symptoms and their treatment is considered cosmetic- not payable.
|
| UPDATES TO PAYABLE PROCEDURES |
Established procedures
61624, 61630, 61635
Experimental procedures
37184, 37185 |
Basic Benefit and Medical Policy
Endovascular Procedures for Intracranial Arterial Disease
The safety and effectiveness of intracranial stent placement is considered established as part of the endovascular treatment of intracranial aneurysms for patients when surgical treatment is not appropriate and standard endovascular techniques do not allow for complete isolation of the aneurysm; e.g., wide-neck aneurysm (4 mm or more) or sack-to-neck ratio less than 2:1.
Intracranial stent placement is considered experimental in the treatment of intracranial aneurysms except as noted above.
Intracranial percutaneous transluminal angioplasty with or without stenting is considered experimental in the treatment of atherosclerotic cerebrovascular disease.
Endovascular interventions (mechanical embolectomy, angioplasty, stenting) are considered experimental in the treatment of acute stroke.
Criteria has been updated, effective May 1, 2014. |
73500, 73510, 73520 |
Basic Benefit and Medical Policy
Payable to rheumatologists under the PPO Radiology Management Program, effective May 1, 2013.
Federal Employee Program® and State of Michigan are excluded from the PPO Radiology Management Program. |
99495 |
Procedure code *99495 is not payable, effective Aug. 1, 2014.
This change excludes FEP members. |
| POLICY CLARIFICATIONS |
0310T |
Basic Benefit and Medical Policy
Navigated transcranial magnetic stimulation is considered experimental for all purposes, including but not limited to the preoperative evaluation of patients being considered for brain surgery, when localization of eloquent areas of the brain are an important consideration in surgical planning. This policy is effective May 1, 2014. |
Established procedures
21120-21123, 21141, 21196, 21198, 21199, 42140, 42145
Experimental procedures
41512, 41530, 42299, S2080 |
Basic Benefit and Medical Policy
The Obstructive Sleep Apnea and Snoring-Surgical Treatment Policy has been updated. This policy is effective May 1, 2014.
Certain surgical procedures have been established as safe and effective for the treatment of clinically significant obstructive sleep apnea when conservative therapies or CPAP alone have failed. The choice of the procedure should be tailored to the individual patient’s need based on anatomy and etiology.
Inclusionary Guidelines
- Uvulectomy or uvulopalatopharyngoplasty for the treatment of clinically significant** obstructive sleep apnea syndrome in adult patients who have not responded to or do not tolerate continuous positive airway pressure
- Hyoid suspension, surgical modification of the tongue, or maxillofacial surgery, including mandibular-maxillary advancement in adult patients with clinically significant** OSA and objective documentation of hypopharyngeal obstruction who have not responded to or do not tolerate CPAP
- Adenotonsillectomy in pediatric patients with OSA and hypertrophic tonsils and:
- AHI or respiratory disturbance index of at least five per hour or
- AHI or RDI of at least 1.5 per hour in a patient with excessive daytime sleepiness, behavioral problems or hyperactivity
**Clinically significant obstructive sleep apnea is defined as failure of conservative treatments for sleep apnea, such as weight loss, modification of the patient's sleep position, medications to relieve nasal obstruction and avoidance of evening alcohol and hypnotics, use of CPAP or oral appliances and polysomnography with:
- AHI or RDI greater than or equal to 15 events per hour, or
- AHI or RDI greater than or equal to five events and less than or equal to 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease or history of stroke
Exclusionary Guidelines
- Laser-assisted palatoplasty
- Midline glossectomy
- Palatal stiffening procedures, such as cautery-assisted and injection snoreplasty
- Palatal implants
- Radiofrequency volumetric tissue reduction of the tongue
- Radiofrequency reduction of the palatal tissues (e.g., somnoplasty)
- Tongue base suspension (e.g., repose system)
- All other minimally invasive surgical procedures not described above
All interventions for the treatment of snoring in the absence of documented OSA. |
33999, 93799, A4649 |
Basic Benefit and Medical Policy
Open Repair of Right Ventricular Outflow Obstruction Using a Pulmonary Bovine Valved Conduit Graft System
The open implantation of a pulmonary bovine valved conduit graft is established for patients meeting specific selection criteria under a humanitarian device exemption. They are useful therapeutic options for these patients when indicated.
This policy is effective May 1, 2014.
Inclusionary Guidelines
Pulmonary bovin-valved conduits (e.g., Contegra) are indicated for implantation into patients less than 18 years of age presenting with one of the following clinical conditions:
- Correction or reconstruction of the right ventricular outflow tract in congenital heart malformations (e.g., pulmonary atresia, tetralogy of Fallot, truncus arteriosis, transposition with ventricular septal defect pulmonary stenosis, etc.)
- Replacement of a previously implanted but dysfunctional pulmonary homograft or a failed pulmonary prosthesis
Exclusionary Guidelines
Pulmonary bovine-valved conduits are contraindicated for use in the following clinical conditions:
- Patients 18 years of age and older needing RVOT-reconstructive surgery, Ross procedure or replacement of dysfunctional pulmonary homograft or failed pulmonary prosthesis
- Left heart surgical procedures
- If, after the physician assesses the risk-to-benefit ratio, established alternative medical or surgical techniques suggest superior clinical results.
|
77520,77522, 77523, 77525 |
Basic Benefit and Medical Policy
The criteria for the Charged-Particle (Proton or Helium Ion) Radiation Therapy policy have been updated. This policy is effective March 1, 2014.
Charged-particle irradiation with proton or helium ion beams may be considered established in the following clinical situations:
- Primary therapy for melanoma of the uveal tract (iris, choroid or ciliary body), with no evidence of metastasis or extrascleral extension and with tumors up to 24 mm in largest diameter and 14 mm in height
- Postoperative therapy (with or without conventional high-energy x-rays) in patients who have undergone biopsy or partial resection of chordoma or low-grade (I or II) chondrosarcoma of the basisphenoid region (skull-base chordoma or chondrosarcoma) or cervical spine. Patients eligible for this treatment have residual localized tumor without evidence of metastasis.
- In the treatment of pediatric central nervous system tumors.
Charged-particle irradiation with proton beams using standard treatment doses is considered not medically necessary in patients with clinically localized prostate cancer because the clinical outcomes with this treatment have not been shown to be superior to other approaches including intensity-modulated radiation therapy or conformal radiation therapy, yet proton beam therapy is generally more costly than these alternatives.
Other applications of charged-particle irradiation with proton beams are considered experimental. These include, but are not limited to:
- Non-small-cell lung cancer at any stage or for recurrence
- Pediatric non-central nervous system tumors
- Tumors of the head and neck (other than skull-based chordoma or chondrosarcoma)
Inclusionary Guidelines**
Charged-particle irradiation with proton or helium ion beams is established for the following indications:
- Primary therapy for melanoma of the uveal tract (iris, choroid or ciliary body), with no evidence of metastasis or extrascleral extension and with tumors up to 24 mm in largest diameter and 14 mm in height
- Postoperative therapy (with or without conventional high-energy X-rays) in patients who have undergone biopsy or partial resection of chordoma or low-grade (I or II), chondrosarcoma of the basisphenoid region (skull-base chordoma or chondrosarcoma) or cervical spine. Patients eligible for this treatment have residual localized tumor without evidence of metastasis.
- In the treatment of pediatric (through 21 years of age) central nervous system tumors.
**Effective July 1, 2014, use of PBT may require prior authorization to verify that BCBSM or BCN criteria are met and, where appropriate, to explore the appropriateness of using alternative therapeutic modalities; e.g., IMRT, 3-D conformal radiation therapy). Mail or fax preauthorization requests to
Write: |
Preauthorization, Provider Inquiry Services
Blue Cross Blue Shield of Michigan
P.O. Box 2227
Detroit, MI 48231-2227 |
Fax: |
1-866-311-9603 |
Exclusions Guidelines
- Proton beam therapy for the treatment of prostate cancer is not medically necessary.
- All other applications of charged-particle irradiation, including non-small-cell lung cancer at any stage or for recurrence, are considered experimental.
- Pediatric non-central nervous system tumors
- Tumors of the head and neck (other than skull-based chordoma or chondrosarcoma)
- Proton beam therapy for the treatment of macular degeneration or choroidal neovascularization and hemangiomas
|
78608, 78609, 78811, 78812, 78813 |
Basic Benefit and Medical Policy
The safety and effectiveness of positron emission tomography scanning have been established. It is a useful diagnostic option for patients meeting patient selection criteria. Inclusionary and exclusionary criteria have been updated, effective May 1, 2014.
This service may be subject to the PPO Radiology Management Program, where applicable.
Inclusionary Guidelines
Positron emission tomography using 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG) may be considered established in:
- The assessment of selected patients with epileptic seizures who are candidates for surgery or
- The diagnosis of chronic osteomyelitis (Note: See Medicare exceptions.)
Exclusionary Guidelines
The use of PET for all other miscellaneous indications is considered experimental for other conditions, including, but not limited to:
Central nervous system diseases
- Autoimmune disorders with CNS manifestations, including:
- Behçet's syndrome
- Lupus erythematosus
- Cerebrovascular diseases, including:
- Arterial occlusive disease (arteriosclerosis, atherosclerosis)
- Carotid artery disease
- Cerebral aneurysm
- Cerebrovascular malformations (AVM and Moya-Moya disease)
- Hemorrhage
- Infarct
- Ischemia
- Degenerative motor neuron diseases, including:
- Amyotrophic lateral sclerosis
- Friedreich's ataxia
- Olivopontocerebellar atrophy
- Parkinson's disease
- Progressive supranuclear palsy
- Shy-Drager syndrome
- Spinocerebellar degeneration
- Steele-Richardson-Olszewski disease
- Tourette's syndrome
- Dementias, including: (Note: see Medicare exceptions)
- Alzheimer's disease
- Multi-infarct dementia
- Pick's disease
- Frontotemporal dementia
- Dementia with Lewy-Bodies
- Presenile dementia
- Demyelinating diseases, such as multiple sclerosis
- Developmental, congenital or inherited disorders, including:
- Adrenoleukodystrophy
- Down's syndrome
- Huntington’s chorea
- Kinky-hair disease (Menkes’ syndrome)
- Sturge-Weber syndrome (encephalofacial angiomatosis) and the phakomatoses
- Miscellaneous
- Chronic fatigue syndrome
- Sick building syndrome
- Post-traumatic stress disorder
- Nutritional or metabolic diseases and disorders, including:
- Acanthocytes
- Hepatic encephalopathy
- Hepatolenticular degeneration
- Metachromatic leukodystrophy
- Mitochondrial disease
- Subacute necrotizing encephalomyelopathy
- Psychiatric diseases and disorders, including:
- Affective disorders
- Depression
- Obsessive-compulsive disorder
- Psychomotor disorders
- Schizophrenia
- Pyogenic infections, including:
- Aspergillosis
- Encephalitis
- Substance abuse, including the CNS effects of alcohol, cocaine, and heroin
- Trauma, including brain injury and carbon monoxide poisoning
- Viral infections, including:
- Acquired immune deficiency syndrome (AIDS)
- AIDS dementia complex
- Creutzfeldt-Jakob syndrome
- Progressive multifocal leukoencephalopathy
- Progressive rubella encephalopathy
- Subacute sclerosing panencephalitis
- Mycobacterium infection
- Migraine
- Anorexia nervosa
- Cerebral blood flow in newborns
- Vegetative versus "locked-in" state
Pulmonary diseases
- Adult respiratory distress syndrome
- Diffuse panbronchiolitis
- Emphysema
- Obstructive lung disease
- Pneumonia
Musculoskeletal diseases
- Spondylodiscitis
- Joint replacement follow-up
Other
- Giant cell arteritis
- Vasculitis
- Inflammatory bowel disease
|
81403-81406, 81479, S3800 |
Basic Benefit and Medical Policy
The Genetic Testing for Amyotrophic Lateral Sclerosis Policy has been updated. This policy is effective May 1, 2014.
Preconception genetic counseling and testing of any genes associated with familial amyotrophic lateral sclerosis are considered established when the test results will impact decisions regarding family planning.
Inclusionary Guidelines
Preconception genetic testing for familial ALS in individuals of reproductive years is indicated when any of the following criteria are met:
- A known mutation of any ALS-associated gene exists in a parent or sibling
- There are two or more first-degree relatives with ALS of unknown genetic cause
Exclusionary Guidelines
- Genetic testing for ALS in individuals not considering conception
|
84999 |
Basic Benefit and Medical Policy
Mass spectrometry-based proteomic profiling to determine treatment for non-small-cell lung cancer is considered experimental. There is insufficient evidence in medical literature to demonstrate that the use of this testing results in improved patient clinical outcomes. This policy is effective May 1, 2014. |
87535-87539, 87900, 87901, 87903, 87904, 87906 |
Basic Benefit and Medical Policy
The safety and effectiveness of human immunodeficiency virus genotyping or phenotyping have been established. They may be considered useful diagnostic options when indicated for patients meeting selection criteria. This policy is effective May 1, 2014.
Inclusionary Guidelines (must meet one)
- HIV genotyping or phenotyping in patients who (must meet one):
- Have active HIV and are on a current treatment regimen, to assist in the selection of active drugs when changing antiretroviral regimens in cases of virologic failure
- Have achieved a suboptimal response after the initiation of antiretroviral therapy
- Have an acute or recent infection, for the purpose of guiding treatment decisions
- Are antiretroviral naïve and are entering treatment
- Have been infected with HIV for less than 12 months
- Are undergoing the first ART regimen regardless of duration of infection
- Are entering pregnancy with detectable HIV RNA in plasma while on therapy
- Are pregnant but have not had prior initiation of therapy
- Drug susceptibility phenotype prediction using genotypic comparison to a known genotypic/phenotypic database (virtual phenotyping).
Genotyping is typically done first, followed by virtual phenotyping in order to direct therapy. Both genotyping and full phenotyping may be necessary when genotyping and virtual phenotyping fail to provide the necessary information needed to guide therapy.
Exclusionary Guidelines
- Routine use of combined genotyping and phenotyping.
|
E0830, E0941, E1399 |
Basic Benefit and Medical Policy
The use of pneumatic, autotraction and gravity-dependent (axial spinal unloading) lumbar traction devices are considered experimental in any setting. These devices have not been scientifically demonstrated to be safe and effective for the treatment of low back pain, herniated disc or other indications and have not been shown to improve patient outcomes. This policy is effective May 1, 2014.
Exclusionary Guidelines
Non-established lumbar traction devices include, but are not limited to:
- Pneumatic lumbar traction devices (e.g., Saunders Lumbar HomeTrac, Saunders STx, Orthotrac Pneumatic Vest).
- Autotraction devices (e.g., the Spinalator Spinalign massage intersegmental traction table, the Arthrotonic stabilizer, the Quantum 400 intersegmental traction table and the Anatomotor)
- Axial spinal unloading (gravity-dependent traction) devices (e.g., LTX 3000).
- Conventional lumbar traction using a type of pelvic harness attached to pulleys and weights, now considered to be obsolete.
|
| EXPERIMENTAL PROCEDURES |
0338T, 0339T |
Basic Benefit and Medical Policy
Radiofrequency ablation of the renal sympathetic nerves as a treatment of resistant hypertension is considered experimental. The evidence is insufficient to determine whether radiofrequency ablation of the renal sympathetic nerves improves health outcomes in patients with resistant hypertension. This policy is effective May 1, 2014. |
81287 |
Basic Benefit and Medical Policy
The peer-reviewed medical literature has not demonstrated the validity and clinical utility of MGMT (methyl guanine methyl transferase) promoter methylation testing for prognostic value or as a predictive biomarker for response to treatment with alkylating agents. Therefore, this test is considered experimental. This policy is effective May 1, 2014. |
81401, 81403-81407, 81479 |
Basic Benefit and Medical Policy
Genetic testing for epilepsy is considered experimental. The peer reviewed medical literature has not demonstrated the clinical utility of this testing or its impact on patient outcomes. This policy is effective May 1, 2014. |
81401, 81405, 81408 |
Basic Benefit and Medical Policy
The peer-reviewed medical literature has not demonstrated the validity and clinical utility of MGMT (methyl guanine methyl transferase) promoter methylation testing for prognostic value or as a predictive biomarker for response to treatment with alkylating agents. Therefore, this test is considered experimental. This policy is effective May 1, 2014. |
81599 |
Basic Benefit and Medical Policy
Gene expression analysis to guide management of prostate cancer is considered experimental in all situations. There is insufficient evidence in the peer reviewed medical literature to establish the analytic validity, clinical validity, or clinical utility of this testing. This policy is effective May 1, 2014. |
| GROUP BENEFIT CHANGES |
Covisint Corporation |
The Covisint Corporation, group number 71581, joined the Blues, effective April 1, 2014. The members in this group were previously under a Compuware contract.
The group is offering three PPO and two health savings account plans with medical, hearing and prescription drug coverage.
Member ID cards will show alpha prefix CCP for PPO coverage. |
Lutheran Church Michigan District Associationn |
Effective May 1, 2014, Medicare-eligible retirees of the Lutheran Church Michigan District Association will have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus BlueSM Group PPO for their medical, surgical and prescription drug benefits. The group number is 60609, with suffixes 600, 601 and 602. You can identify members by the XYL prefix on their ID cards, like those of other Medicare Plus Blue Group PPO plans.
For information about our Medicare Advantage PPO plan, go to bcbsm.com/provider/ma. |
Visteon – Hourly & Salary |
Effective June 1, 2014, Visteon hourly and salaried members will have their prescription drug plan with Express Scripts® and will now be handled through BCBSM. The current medical benefits will not change. |
Navigating the electronic Record
As part of our efforts to make it easier to do business with us, we’d like to offer some tips for using the electronic Record.
Understanding the format
- The upper portion of the newsletter features up to four articles that relate to the main area of interest you chose when you subscribed to the newsletter (for example, Professional, Facility, DME). If there are no articles in the issue pertaining to your main area of interest, we’ll feature a few articles from our "All providers" section. This is also the version we post to bcbsm.com.
- The bottom portion of the newsletter serves as an interactive index, listing the headlines for all the articles in the issue and giving you access to them.
Printing The Record or individual articles
- You can print individual articles in The Record by clicking on the headlines below the gold bar that reads "For the Record" and then clicking on Print this article at the top of the newsletter.
- If you want to print all the articles in the newsletter, click on the Print entire issue link in the upper right-hand corner of the newsletter’s front page.
- Keep in mind that you may not need to access or print all the articles in the newsletter each month. Check out the list of headlines in the bottom section of the newsletter to determine which articles are important to you. For example, if your work location is a doctor’s office, you may not be interested in the articles in the Facility section.
Forwarding The Record
- You can easily forward The Record by using the Forward to a Friend link at the top of the front page.
- If youre reading an article youd like to share, you can click on the Forward to a Friend link at the top of the article.
Accessing The Record online
- You can quickly access current and past issues of the newsletter, dating back to January 2010, along with an index, on The Record Archive.
- You can also access the newsletter via web-DENIS by clicking on BCBSM Provider Publications and Resources from the web-DENIS home page. Issues in this archive go back to March 1998.
Subscribing to The Record,
You can subscribe to the electronic Record or invite a colleague to subscribe by clicking here or on the Subscribe link at the top of each page of the newsletter.
Customizing your subscription
As part of the subscription process, youll be asked to indicate your main area of interest. You may choose from these topics:
- All providers
- Professional
- Facility
- Pharmacy
- Medicare Advantage
- DME
- Vision
- Auto groups
Once you select a topic, you’ll generally see about four of those articles in that category highlighted at the top of your email each month. All the articles for that topic — and all other articles in that month’s Record — are listed below the gold bar that says "For the Record." You’ll see the topics reflected in the colored headings.
You may change your topic selection at any time by clicking on the Update Profile link at the very bottom of The Record email. On this page, you may also update your contact information and email address.
Summer training scheduled across state
We’ve scheduled the following professional training opportunities this summer, with classes held at 11 locations around the state. (See schedule at the end of article.)
The classes will cover topics such as:
- Coding and documentation
- Risk adjustment
- Diagnostic closure incentive program
- Performance recognition program
- Health e-blueSM
- ICD-10
There will also be a late afternoon Q&A.
If additional classes are offered or there are schedule changes, we’ll publish that information in future issues of The Record.
Here’s additional information:
- Full-day classes start at 9 a.m. and end at 4 p.m., with registration beginning at 8:30 a.m.
- To accommodate driving schedules to the Upper Peninsula, classes will begin one hour later than usual. Registration for the Marquette classes will begin at 9:30 a.m., with class starting at 10 a.m. Please note that this is for the U.P. classes only.
- A lunch break will be provided between noon and 1 p.m., with lunch served at all 11 locations.
- Classes might extend later or end earlier, depending on the number of participant questions.
To register, send an email to Jeff Holzhausen at JHolzhausen@bcbsm.com. In the subject line, write "RMRA/Stars" and the city where you wish to attend the class. Include the class date and the names and number of attendees expected from your facility. You will receive a confirmation within 72 hours of registering. It’s important that you register so we can have an accurate headcount for lunch.
The Blues will provide continuing education credits through AAPC. For more information, please contact your provider consultant.
Training schedule
Class location |
Date |
Kalamazoo – Radisson Kalamazoo, 100 West Michigan Ave. 49007 |
Wednesday, July 16, 2014 |
Grand Rapids – Frederik Meijer Gardens & Sculpture Park, 1000 East Beltline Ave NE 49525 |
Thursday, July 17, 2014 |
Novi – Sheraton Novi, 21111 Haggerty Road 48375 |
Tuesday, July 22, 2014 |
Lansing – Ramada Lansing, 7501 West Saginaw Highway 48917 |
Thursday, July 24, 2014 |
Sterling Heights – Best Western Sterling Inn, 34911 Van Dyke Ave 48312 |
Wednesday, July 30, 2014 |
Southgate – Holiday Inn Southgate - Banquet & Conference Center, 17201 Northline Road 48195 |
Thursday, July 31, 2014 |
Alpena – Sanctuary Inn & Conference Center, 1000 US 23 North 49707 |
Tuesday, Aug. 5, 2014 |
Traverse City – West Bay Beach-A Holiday Inn Resort, 615 East Front Street 49686 |
Thursday, Aug. 7, 2014 |
Frankenmuth – Bavarian Inn Lodge, One Covered Bridge Lane 48734 |
Tuesday, Aug. 12, 2014 |
Port Huron – Doubletree Port Huron, 800 Harker Street 48060 |
Wednesday, Aug. 13, 2014 |
Marquette – Holiday Inn Marquette, 1951 U.S. 41 West 49855 |
Tuesday, Aug. 19, 2014 |
Updates announced for BCBSM’s Prescriber Prescription Block Policy
Blue Cross Blue Shield of Michigan has updated its Prescriber Prescription Block Policy. The policy, which became effective on Sept. 1, 2013, was previously announced in the June 2013 edition of The Record.
Criteria under which a provider may be recommended for the Prescriber Prescription Block Program now include:
- Any felony or misdemeanor conviction, guilty plea, plea of nolo contendere or placement in a diversion program for any crime related to the payment of pharmacy claims involving BCBSM, Medicare, Medicaid and other health care insurers.
- Prescribers who continue to be noncompliant in their prescribing patterns after documented notification by BCBSM, law enforcement or any government agency.
- Prescribers demonstrating a pattern of prescribing medications that are significantly aberrant from their peers with similar board certifications as confirmed by data and expert medical consultant opinion.
- Prescribers consistently prescribing medications or combinations of medications that have been shown to put patients at high risk for overdose or death as confirmed by an expert medical consultant.
- Prescribers demonstrating a pattern of billing for services not rendered or not medically necessary as documented by internal or external investigations.
- Prescribers refusing access to records which substantiate the medical necessity for the services rendered and which are deemed essential by BCBSM for BCBSM to determine its liability.
For more information, see the updated Prescriber Prescription Block Policy.
Additional specialty medical drugs require prior authorization starting July 1
Thirteen additional specialty drugs administered by health care practitioners will require prior authorization by BCBSM in order to be covered under members’ medical benefits, starting July 1, 2014.
Ensuring proper utilization and addressing the potential safety issues of these high-cost medications will address concerns that many of our major group customers have expressed.
The following drugs will require prior authorization starting July 1, 2014:
Drug name |
Procedure code |
Bivigam™ |
J1556 |
Carimune® NF |
J1566 |
Febogamma® DIF |
J1572 |
Gammagard® Liquid or S/D |
J1569 |
Gammaplex® |
J1557 |
Gamunex® (IV and SubQ) |
J1561 |
Hizentra® (SubQ only) |
J1559 |
Octagam® |
J1568 |
Privigen® |
J1459 |
Ig, IV injection, NOS |
J1599 |
Immune globulin |
*90283 |
Immune globulin |
*90284 |
Immune globulin |
*90399 |
You can find a complete list of medications that require prior authorization on web-DENIS:
- Click on BCBSM Provider Publications and Resources.
- Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
- Click on Physician administered medications (on the right side under Frequently used forms).
Criteria for authorization of these medications are included on web-DENIS. We will not consider a request for coverage until we receive a physician-signed medication request form for review or the request uploaded onto the online-based tool, Novologix. Requests will follow BCBSM timeframes for coverage determination.
Blue Cross Blue Shield of Michigan reserves the right to change this list at any time.
Obtaining prior authorization
To obtain prior authorization, follow these steps:
- Click on BCBSM Provider Publications and Resources.
- Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
- Click on Physician administered medications (on the right side under Frequently used forms).
Note: The prior authorization requirement does not apply to Medicare, Medicare Advantage or Federal Employee Program® members. Refer to the opt-out list for groups that currently do not require members to participate in this program.
BCBSM making system changes for DME and P&O providers
Blue Cross Blue Shield of Michigan is making some changes to how we process claims for durable medical equipment and prosthetic and orthotic providers.
The claims processing system will soon be updated to reject claims for P&O services billed by DME providers, and DME services billed by P&O providers. Providers will be required to bill with the appropriate provider personal identification number, which aligns the services rendered with the PIN.
In previous issues of The Record, we let DME and P&O providers know we were recredentialing all providers in our DME and P&O provider network. We asked that all DME and P&O providers submit the certification letter that they received from the Centers for Medicare & Medicaid Services as well as a current copy of their site accreditation. For more details, refer to the March 2014 issue.
DME providers that bill for P&O services will be required to bill with a separate CMS accredited P&O PIN.
For more information, contact your provider consultant. You can also contact BCBSM’s Department of Provider Enrollment and Data Management at 1-800-822-2761, fax the department at 1-866-900-0250 or send an email to Providerenroll@bcbsm.com.
For claims-related inquiries, please continue to contact Provider Inquiry. Please review the Blue Pages directory of your online provider manual for telephone numbers and hours of operation.
Register today for annual hospital forum in Frankenmuth
The Blues invite you to the annual hospital morning forum sponsored by the Benefit Administration Committee. This year’s forum is scheduled for Tuesday, June 10, 2014, for all hospital billing staff, managers and directors.
The event includes information on web-DENIS, BlueCard®, Medicare Advantage and ICD-10. The forum starts with an information fair during registration, followed by classroom-style presentations on a variety of important topics. A lunch featuring Frankenmuth’s famous chicken will be served following the event.
Where: |
Bavarian Inn Lodge
1 Covered Bridge Lane
Frankenmuth, Michigan
1-888-775-6343
|
Who: |
All hospital billing managers, directors and staff
|
Schedule: |
Registration and information fair: 8:15 a.m.
Program: 9 a.m.
Lunch: noon |
RSVP to jholzhausen@bcbsm.com by Friday, June 6. In the subject line, indicate "BAC Forum" and list your name, facility and the total number of people attending from your facility. Your response is also an RSVP for lunch.
If you have other agenda topic suggestions, please include them in your email, and we’ll plan to address them at this or future forums.
Visits to ER spanning more than one day
For patients whose visit to the emergency room spans more than one day, please record the date span on the ER revenue code line. Doing so will avoid rejection of other services with different dates of service.
Reminder: Update your primary location address
Do we have your correct primary location address in our records?
It’s important we have the correct information. If you need to update your facility’s primary address, here’s what you need to know:
- To add, remove or change a primary practice location, fill out the BCBSM/BCN Facility Change Form (PDF).
- Visit bcbsm.com/provider.
- Click on Join the Blues Network, Enrollment and Changes.
- Click on provider enrollment form.
- Select Hospitals and Facilities and follow the prompts.
- Fax the Change Form along with supporting documentation for your facility classification to: 1-866-900-0250
Facility classification |
Supporting documentation |
Ambulatory Infusion Center |
- State of Michigan pharmacy license listing address of primary practice location
|
Ambulatory Surgical Facility |
- Medicare approval letter listing address of primary practice location and approval as ambulatory surgical services supplier
- State of Michigan freestanding surgical outpatient facility license with matching address of primary practice location
|
End Stage Renal Disease Facility
Home Health Care Facility |
- Medicare approval letter listing address of primary practice location
|
Federally Qualified Health Center |
- Medicare approval letter listing address of primary practice location and approval as a federally qualified health center
|
Halfway House |
- State of Michigan residential/outpatient substance abuse program license listing address of primary practice location
|
Home Infusion Therapy |
- Medicare Part B approval letter listing address of primary practice location and approval as durable medical equipment supplier
|
Hospice |
- Medicare approval letter listing address of primary practice location and approval as hospice agency
- State of Michigan hospice agency license listing address of primary practice location
|
Long Term Acute Care Hospital |
- Medicare approval letter listing address of primary practice location and approval as long term acute care hospital
- State of Michigan acute care hospital license listing address of primary practice location
|
Outpatient Physical Therapy Facility |
- Medicare approval letter listing address of primary practice location and approval as one of the following:
- Rehabilitation agency for outpatient physical therapy services
- Comprehensive outpatient rehabilitation facility
|
Outpatient Psychiatric Center |
- To add, remove or change a primary practice location, fill out the BCBSM/BCN Facility Change Form(PDF):
- Visit bcbsm.com/provider
- Click on Join the Blues Network, Enrollment and Changes
- Click on provider enrollment form
- Select Hospitals and Facilities and follow the prompts.
|
Rural Health Clinic |
- Medicare approval letter listing address of primary practice location and approval as a rural health clinic. Must bill Medicare services to Medicare as an “institutional provider”
|
Skilled Nursing Facility |
- Medicare approval letter listing address of primary practice location and approval as a skilled nursing facility
- State of Michigan license that lists address of primary practice location, verifies compliance with all federal regulatory requirements and identifies facility as one of the following:
- Nursing home
- Long term care facility
- Hospital long term care unit
- Director of nursing and medical director names
|
Substance Abuse Facility |
- DEA license (if providing Methadone services) listing address of primary practice location
- State of Michigan license, listing address of primary practice location, as one or more of the following:
- Residential (Standard)
- Outpatient (Standard)
- Methadone (Standard)
|
If you have questions about the address change or how it may affect your Blues affiliation, call Provider Enrollment and Data Management at 1-800-822-2761 or your provider consultant.
Helpful tip: Periodically review your address listed in the Find a Doctor tool on bcbsm.com. Contact your provider consultant if you find any incorrect data.
Additional specialty medical drugs require prior authorization starting July 1
Thirteen additional specialty drugs administered by health care practitioners will require prior authorization by BCBSM in order to be covered under members’ medical benefits, starting July 1, 2014.
Ensuring proper utilization and addressing the potential safety issues of these high-cost medications will address concerns that many of our major group customers have expressed.
The following drugs will require prior authorization starting July 1, 2014:
Drug name |
Procedure code |
Bivigam™ |
J1556 |
Carimune® NF |
J1566 |
Febogamma® DIF |
J1572 |
Gammagard® Liquid or S/D |
J1569 |
Gammaplex® |
J1557 |
Gamunex® (IV and SubQ) |
J1561 |
Hizentra® (SubQ only) |
J1559 |
Octagam® |
J1568 |
Privigen® |
J1459 |
Ig, IV injection, NOS |
J1599 |
Immune globulin |
*90283 |
Immune globulin |
*90284 |
Immune globulin |
*90399 |
You can find a complete list of medications that require prior authorization on web-DENIS:
- Click on BCBSM Provider Publications and Resources.
- Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
- Click on Physician administered medications (on the right side under Frequently used forms).
Criteria for authorization of these medications are included on web-DENIS. We will not consider a request for coverage until we receive a physician-signed medication request form for review or the request uploaded onto the online-based tool, Novologix. Requests will follow BCBSM timeframes for coverage determination.
Blue Cross Blue Shield of Michigan reserves the right to change this list at any time.
Obtaining prior authorization
To obtain prior authorization, follow these steps:
- Click on BCBSM Provider Publications and Resources.
- Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
- Click on Physician administered medications (on the right side under Frequently used forms).
Note: The prior authorization requirement does not apply to Medicare, Medicare Advantage or Federal Employee Program® members. Refer to the opt-out list for groups that currently do not require members to participate in this program.
Additional specialty medical drugs require prior authorization starting July 1
Thirteen additional specialty drugs administered by health care practitioners will require prior authorization by BCBSM in order to be covered under members’ medical benefits, starting July 1, 2014.
Ensuring proper utilization and addressing the potential safety issues of these high-cost medications will address concerns that many of our major group customers have expressed.
The following drugs will require prior authorization starting July 1, 2014:
Drug name |
Procedure code |
Bivigam™ |
J1556 |
Carimune® NF |
J1566 |
Febogamma® DIF |
J1572 |
Gammagard® Liquid or S/D |
J1569 |
Gammaplex® |
J1557 |
Gamunex® (IV and SubQ) |
J1561 |
Hizentra® (SubQ only) |
J1559 |
Octagam® |
J1568 |
Privigen® |
J1459 |
Ig, IV injection, NOS |
J1599 |
Immune globulin |
*90283 |
Immune globulin |
*90284 |
Immune globulin |
*90399 |
You can find a complete list of medications that require prior authorization on web-DENIS:
- Click on BCBSM Provider Publications and Resources.
- Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
- Click on Physician administered medications (on the right side under Frequently used forms).
Criteria for authorization of these medications are included on web-DENIS. We will not consider a request for coverage until we receive a physician-signed medication request form for review or the request uploaded onto the online-based tool, Novologix. Requests will follow BCBSM timeframes for coverage determination.
Blue Cross Blue Shield of Michigan reserves the right to change this list at any time.
Obtaining prior authorization
To obtain prior authorization, follow these steps:
- Click on BCBSM Provider Publications and Resources.
- Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
- Click on Physician administered medications (on the right side under Frequently used forms).
Note: The prior authorization requirement does not apply to Medicare, Medicare Advantage or Federal Employee Program® members. Refer to the opt-out list for groups that currently do not require members to participate in this program.
BCBSM making system changes for DME and P&O providers
Blue Cross Blue Shield of Michigan is making some changes to how we process claims for durable medical equipment and prosthetic and orthotic providers.
The claims processing system will soon be updated to reject claims for P&O services billed by DME providers, and DME services billed by P&O providers. Providers will be required to bill with the appropriate provider personal identification number, which aligns the services rendered with the PIN.
In previous issues of The Record, we let DME and P&O providers know we were recredentialing all providers in our DME and P&O provider network. We asked that all DME and P&O providers submit the certification letter that they received from the Centers for Medicare & Medicaid Services as well as a current copy of their site accreditation. For more details, refer to the March 2014 issue.
DME providers that bill for P&O services will be required to bill with a separate CMS accredited P&O PIN.
For more information, contact your provider consultant. You can also contact BCBSM’s Department of Provider Enrollment and Data Management at 1-800-822-2761, fax the department at 1-866-900-0250 or send an email to Providerenroll@bcbsm.com.
For claims-related inquiries, please continue to contact Provider Inquiry. Please review the Blue Pages directory of your online provider manual for telephone numbers and hours of operation.
Type of eye exam or evaluation determines whether cost sharing applies
We’d like to clarify the difference between a complete routine eye exam, in which a cost sharing applies, and a visual acuity screening and brief vision evaluation where cost sharing is waived for children of General Motors salaried active members. (See details on age ranges at end of this article.)
Benefit policy
General Motors salaried active members and General Motors Manufacturing SubSystems are allowed one routine eye exam per calendar year under the medical benefit when reported with specified diagnosis codes and when performed by either an optometrist or ophthalmologist in an office setting or skilled nursing facility. Cost sharing is applied to the service. The procedure and diagnosis codes are listed below:
Procedure codes:
*92002, *92004, *92012, *92014, *92015, S0620, S0621
Diagnosis codes:
V72.0, V80.0, V80.2, 367.0, 367.1, 367.20, 367.21, 367.22, 367.31, 367.32, 367.4, 367.51, 367.52, 367.53, 367.81, 367.89, 367.9, 368.03
A vision acuity screening and brief vision evaluation test are a benefit for all groups** covered by plans under the Affordable Care Act. Cost sharing is waived for children of GM salaried active members when services are provided by in-network providers as follows:
*99172 - Visual acuity screening — for children under age 5
*99173 - Brief vision evaluation — for children through age 21
**This does not include Manufacturing SubSystems as they are a grandfathered group.
Type of eye exam or evaluation determines whether cost sharing applies
We’d like to clarify the difference between a complete routine eye exam, in which a cost sharing applies, and a visual acuity screening and brief vision evaluation where cost sharing is waived for children of General Motors salaried active members. (See details on age ranges at end of this article.)
Benefit policy
General Motors salaried active members and General Motors Manufacturing SubSystems are allowed one routine eye exam per calendar year under the medical benefit when reported with specified diagnosis codes and when performed by either an optometrist or ophthalmologist in an office setting or skilled nursing facility. Cost sharing is applied to the service. The procedure and diagnosis codes are listed below:
Procedure codes:
*92002, *92004, *92012, *92014, *92015, S0620, S0621
Diagnosis codes:
V72.0, V80.0, V80.2, 367.0, 367.1, 367.20, 367.21, 367.22, 367.31, 367.32, 367.4, 367.51, 367.52, 367.53, 367.81, 367.89, 367.9, 368.03
A vision acuity screening and brief vision evaluation test are a benefit for all groups** covered by plans under the Affordable Care Act. Cost sharing is waived for children of GM salaried active members when services are provided by in-network providers as follows:
*99172 - Visual acuity screening — for children under age 5
*99173 - Brief vision evaluation — for children through age 21
**This does not include Manufacturing SubSystems as they are a grandfathered group.
|
