2014 InterQual^® criteria implemented Aug. 4

Blue Cross Blue Shield of Michigan will implement InterQual acute care, rehabilitation, skilled nursing, long-term acute care and home health criteria, effective Aug. 4, 2014. The format for rehabilitation, skilled nursing, long term acute care and home care criteria have not changed.

In 2014, InterQual increased its condition-specific subsets to 32 adult and 25 pediatric acute care criteria. General medical and surgical subsets remain in their customary format as in previous years for those patients who are not in the condition-specific subsets.

The Transition Plan section of the acute care criteria lists conditions associated with high risk of readmissions and an opportunity to refer your patients to our case management department.

The acute care Quality Indicators section lists the quality indicators for improving the quality of hospital care. These indicators are the national standard sets developed by the National Quality Forum.

InterQual criteria should be applied to all elective or emergency hospital admissions.

The BCBSM modifications, or local rules, of the InterQual criteria were published on web-DENIS in late May. To access them:

1. Log in to web-DENIS.
2. Click on BCBSM Provider Publications and Resources in the left-hand column.
3. Click on Newsletters and Resources in the left column or at the top of the page.
4. Click on Clinical Criteria and Other Resources.

BCBSM will only offer comprehensive InterQual training webinars this year. Schedules for the webinars will be published in The Record and posted to web-DENIS.

The Health Insurance Marketplace: What you need to know

In the September 2013 issue of The Record, we published an article titled “The Health Insurance Marketplace: A new way to shop and purchase health insurance.” We’ve recently received requests from health care providers to republish the article and provide updates as necessary. Here’s an overview of what you need to know about the products purchased on the Health Insurance Marketplace.

As part of the Affordable Care Act, consumers were able to purchase health care coverage from the Health Insurance Marketplace for coverage effective Jan. 1, 2014.

Each state had an opportunity to create its own Marketplace, either run by the state in partnership with the U.S. Department of Health and Human Services or independently, according to federal and state laws governing health care. Michigan’s Health Insurance Marketplace represents a partnership between the state and the federal government.

When open enrollment launched in October 2013, the Marketplace enabled consumers to compare prices and coverage among eligible insurance plans. The Marketplace allows consumers to select the plan that best meets their budget and health care needs. Consumers can still purchase health insurance coverage directly from health plans, such as Blue Cross Blue Shield of Michigan and Blue Care Network.

As a health care provider, your patients may have treated you as their primary source of information about health care reform, especially the Marketplace. We gave you information to help you answer some basic questions.

The Marketplace in a nutshell
The Health Insurance Marketplace is essentially a website that allows consumers to compare prices and coverage from different health plans that meet certain government requirements during open enrollment periods. Once a health plan is selected, consumers can either purchase through the Marketplace or directly from health plans.

There are two different Marketplaces, one for individuals and one for small groups:

• Individual Marketplace — For consumers purchasing coverage on their own
• Small Business Health Options Program, also known as SHOP — For businesses with 50 or fewer full-time-equivalent employees

Keep the following in mind:

• Open enrollment on the Marketplace for coverage that was effective Jan. 1, 2014, began Oct. 1, 2013.
• Open enrollment for 2014 coverage is over. Your patients can enroll on the Marketplace only if they are experiencing certain life events that qualify them for a special enrollment period. For more information, visit healthcare.gov**.
• Open enrollment for 2015 coverage will begin in November. We’ll provide further details in a future issue of The Record.

Products purchased on the Marketplace
As a reminder, health care providers sign contracts to perform services within certain networks, such as our PPO or HMO. Keep in mind that providers are required to accept new members within the network they are contracted with, whether a product was purchased on or off the Marketplace. The only exception is if a practice has been closed to new patients. If you have any questions about the contracting or reimbursement process, please contact your provider consultant.

The information in this document is based on preliminary review of the national health care reform legislation and is not intended to impart legal advice. The federal government continues to issue guidance on how the provisions of national health reform should be interpreted and applied. The impact of these reforms on individual situations may vary. 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. As required by U.S. Treasury regulations, we also inform you that any tax information contained in this communication is not intended to be used and cannot be used by any taxpayer to avoid penalties under the Internal Revenue Code.

**BCBSM does not control this website or endorse its general content.

Register today to attend live webinar on ACE inhibitors and ARBs in hypertensive diabetic patients

Blue Cross Blue Shield of Michigan will be launching a series of educational webinars for health care providers to discuss two pharmacy-related Medicare Stars measures — high risk medications in older adults and the use of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers in hypertensive diabetics.

The first webinar, to be held on July 16, 2014, at 7:30 a.m., will address the use of ACE inhibitors and ARBs in hypertensive diabetic patients. It will be conducted by Dr. William Herman, director of the Michigan Center for Diabetes Translational Research and associate medical director at Blue Care Network. The 30-minute webinar will be followed by a question-and-answer session.

To register, email SEprofessionaleducationregistration@bcbsm.com. Include the date, time and name of the class you wish to attend, as well as your national provider identifier. You’ll receive a confirmation email within 72 hours of registering. Instructions on how to access the webinar via WebEx will be sent in the confirmation email or prior to the webinar.

If you have questions about the content of the webinar or the registration process, contact Lawrence Beal at 313-225-8981.

If you have technical issues or questions, call the BCBSM Web support help desk at 1-877-258-3932.

Additional webinars in this series will be announced in future issues of The Record and on web-DENIS.

New eLearning modules offer training in proper coding, documentation

BCBSM and BCN are pleased to offer web-based eLearning modules that give professional billers and coders in-depth training about proper claim coding and documentation.

The two new interactive eLearning training modules are enriched with multimedia elements, examples and case studies. When you finish each of the modules, your understanding of the material will be assessed. You’ll receive a Certificate of Completion for the training if you answer 90 percent of the questions correctly. Here’s how to access the training:

• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters and Resources.
• The Documentation and Coding Accuracy eLearning modules can be found under What’s New and Provider Training.

The training modules are also available within BCN Provider Publications and Resources on the Learning Opportunities page.

These new training modules are a great addition to the documentation and coding webinars and presentations offered by the Blues in 2013. If you missed last year’s webinars, you can still view the coding initiative presentation online. Follow the above instructions to get to the BCBSM Provider Training page, and then scroll down to eLearning (web-based training) resources. The same training is also available on the BCN Learning Opportunities page.

Contact your BCBSM and BCN provider consultant to share your thoughts on the new training or you may email us at ProviderTraining@bcbsm.com.

Here’s a revised schedule for ICD-10 overview training

Now that the ICD-10 implementation has been postponed until Oct. 1, 2015, BCBSM will offer ICD-10 training once a month instead of twice a month in 2014. If you previously registered for a training date not listed below, we’ll notify you about rescheduling.

To register, email SEprofessionaleducationregistration@bcbsm.com. Include the date and time of the class that you wish to attend. You’ll receive a confirmation within 72 hours of registering. The Blues will provide continuing education credits for billers and office managers who may qualify for certain education sessions.

This schedule has also been posted on web-DENIS.

As a reminder, these sessions provide an overview of ICD-10 and are not intended to teach you how to code.

• All classes will be held in the Midnight Training Room at the Lyon Meadows Conference Center, 53200 Grand River, New Hudson.
• The sessions are from 9 a.m. to noon, with registration at 8:30 a.m.

Training schedule

The revised 2014 qualification form is here

In response to questions and feedback we’ve received about the 2014 qualification form, Blue Cross Blue Shield of Michigan has revised the form to clarify the instructions.

As of July 1, 2014, there’s a separate qualification form for members with health plans that require cotinine testing to confirm non-tobacco use. This form should be used for members in the Healthy Blue Achieve^® or Healthy Blue Outcomes^® plans. Members with health plans that don’t require the cotinine test will use the new standard form.

The forms are marked with clear titles for easy identification:

• Qualification Form — Standard
• Qualification Form — Cotinine Test is Required 

The member welcome packet, in addition to the member and provider portals, contain updated instructions for completing the new forms.

Remember that members in the Healthy Blue Achieve and Healthy Blue Outcome plans should receive a cotinine test to confirm non-tobacco use. Cotinine tests are typically not a covered benefit, so please don’t order the test for a patient who doesn’t need it.

Reminder: Providers responsible for verifying member eligibility and benefits

We’ve experienced an increase in calls from members telling us that their providers are placing the responsibility on members to verify eligibility and benefits for services. 

Please note that, as a provider, it’s your responsibility to verify member eligibility and benefits. Because coverage changes can occur, it’s important to check this information on behalf of your patients each time you provide services. 

In addition to ensuring that coverage is up to date, verifying member eligibility and benefits on behalf of your patients ensures that you have the correct information.

There are three ways to check your patients’ eligibility and benefits:

• Use web-DENIS to access this information online by logging into Provider Secured Services. You can access Provider Secured Services at bcbsm.com.
• Call our automated and interactive phone system, CAREN.
• Call our Blue Cross Blue Shield of Michigan or Blue Care Network Provider Inquiry line. Provider Inquiry will help answer questions that web-DENIS and CAREN can’t.

Reminder: Provider ID verification required to keep members’ data safe

Protecting the health information of Blue Cross Blue Shield of Michigan members is important to us. We’re also required by the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 to verify the identity and authority of anyone requesting sensitive information about our members.

So we want to remind all health care providers, billers, clearinghouses and service bureaus that when you call us, we must confirm your identity prior to releasing our members’ protected health information, or PHI.

Our identity verification procedures require you to provide the following data elements before we disclose PHI:

• Caller’s name
• Name of health care provider, facility or office
• Reason for call
• Member’s contract number
• Member’s name

BCBSM will release PHI after all of these elements have been verified.

Provider identification data
Michigan providers will also be asked for the following identity information:

Out-of-state providers will also be asked for the following identity information:

Reference the Disclosure Use Guide to determine what data can be disclosed.

By following this identity verification process, you will assist BCBSM in protecting the privacy and security of your patients’ protected health information.

For more information, contact your provider consultant.

Prescription drug lists updated, available on our website

Blue Cross Blue Shield of Michigan updated its prescription drug lists, sometimes called formularies, in early June.

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 access other pharmacy-related information at the website.

Our prescription drug lists can help prescribers make better-informed prescribing decisions that can lead to increased medication adherence and can help providers explain prescription drug coverage to our members.

CMS establishes procedure code for Injectafer^®

Effective July 1, 2014, the Centers for Medicare & Medicaid Services has established a procedure code for Injectafer^® (ferric carboxymaltose).

All claims with dates of services from July 25, 2013, through June 30, 2014, will continue to be reported with not-otherwise-classified procedure code J3490. Claims with dates of service on and after July 1, 2014, must be reported with procedure code Q9970.

This procedure is approved for the treatment of iron deficiency anemia in adult patients.

Dosage and administration:

• Up to 750 mg can be delivered in a single dose.
• Give two doses separated by at least seven days for a total cumulative dose of 1500 mg per course.
• Administer intravenously by:
• Infusion over a period of at least 15 minutes
• Slow push injection at the rate of approximately 100 mg (2 mL) per minute over at least seven-and-a-half minutes

Note: For patients weighing less than 50 kg (110 lbs.), give each dose as 15 mg/kg body weight. When administered via infusion, dilute up to 750 mg of iron in no more than 250 mL of sterile 0.9% sodium chloride injection USP, such that the concentration of the infusion is not <2 mg of iron per mL and administer over a period of at least 15 minutes. When administering as a slow intravenous push, give at the rate of approximately 100 mg (2 mL) per minute.

Several HCPCS codes added, 1 deleted

The Centers for Medicare & Medicaid Services has added 10 new HCPCS codes, added two modifiers and deleted one code as part of its regular quarterly HCPCS updates.

The new codes are listed below.

The deleted code is listed below.

Keep in mind these tips to improve medical record documentation for neoplasm coding

Neoplasm should be properly documented in the medical record to support the ICD-9-CM diagnosis code selected. 

Neoplasm diagnosis codes are located in chapter two (codes 140-239) of the ICD-9-CM manual; however, there are some benign neoplasms located in the specific body system chapter.

Common neoplasm terms include:

• Malignant includes primary, secondary and "in situ." It extends beyond the primary site, attaches to adjacent structures and can spread:
• Primary is the original site (tissue or organ) where the cancer started.
• Secondary is a cancer that refers either to a second primary cancer or to cancer that has spread from one part of the body to another, also known as metastatic cancer.
• In situ refers to a cancer that has stayed in the place where it began and has not spread to neighboring tissues.
• Benign isn’t invasive and doesn’t spread to adjacent or distant sites.
• Uncertain behavior is behavior that can’t be determined; there’s no distinction between malignant and benign.

In order to properly code neoplasm, it’s necessary to determine from the documentation if the neoplasm is benign, in situ, malignant or of uncertain behavior. Secondary (metastatic) sites should also be determined when malignant neoplasm is involved.

In the Alphabetical Index (Volume 2) of the ICD-9-CM manual, there is a neoplasm table. This should be referenced first when choosing a code. The exception is when the histological term is documented. In this instance, refer to the term in the Alphabetical Index to see the entries, as well as the instructional note — “see also neoplasm, by site, benign” — under the term. After locating the code in the table, the Tabular List (Volume 1) should be referenced to verify the correct code has been selected. Remember to always code to the highest specificity per the documentation.

Some tips to remember when coding neoplasm

• If treatment is directed at the site of the malignancy, the principal or first-listed diagnosis should be the code for the malignancy. 
• For example, if a patient comes in for a recheck of his prostate cancer, and the doctor  reviews his PSA and increases his medication dose, you would code 185 – Malignant neoplasm of prostate.

• When a primary malignancy metastasizes and the treatment is directed at the secondary site, the secondary neoplasm is the principal or first-listed diagnosis. 
• For example, a patient comes in for treatment of lung cancer, which has metastasized from his primary site of colon cancer. In this instance, you would code 162.9 - Malignant neoplasm of bronchus and lung, unspecified as the principal diagnoses because that’s what’s being treated. The secondary diagnosis would be 153.9 - Malignant neoplasm of colon, unspecified site because the treatment for that visit is being directed at the lung cancer.

• If a patient is being seen for the sole purpose of administration of chemotherapy, immunotherapy or radiation therapy, the use of code V58.x should be the principal or first-listed diagnosis. 
• For example, if a patient has breast cancer and she is being seen that day for administration of radiation therapy only, you would code V58.0 – Radiotherapy, first, followed by 174.9 – Breast (female), unspecified.

• When coding a malignancy with a complication and management is directed only at the complication, it would be listed as the principal or first-listed diagnosis and the malignancy would be listed second.
• For example, a physician documents that his patient has anemia associated with colon cancer. The patient is at the office today for treatment of the anemia. The correct sequence for this date of service would be to code 285.22 – Anemia in neoplastic disease as the primary diagnosis, and 153.9 – Malignant neoplasm of colon, unspecified site as the secondary diagnosis.

• If a primary malignancy has been eradicated, there is no current treatment directed at the primary malignancy site and there is no evidence of the primary malignancy, please use a code from category V10 (Personal history of malignant neoplasm).
• If a physician documents “patient diagnosed with breast cancer, 5/2001, surgery. Tamoxifen therapy discontinued 8/2009, no evidence of recurrence of malignancy. Routine yearly mammograms have remained non-eventful.” This would be coded as V10.3 – Personal history of malignant neoplasm; Breast.

Coding breast cancer
According to the American Cancer Society, it was estimated that there would be 297,000 new female breast cancer cases in 2013 (in situ and invasive combined) and 39,600 women were expected to die from breast cancer. Only lung cancer is responsible for more cancer deaths in women, ahead of breast cancer.

Documenting the specific location of the neoplasm is important because there are codes for the various regions of the breast, as well as an unspecified code. Also, per ICD-9-CM guidelines, the physician should always document the estrogen receptor status when a diagnosis of active breast cancer is listed.

Coding colon cancer
Colon cancer is the third most common cancer among men and women. The American Cancer Society estimates that there will be 136,000 new colorectal cancer cases in 2014, with approximately 50,000 of those resulting in death.

As with breast cancer, documenting the specific location of the neoplasm is important because there are codes for the various regions of the colon.

It’s important to review the ICD-9-CM Coding Guidelines (Chapter Two: Neoplasms, codes 140-239), as well as any instructional notes under the codes in the tabular list of the ICD-9-CM manual, in order to select the correct code, review the additional codes required and find sequencing information.

For questions or more information, please contact your provider consultant.

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.

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 you’re reading an article you’d 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, you’ll 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.

Concierge medicine model prohibited by Blues provider affiliation agreements

We want to remind you that, as part of our nondiscrimination policy, Blue Cross Blue Shield of Michigan and Blue Care Network affiliation agreements do not permit the concierge medicine model.

In a “concierge” or “retainer” practice, members pay membership fees to a provider or third-party vendor for enhanced services or amenities. As a benefit of paying this “concierge” fee, members typically receive:

• Immediate appointment access
• Extended office visits
• Extended or enhanced email and telephone communication
• Care coordination between specialists, including referral coordination
• Wellness programs and plans, genetic and nutritional counseling and risk appraisals

This model violates the nondiscrimination provision in Blues affiliation agreements because open and ready access to care would not be provided to all of our members at the same level. As a result, the following affiliation agreements do not permit concierge services: TRUST Network Practitioner Affiliation Agreement, Traditional Participation Agreement, Medicare Advantage PPO Provider Agreement and Blue Preferred Plus^SM Affiliation Agreement.

Under the terms of these agreements, providers cannot intentionally segregate Blues members in any way. They also cannot:

• Treat members in a manner or location different from other people receiving health care services
• Treat members differently based on payment level, benefit or reimbursement policies

Additionally, many of the services that are considered to be “enhanced” in the concierge model are, when medically necessary, those that are covered services under the affiliation agreements. For example, members who would benefit from appropriate preventative care or wellness counseling should receive those services through covered office visits, written handouts, nurse counseling, etc. According to the affiliation agreements, providers should not require members to pay for services that are not medically necessary under the umbrella of an “enhanced service.”

GY and GZ modifiers, Advance Notice of Member Responsibility required for all claims that BCBSM is expected to reject

Beginning Sept. 1, 2014, all professional, non-Medicare claims that include the modifiers GY or GZ, along with modifier GA, will be rejected. The member will be responsible for paying for the services provided.  

Blue Cross Blue Shield of Michigan is adopting Medicare’s Advance Beneficiary Notice policy and refers to it as Advance Notice of Member Responsibility. Health care providers should include the GA modifier on all claims billed with a GY or GZ modifier, which will acknowledge that:

• The services are expected to be rejected.
• The member was informed and agreed to accept total responsibility.
• An Advance Notice of Member Responsibility form was signed prior to services rendered and is on file.
• This does not apply to Medicare supplemental and MESSA group member claims.

If providers don’t include the GA modifier on claims appended with a GY or GZ modifier, they will be held responsible for the cost of the services. 

Advance Notice of Member Responsibility
Providers must present a written notice to Blue Cross members before providing medical services or supplies that are expected to be rejected.

For the notice to be acceptable, a provider must:

• Use Blue Cross’ Advance Notice of Member Responsibility form for dates of services on or after Sept. 1, 2014.
• Complete the responsibility form in its entirety.
• Clearly identify the particular item or service that is expected to be denied.
• State the specific reason that BCBSM will deny payment for the particular item or service.
• Indicate the estimated cost of the item or service that is associated with the denied claim and the member is responsible.

Member responsibility form
The form should be issued prior to rendering a service or dispensing durable medical equipment, prosthetics and orthotics, or medical supplies that Blue Cross isn’t expected to cover. This form does not take the place of or change any member’s benefits.

Here are some reasons why the medical claims for those items may be rejected:

• Blue Cross medical criteria have not been met.
• Blue Cross doesn’t usually pay for this many treatments or services.
• Blue Cross doesn’t usually pay for this service.
• Blue Cross doesn’t pay for this service because it’s a treatment that hasn’t been proven safe or effective.
• Blue Cross doesn’t pay for this many services within this period of time.
• Blue Cross doesn’t pay for such an extensive treatment.
• Blue Cross doesn’t pay for this medical equipment for the illness or condition stated.

If a provider properly issues a notice, the member will be held financially liable for the reason indicated on the signed form. Keep in mind that a provider who fails to properly issue a notice will be held liable for the medical service. The provider will not be allowed to bill or collect funds from the member, and the provider must refund money collected from the member.

Other important information about the Advance Member Notice of Responsibility form

• For an extended course of treatment, a member responsibility form is valid for one year. If the course of treatment extends beyond one year, a new form is required each year for the remainder of the treatment.

• Once signed by the member, a member responsibility form may not be modified or revised. When a member must be notified of new information, a new form must be provided and signed.

PPO TRUST and Traditional professional retrospective profiles now available by mail, fax or email

PPO TRUST and Traditional program professional retrospective profiles are now available by mail, fax and email requests. To obtain copies of your practice profiles, please include your name, signature, address and Blue Cross Blue Shield of Michigan provider ID number using one of these methods:

Mail:	Information Management ─ Mail Code J426 Blue Cross Blue Shield of Michigan 600 E. Lafayette Blvd Detroit, Michigan 48226
Fax:	313-225-0956
Email:	IMPRPProfileRequest@bcbsm.com

Practice profiles requested by email can be sent either from the physician’s personal or business email address, but must contain the physician’s electronic signature. 

Profiles are based on 12 months of paid claims data. Updated data is available every six months as follows:

• Full-year (Jan. 1 to Dec. 31) is available in March of the following year.
• Mid-year (July 1 to June 30) is available in September of the current year.

If your request is received just prior to new data becoming available, the request will be honored once that data is available. Follow-up inquiries may be faxed to the number provided above.

Not in PGIP? Here’s your chance

We’ll be accepting applications from physician organizations that would like to join our Physician Group Incentive Program from July 1 through Aug. 29, 2014.

This innovative program, developed with input from physicians across Michigan, is helping improve the quality, value and efficiency of health care in the state. PGIP facilitates change through a wide variety of initiatives, and rewards physician organizations for improving health care delivery.

If you represent a physician organization and would like to complete an application, email the Value Partnerships staff at providerpartnerships@bcbsm.com. The Blues must receive completed application packets by Aug. 29, 2014.

Keep in mind that physicians must join PGIP as part of a physician organization. Details on the requirements for participating and instructions on how to join are in the health care provider area of our website.

If you’re an individual practitioner with questions about participating in PGIP, contact your provider consultant. Not sure who that is? Check our website.

We heard from physician office staff in recent survey

Blue Cross Blue Shield of Michigan recently released the results of a survey of physician office staff about their interactions and experiences with us.

An independent research firm conducted the survey by mail and online in November 2013. A total of 1,727 physician office staff and billing managers responded. Here are key findings:

• Nearly eight in 10 physician offices are satisfied with BCBSM overall and with the ease of doing business with BCBSM. And about the same number consider BCBSM to be better overall compared to other insurance plans. See chart below.

• Overall satisfaction with provider consultants increased significantly from the prior survey period. Satisfaction with other areas of the business, including Medicare Advantage service and CAREN, increased as well.

• Areas of concern included BlueCard^® claims and inquiries, web-DENIS functionality and the more timely resolution and payment accuracy of complex or non-routine claims.

As always, we appreciate your feedback and are working to address your concerns and make it easier to do business with us. If you have any additional problems or concerns, please contact your provider consultant.

**This refers to respondents who selected “satisfied” or “very satisfied” on survey questions.

Prescription drug benefits change for some members

Some BCBSM and BCN health plans now use our new, cost-effective drug list, called the Custom Select Drug List. As members move into these Affordable Care Act-compliant health plans, we’re encouraging them to talk with their physicians about medication options if they’ve been taking a prescription drug that may no longer be covered.

Although the Custom Select Drug List covers more than 3,000 prescription medications and certain preventive over-the-counter products, some drugs are not covered that may have been benefits under members’ previous drug plans.

The Custom Select Drug List groups medications into categories called tiers. Drugs that have proven track records and are the least expensive are in the lowest tiers to help protect members’ health and minimize their costs. If a drug is not on this list, it’s not covered. However, most excluded drugs are available in generic or over-the-counter forms.

We want members to be able to find covered medicines that meet their needs and help keep them healthy. You can check our member guide for an overview of the drugs covered by plans using the Custom Select Drug List. You can also review the full drug list.

What’s not covered

Drugs that are not on the Custom Select Drug List are not covered, even if a member is currently taking one. Some examples of drugs or drug categories not covered are:

• Brand-name drugs that have generic equivalents
• Drugs for erectile dysfunction, such as Viagra^® and Cialis^®
• Drugs for weight loss
• Drugs used for coughs and colds
• Most allergy medications, such as Allegra^®, Claritin^® and Zyrtec^®
• Most drugs to treat heartburn and acid reflux, such as Nexium^® and Dexilant^®
• Prenatal vitamins
• Compounded drugs, with some exceptions
• Certain habit-forming pain medications, such as Opana^®

DME professional providers should report NDC quantity on medical drug claims

We previously told you that durable medical equipment providers soon would be subject to national drug code pricing for inhalation solutions. We ask that you submit matching HCPCS code and NDC information on your inhalation solution claims, starting July 1.

If you’re unable to report the NDC quantity at this time, we’ll assist you with the calculation until Nov. 1, 2014. If a medical drug claim doesn’t include the NDC quantity, we’ll use the HCPCS code and quantity in conjunction with a matching national drug code to calculate the NDC quantity. BCBSM will pay average wholesale prices based on that quantity, plus or minus the drug discount, as listed in the Injections or DME Fee Schedule.

BCBSM will pay the lowest or minimum fee listed in the Injections or DME Fee Schedule if claims are submitted with:

• No national drug code
• Invalid national drug codes
• NDC and HCPCS codes that don’t match

Claims submitted with not-otherwise-classified drug codes (J3490, for example) still require accurate NDCs and NDC quantities as they have in the past.

BCBSM will reinstitute the requirement to bill a matching and valid HCPCS and NDC code and quantity combination, along with the NDC unit of measures on medical drug claims, effective Nov. 1, 2014. BCBSM will no longer calculate the NDC quantity beginning on that date.

To recap, if the information is missing or invalid, we’ll reimburse the claim at the lowest average wholesale price or minimum fee, as described in this article.

For details about national drug code and unit of measure reporting, see the October 2013 issue of The Record.

For questions about the calculations, hard copy claims or other inquiries, contact your provider consultant. For questions about electronic 837 reporting requirement, call the e-BIG/EDI helpdesk at 1-800-542-0945.

Additional specialty drugs to require prior authorization

Five additional specialty drugs administered by health care practitioners will require prior authorization by BCBSM in order to be covered under members’ medical benefits, starting Oct. 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.

You can find a 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-hand side under Frequently used forms).

The 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 is uploaded on the online-based tool called Novologix. Requests will follow BCBSM timeframes for coverage determination.

The following drugs will require prior authorization, effective Oct. 1, 2014:

We’re removing the requirement of prior authorization on the following drug as of Oct. 1, 2014:

Blue Cross Blue Shield of Michigan reserves the right to change this list at any time.

Note: The prior authorization requirement does not apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

Preauthorization for proton beam therapy required

Effective July 1, 2014, Blue Cross Blue Shield of Michigan will require preauthorization for both in-state and out-of-state providers for proton beam therapy services. This will affect procedure codes *77520, *77522, *77523 and *77525 when reported with revenue code 0333.

The ordering physician must submit a preauthorization request before the treatment is provided and include the following information:

• Radiology report and rationale to support medical necessity
• Diagnosis codes
• Procedure codes
• Planned duration of treatment

For treatment plans effective July 1 through Aug. 30, 2014, please mail or fax preauthorization requests to:

For treatment that begins after Sept. 1, 2014, preauthorization requests must be made by calling American Imaging Management at 1-800-728-8008. AIM will review the requests and respond to BCBSM Provider Inquiry.

After a preauthorization request is received by BCBSM, the provider will receive a written response, detailing what the preauthorization approval includes, within approximately 15 days. The provider is required to follow the terms of the preauthorization as detailed in the written response.

This preauthorization process helps ensure that BCBSM criteria are met and, where appropriate, explains the proper use of alternative therapeutic modalities. To review the Charged-Particle (Proton or Helium Ion) Radiation Therapy Policy, click here.

Proton beam therapy, used for prostate cancer, hasn’t been demonstrated to be superior to other forms of external beam radiation therapy. The benefit and payment terms are limited to the allowed amount equivalent to intensity-modulated radiation therapy services. For contracted providers, this level of payment is considered payment in full and balance billing the member is not permitted.

Keep in mind that proton beam therapy must be provided in a facility and reported to BCBSM on a facility UB-04 claim. (Out-of-state providers can bill us on either a CMS-1500 or UB-04 claim form.)

Note: The preauthorization requirements described in this article do not apply to Chrysler, Ford, General Motors, Delphi, URMBT, State of Michigan or Federal Employee Program^® members. Please refer to the medical policy to determine if medical necessity criteria have been met.

Blues eliminates Provider Claims Correction tool

Blue Cross Blue Shield of Michigan will remove the PCC tool from Provider Secured Services this fall for both facility and professional providers.

This change is due to the low volume of Michigan Operating System edits that are currently in the PCC tool, as well as the migration of all local groups to the NASCO platform.

Because of this change, all claims that were corrected using PCC will now be rejected with the appropriate reason code. This removal won’t affect your access to other tools on the provider portal.

If you have any questions, please contact your provider consultant.

Reminder: Dental medical-surgical coverage guidelines

Blue Cross Blue Shield of Michigan dental programs are intended to cover services for the treatment of the teeth and supporting structures. These include routine care, treatment and replacement of structures that directly involve the teeth or support the teeth.

These services are generally excluded from coverage under BCBSM medical-surgical benefit plans. However, dental services and surgeries that are “dental in nature” (for example, restoration and extraction of teeth) may qualify for payment as a medical-surgical benefit if the following criteria are met.

Inclusions

• Services are part of the member’s benefit design and required criteria are met. (Some groups have specifically opted to have certain specific primary dental procedures covered under their medical-surgical benefit).
• A member is admitted to the hospital as an inpatient with a medical condition that is negatively impacted by a dental condition.
• The treatment of that dental condition is medically necessary to optimize the treatment of the primary medical problem.
• A member requires prophylactic extractions performed as an in-patient before an organ transplant, cardiac valve surgery or ionizing radiation (5,000 cGy or more) that involves the jaw.
• Services are part of the accidental dental injury benefit. This benefit applies when a patient experiences an external force to the lower half of the face or jaw that damages or breaks the teeth, periodontal structures or bone (other than by self-inflicted external force or chewing).

Exclusions

• Extraction of teeth except when extraction occurs:
• Prior to therapeutic radiation therapy (5000 cGy or more) for a patient with cancer of the head and neck
• Immediately prior to transplant surgery
• In the case of impending cardiac surgery, such as artificial cardiac valve replacement
• When a hospitalized member has a dental condition that is adversely affecting a medical condition and the dental extraction is intended to optimize the treatment of the primary medical problem
• Dentoalveolar surgery
• Endodontic treatment
• Periodontal treatment
• Orthodontic treatment
• Prosthodontic treatment
• Routine dental care
• Restorative dental treatment
• Dental implant surgery and related services including surrounding tissue preparation procedures, repair and maintenance of implants and surrounding tissue (e.g., extraction site preservation, bone replacement grafts, sinus lift surgery, soft tissue grafts and guided tissue regeneration procedures)
• Reversible or irreversible dental services performed for diagnosis or treatment of temporomandibular joint (jaw joint) dysfunction, except for:
• Surgery to the temporomandibular joint (jaw joint) and related anesthesia services
• Diagnostic X-rays
• Arthrocentesis
• Physical therapy
• Reversible appliance therapy
• Devices for the diagnosis or treatment of temporomandibular joint (jaw joint) dysfunction
• Cosmetic surgery for congenital deformities of the teeth

Note: Contract and group coverage may vary. Please check the contract, certificate and rider for specific coverage information. For additional details and guidelines, reference the BCBSM Guide for Dental Care Providers.

Preauthorization for proton beam therapy required

Effective July 1, 2014, Blue Cross Blue Shield of Michigan will require preauthorization for both in-state and out-of-state providers for proton beam therapy services. This will affect procedure codes *77520, *77522, *77523 and *77525 when reported with revenue code 0333.

The ordering physician must submit a preauthorization request before the treatment is provided and include the following information:

• Radiology report and rationale to support medical necessity
• Diagnosis codes
• Procedure codes
• Planned duration of treatment

For treatment plans effective July 1 through Aug. 30, 2014, please mail or fax preauthorization requests to:

For treatment that begins after Sept. 1, 2014, preauthorization requests must be made by calling American Imaging Management at 1-800-728-8008. AIM will review the requests and respond to BCBSM Provider Inquiry.

After a preauthorization request is received by BCBSM, the provider will receive a written response, detailing what the preauthorization approval includes, within approximately 15 days. The provider is required to follow the terms of the preauthorization as detailed in the written response.

This preauthorization process helps ensure that BCBSM criteria are met and, where appropriate, explains the proper use of alternative therapeutic modalities. To review the Charged-Particle (Proton or Helium Ion) Radiation Therapy Policy, click here.

Proton beam therapy, used for prostate cancer, hasn’t been demonstrated to be superior to other forms of external beam radiation therapy. The benefit and payment terms are limited to the allowed amount equivalent to intensity-modulated radiation therapy services. For contracted providers, this level of payment is considered payment in full and balance billing the member is not permitted.

Keep in mind that proton beam therapy must be provided in a facility and reported to BCBSM on a facility UB-04 claim. (Out-of-state providers can bill us on either a CMS-1500 or UB-04 claim form.)

Note: The preauthorization requirements described in this article do not apply to Chrysler, Ford, General Motors, Delphi, URMBT, State of Michigan or Federal Employee Program^® members. Please refer to the medical policy to determine if medical necessity criteria have been met.

Blues eliminates Provider Claims Correction tool

Blue Cross Blue Shield of Michigan will remove the PCC tool from Provider Secured Services this fall for both facility and professional providers.

This change is due to the low volume of Michigan Operating System edits that are currently in the PCC tool, as well as the migration of all local groups to the NASCO platform.

Because of this change, all claims that were corrected using PCC will now be rejected with the appropriate reason code. This removal won’t affect your access to other tools on the provider portal.

If you have any questions, please contact your provider consultant.

Reminder: Dental medical-surgical coverage guidelines

Blue Cross Blue Shield of Michigan dental programs are intended to cover services for the treatment of the teeth and supporting structures. These include routine care, treatment and replacement of structures that directly involve the teeth or support the teeth.

These services are generally excluded from coverage under BCBSM medical-surgical benefit plans. However, dental services and surgeries that are “dental in nature” (for example, restoration and extraction of teeth) may qualify for payment as a medical-surgical benefit if the following criteria are met.

Inclusions

• Services are part of the member’s benefit design and required criteria are met. (Some groups have specifically opted to have certain specific primary dental procedures covered under their medical-surgical benefit).
• A member is admitted to the hospital as an inpatient with a medical condition that is negatively impacted by a dental condition.
• The treatment of that dental condition is medically necessary to optimize the treatment of the primary medical problem.
• A member requires prophylactic extractions performed as an in-patient before an organ transplant, cardiac valve surgery or ionizing radiation (5,000 cGy or more) that involves the jaw.
• Services are part of the accidental dental injury benefit. This benefit applies when a patient experiences an external force to the lower half of the face or jaw that damages or breaks the teeth, periodontal structures or bone (other than by self-inflicted external force or chewing).

Exclusions

• Extraction of teeth except when extraction occurs:
• Prior to therapeutic radiation therapy (5000 cGy or more) for a patient with cancer of the head and neck
• Immediately prior to transplant surgery
• In the case of impending cardiac surgery, such as artificial cardiac valve replacement
• When a hospitalized member has a dental condition that is adversely affecting a medical condition and the dental extraction is intended to optimize the treatment of the primary medical problem
• Dentoalveolar surgery
• Endodontic treatment
• Periodontal treatment
• Orthodontic treatment
• Prosthodontic treatment
• Routine dental care
• Restorative dental treatment
• Dental implant surgery and related services including surrounding tissue preparation procedures, repair and maintenance of implants and surrounding tissue (e.g., extraction site preservation, bone replacement grafts, sinus lift surgery, soft tissue grafts and guided tissue regeneration procedures)
• Reversible or irreversible dental services performed for diagnosis or treatment of temporomandibular joint (jaw joint) dysfunction, except for:
• Surgery to the temporomandibular joint (jaw joint) and related anesthesia services
• Diagnostic X-rays
• Arthrocentesis
• Physical therapy
• Reversible appliance therapy
• Devices for the diagnosis or treatment of temporomandibular joint (jaw joint) dysfunction
• Cosmetic surgery for congenital deformities of the teeth

Note: Contract and group coverage may vary. Please check the contract, certificate and rider for specific coverage information. For additional details and guidelines, reference the BCBSM Guide for Dental Care Providers.

Behavioral health authorization process changes

Blue Cross Blue Shield of Michigan is changing the behavioral health authorization process to assure alignment with the federally mandated mental health parity regulations. MHP regulations require that the rules governing behavioral health and substance abuse services are no more stringent than those applied to medical services.

As you may know, Magellan Behavioral of Michigan, Inc. manages the Blue Cross review process for psychiatric inpatient and partial hospitalizations and hospital-based substance abuse admissions.

The changes to the behavioral health authorization process apply to all psychiatric facilities and hospital-based substance abuse facilities that provide inpatient services to BCBSM members.

Keep in mind that the changes impact Blues members with either Blue Traditional or PPO coverage. They do not apply to customer groups that have chosen a third party to administer their behavioral health benefits. Also, they do not currently apply to freestanding substance abuse facilities.

In addition, select Blue Choice PPO and Federal Employee Program^® members are exempt from the fax notification process. These members will continue to require precertification and recertification by phone beginning day one for admissions that require authorization.

Changes effective for admissions on or after Sept. 1
To align behavioral health and medical authorization practices, the following authorization rules will be consistently applied to all facilities required to obtain authorization for inpatient behavioral health services:

• There will no longer be a facility designation program for behavioral health.
• All inpatient behavioral health facilities will be required to fax a notification form for all admissions and discharges.
• All inpatient behavioral health facilities will be required to fax, email or call for clinical review through discharge for all admissions exceeding four days.
• Non-acute day assessments for the purpose of establishing designation status will no longer be conducted. BCBSM retains the right to audit any service to determine medical necessity or appropriateness.

Facility Admission, Recertification and Discharge Notification Form
Facilities will continue to be required to use this form for patient admissions and discharges.

• Fax the form to Magellan at 1-888-656-1637 within 24 hours of an admission.
• When a patient’s hospital stay is four days or fewer, the facility must fax the discharge information on the same form to Magellan within 24 hours of discharge.
• If the length of stay exceeds four days, the facility is required to fax, email or call Magellan for a clinical review on day five of the admission. (Use the form when faxing or emailing for recertification.)
• Fax: 1-888-656-1637
• Email: BCBSMNotification@MagellanHealth.com
• Phone: 1-800-762-2382.

Upon discharge, the facility must fax the discharge information on the form to Magellan within 24 hours of discharge.

• If a member is admitted to a partial hospitalization program following an inpatient admission, the facility must fax, email or call for clinical review at admission.

The form is accessible online on web-DENIS. The form includes submission instructions. To download the form:

• Log in to web-DENIS.
• In the left-hand navigation area, click on BCBSM Provider Publications and Resources.
• Click on Newsletters & Resources.
• Under “Other Resources,” click on Clinical Criteria & Resources.
• In the right-hand column under “Frequently Used Forms,” click on the Facility Admission, Recertification and Discharge Notification Form. If you have other questions about behavioral health admissions, call Magellan at 1-800-762-2382.

Reminder: Providers responsible for obtaining preservice reviews for out-of-area Blues members prior to inpatient admissions

As we informed you in a March 2014 Record article, Blue Cross and Blue Shield Association’s Provider Financial Responsibility Mandate dictates that all participating facilities are financially responsible for obtaining an inpatient preservice review for out-of-area Blues members when required by the member’s plan. This requirement is effective July 1, 2014.

Here’s what participating facilities need to do:

• Obtain preservice reviews prior to admissions for all inpatient facility services when such a review is required under the member’s plan. Policy requirements for preservice reviews remain the responsibility of the home plan. The Medical Policy/Pre-Authorization router can be used to obtain preservice requirements for the plan.
• Facilities are required to notify the home plan within 48 hours of a change to the original authorization. Changes could include clinical complications resulting in a change to the admission type or days approved. 
• Facilities are required to request preservice review within 72 hours of an emergency or urgent care admission.
• Out-of-area Blues members cannot be held financially responsible for any inpatient facility services provided if a preservice review is required and not performed prior to the admission.
• Failure to adhere to the requirements of this mandate could result in a partial or full denial of the claim for the inpatient services.

Providers can use the Electronic Provider Access tool to request a preservice review. You can access the tool by going to bcbsm.com/providers and logging in. For complete details, see the article in the October Record.

Here’s more of what you need to know about ER visits spanning more than 1 day

In the May Record, we published an article about emergency room visits that span more than one day. The article indicated that you must report the date span on the ER revenue code line to help ensure that all services provided during an ER visit are paid promptly. Here are some additional details to keep in mind.

All Blue Cross Blue Shield of Michigan trading partners** should follow these reporting requirements when using outpatient bill type 131.

When the emergency room visit spans more than one day, report the dates at claim level in Loop 2300 and also do the following:

• Report qualifier “434” in segment DTP01.
• Report qualifier “RD8” in DTP02.
• Report the “from” and “to” dates in DTP03.
• Report the date span on the ER revenue code (045x) line in Loop 2400.
• Report qualifier “472” in Segment DTP01.
• Report qualifier “RD8” in DTP02.
• Report the range of dates in DTP03.

Contact your software vendor or clearinghouse if you need assistance with your practice management system. For questions about 837 electronic claims, call the e-BIG/EDI Business Helpdesk at 1-800-542-0945.

**This includes Federal Employee Program^® trading partners.

We heard from hospitals in recent survey

Blue Cross Blue Shield of Michigan recently released the results of a survey of hospital patient account managers and directors from acute care facilities in Michigan.

BCBSM commissioned an independent research firm to conduct the survey in November 2013 to assess our performance. Here are key findings:

• Overall, seven in 10 hospitals are satisfied with BCBSM and nearly nine in 10 agree that BCBSM is the leader in improving health and health care in Michigan.

• BCBSM provider consultants continue to be highly valued and significantly outperform competitors. Satisfaction with the service and accessibility of provider consultants increased significantly compared to prior survey results. See chart below for additional details.

• Areas of concern included BlueCard^® claims and inquiries, web-DENIS functionality and the more timely resolution and payment accuracy of complex or non-routine claims.

We appreciate the feedback we received from the 72 hospital administrators who completed the survey and are working to address your concerns and make it easier for you to do business with us. If you have any additional problems or concerns, please contact your provider consultant.

**This refers to respondents who selected “satisfied” or “very satisfied” on survey questions.

Prescription drug benefits change for some members

Some BCBSM and BCN health plans now use our new, cost-effective drug list, called the Custom Select Drug List. As members move into these Affordable Care Act-compliant health plans, we’re encouraging them to talk with their physicians about medication options if they’ve been taking a prescription drug that may no longer be covered.

Although the Custom Select Drug List covers more than 3,000 prescription medications and certain preventive over-the-counter products, some drugs are not covered that may have been benefits under members’ previous drug plans.

The Custom Select Drug List groups medications into categories called tiers. Drugs that have proven track records and are the least expensive are in the lowest tiers to help protect members’ health and minimize their costs. If a drug is not on this list, it’s not covered. However, most excluded drugs are available in generic or over-the-counter forms.

We want members to be able to find covered medicines that meet their needs and help keep them healthy. You can check our member guide for an overview of the drugs covered by plans using the Custom Select Drug List. You can also review the full drug list.

What’s not covered

Drugs that are not on the Custom Select Drug List are not covered, even if a member is currently taking one. Some examples of drugs or drug categories not covered are:

• Brand-name drugs that have generic equivalents
• Drugs for erectile dysfunction, such as Viagra^® and Cialis^®
• Drugs for weight loss
• Drugs used for coughs and colds
• Most allergy medications, such as Allegra^®, Claritin^® and Zyrtec^®
• Most drugs to treat heartburn and acid reflux, such as Nexium^® and Dexilant^®
• Prenatal vitamins
• Compounded drugs, with some exceptions
• Certain habit-forming pain medications, such as Opana^®

DME professional providers should report NDC quantity on medical drug claims

We previously told you that durable medical equipment providers soon would be subject to national drug code pricing for inhalation solutions. We ask that you submit matching HCPCS code and NDC information on your inhalation solution claims, starting July 1.

If you’re unable to report the NDC quantity at this time, we’ll assist you with the calculation until Nov. 1, 2014. If a medical drug claim doesn’t include the NDC quantity, we’ll use the HCPCS code and quantity in conjunction with a matching national drug code to calculate the NDC quantity. BCBSM will pay average wholesale prices based on that quantity, plus or minus the drug discount, as listed in the Injections or DME Fee Schedule.

BCBSM will pay the lowest or minimum fee listed in the Injections or DME Fee Schedule if claims are submitted with:

• No national drug code
• Invalid national drug codes
• NDC and HCPCS codes that don’t match

Claims submitted with not-otherwise-classified drug codes (J3490, for example) still require accurate NDCs and NDC quantities as they have in the past.

BCBSM will reinstitute the requirement to bill a matching and valid HCPCS and NDC code and quantity combination, along with the NDC unit of measures on medical drug claims, effective Nov. 1, 2014. BCBSM will no longer calculate the NDC quantity beginning on that date.

To recap, if the information is missing or invalid, we’ll reimburse the claim at the lowest average wholesale price or minimum fee, as described in this article.

For details about national drug code and unit of measure reporting, see the October 2013 issue of The Record.

For questions about the calculations, hard copy claims or other inquiries, contact your provider consultant. For questions about electronic 837 reporting requirement, call the e-BIG/EDI helpdesk at 1-800-542-0945.

Additional specialty drugs to require prior authorization

Five additional specialty drugs administered by health care practitioners will require prior authorization by BCBSM in order to be covered under members’ medical benefits, starting Oct. 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.

You can find a 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-hand side under Frequently used forms).

The 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 is uploaded on the online-based tool called Novologix. Requests will follow BCBSM timeframes for coverage determination.

The following drugs will require prior authorization, effective Oct. 1, 2014:

We’re removing the requirement of prior authorization on the following drug as of Oct. 1, 2014:

Blue Cross Blue Shield of Michigan reserves the right to change this list at any time.

Note: The prior authorization requirement does not apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

DME professional providers should report NDC quantity on medical drug claims

We previously told you that durable medical equipment providers soon would be subject to national drug code pricing for inhalation solutions. We ask that you submit matching HCPCS code and NDC information on your inhalation solution claims, starting July 1.

If you’re unable to report the NDC quantity at this time, we’ll assist you with the calculation until Nov. 1, 2014. If a medical drug claim doesn’t include the NDC quantity, we’ll use the HCPCS code and quantity in conjunction with a matching national drug code to calculate the NDC quantity. BCBSM will pay average wholesale prices based on that quantity, plus or minus the drug discount, as listed in the Injections or DME Fee Schedule.

BCBSM will pay the lowest or minimum fee listed in the Injections or DME Fee Schedule if claims are submitted with:

• No national drug code
• Invalid national drug codes
• NDC and HCPCS codes that don’t match

Claims submitted with not-otherwise-classified drug codes (J3490, for example) still require accurate NDCs and NDC quantities as they have in the past.

BCBSM will reinstitute the requirement to bill a matching and valid HCPCS and NDC code and quantity combination, along with the NDC unit of measures on medical drug claims, effective Nov. 1, 2014. BCBSM will no longer calculate the NDC quantity beginning on that date.

To recap, if the information is missing or invalid, we’ll reimburse the claim at the lowest average wholesale price or minimum fee, as described in this article.

For details about national drug code and unit of measure reporting, see the October 2013 issue of The Record.

For questions about the calculations, hard copy claims or other inquiries, contact your provider consultant. For questions about electronic 837 reporting requirement, call the e-BIG/EDI helpdesk at 1-800-542-0945.

Additional specialty drugs to require prior authorization

Five additional specialty drugs administered by health care practitioners will require prior authorization by BCBSM in order to be covered under members’ medical benefits, starting Oct. 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.

You can find a 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-hand side under Frequently used forms).

The 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 is uploaded on the online-based tool called Novologix. Requests will follow BCBSM timeframes for coverage determination.

The following drugs will require prior authorization, effective Oct. 1, 2014:

We’re removing the requirement of prior authorization on the following drug as of Oct. 1, 2014:

Blue Cross Blue Shield of Michigan reserves the right to change this list at any time.

Note: The prior authorization requirement does not apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

ValueOptions to administer mental health, substance abuse claims for Chrysler Bargaining Unit members

Mental health and substance abuse claims for Chrysler Bargaining Unit members will be administered by ValueOptions, effective July 1, 2014. Previously, ValueOptions was only used for precertification.

Members will receive a new identification card with an issue date of June 2014.

Blue Cross Blue Shield of Michigan will reject claims that are not submitted to ValueOptions for dates of service July 1, 2014, and beyond. Health care providers who submit claims for these services will receive a message instructing them to bill ValueOptions. Please note that BCBSM will assume responsibility for inpatient hospitalization claims if admitted prior to July 1, 2014.

Claims can be submitted directly through ValueOptions’ secure portal, ProviderConnect. If you have any questions  about using ProviderConnect, contact the Value Options e-support help desk at 1-888-247-9311, Monday through Friday, from 8 a.m. to 6 p.m. Eastern time or by email at e-supportservices@valueoptions.com.

The mailing address for paper claims is ValueOptions, P.O. Box 930829, Wixom, MI 48393-0821.

If you have mental health or substance abuse questions about such issues as claims, benefits, eligibility, precertification or cost sharing for Chrysler Bargaining Unit members, call Value Options toll-free at 1-800-346-7651. (This is the same number that was previously used for precertification, and it will continue to be used for precertification for inpatient hospitalization.)