Blues provider portal gets new web address

In October, Blue Cross Blue Shield of Michigan and Blue Care Network will begin upgrading their internal systems that support all of our online provider services, including access to web-DENIS features. 

This update won’t change the look and feel of the system, and all navigation will remain the same. However, the web address to access the portal will change, so we’re asking for your help in preparing for the change.

The best way to log in to Provider Secured Services is to  follow these steps:

• Visit bcbsm.com.
• Select LOGIN.
• Select Provider.
• Enter your ID and password.

For a smooth transition, eliminate former bookmarks and save bcbsm.com as your “favorite.”

If you continue to use an existing favorite or bookmark, you’ll receive an error and won’t be able to log in to the portal. This can be avoided by visiting bcbsm.com and following the instructions above.

We’ll let you know through an alert on web-DENIS when the upgrade is complete and it is time to log in directly at bcbsm.com as illustrated above.

For questions regarding this change, please contact the Web Support Help Desk at 1-877-258-3932.

The Blues make it easier for members to manage their own health plan at bcbsm.com

To help your Blues patients understand and better manage their health coverage, encourage them to register at bcbsm.com so that you and your staff can spend less time handling benefit questions and more time providing quality health care.

When members create an account at bcbsm.com and log in, they have access to:

Personal snapshot of their plan: Your patients with Blues coverage can go online and check out easy-to-understand charts that show deductible and coinsurance information, recent claims activity and other important cost information that will help them better understand what they may owe you after visiting your office. They can access their claims information on-demand and retrieve Explanation of Benefits statements before they arrive in the mail.

Virtual ID card: Now, when a member forgets to bring their Blues ID card to their appointment, they can easily log in to their account at bcbsm.com through their mobile device and show their virtual ID card to you as proof of coverage. Access to this great feature and other plan information is available 24 hours a day, seven days week with a mobile device.

Powerful doctor and hospital search: Members can find doctors or hospitals that accept their coverage with our Find a Doctor feature at bcbsm.com. They can search by location, specialty, extended office hours, languages spoken and more, and even read reviews from other patients and leave reviews of their own. Plus, we’ve made it easy for them to compare quality and estimate treatment costs for more than 400 health services across the country.** Our Find a Doctor feature has the ability to bring you additional patients more suited to your specialty.

If you would like more information about the benefits of our site for your Blues patients, contact your provider consultant.

Note: Federal Employee Program^® members cannot register on bcbsm.com as FEP has its own secure member portal that members access through fepblue.org.

**Cost information for PPO members only.

New Health e-Blue^SM site allows you to manage patient care for Blue Cross individual and group patients

The new BCBSM Health e-Blue^SM site for our individual and group members is now operational and accessible through our Provider Secured Services portal.

Health e-Blue is an online tool designed to make the process of managing diagnosis gaps and treatment opportunities easy and efficient for providers.

Previously available for Medicare Advantage PPO and Blue Care Network patients, Health e-Blue has been expanded to include individual and group patients.

Existing Medicare Advantage PPO and BCN Health e-Blue users have received automatic access to commercial BCBSM Health e-Blue. If you don’t have current access to Health e-Blue, sign up today.
The following provider types can be granted access to Health e-Blue:

• BCN primary care physicians and medical care group administrators
• Blue Cross physicians and physician organizations from the following specialties:
• Adult medicine
• Family medicine 
• Family practice 
• General practice 
• Geriatric medicine 
• Health clinic practice 
• Internal medicine 
• Nurse practitioner 
• Osteopathy
• Pediatrics 
• Physician assistant 

The following are key items to note about BCBSM Health e-Blue:

• There’s a user’s guide available in the Resources and Training section of Health e-Blue.
• Diagnosis gaps will be updated every 30 days. Treatment opportunities will update every 60 days. Alerts will be posted on BCBSM Health e-Blue when each refresh takes place. In the future, a monthly refresh and retrieval schedule will be posted.
• Health e-Blue allows users to enter a 2013 date of service for a 2014 diagnosis gap. Ensure that you are entering a 2014 date of service to properly close a 2014 diagnosis gap. If a prior year date of service is entered for a 2014 diagnosis gap, the gap will not be closed.
• Click on the Feedback button found in the upper right of each screen to send comments or ask question about Health e-Blue.
• Before using the Feedback button, verify the correct product line — Blue Cross, BCN or Medicare Advantage PPO. You’ll find it listed near the upper left of each page in small, blue font. If necessary, you’ll be contacted for more information related to your comment or question within 72 hours. A response will be returned via a secure email. Click on Yes to open the email. It may take longer to respond to questions that require investigation and corrective action.

Training opportunities
Provider training webinars were offered in August 2014. If you were unable to attend one of these webinars, but would still like to learn more about BCBSM Health e-Blue, contact your provider consultant who can assist you with training.

Web-DENIS expands to include individual and group patient gaps in care
In addition to the launch of BCBSM Health e-Blue, web-DENIS enhancements make it easier to identify patient gaps in care for individual and group patients. Clicking on a member care alert will open a page in web-DENIS that displays a printable list of diagnosis gaps and treatment opportunities by patient.

When you click on an individual or group diagnosis gap or treatment opportunity from the list, you’ll be directed to the Blue Cross Health e-Blue home page if you have access to the site. Once in Health e-Blue, you may navigate to the Diagnosis Evaluation panel or Treatment Opportunities by Condition/Measure panel to close patient gaps.

If you have questions about Health e-Blue, reference our frequently-asked-questions document in the Resources section of BCBSM Health e-Blue, or contact your provider consultant.

Diagnosis-specific pricing helps balance cost of services with effectiveness

When the cost of newer technology is significantly higher than other equally effective approaches, the cost of care can be unnecessarily inflated.

That’s why the Blues are implementing what we call diagnosis-specific pricing. The process helps ensure that the cost of a service is in line with its effectiveness.

It takes into account not only the procedure performed but also the patient’s diagnosis or condition. When a procedure for a particular diagnosis is established according to Blues medical policy, then the fee will be in line with the given procedure. If the procedure performed is considered not medically necessary, then the fee will be in line with an alternative, equally effective and less-costly treatment approach.

Blue Cross Blue Shield of Michigan has already implemented this approach for future proton beam therapy procedures performed in Michigan. Effective Feb. 1, 2015, the Blues will begin applying this diagnosis-specific pricing process for select intensity-modulated radiation therapy procedures.

The specific procedure codes that will be affected for proton beam therapy are *77520, *77522, *77523 and *77525. For intensity-modulated radiation therapy, the procedures codes are *0073T, *77301, *77338, *77418. The established diagnosis fees and not-medically-necessary diagnosis fees for the listed codes will be published on web-DENIS on or before Nov. 1, 2014.

Information on established diagnosis codes will be provided in the near future.

BCBSM adds residential psychiatric treatment benefits

Blue Cross Blue Shield of Michigan began covering residential psychiatric treatment, effective July 1, 2014.

Residential psychiatric treatment takes place in a state-licensed facility (e.g., an adult or child foster care facility) with a multidisciplinary treatment team. The following services are available to assist with medical issues, administration of medication and crisis intervention as needed:

• Nursing care is onsite or on call, and no more than fifteen minutes away 24/7.
• A psychiatrist is on call 24/7.
• A psychiatrist is onsite a minimum of two days per week.

Always check a member’s coverage to see if it includes residential psychiatric treatment benefits.

If you have questions about treatment, facilities or obtaining preauthorization for members who have the residential psychiatric treatment benefit, call Magellan Behavioral Health of Michigan, Inc., at 1-800-762-2382 or the appropriate behavioral health vendor. Keep in mind that residential treatment must be medically necessary and meet use and quality criteria.

Check future issues of The Record and web-DENIS for updates.

CAREN retiring soon, to be replaced by improved IVR system called PARS

A new and enhanced interactive voice response system called the Provider Automated Response System, also known as PARS, is replacing CAREN.

We’re transitioning to PARS in phases:

• On Sept. 15, 2014, the vision and hearing lines of business will move to PARS.
• On Sept. 23, 2014, professional, facility, BCN and Medicare Advantage will move to PARS.
• The Federal Employee Program^® will move to PARS during the first quarter of 2015. We’ll notify you of the date as we get closer to the transition.

All phone numbers will remain the same and the format of the calls will be very similar, although you will hear a new “voice.” And some categories will have different names; for example, OB/GYN will become “Women’s Health.”

PARS features many enhancements to improve your experience, including:

• Speech recognition
• Improved process for collecting and associating email addresses with your fax number. If you already set up your email address, it will carry over to PARS.
• An improved format for fax and email documents (Please note that BCN does not have the fax and email options.)
• Multiple Inquiry Routing Selection — if you request a transfer after multiple inquiries on the IVR, you can select the specific contract you want to transfer to for accurate routing.

The new PARS software is considered best in class for speech recognition but will require testing to make sure it’s working at the highest level. After PARS is implemented, we will conduct two tunings. Each tuning will assess actual calls to determine if any adjustments need to be made. Based on the assessment, the speech recognition software may be adjusted.

Updated PARS “Navigating with Ease” brochures are available on web-DENIS.  To access them:

• From the web-DENIS homepage, click on BCBSM Provider Publications and Resources.
• Click on Newsletters & Resources.
• Click on Provider Training.
• Go to the “Job Aids, FAQs, Tips, Q&A documents, brochures and flyers” section of the page.

If you have any questions or feedback about PARS, contact us at PIBS@bcbsm.com.

Amendments made to Trading Partner Agreement

Blue Cross Blue Shield of Michigan has amended its Trading Partner Agreement to permit us to engage in key business functions in the nonparticipating provider space.

The TPA is the mechanism that governs how electronic data interchange, or electronic claims transactions, will be conducted between BCBSM and its trading partner — typically providers, billing agents and other health plans.

The amended TPA makes it clear that nonparticipating providers must do the following:

• Comply with billing publications or guidelines issued by BCBSM or ensure that his or her billing agent complies.
• Retain all original medical and business office records in accordance with BCBSM’s retention period, rules of applicable accrediting organizations and legal requirements.
• Permit BCBSM or its designee physical access to the premises to review any and all medical and billing records submitted by it or its billing agent for any permissible purpose, including for BCBSM’s risk-adjustment and revenue-management programs.
• Provide copies of any medical and billing records to BCBSM or its designee for a nominal fee.

Additionally, BCBSM has amended the TPA to make it clear that the nonparticipating provider must agree to the following if he or she agrees to accept assignment, participate with BCBSM or wants to receive payment directly from BCBSM for the services provided to a BCBSM member:

• Accept BCBSM’s payment as payment in full, and should not, with the exception of applicable deductible, co-payment or co-insurance amounts, balance-bill the member the difference between the charged amount and BCBSM’s payment.
• Continue to accept payment directly and in full for that same service for all BCBSM members — as long as they are payable benefits — for the remainder of the calendar year.

These amendments will become effective automatically on Nov. 1, 2014. There is no action required on the part of BCBSM’s trading partners in order for the amendment to become effective.

If you have questions about updates to the TPA, please contact your provider consultant.

Register now to attend webinars on ACE inhibitors, ARBs, use of nonbenzodiazepine hypnotics

Blue Cross Blue Shield of Michigan offers monthly educational webinars to discuss two pharmacy-related Medicare star measures — High Risk Medications in Older Adults and Use of ACE Inhibitors and ARBs in Hypertensive Diabetics.

There will be two webinars in September. The first webinar on Sept. 19 will begin at 7:30 a.m. The topic is “ACEIs and ARBs, The Good, The Bad and The Ugly.”

The speaker will be Joel Topf, M.D., a board-certified nephrologist who practices at St. Clair Specialty Physicians and St. John Hospital and Medical Center. He is also an investigator at Renaissance Renal Research Institute and an assistant clinical professor at Wayne State University School of Medicine and Oakland University’s William Beaumont School of Medicine.

The second webinar on Sept. 24 will begin at 8 a.m. The topic is “Clinical Considerations for the Use of Nonbenzodiazepine Hypnotics in Patients 65 and Older.” The speaker will be Karen E. Hall, M.D., Ph.D. Dr. Hall is a clinical professor in the Division of Geriatric and Palliative Medicine at the University of Michigan Healthcare System, the medical director at U. of M. St. Joseph Hospital’s Acute Care for Elders Unit , and a research scientist at the V.A. Geriatric Research Education and Clinical Center. She is board-certified in internal medicine, with subspecialties in geriatric medicine, and hospice and palliative medicine.

Both 30-minute webinars will be followed by question- and-answer sessions. There will also be an email address available to send in additional questions.

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.

Use new fax number when submitting Facility and Professional Supply Requisition order form

We revised the BCBSM Facility and Professional Supply Requisition form to include a new fax number to use when submitting it.

Please discontinue using the old fax number to avoid a delay in processing your order. Submit supply requisition forms to our new toll-free fax number at 1-866-306-0555, or mail them to the address provided on the form.

The revised Facility and Professional Supply Requisition order form is available on bcbsm.com and on web-DENIS:

• From the web-DENIS homepage, click on BCBSM Provider Publications and Resources.
• Click on Newsletters and Resources.
• Go to the “Frequently Used Forms” section of the page to access the form.

Or you can access the form via your provider manual:

• From the web-DENIS homepage, click on BCBSM Provider Publications and Resources.
• Click on Provider Manual.
• Click on Provider Type and select yours from the “Make Selection” box.
• Click on the Search button and then on the Blue Pages Directory chapter.
• Click on Forms and supplies and then on Facility and Professional Supply Requisition.

Reminder: Updated billing guidelines for hospital readmissions

Blue Cross Blue Shield of Michigan recently updated a couple of its readmission guidelines. We’ve noted the updates in the chart.

These charts will help guide you through the readmission billing process. The first chart explains when admissions should be billed separately. The second chart shows when admissions should have combined billings.

Bill as separate admissions:

Bill as combined admissions:

Reminder: Keep practice address information up-to-date with BCBSM

It’s important to make sure that Blue Cross Blue Shield of Michigan has your correct practice address information in our records. If you need to update your practice’s address information, here’s important information to know:

• To change or add a primary practice location: Practitioners should submit changes to the Council for Affordable Quality Healthcare's Universal Provider Datasource^®. For help with the UPD, practitioners can call the CAQH Support Desk at 1-888-599-1771 or email caqh.updhelp@acsgs.com. More information is available at upd.caqh.org**.

• To add or remove practice locations: Submit the information using the Practitioner Change Form (PDF) that is available at bcbsm.com/provider by clicking on Enrollment and Changes and following the prompts. This applies to solo practitioners who work in Michigan at multiple locations outside of an established group affiliation. Note: If you only practice through a group affiliation, you don’t need to submit additional practice locations. The maintenance of group practice locations is handled by your group practice administrator.

• For practice locations outside of Michigan: You must maintain an active Michigan practice address on CAQH, as well as meet the licensure requirements for enrollment. You can designate the Michigan address as either your primary or an additional practice location on CAQH. If you do not have an active Michigan practice location listed in CAQH, you may be subject to full disaffiliation with BCBSM.

• If you practice exclusively in a hospital: You should record your primary hospital's address upon initial enrollment. When completing the CAQH application, you will indicate that you practice exclusively in a hospital. CAQH will send the Blues a notification that your practice location matches that of your primary hospital. If you do not wish for the hospital's address to be recorded as your primary practice location, please do not indicate that you practice exclusively in a hospital setting on CAQH.

If you’re making an address change and you have questions regarding how it may affect your Blues affiliation, please call Provider Enrollment and Data Management at 1-800-822-2761 or call your provider consultant.

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

BlueCard^® program: Check out provider manuals on web-DENIS for useful, up-to-date information

This is part of a series designed to improve your experience with the BlueCard program.

BlueCard members living in Michigan with out-of-state plans often have benefits, medical policies and authorization requirements that are different from Blue Cross Blue Shield of Michigan’s.

Information about out-of-state Blue plans can’t be accessed on web-Denis, and as a result, determining coverage for those BlueCard members can be more challenging.

But to assist you with providing services to BlueCard members, we’ve created a chapter in our provider manuals that discusses the BlueCard program. The chapter includes:

• The latest information on how to determine eligibility, benefits, authorization and reporting requirements, and how to check the status of BlueCard claims
• Links to online tools that allow you to check a Blue plan’s medical policy for service and authorization requirements
• The process for executing electronic authorizations for Blue plans that make the same process available to their local providers
• Links to Record articles that discuss the BlueCard program

To find the provider manuals, log in to web-DENIS and click on BCBSM Provider Publications and Resources.

We encourage you to review the BlueCard chapter, and contact your provider consultant if you have any questions or suggestions for additional information you’d like to see included in the chapter.

Next month, we’ll discuss the BCBSM BlueCard Department and its staff members who are dedicated to helping you provide services to BlueCard members.

Here’s a recap of coding tips to improve medical record documentation

Since May 2013, we’ve been running a series of articles in The Record focusing on coding tips for various conditions.

To assist you in your efforts to improve medical record documentation, we’ve compiled the coding tips from May 2013 through August 2014 into a single document that you can access by clicking here. You’ll also want to check out the article on coding for chronic kidney disease in this issue of the newsletter.

Keep in mind these coding tips for chronic kidney disease to improve medical record documentation

The complex nature of chronic kidney disease makes accurate code selection essential. A basic understanding of CKD, its causes and its comorbidities can help you assign the highest specificity of codes.

Chronic kidney disease is a condition characterized by a gradual loss of kidney function. When kidney disease gets worse, the nephrons that filter out wastes and other fluids from the bloodstream lose the ability to filter, causing the kidneys to lose functionality.

Complications of CKD include high blood pressure, anemia, weak bones and nerve damage. CKD may also increase the risk of developing heart or blood vessel disease.

ICD-9-CM codes are based on the severity of CKD. The provider must clearly document the CKD stage to ensure codes are chosen to the highest level of specificity. Coders can’t assign a CKD code based on the glomerular filtration rate alone and should be as specific as possible:

• Stage I — 585.1 (glomerular filtration rate > 90)
• Stage II — 585.2 (mild) (GFR 60-89)
• Stage III — 585.3 (moderate) (GFR 30-59)
• Stage IV — 585.4 (severe) (GFR 15-29)
• Stage V — 585.5 (severe) excludes CKD stage V, requiring chronic dialysis (585.6)
• End stage renal disease (ESRD) — 585.6 or CKD stage V, requiring chronic dialysis
• Unspecified — 585.9

Chronic kidney disease and diabetes
If the patient has CKD caused by diabetes, the code for diabetes would be assigned first according to ICD-9-CM guidelines.

• Assign 250.4X (primary diabetes) or 249.4X (secondary diabetes) followed by the appropriate CKD code.
• Documentation must show causality between the two conditions. For example, diabetic nephropathy or CKD due to diabetes.
• Although the word “with” is considered acceptable linkage within the context of the ICD-9-CM, BCBSM does not consider the word “with” to be an acceptable linking word in provider documentation.

Chronic kidney disease and anemia
When CKD is present, the kidneys may not make enough erythropoietin, a hormone that controls red blood cell production. This may cause anemia to develop. When documentation indicates the link between the two conditions, assign code 285.21, Anemia in CKD. Also report a code from category 585.X, to indicate the stage of CKD.

Chronic kidney disease and hypertension
ICD-9-CM presumes a cause-and-effect relationship, and classifies CKD with hypertension as Hypertensive CKD whether or not it’s documented. So, when CKD is present with hypertension, assign codes from category 403.XX, Hypertensive CKD.

• Assign a fourth digit for hypertensive CKD, 403.XX, based on whether the hypertension is documented as malignant (0), benign (1) or unspecified (9).
• Report a fifth digit to identify the stage of CKD that is documented:
• If CKD stage I through stage IV or unspecified, use 0 for the fifth digit (403.X0)
• If CKD stage V or end-stage renal disease, use 1 for the fifth digit (403.X1).
• Use an additional code to identify the stage of chronic kidney disease (585.1-585.6, 585.9)

Hypertensive heart and chronic kidney disease
Report hypertensive heart and CKD with a code from the combination category 404.XX when both conditions are stated in the diagnosis. The relationship between the hypertension and CKD is still assumed, but heart disease and CKD don’t have an assumed relationship. Documentation must state a cause-and-effect relationship.

• Assign a fourth digit for hypertensive heart and CKD, 404.XX, based on whether the hypertension is documented as malignant (0), benign (1) or unspecified (9).
• Report hypertensive heart and CKD, 404.XX, with a fifth digit according to the relationship documented between the heart failure and CKD and the stage of CKD documented.
• Use “0” for hypertensive heart and CKD without heart failure and CKD stage I through stage IV, or unspecified.
• Use “1” for hypertensive heart and CKD with heart failure and CKD stage I through IV, or unspecified.
• Use “2” for hypertensive heart and CKD without heart failure and CKD stage V or end-stage renal disease.
• Use “3” for hypertensive heart and CKD with heart failure and CKD stage V or ESRD.
• Also use additional codes to identify the stage of chronic kidney disease (585.1-585.6, 585.9) and to code the specific type of heart failure (428.0-428.43), if known.
• More than one code from category 428 may be assigned if the patient has systolic or diastolic failure and congestive heart failure.

Coding kidney dialysis and transplants
Early detection and treatment can often keep chronic kidney disease from getting worse, but when kidney disease progresses it can lead to kidney failure which often requires dialysis or a kidney transplant to maintain life.

• If the patient is admitted solely for dialysis treatment, use V56.0 (renal) dialysis NOS as the primary code and then code V45.11 (renal dialysis status). The renal condition is also assigned as an additional diagnosis.
• Report V45.12 for patients who are noncompliant with renal dialysis. 
• Patients who have undergone a kidney transplant may still have CKD. A kidney transplant does not always restore full kidney function.
• Assign the appropriate CKD (585.X) code for the patient’s stage followed by code V42.0, kidney replaced by transplant.
• Kidney transplant complication codes are only assigned if the complication affects the function of the transplanted organ.
• Two codes are required to fully describe a transplant or rejection of transplant complication, code 996.81 and a secondary code that identifies the complication.

To see a compilation of additional coding tips that have been featured in The Record over the past 14 months, click here. Also, be sure to check out next month’s issue of The Record, which will include an article on coding tips for pregnancy complications.

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

Final reminder: Blues retiring local system

Time is running out! Claims filed on the local system must be received by Sept. 15, 2014.

Over the past several months, we’ve reminded you that the local system will retire on Oct. 31, 2014. Since we will no longer process claims on that system, all claims filed on the local system must be submitted and received by Sept. 15, 2014, in order to be processed.

Keep in mind that you’ll only be able to view professional and facility claims on web-DENIS until Oct. 31, 2014.

As a reminder, all health care providers must follow claims filing deadlines. If you submit a claim after the filing limits, Blue Cross Blue Shield of Michigan will not offer any special handling or filing extensions, and no payment will be due from BCBSM or the subscriber.

For more information about the retirement of the local system, please refer to the March 2014 Record.

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.

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

In a previous edition of The Record, we announced that effective Sept.1, 2014, Blue Cross Blue Shield of Michigan will reject all professional, non-Medicare claims that are billed with the modifiers GY or GZ, along with modifier GA.

As part of this new policy, health care providers must present a written notice to Blue Cross members before providing medical services or supplies that are expected to be rejected. The Advance Notice of Member Responsibility form serves as this written notice, and it requires signatures from the provider and member to ensure that the member is informed and accepts financial responsibility.

Members must sign the Advance Notice of Member Responsibility form

• The provider has verified that the member does not meet the specific criteria for the service.
• The member agrees to accept financial responsibility for the service.
• The modifiers GY or GZ, along with GA, must be appended to the claim.

It’s unnecessary to use the form if:

• Providers have verified that the service is not a contract benefit. (Noncovered group benefits should follow the standard claim submission process for a rejection.)
• The member does not agree to accept financial responsibility.

 In order for the member to be financially responsible for the service:

• The provider must verify that the service does not meet the member’s benefit requirements.

• The provider must notify the member before rendering the service that the member does not meet the medical necessity requirements for the service. The provider must also explain why the member doesn’t meet the requirements. 

• The member must agree to accept financial responsibility by signing the Advance Notice of Member Responsibility form. 

Charging for “access fees” or “special access fees” is never allowed under our Blue Cross Blue Shield of Michigan provider agreements. The member can only be billed in the instances described on the Advance Notice of Member Responsibility form and if none of the services in question are benefits for which the member is eligible. Providers must seek payment from BCBSM for all covered services and must accept our fee schedule maximums as payment in full.

The form should be kept in the member’s file and available upon audit request. A copy should be provided to the member.

Keep in mind that the Advance Notice of Member Responsibility form doesn’t apply to Medicare primary claims, Medicare Advantage or MESSA group members.

ACA’s wellness regulations may cause some claims to be reprocessed

Under the terms of the Affordable Care Act, individuals enrolled in wellness programs — such as Blue Cross Blue Shield of Michigan’s Healthy Blue Incentives and Healthy Blue Achieve — must be able to receive the full benefit of program rewards for the entire benefit year.

That means that members who began the year at the standard benefit level but subsequently met the product requirements would be shifted to the enhanced benefit level, retroactive to the first day of the group’s benefit year. For members who have the Healthy Blue Incentives product, all claims incurred during the first six months of the group’s benefit year will be reprocessed at the enhanced benefit level if the member met the product requirements.

Note: A similar approach to claims processing for members with the Healthy Blue Achieve product will begin in the second quarter of 2015.

Following are examples of adjustment reason messages that may appear on your voucher if adjustments need to be made:

WE PREVIOUSLY PAID $42.30 FOR THIS CLAIM. THE CORRECT PAYMENT SHOULD HAVE BEEN $58.33. AN ADDITIONAL PAYMENT HAS BEEN MADE FOR THE DIFFERENCE. (Z989)

THIS CLAIM IS AN ADJUSTMENT TO A PREVIOUSLY PROCESSED CLAIM. (Z998)

If you receive such a message, you will need to refund your patient for any amount they overpaid.

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

Enrollment for BCBSM’s new freestanding radiology center network begins on Oct. 1

In the August Record, we explained that Blue Cross Blue Shield of Michigan is establishing a Traditional freestanding radiology center network. Establishing an FRC network allows us to recognize and reimburse freestanding providers of diagnostic imaging services. Members will have access to the new network, beginning Jan. 1, 2015.

After this information is shared with BCBSM’s Professional Provider Relations and Participating Hospital Agreement Advisory committees, enrollment materials will be available on bcbsm.com on Sept. 17, 2014. Eligible FRCs, including those owned by hospitals, may enroll in the BCBSM Traditional FRC network, starting Oct. 1, 2014.

All participating FRCs will be considered in-network for PPO members, and out-of-network sanctions will be waived.

Creation of the FRC network means that:

• BCBSM will designate FRCs as a unique provider type.
• BCBSM will formally contract with FRCs that are eligible to enroll, including those owned by hospitals, for the Traditional program.
• Participating FRCs will be included in provider directories at bcbsm.com and on the Blue Cross and Blue Shield Association^® website.
• BCBSM will list FRC cost information, by procedure, for each of the FRCs in the provider directories.
• FRCs will be reimbursed for all diagnostic imaging services that are covered benefits.
• Participating FRCs will be reimbursed using the BCBSM professional fee schedule. FRCs will not be eligible for the BCBSM Physician Group Incentive Program’s radiologist fee uplifts at this time.

Diagnostic imaging services performed in FRCs will be subject to the current Radiology Management program preauthorization and privileging requirements. (Please note that the Federal Employee Program^® is not subject to the Radiology Management preauthorization process.)

Qualified applicants that are currently enrolled as physician group practices will be asked to terminate their current provider identification number and enroll under a new one. The existing National Provider Identifier will be mapped to the new FRC record.

To apply, log in to the provider portal on bcbsm.com and follow these steps:

• Click on Enrollment and Changes.
• Click on Physicians and Professionals.
• Click on Enroll a new provider.
• Click on Freestanding Radiology Center in the provider type section.

Once you have received your FRC provider PIN, the provider PIN and NPI must be registered with our Electronic Data Interchange department for electronic claims submission. For questions about electronic claim submission or registering your NPI, visit bcbsm.com or call the EDI Help Desk at 1-800-542-0945.

As part of the enrollment process, BCBSM will be using AIM Specialty Health’s OptiNet assessment tool to collect information on our contracted providers’ imaging equipment and staffing credentials. OptiNet is an online tool that enables reporting of accurate and current information about the capabilities of participating imaging facilities and providers. BCBSM will publish more information about the OptiNet tool, provider registration and how to submit information in October.

For more details about the FRC network, please review the August Record article or contact your BCBSM provider consultant.

Reminder: Blues to retire Facility and Provider Claims Correction tool

Blue Cross Blue Shield of Michigan will remove the PCC tool from Provider Secured Services in October 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.

Tamoxifen, raloxifene added to PPACA preventive drug coverage list

Beginning Sept. 30, 2014, generic tamoxifen and raloxifene will be eligible for coverage with no cost-sharing when prescribed for primary prevention of breast cancer in women at high risk. This change affects our commercial health plan members with Blue Cross Blue Shield of Michigan or Blue Care Network prescription coverage.

These additions are recommended by the U.S. Preventive Services Task Force under the Affordable Care Act.

Members must meet plan requirements and a prescription is required for coverage. To request a review for a patient to receive these drugs at $0 copay, prescribers can contact the Pharmacy Clinical Help Desk at 1-800-437-3803. Members can call the Customer Service number on the back of their Blues member ID card. Cost-sharing will continue to apply when these drugs are prescribed as a treatment for breast cancer.

The ACA preventive drug coverage list will be updated on Sept. 30, 2014. To access the ACA preventive drug coverage list, please click here.

We have new quantity limits for 2 opioid medications

On Sept. 2, 2014, Blue Cross Blue Shield of Michigan will implement new quantity limits for the following drugs:

The new limits apply to all strengths of the generic and brand-name versions of these drugs. This change will only affect BCBSM commercial (non-Medicare) members who have BCBSM pharmacy benefits that include quantity limits. It doesn’t apply to MESSA members.

As always, our goal is to provide our members with safe, high-quality prescription drug therapies. We realize that some patients can benefit greatly from the effective pain relief offered by these drugs. However, unsupervised use, misuse or abuse of prescription painkillers can lead to addiction, hospitalization and even death.

We began sending letters to notify members who may be affected by these quantity limit changes in August. The letters encourage them to discuss treatment options with their physicians.

If necessary, you can request an override for the quantity limits for your patients. The request will need to include documentation that the amount prescribed is medically necessary.

To obtain the form that requests a quantity limit override, log in as a provider at bcbsm.com or call the Pharmacy Services Clinical Help Desk at 1-800-437-3803.

If you have any questions about this program, contact the Pharmacy Services Clinical Help Desk.

Here’s how to file ancillary claims

In November 2013, we updated you on the Blue Cross and Blue Shield Association’s mandate for reporting ancillary laboratory and DME claims. We continue to get inquiries on how these claims should be reported and whom you should contact when you have questions. The information below should assist you.

In general, health care providers should file claims for services rendered to Blue Cross Blue Shield members with the member’s local Blue plan. However, some special rules apply when filing ancillary claims for laboratory, durable medical equipment and specialty pharmacy services.

The Blue Cross and Blue Shield Association has mandated that BlueCard^® ancillary claims for laboratory, DME and specialty pharmacy services must be filed in the state where the referring provider resides. Here are additional details.

Independent clinical laboratory services — Claims for laboratory services must be billed to the Blue plan in the state where the referring provider resides.

Durable medical equipment — Regardless of where the order for the equipment was originated, the claim must be reported to the plan where the equipment was shipped to (use location 12-home) or purchased at (use location 11-office), if bought at a retail store.

Specialty pharmacy — This is a pharmacy that provides non-routine, biological therapeutics, ordered by a health care professional, and covered as a medical benefit, as defined by the plan’s specialty pharmacy formulary, or drug list. A specialty pharmacy generally offers injectables and infusion therapies, high-cost therapies and therapies requiring complex care. Specialty pharmacy claims should be filed with the plan where the ordering physician is located.

You can find a list of plan addresses on web-DENIS by following these steps:

• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters and Resources.
• Click on Other BCBS Plan Claim Addresses under Operations and Training.

When there are multiple Blue plans within a state
Some providers may not be sure where to submit ancillary claims when there are multiple plans operating within a state, such as in New York, Pennsylvania and California. In these instances, providers should file the claim with the plan where the referring provider is registered. If you’re unsure of where the referring provider is registered, contact our Provider Inquiry department, which can help you determine where to file the claim.

When a claim is rejected
If you’re the billing provider and you receive a claim rejection advising you to report the claim to your home plan — and you believe you had filed the claim correctly with the appropriate plan — contact Provider Inquiry to assist you. If you have any further concerns, please contact your provider consultant.

To read more about BlueCard, see this month’s installment in our BlueCard series, also in this issue.

Note added to Max Fee for a Code feature on web-DENIS

Beginning in September 2014, the web-DENIS display for the Max Fee for a Code feature will include a note about national drug code pricing.

This change explains that Healthcare Common Procedure Coding System and Current Procedural Terminology codes subject to NDC pricing will display a value that represents the minimum fee. The change was made to align the code look-up feature with the information posted in fee schedules.

Starting Sept. 1, 2014, our display will show the following:
                                       
Max Fee for a Code – Allows access to Max Fees for a procedure code.
NOTE: For codes eligible for NDC pricing (see Injection Fee Schedule and DME/P&O Fee Schedule), the statewide Price Values returned represent the Minimum Fee.

For more information, refer to The Record articles in the following issues:

• September 2013 Record
• October 2013 Record
• July 2014 Record

Here’s a screen shot of the current display:

ACA’s wellness regulations may cause some claims to be reprocessed

Under the terms of the Affordable Care Act, individuals enrolled in wellness programs — such as Blue Cross Blue Shield of Michigan’s Healthy Blue Incentives and Healthy Blue Achieve — must be able to receive the full benefit of program rewards for the entire benefit year.

That means that members who began the year at the standard benefit level but subsequently met the product requirements would be shifted to the enhanced benefit level, retroactive to the first day of the group’s benefit year. For members who have the Healthy Blue Incentives product, all claims incurred during the first six months of the group’s benefit year will be reprocessed at the enhanced benefit level if the member met the product requirements.

Note: A similar approach to claims processing for members with the Healthy Blue Achieve product will begin in the second quarter of 2015.

Following are examples of adjustment reason messages that may appear on your voucher if adjustments need to be made:

WE PREVIOUSLY PAID $42.30 FOR THIS CLAIM. THE CORRECT PAYMENT SHOULD HAVE BEEN $58.33. AN ADDITIONAL PAYMENT HAS BEEN MADE FOR THE DIFFERENCE. (Z989)

THIS CLAIM IS AN ADJUSTMENT TO A PREVIOUSLY PROCESSED CLAIM. (Z998)

If you receive such a message, you will need to refund your patient for any amount they overpaid.

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

Enrollment for BCBSM’s new freestanding radiology center network begins on Oct. 1

In the August Record, we explained that Blue Cross Blue Shield of Michigan is establishing a Traditional freestanding radiology center network. Establishing an FRC network allows us to recognize and reimburse freestanding providers of diagnostic imaging services. Members will have access to the new network, beginning Jan. 1, 2015.

After this information is shared with BCBSM’s Professional Provider Relations and Participating Hospital Agreement Advisory committees, enrollment materials will be available on bcbsm.com on Sept. 17, 2014. Eligible FRCs, including those owned by hospitals, may enroll in the BCBSM Traditional FRC network, starting Oct. 1, 2014.

All participating FRCs will be considered in-network for PPO members, and out-of-network sanctions will be waived.

Creation of the FRC network means that:

• BCBSM will designate FRCs as a unique provider type.
• BCBSM will formally contract with FRCs that are eligible to enroll, including those owned by hospitals, for the Traditional program.
• Participating FRCs will be included in provider directories at bcbsm.com and on the Blue Cross and Blue Shield Association^® website.
• BCBSM will list FRC cost information, by procedure, for each of the FRCs in the provider directories.
• FRCs will be reimbursed for all diagnostic imaging services that are covered benefits.
• Participating FRCs will be reimbursed using the BCBSM professional fee schedule. FRCs will not be eligible for the BCBSM Physician Group Incentive Program’s radiologist fee uplifts at this time.

Diagnostic imaging services performed in FRCs will be subject to the current Radiology Management program preauthorization and privileging requirements. (Please note that the Federal Employee Program^® is not subject to the Radiology Management preauthorization process.)

Qualified applicants that are currently enrolled as physician group practices will be asked to terminate their current provider identification number and enroll under a new one. The existing National Provider Identifier will be mapped to the new FRC record.

To apply, log in to the provider portal on bcbsm.com and follow these steps:

• Click on Enrollment and Changes.
• Click on Physicians and Professionals.
• Click on Enroll a new provider.
• Click on Freestanding Radiology Center in the provider type section.

Once you have received your FRC provider PIN, the provider PIN and NPI must be registered with our Electronic Data Interchange department for electronic claims submission. For questions about electronic claim submission or registering your NPI, visit bcbsm.com or call the EDI Help Desk at 1-800-542-0945.

As part of the enrollment process, BCBSM will be using AIM Specialty Health’s OptiNet assessment tool to collect information on our contracted providers’ imaging equipment and staffing credentials. OptiNet is an online tool that enables reporting of accurate and current information about the capabilities of participating imaging facilities and providers. BCBSM will publish more information about the OptiNet tool, provider registration and how to submit information in October.

For more details about the FRC network, please review the August Record article or contact your BCBSM provider consultant.

Reminder: Blues to retire Facility and Provider Claims Correction tool

Blue Cross Blue Shield of Michigan will remove the PCC tool from Provider Secured Services in October 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.

Tamoxifen, raloxifene added to PPACA preventive drug coverage list

Beginning Sept. 30, 2014, generic tamoxifen and raloxifene will be eligible for coverage with no cost-sharing when prescribed for primary prevention of breast cancer in women at high risk. This change affects our commercial health plan members with Blue Cross Blue Shield of Michigan or Blue Care Network prescription coverage.

These additions are recommended by the U.S. Preventive Services Task Force under the Affordable Care Act.

Members must meet plan requirements and a prescription is required for coverage. To request a review for a patient to receive these drugs at $0 copay, prescribers can contact the Pharmacy Clinical Help Desk at 1-800-437-3803. Members can call the Customer Service number on the back of their Blues member ID card. Cost-sharing will continue to apply when these drugs are prescribed as a treatment for breast cancer.

The ACA preventive drug coverage list will be updated on Sept. 30, 2014. To access the ACA preventive drug coverage list, please click here.

Retail health clinics will be considered in-network for URMBT’s Traditional, PPO groups, beginning Jan. 1

Effective Jan. 1, 2015, the UAW Retiree Medical Benefits Trust will cover medical claims for services performed at retail health clinics. These clinics will be considered in-network for URMBT’s Traditional and PPO members. Providers should only bill for the services allowed within their scope of practice.

It’s also important to note that:

• Vaccines and vaccine-related administration services at retail health clinics will be covered at 100 percent if they are submitted as a separate claim.

• Vaccines and vaccine-related administration services billed with other services at retail health clinics will be subject to copays.

We’ll be providing more detailed information on this topic in The Record later this year.

Tamoxifen, raloxifene added to PPACA preventive drug coverage list

Beginning Sept. 30, 2014, generic tamoxifen and raloxifene will be eligible for coverage with no cost-sharing when prescribed for primary prevention of breast cancer in women at high risk. This change affects our commercial health plan members with Blue Cross Blue Shield of Michigan or Blue Care Network prescription coverage.

These additions are recommended by the U.S. Preventive Services Task Force under the Affordable Care Act.

Members must meet plan requirements and a prescription is required for coverage. To request a review for a patient to receive these drugs at $0 copay, prescribers can contact the Pharmacy Clinical Help Desk at 1-800-437-3803. Members can call the Customer Service number on the back of their Blues member ID card. Cost-sharing will continue to apply when these drugs are prescribed as a treatment for breast cancer.

The ACA preventive drug coverage list will be updated on Sept. 30, 2014. To access the ACA preventive drug coverage list, please click here.

The Blues to begin formal participation review process for pharmacies

Blue Cross Blue Shield of Michigan and Blue Care Network are dedicated to making sure participating pharmacies meet and maintain credentialing requirements. Currently, pharmacies must undergo an initial credentialing and contracting process to determine if we’ll participate with them.

The Blues are beginning a formal continuing participation verification review process, which will allow us to monitor information on file for pharmacies during their participation term. This will ensure that we have the most current and accurate information on file.

The process will also provide a more structured and timely review of pharmacy network provider information and ensure compliance with the Blues’ pharmacy contracts.

All pharmacies will be required to verify certain information in order to participate with us. The process will occur approximately every two years, depending on the pharmacy’s licensing renewal date.

We’ll let pharmacies know when their verification process will begin and will send a participation packet in the mail. Pharmacies will be required to complete the new application form and provide the following documents within 30 days of receiving the packet:

• Pharmacy license
• Pharmacy’s liability insurance certificate
• DEA license
• Pharmacists’ license (owner and dispensing)
• Pharmacy’s certificate of occupancy (if it isn’t already on file for current location)
• Complete list of pharmacy owners

We advise to have these documents readily available prior to receiving the participation packet. For questions regarding this process, please send an email to pharmacynetworkadmin@bcbsm.com.

We have new quantity limits for 2 opioid medications

On Sept. 2, 2014, Blue Cross Blue Shield of Michigan will implement new quantity limits for the following drugs:

The new limits apply to all strengths of the generic and brand-name versions of these drugs. This change will only affect BCBSM commercial (non-Medicare) members who have BCBSM pharmacy benefits that include quantity limits. It doesn’t apply to MESSA members.

As always, our goal is to provide our members with safe, high-quality prescription drug therapies. We realize that some patients can benefit greatly from the effective pain relief offered by these drugs. However, unsupervised use, misuse or abuse of prescription painkillers can lead to addiction, hospitalization and even death.

We began sending letters to notify members who may be affected by these quantity limit changes in August. The letters encourage them to discuss treatment options with their physicians.

If necessary, you can request an override for the quantity limits for your patients. The request will need to include documentation that the amount prescribed is medically necessary.

To obtain the form that requests a quantity limit override, log in as a provider at bcbsm.com or call the Pharmacy Services Clinical Help Desk at 1-800-437-3803.

If you have any questions about this program, contact the Pharmacy Services Clinical Help Desk.

Here’s how to file ancillary claims

In November 2013, we updated you on the Blue Cross and Blue Shield Association’s mandate for reporting ancillary laboratory and DME claims. We continue to get inquiries on how these claims should be reported and whom you should contact when you have questions. The information below should assist you.

In general, health care providers should file claims for services rendered to Blue Cross Blue Shield members with the member’s local Blue plan. However, some special rules apply when filing ancillary claims for laboratory, durable medical equipment and specialty pharmacy services.

The Blue Cross and Blue Shield Association has mandated that BlueCard^® ancillary claims for laboratory, DME and specialty pharmacy services must be filed in the state where the referring provider resides. Here are additional details.

Independent clinical laboratory services — Claims for laboratory services must be billed to the Blue plan in the state where the referring provider resides.

Durable medical equipment — Regardless of where the order for the equipment was originated, the claim must be reported to the plan where the equipment was shipped to (use location 12-home) or purchased at (use location 11-office), if bought at a retail store.

Specialty pharmacy — This is a pharmacy that provides non-routine, biological therapeutics, ordered by a health care professional, and covered as a medical benefit, as defined by the plan’s specialty pharmacy formulary, or drug list. A specialty pharmacy generally offers injectables and infusion therapies, high-cost therapies and therapies requiring complex care. Specialty pharmacy claims should be filed with the plan where the ordering physician is located.

You can find a list of plan addresses on web-DENIS by following these steps:

• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters and Resources.
• Click on Other BCBS Plan Claim Addresses under Operations and Training.

When there are multiple Blue plans within a state
Some providers may not be sure where to submit ancillary claims when there are multiple plans operating within a state, such as in New York, Pennsylvania and California. In these instances, providers should file the claim with the plan where the referring provider is registered. If you’re unsure of where the referring provider is registered, contact our Provider Inquiry department, which can help you determine where to file the claim.

When a claim is rejected
If you’re the billing provider and you receive a claim rejection advising you to report the claim to your home plan — and you believe you had filed the claim correctly with the appropriate plan — contact Provider Inquiry to assist you. If you have any further concerns, please contact your provider consultant.

To read more about BlueCard, see this month’s installment in our BlueCard series, also in this issue.

Note added to Max Fee for a Code feature on web-DENIS

Beginning in September 2014, the web-DENIS display for the Max Fee for a Code feature will include a note about national drug code pricing.

This change explains that Healthcare Common Procedure Coding System and Current Procedural Terminology codes subject to NDC pricing will display a value that represents the minimum fee. The change was made to align the code look-up feature with the information posted in fee schedules.

Starting Sept. 1, 2014, our display will show the following:
                                       
Max Fee for a Code – Allows access to Max Fees for a procedure code.
NOTE: For codes eligible for NDC pricing (see Injection Fee Schedule and DME/P&O Fee Schedule), the statewide Price Values returned represent the Minimum Fee.

For more information, refer to The Record articles in the following issues:

• September 2013 Record
• October 2013 Record
• July 2014 Record

Here’s a screen shot of the current display:

Insulin pumps can now be billed with National Drug Code

Effective Sept. 1, 2014, Blue Cross will allow DME providers that bill for insulin pumps (procedure code E0784) to report the National Drug Code in addition to the Healthcare Common Procedure Coding System code, known as HCPCS, for the item being supplied. Billing with the NDC eliminates the need to send in a copy of the manufacturer’s invoice and allows claims to be submitted electronically. However, you can continue to bill these claims with the manufacturer’s invoice as you do today.

The NDC is available on the packaging label or from the wholesaler.

Submitting the NDC on claims
Here are some general guidelines to assist you with proper submission of valid NDCs and related information on professional claims:

• The NDC must be submitted along with the applicable HCPCS code.
• The NDC must follow the “5digit4digit2digit” format (11 numeric characters with no spaces or special characters). If the NDC on the package label is fewer than 11 digits, you must add zeroes. See the chart below.

• The NDC must be active for the date of service.
• To submit electronic claims in the American National Standards Institute format (ANSI 837P format), report the following information:

• To submit paper claims, enter the NDC information in field 24 of the CMS-1500 claim form. In the shaded portion of field 24A-24G, enter the qualifier “N4” left-justified, immediately followed by the national drug code. Next, enter the appropriate qualifier for the correct dispensing unit, followed by the quantity, as indicated in the example below.

The format for billing should be:

N4 + NDC code + three spaces + unit of measure + quantity

Example: N476300075115   UN1

Contact your provider consultant if you have any questions.

Retail health clinics will be considered in-network for URMBT’s Traditional, PPO groups, beginning Jan. 1

Effective Jan. 1, 2015, the UAW Retiree Medical Benefits Trust will cover medical claims for services performed at retail health clinics. These clinics will be considered in-network for URMBT’s Traditional and PPO members. Providers should only bill for the services allowed within their scope of practice.

It’s also important to note that:

• Vaccines and vaccine-related administration services at retail health clinics will be covered at 100 percent if they are submitted as a separate claim.

• Vaccines and vaccine-related administration services billed with other services at retail health clinics will be subject to copays.

We’ll be providing more detailed information on this topic in The Record later this year.

United Auto Workers group undergoes recovery and adjustments

The UAW Staff group, with approximately 750 retired members who have concurrent UAW Retiree Medical Benefits Trust coverage, is undergoing a massive recovery and adjustment effort because of incorrectly processed claims.

BCBSM is in the process of reprocessing the claims and fixing the system. We’ve corrected the error manually and have been reprocessing claims since March 1, 2014.

As a result, providers will be receiving payments by check. Please work with UAW members to reimburse them for any monies they are owed.

The recovery includes claims received by Aug. 1, 2013, through March 1, 2014.

BCBSM Medicare Advantage PPO will update its physician office lab list

Blue Cross Blue Shield of Michigan will update its Medicare Advantage PPO Physician Office Lab List on or after Oct. 29, 2014, to more accurately reflect currently recognized codes and procedures.

The list is housed on the Medicare Advantage section of BCBSM’s provider website at bcbsm.com/provider/ma. To find the list:

• Click on Medicare Plus Blue.
• Click on Provider Toolkit.
• Under “Coverage Details,” clickon Medicare Advantage PPO lab network.
• You can find the list near the bottom of the page.

Keep the following in mind:

• Providers who render lab services that aren’t on this list will not be paid.
• BCBSM Medicare Advantage PPO members cannot be billed for a lab service that isn’t on this list.
• Providers must have the appropriate complexity level of certification required to perform and bill applicable procedures.

Among the key changes are:

• Seventeen procedure codes will be deleted.
• Forty procedure codes will be added.
• Some of the new codes added will include select provider-performed microscopy procedures and two blood count codes.

In the meantime, you can continue to use the current Medicare Advantage Physician Office Lab List. If you have any questions, please contact your provider consultant.

Clarification: Two-midnight rule and related changes for BCBSM Medicare Advantage PPO

In the February 2014 Record, Blue Cross Blue Shield of Michigan announced its intent to align with the Centers for Medicare & Medicaid Services in implementing Medicare 2014 inpatient rule changes for Medicare Advantage PPO plans, including the two-midnight rule, effective April 1, 2014.

Following that announcement, Blue Cross received numerous requests from providers for additional information. The following are answers to the most frequently asked questions:

1. Why do hospitals have to complete prenotification if the case meets criteria for medical necessity and the stay is greater than two midnights?
   
   Blue Cross Medicare Advantage PPO plans contractually require participating Medicare Advantage providers to submit prenotification of all acute inpatient hospital admissions. The physician’s decision to admit a patient should be based on medical necessity and follow the CMS guidelines for an inpatient stay. Blue Cross Medicare Advantage PPO plans use the admission information supplied by the hospitals to promote the highest quality of care for members by referring appropriate cases to our wellness and care management programs when appropriate. This also helps ensure seamless transitions from the inpatient setting back home or to an alternate level of care.
   
   
2. Should hospitals wait until the second day of a stay to review cases to ensure the patient stayed two midnights and met the InterQual criteria for an inpatient stay? Would waiting affect our prenote reporting?

Hospitals should continue to review cases according to their established schedule and process while providing Blue Cross with timely prenotification of medically necessary inpatient admissions. The expectation that providers use web-DENIS to promptly notify Blue Cross of inpatient admissions has not changed.

As stated in the 2014 Inpatient Prospective Payment System final rule issued by CMS, if the order is not properly documented in the medical record, the hospital should not submit a claim for Part A payment (78 FR 50941). Meeting the two-midnight benchmark does not, in itself, render a beneficiary an inpatient or qualify that beneficiary for payment under Part A. Rather, as provided in CMS regulations, a beneficiary is considered an inpatient (and Part A payment may only be made) if that beneficiary is formally admitted pursuant to an order for inpatient admission by a physician or other appropriate practitioner. 

3. We have a patient who was admitted as an inpatient but did not meet the InterQual criteria for an inpatient stay. Our physician advisor reviewed the case and recommended observation status, but the attending physician would not change the order. What can we do?

Blue Cross does not engage in the hospital’s management of disagreements between its physicians. The CMS regulations specify that the decision to admit should generally be based on the treating physician’s reasonable expectation of a length of stay spanning two or more midnights, taking into account complex medical factors that must be documented in the medical record. Because this is based upon the physician’s expectation, as opposed to a retroactive determination based on actual length of stay, unforeseen circumstances that result in a shorter stay than the physician’s reasonable expectation may still result in a hospitalization that is appropriately considered inpatient. In accordance with the Blue Cross Medicare Advantage PPO provider manual, if a doctor is overriding InterQual inpatient criteria, then the hospital must provide the doctor’s name and phone number in the prenote documentation.

If the physician is unable to determine, when the beneficiary arrives at the hospital, whether he or she will require two or more midnights of hospital care, the physician may order observation services and reconsider providing an order for inpatient admission at a later point in time.

In considering stays lasting less than two midnights following formal inpatient admission (i.e., those stays not receiving presumption of inpatient medical necessity), the reasonableness of the physician's expectation of the need for and duration of care must be clearly documented in the medical record. These reasons should be based on complex medical factors, such as history and comorbidities, the severity of signs and symptoms, current medical needs and the risk of an adverse event.

4. Under the new CMS guidance, will all inpatient stays of less than two midnights after formal inpatient admission be automatically denied?

No. Under the CMS guidelines, there will still be services payable under Part A in a number of instances for inpatient stays less than two total midnights after formal inpatient admission. Hospitals should focus their attention on short (0-1 total days) stays (without death, transfer, discharge against advice, an inpatient-only service or a preceding outpatient stay over midnight) to ensure that the physician clearly expected a longer stay, the discharge was unexpected, or some other rare and unusual circumstance supports that the Part A claims represent appropriate, payable inpatient services. For example:

• There will be cases where the physician had a reasonable expectation of a two-midnight stay, but there was an unforeseen circumstance that resulted in a shorter stay than the physician’s reasonable expectation.
• If the beneficiary received a medically necessary service on the Inpatient-Only List and was able to be discharged before two midnights passed, those claims would be appropriately inpatient for Part A payment.
• Inpatient claims for patients who unexpectedly improved and were discharged in less than two midnights would be payable as long as the medical record clearly demonstrated that the admitting physician had reasonable expectation of a two-midnight stay and the improvement that allowed an earlier discharge was clearly unexpected.

For more information, please refer to Q4.9 on Page 14 of the CMS frequently-asked-questions document**.

5. Are hospitals allowed to change an inpatient stay to observation status after discharge?
   
   Yes. In cases where a hospital determines that an inpatient admission does not meet the hospital’s inpatient criteria, prior to submission of a claim, the hospital may change the beneficiary’s status from inpatient to outpatient and submit an outpatient claim (bill type 13x or 85x) for medically necessary Medicare Part B services that were furnished to the beneficiary, provided all the following conditions are met:
• The hospital has not submitted a claim to Medicare for the inpatient admission.
• The practitioner responsible for the care of the patient (and the Utilization Review committee, if applicable) concur with the decision.
• The concurrence of the practitioner responsible for the care of the patient (and the UR committee, if applicable) is documented in the patient’s medical record.

This change in status is typically billed with condition code “44.” Blue Cross Medicare Advantage PPO plans have waived the requirement that the change in patient status from inpatient to outpatient must be made while the beneficiary is still a patient of the hospital, prior to discharge or release.
When an inpatient claim has already been denied by Medicare and the hospital loses an appeal, or decides not to appeal, it may rebill for Part B services which are medically necessary. The hospital can also bill for the services provided as an outpatient during the three-day window. Hospitals submitting Part B inpatient claims in these situations need to include condition code “W2” on the rebilled claim.

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Reminder: BCBSM Medicare Advantage PPO processing system for pre-2013 claims to shut down

BCBSM’s Medicare Advantage PPO’s claim processing system for claims with dates of service before 2013 will shut down Dec. 31, 2014.

To avoid any claims processing problems, be sure to submit any adjustment requests for claims for services provided prior to Jan. 1, 2013, as soon as possible.

Also, if you discover an overpayment and the date of service is before Dec. 31, 2012, send a check with the applicable member and claims information to:

Senior Business Division
Blue Cross Blue Shield of Michigan
P.O. Box 441187
Detroit, MI 48244-1187