We’re preparing to launch new local network called Metro Detroit EPO

The Blues are partnering with health care providers in Southeast Michigan to offer cost-conscious consumers affordable, coordinated care through localized networks.

The Metro Detroit exclusive provider organization, or EPO, network includes 25 hospitals and more than 6,300 doctors located in Livingston, Macomb, Oakland, St. Clair, Washtenaw and Wayne counties. It’s part of our ongoing efforts to increase access to high-quality, lower cost health care for Michigan residents.

There is also a new Metro Detroit HMO that Blue Care Network is offering in three counties: Oakland, Macomb and Wayne. See November-December issue of BCN Provider News for complete details.

Here are three important points to keep in mind:

• Other than eligible emergency services and accidental injuries, members who have enrolled in a Metro Detroit EPO plan do not have coverage if they visit a doctor that is outside the network.
• Be sure to always refer members to health care providers that are in the Metro Detroit EPO network . You can use the Find a Doctor search tool on bcbsm.com to verify that a doctor or hospital is in this network.
• Be sure your office staff knows if you are in this localized network.

Participating hospitals include:

• Detroit Medical Center
• DMC – Sinai Grace
• DMC – Rehab Institute of Michigan
• DMC – Huron Valley Sinai
• DMC – Children’s Hospital
• DMC – Harper-Hutzel
• DMC – Detroit Receiving

• Oakwood Healthcare
• Oakwood Hospital Dearborn
• Oakwood Hospital Southshore
• Oakwood Hospital Taylor
• Oakwood Hospital Wayne

• St. John Providence Health System
• St. John Macomb – Oakland Hospital Macomb Center
• St. John Macomb – Oakland Hospital Oakland Center
• St. John River District Hospital
• St. John Hospital and Medical Center
• Providence Park Hospital
• Providence Hospital

• Saint Joseph Mercy Health System/CHE Trinity Health
• St. Joseph Mercy – Oakland
• St. Joseph Mercy – Ann Arbor
• St. Joseph Mercy – Livingston
• St. Mary Mercy Hospital – Livonia
• St. Joseph Mercy Chelsea

• Botsford Hospital
• Garden City Hospital
• Stonecrest Center for Behavioral Health
• Straith Hospital for Special Surgery

Product names include:

• Blue Cross^® Metro Detroit EPO Gold Extra
• Blue Cross^® Metro Detroit EPO Silver Extra
• Blue Cross^® Metro Detroit EPO Silver
• Blue Cross^® Metro Detroit EPO Bronze Extra
• Blue Cross^® Metro Detroit EPO Bronze

These products will be available to consumers beginning Nov. 15, when open enrollment begins, for coverage effective Jan. 1, 2015. They can be purchased on the Health Insurance Marketplace** and directly through BCBSM or independent insurance agents.

**Blue Cross Blue Shield of Michigan does not control this website or endorse its general content.

The Blues to offer a variety of individual products for 2015

When the Health Insurance Marketplace opens on Nov. 15, Blue Cross Blue Shield of Michigan and Blue Care Network and will have many new products available for coverage beginning Jan. 1, 2015, or later.

The Blues are offering 41 individual products, 24 of which are BCN HMO plans and 17 of which are Blue Cross PPO plans. Keep in mind that some plans are closing.

Note: Blue Care of Michigan’s Personal Plus^SM will remain open in 2015, but it will not be available to new contracts.

Plans that are being discontinued

• BCBSM’s Keep Fit^SM will no longer be offered. Keep Fit members will need to have purchased another individual plan that becomes effective January 2015.
• Blue Cross Partnered Value and Blue Cross Preferred Value plans will be discontinued, effective Dec. 31, 2014.

New plans for 2015

• Blue Cross^® Metro Detroit EPO — an exclusive provider organization in six counties offered by Blue Cross (For more information, see article titled “We’re preparing to launch new local network called Metro Detroit EPO,” also in this issue.)
• Blue Cross^® Metro Detroit HMO — a local network HMO in three counties offered by Blue Care Network. Members must reside in Wayne, Oakland or Macomb counties (For more information, see the November-December issue of BCN Provider News.
• New “Extra” plans — plans that include a basic individual product benefit design plus the following:
• The plan pays the first four specialist office visits per member before the deductible; copayments will apply.
• The plan pays Tier 1A and Tier 1B generic prescription drugs before the deductible; copays will apply.

Highlights of cost-sharing changes for the “Extra” plans include:

• Simplified cost sharing — Copays have been removed for imaging services (such as CT scans, PET scans and MRIs) and outpatient mental health and substance abuse.
• Inpatient copay — No $500 copay for a stay in a hospital, mental health, substance abuse or skilled nursing facility. Also, no copay for delivery and all inpatient maternity services. Coinsurance will continue to apply.
• Office visits — Primary care physician office copay is reduced to $20 for Silver and Gold Extra plans. For Bronze Extra plans, the primary care physician office copay is $40 and the specialist office copay is $75. (Applies to Blue Care Network only)

Blue Cross will continue to offer the Premier and Multi-State PPO. The plan gives members a broad choice of doctors and hospitals in the Blue Cross statewide PPO network, including nationwide coverage. Members may receive services from hospitals or doctors outside the network, but will pay less if they use in-network providers.

New Medicare Advantage product

BCN Advantage^SM ConnectedCare HMO is a new individual Medicare Advantage HMO product with an exclusive provider network developed primarily around Southeast Michigan and Kalamazoo County. Open enrollment for Medicare Advantage^SM began on Oct. 1, 2014 for a Jan. 1, 2015 effective date. (For details about BCN Advantage^SM ConnectedCare HMO, see the November-December issue of BCN Provider News.

Check member eligibility and benefits

Providers should be sure to check eligibility and benefits before providing services. It’s important to check both the plan name and the network associated with the plan. For local plans, such as the Metro Detroit EPO or HMO, you should always refer within the local network.

Finding your Blues plans and provider networks

For information about how to find the Blues plans you’re contracted to provide services for, check out the new document that’s been posted on web-DENIS:

• From the web-DENIS homepage, click on BCBSM Provider Publications and Resources.
• Click on Newsletters & Resources.
• Click on Finding Blues plans and networks at the top of the page.

Register today for Nov. 5 webinar

As you read in the October Record, Blue Cross Blue Shield of Michigan is conducting a series of educational webinars for health care providers to discuss two pharmacy topics related to Medicare star ratings.

Blue Cross is hosting a webinar on Nov. 5 titled “Clinical considerations for the use of skeletal muscle relaxants in patients 65 years and older.” The speaker will be Carl Christensen, M.D., Ph.D., a board-certified OB/GYN.

The 30-minute webinar will begin at 7:30 a.m. and be followed by a question-and-answer session. We’ll also provide you with an email address in case you have additional questions following the webinar.

To register, send an email to 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. For technical issues or questions, call the BCBSM Web Support Help desk at 1-877-258-3932.

Keep these coding tips for airway-related conditions in mind to improve medical record documentation

This is part of an ongoing series of articles on coding tips.

The overlap in terminology used to define airway-related conditions, such as chronic obstructive pulmonary disease, asthma, emphysema and chronic bronchitis, can often be confusing. The appropriate terminology for these conditions can best be determined through the careful use of the ICD-9-CM Alphabetic Index.

Two particularly challenging conditions for coders are COPD and asthma. Although both share airway obstruction as a common feature, they’re at different ends of the clinical spectrum. However, the two conditions may overlap in many patients late in life.

Asthma often develops during childhood and can cause temporary airway obstruction. It’s often caused by allergies, too. In contrast, COPD usually develops later in life, is often related to smoking, and causes permanent airway obstruction. The two main forms of COPD are emphysema and chronic bronchitis. Asthma and COPD can often overlap, especially in elderly patients who might be affected by both diseases.

In 1990, a new subclassification was created for this condition, called chronic obstructive asthma (493.2X). Other nomenclature for this condition includes asthma with COPD and chronic asthmatic bronchitis. The condition can also be reported whenever a diagnosis of asthma is documented with COPD, whether or not the provider documents chronic obstructive asthma (Coding Clinic, 2Q, 1990, pg. 20).

Careful attention should be paid to documentation for a patient with a form of COPD and asthma. Here’s an example of how to assign documentation codes for a patient who is affected by both conditions:

Assessment

• Acute exacerbation of COPD
• Acute bronchitis
• Acute exacerbation of asthma

Report diagnosis code 491.22 for the acute exacerbation of COPD with acute bronchitis. Assign code 493.22 for the acute exacerbation of asthma.

There’s a note under subclassification 491.21 (obstructive chronic bronchitis with acute exacerbation) that excludes chronic obstructive asthma with acute exacerbation. In this case, the note indicates that the terms excluded from the code are to be coded elsewhere.

The asthma category includes the following codes:

A fifth digit is required for subcategories 493.0, 493.1, 493.2 and 493.9. The fifth digits for asthma include:

According to the ICD-9-CM guidelines, acute exacerbation of asthma is an increased severity of the asthma symptoms, such as wheezing and shortness of breath. Status asthmaticus is defined as a patient’s failure to respond to therapy administered during an asthmatic episode and is a life-threatening complication that requires emergency care.

Coding guidelines also indicate that if status asthmaticus is documented by the provider with any type of COPD or with acute bronchitis, the status asthmaticus should be listed first.

For more information about coding COPD, refer to the November 2013 Record article.

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

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

Procedure code S2083 considered inclusive when reported with *43770 or *43771

When procedure code S2083 is billed within the post-operative period assigned to procedure codes *43770 or *43771, it is considered inclusive.

That means that Blue Cross Blue Shield of Michigan will not pay for this procedure separately if it is considered an integral part of the principal procedure being performed.

This payment policy is aligned with the standard of care for these services.

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.

PGIP expands number of specialty types eligible for fee uplifts in 2015

Since 2012, Blue Cross Blue Shield of Michigan’s Physician Group Incentive Program has continually expanded the number of specialty types eligible for fee uplifts. Our efforts support the transition from a payment approach based solely on fee-for-service to an approach that layers fee-for-value upon the fee-for-service foundation.

Beginning in 2015, PGIP member practices in the following specialties will be considered for fee uplifts:

MDs and DOs in other specialty areas not identified above (such as, but not limited to, addiction medicine**, sports medicine, occupational medicine**, sleep medicine** and urgent care**) will also be considered for fee uplifts. Anesthesiologists will not be eligible for fee uplifts at this time.

**Denotes a new specialty type eligible for fee uplifts in 2015

To receive a fee uplift, the following criteria apply:

• Practitioners must be a member of a PGIP physician organization and participating in PGIP through the physician organization as of July 1, 2014.
• At least one PGIP physician organization (or two in some cases) must have nominated each specialty practice by Oct. 13, 2014.
• Once nominated, specialist practices must meet performance metric rankings developed by Blue Cross Blue Shield of Michigan.

PGIP POs may nominate specialist practices that:

• Include at least one practitioner from one or more of the eligible specialties
• Have signed a Primary Care-Specialist Agreement with the PO
• Have displayed a high level of engagement with the PO
• Are actively involved in managing and optimizing the use of services and quality of care
• Are partnering with primary care physicians to improve care processes and coordination

Nomination is a necessary, but not sufficient, factor for receipt of the fee uplifts. Blue Cross uses population-based, specialty-specific measures of performance to rank and select the nominated specialist practices to receive the fee uplifts.

More than 5,000 specialists are receiving fee uplifts in 2014. With the rapid growth in the number of specialists who have joined PGIP and the expansion of eligible specialty types, we anticipate that over 6,000 specialists will receive fee uplifts in 2015, an increase of more than 20 percent.

The growth in the number of specialists in PGIP is substantial and gratifying. In order to extend the fee uplifts to additional specialty types in 2015, it is necessary to make a slight reduction in the proportion of each specialty type receiving the fee uplifts. In 2015, the top quartile of fully nominated adult specialty practices will receive a 10 percent fee uplift and the second quartile will receive a 5 percent fee uplift. The top half of fully nominated pediatric specialty practices will receive a 10 percent fee uplift and the second half will receive a 5 percent fee uplift.

The selected practices will receive a fee uplift for one year — from Feb. 1, 2015, through Jan. 31, 2016. The nomination and selection process will be repeated annually.

Thinking ahead to 2016, practitioners will need to have been enrolled in PGIP as of summer 2014 to be nominated for a fee uplift that will become effective Feb. 1, 2016. Nominations must occur by the fall of 2015.

The specialist fee uplifts are applied to most procedure codes, except those for ambulance, durable medical equipment, prosthetics and orthotics, anesthesia, immunizations, hearing, routine vision services, non-RVU lab services, dental and most injections.

In addition, the fee uplifts are not applied in the following circumstances:

• Services billed through a BCBSM-participating urgent care center***
• Professional services billed on a facility claim
• Services billed through independent pathology laboratories***
• Services billed through a freestanding radiology center (new network to be launched Jan. 1, 2015)***

***Blue Cross is exploring approaches that would allow for fee uplifts for these services in the future.

Other changes to the specialist fee uplift program in 2015 include the following:

• Oncologists who are not selected for the performance based fee uplifts described above will no longer be eligible for a 5 percent fee uplift based on their participation in the Michigan Oncology Clinical Treatment Pathways Program and the Michigan Oncology Quality Collaborative or certification through the Quality Oncology Practice Initiative. This change is designed to make the fee uplift options available to oncologists more consistent with those offered to other specialty types. 
• The 2 percent fee uplift associated with the Collaborative Quality Initiatives physician recognition program is being discontinued, effective Jan. 31, 2015. Alternate options more suitable for CQI participation and engagement are being considered. More details to come in 2015.

For more information, contact your provider consultant.

Clarification: Here are guidelines for using Advance Notice of Member Responsibility form

We received some questions about the Advance Notice of Member Responsibility policy since writing about it in the September Record. We’d like to provide clarity on the intended use of the Advance Notice of Member Responsibility form and the requirement for using modifiers GY or GZ and GA.

Modifiers GY or GZ are not required for every claim. If you bill for professional services using the GY or GZ modifier, Blue Cross Blue Shield of Michigan requires providers to complete the Advance Notice of Member Responsibility form. The form was recently updated and you can access it through web-DENIS or by clicking here. Once the form is complete, providers are then required to report the GA modifier. Modifier GA acknowledges that the member has signed the form prior to any services rendered and has agreed to accept financial responsibility for the service.

The form and the modifiers work together in this new policy. If the modifiers GY or GZ are not billed, the form is not required. The provider must keep the form in the member's file and provide a copy to the member.

The Advance Notice of Member Responsibility form should not be used and the modifiers should not be reported when it has been verified that a service is not a contract benefit. Providers should follow the normal billing guidelines for a routine system rejection for noncovered group benefits. In addition, the form should not be used and the modifiers should not be reported if the member does not agree to accept financial responsibility. The Advance Notice of Member Responsibility policy does not apply to facility services, MESSA group members, Medicare primary or Medicare Advantage members. It also does not apply in the following scenarios:

• The health care practitioner provides professional services that are not a contract benefit. (The system already has edits to reject as not a benefit.)
• The member refuses to sign the form.
• The provider did not verify coverage.

The Advance Notice of Member Responsibility form is only required when the modifiers GY or GZ and GA are reported for the service. All services reported with modifiers GY or GZ must be reported with a modifier GA in order for the claim to reject as the member responsibility. If the provider reports the GY or GZ modifier alone, the service will be rejected as the provider’s responsibility.

Reminder: BCBSM 101 professional training

We’d like to remind you that BCBSM 101, a training class for new professional billing staff and others looking for a refresher, will be offered in November at four locations across the state (Southfield, Sterling Heights, Grand Rapids and Frankenmuth). The class will provide information on documentation and coding; BlueCard^®; self-help tools, such as web-DENIS and PARS; and other important aspects of working with Blue Cross.

To register, send an email to Jeff Holzhausen at jholzhausen@bcbsm.com. In the subject line, write “New Billing Staff” and the city where you wish to attend the class. Include the class date and the number and names of attendees expected from your office. You’ll receive a confirmation within 72 hours of registering.

It’s important to register so that we have an accurate headcount for lunch. If you register, please make every attempt to attend or send an alternate.

For information on the BCBSM 101 professional training sessions, see the October Record article.

Blue Cross to allow HIT providers to bill daily for continuous infusions, beginning next year

Effective Jan. 1, 2015, Blue Cross Blue Shield of Michigan will allow home infusion therapy providers to bill “S” codes daily for continuous infusions through surgically implanted pumps. Please note that this is a change in the policy reported in an April 2012 article of The Record.

Contact your provider consultant if you have any questions about this policy change.

Enforcement of preauthorization requirements for outpatient hospital procedures takes effect Jan. 1, 2015

As we announced in the August Record, effective Jan. 1, 2015, services requiring preauthorization in the hospital outpatient and ambulatory surgical facility locations will be denied when preauthorization is not obtained by the ordering physician.

Rejections will affect all components of service (global, technical and professional). And members cannot be billed for these denied services.

These changes apply specifically to members enrolled in our Radiology Management Program, inclusive of echocardiography procedures and future implemented preauthorization programs. Future programs include the In-lab Sleep Studies Program, which will be implemented Feb. 1, 2015.

To avoid claims rejections, hospitals should always verify that preauthorization was obtained for services performed in the outpatient setting prior to scheduling the procedure. Once enforcement is implemented, quarterly hospital compliance letters that are currently issued to hospitals will be discontinued.

Services performed as the result of emergency, urgent or observation care — or taking place in the labor room — do not require preauthorization. In these instances, the professional component of the service must be billed with the emergency services or ET modifier so that the preauthorization requirement will be waived.

To verify that a preauthorization was obtained, you can contact AIM one of two ways:

• Access AIM’s online ProviderPortal (aimspecialtyhealth.com/goweb**), which is available 24 hours a day, seven days a week. Providers can register at aimspecialtyhealth.com/goweb**. If you have questions about the registration process, call AIM’s Web Help Desk at 1-800-252-2021.
• Call AIM toll-free at 1-800-728-8008, Monday through Friday from 8 a.m. to 5 p.m., to submit a request or verify that an order number has been issued.

If you have questions about these changes, refer to your provider manual, available on web-DENIS, or contact your provider consultant.

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

Reminder: Hospital reimbursement policy for serious adverse events

As you’ve read previously in The Record, Blue Cross Blue Shield of Michigan and Blue Care Network developed a hospital reimbursement policy for serious adverse events. It has been in effect since Oct. 1, 2008.

Serious adverse events are reasonably preventable conditions that result from medical errors in the hospital or improper hospital care.

Consistent with the Centers for Medicare & Medicaid rulings for discharges on or after Oct. 1, 2008, Blue Cross and BCN do not pay hospitals and physicians for costs incurred when treating a condition that resulting from a serious adverse event.

Note: CMS refers to a serious adverse condition as an HAC, which stands for hospital-acquired condition.

The policy also is consistent with Blue Cross’ existing reimbursement structure under our participating hospital agreements and other health care provider contracts. These agreements and contracts don’t allow payment for medically unnecessary services, regardless of the cause.

Background
Effective Oct. 1, 2008, Blue Cross and Blue Care Network applied the new policy across all health plans. Provisions of the policy include the following:

• Blue Cross and Blue Care Network will no longer reimburse a hospital or physician for costs associated with direct actions resulting in a serious adverse event.
• Serious adverse events covered under the Blue Cross policy are consistent with CMS policy payment for an HAC.
• Participating hospitals are required to report a “present on admission” indicator for all claims.
• Participating hospital and physicians may not “balance bill” members for any incremental costs associated with treatment of a serious adverse event. This policy can’t be changed by any customer.

Submitting codes for serious adverse events
Keep in mind that you must report the appropriate codes for serious adverse events. CMS updates the list yearly. For more information, visit CMS.gov** and type “hospital acquired conditions” in the search bar.

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

FEP^® members’ preferred provider network for behavioral health services changing Jan. 1

The preferred provider network for behavioral health services for Federal Employee Program^® members is changing Jan. 1, 2015. It’s moving from the BCBSM Mental Health and Substance Abuse Managed Care Program network to the TRUST PPO network.

Since the TRUST PPO network is larger than the one that FEP members are currently using, we anticipate that the disruption to FEP members will be minimal.

Health care providers in the Mental Health and Substance Abuse Managed Care Program network who are not in the PPO network will be considered out of network for their FEP patients, starting Jan. 1, 2015. This means that beginning Jan. 1, out-of-network sanctions will apply for FEP members who continue to see behavioral health care providers who are not in the newly designated preferred network.

Note: If you’re eligible and would like to join the TRUST PPO network, please contact your BCBSM provider consultant.

For FEP Standard Option members (enrollment codes 104 and 105), higher cost-sharing will apply for out-of-network services. For FEP Basic Option members (enrollment codes 111 and 112), there is no benefit coverage for out-of-network services.

Behavioral health care providers who will no longer be considered preferred for FEP members should immediately notify their FEP patients of this change to allow them ample time to transition to a preferred provider.

Submit flu shots, other vaccines as medical claims, not pharmacy claims, for Blue Cross non-Medicare members

We recently learned that some pharmacies have been submitting claims for flu shots and other vaccines for Blue Cross Blue Shield of Michigan non-Medicare members as pharmacy claims. Claims for flu shots and other vaccines for Blue Cross non-Medicare members should be submitted as medical (professional) claims.

Only pharmacies that are part of Blue Cross Blue Shield of Michigan’s Vaccine Affiliation Program can submit claims for vaccines to Blue Cross members.

Which members are covered?
Before giving a flu shot, be sure the member has immunization coverage. You can check coverage on web-DENIS or by calling Provider Inquiry at the number listed for your area code.

**Only the following counties within this area code should call this number: Alcona, Alpena, Crawford, Iosco, Montcalm, Montmorency, Ogemaw, Oscoda, Otsego, Presque Isle and Roscommon.

You can use the following procedure codes when checking for coverage.

Submitting claims for flu shots and other vaccines:
Be sure to submit claims for flu shots and other vaccines administered to Blue Cross Blue Shield of Michigan non-Medicare members as medical (professional) claims through the medical claim system used by your pharmacy. You can work with your claim clearinghouse vendor or IT department if you are unsure of how to bill medical claims in your system. Claims for flu shots submitted as a pharmacy service through the pharmacy claim system will not be paid.

For members with Blue Care Network coverage:
For members with BCN commercial coverage, continue to follow the BCN billing process for vaccines.

For Medicare Advantage members:
For members with Medicare Advantage, continue to follow the Medicare Advantage billing process for vaccines.

Chrysler groups to participate in prior authorization program

Beginning Jan. 1, 2015, all Chrysler group segments will participate in the Medical Drug Prior Authorization Program.

Keep in mind that the prior authorization requirement does not apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

The list below reflects all the medications that are part of the Medical Drug Prior Authorization Program.

Enforcement of preauthorization requirements for outpatient hospital procedures takes effect Jan. 1, 2015

As we announced in the August Record, effective Jan. 1, 2015, services requiring preauthorization in the hospital outpatient and ambulatory surgical facility locations will be denied when preauthorization is not obtained by the ordering physician.

Rejections will affect all components of service (global, technical and professional). And members cannot be billed for these denied services.

These changes apply specifically to members enrolled in our Radiology Management Program, inclusive of echocardiography procedures and future implemented preauthorization programs. Future programs include the In-lab Sleep Studies Program, which will be implemented Feb. 1, 2015.

To avoid claims rejections, hospitals should always verify that preauthorization was obtained for services performed in the outpatient setting prior to scheduling the procedure. Once enforcement is implemented, quarterly hospital compliance letters that are currently issued to hospitals will be discontinued.

Services performed as the result of emergency, urgent or observation care — or taking place in the labor room — do not require preauthorization. In these instances, the professional component of the service must be billed with the emergency services or ET modifier so that the preauthorization requirement will be waived.

To verify that a preauthorization was obtained, you can contact AIM one of two ways:

• Access AIM’s online ProviderPortal (aimspecialtyhealth.com/goweb**), which is available 24 hours a day, seven days a week. Providers can register at aimspecialtyhealth.com/goweb**. If you have questions about the registration process, call AIM’s Web Help Desk at 1-800-252-2021.
• Call AIM toll-free at 1-800-728-8008, Monday through Friday from 8 a.m. to 5 p.m., to submit a request or verify that an order number has been issued.

If you have questions about these changes, refer to your provider manual, available on web-DENIS, or contact your provider consultant.

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

Reminder: Hospital reimbursement policy for serious adverse events

As you’ve read previously in The Record, Blue Cross Blue Shield of Michigan and Blue Care Network developed a hospital reimbursement policy for serious adverse events. It has been in effect since Oct. 1, 2008.

Serious adverse events are reasonably preventable conditions that result from medical errors in the hospital or improper hospital care.

Consistent with the Centers for Medicare & Medicaid rulings for discharges on or after Oct. 1, 2008, Blue Cross and BCN do not pay hospitals and physicians for costs incurred when treating a condition that resulting from a serious adverse event.

Note: CMS refers to a serious adverse condition as an HAC, which stands for hospital-acquired condition.

The policy also is consistent with Blue Cross’ existing reimbursement structure under our participating hospital agreements and other health care provider contracts. These agreements and contracts don’t allow payment for medically unnecessary services, regardless of the cause.

Background
Effective Oct. 1, 2008, Blue Cross and Blue Care Network applied the new policy across all health plans. Provisions of the policy include the following:

• Blue Cross and Blue Care Network will no longer reimburse a hospital or physician for costs associated with direct actions resulting in a serious adverse event.
• Serious adverse events covered under the Blue Cross policy are consistent with CMS policy payment for an HAC.
• Participating hospitals are required to report a “present on admission” indicator for all claims.
• Participating hospital and physicians may not “balance bill” members for any incremental costs associated with treatment of a serious adverse event. This policy can’t be changed by any customer.

Submitting codes for serious adverse events
Keep in mind that you must report the appropriate codes for serious adverse events. CMS updates the list yearly. For more information, visit CMS.gov** and type “hospital acquired conditions” in the search bar.

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

FEP^® members’ preferred provider network for behavioral health services changing Jan. 1

The preferred provider network for behavioral health services for Federal Employee Program^® members is changing Jan. 1, 2015. It’s moving from the BCBSM Mental Health and Substance Abuse Managed Care Program network to the TRUST PPO network.

Since the TRUST PPO network is larger than the one that FEP members are currently using, we anticipate that the disruption to FEP members will be minimal.

Health care providers in the Mental Health and Substance Abuse Managed Care Program network who are not in the PPO network will be considered out of network for their FEP patients, starting Jan. 1, 2015. This means that beginning Jan. 1, out-of-network sanctions will apply for FEP members who continue to see behavioral health care providers who are not in the newly designated preferred network.

Note: If you’re eligible and would like to join the TRUST PPO network, please contact your BCBSM provider consultant.

For FEP Standard Option members (enrollment codes 104 and 105), higher cost-sharing will apply for out-of-network services. For FEP Basic Option members (enrollment codes 111 and 112), there is no benefit coverage for out-of-network services.

Behavioral health care providers who will no longer be considered preferred for FEP members should immediately notify their FEP patients of this change to allow them ample time to transition to a preferred provider.

Submit flu shots, other vaccines as medical claims, not pharmacy claims, for Blue Cross non-Medicare members

We recently learned that some pharmacies have been submitting claims for flu shots and other vaccines for Blue Cross Blue Shield of Michigan non-Medicare members as pharmacy claims. Claims for flu shots and other vaccines for Blue Cross non-Medicare members should be submitted as medical (professional) claims.

Only pharmacies that are part of Blue Cross Blue Shield of Michigan’s Vaccine Affiliation Program can submit claims for vaccines to Blue Cross members.

Which members are covered?
Before giving a flu shot, be sure the member has immunization coverage. You can check coverage on web-DENIS or by calling Provider Inquiry at the number listed for your area code.

**Only the following counties within this area code should call this number: Alcona, Alpena, Crawford, Iosco, Montcalm, Montmorency, Ogemaw, Oscoda, Otsego, Presque Isle and Roscommon.

You can use the following procedure codes when checking for coverage.

Submitting claims for flu shots and other vaccines:
Be sure to submit claims for flu shots and other vaccines administered to Blue Cross Blue Shield of Michigan non-Medicare members as medical (professional) claims through the medical claim system used by your pharmacy. You can work with your claim clearinghouse vendor or IT department if you are unsure of how to bill medical claims in your system. Claims for flu shots submitted as a pharmacy service through the pharmacy claim system will not be paid.

For members with Blue Care Network coverage:
For members with BCN commercial coverage, continue to follow the BCN billing process for vaccines.

For Medicare Advantage members:
For members with Medicare Advantage, continue to follow the Medicare Advantage billing process for vaccines.

Chrysler groups to participate in prior authorization program

Beginning Jan. 1, 2015, all Chrysler group segments will participate in the Medical Drug Prior Authorization Program.

Keep in mind that the prior authorization requirement does not apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

The list below reflects all the medications that are part of the Medical Drug Prior Authorization Program.

Be sure to include prescriber’s NPI on Medicare Part D claims

Based on new requirements from the Centers for Medicare & Medicaid Services, pharmacies must include the prescriber’s NPI in field 411-DB of the NCPDP claim when submitting Medicare Part D claims.

Pharmacies that currently submit claims using Drug Enforcement Administration numbers or state license numbers for Medicare claims should adjust their practice to accommodate this change. If you submit anything other than the prescriber’s NPI in field 411-DB, you’ll receive rejection code 25 (M/I prescriber ID).

As a reminder, CMS expects pharmacies to resolve any rejections related to an invalid prescriber within 24 hours without causing a disruption to the member. Claims submitted with a Submission Clarification Code will be subject to post-adjudication review and may be reversed if a valid prescriber NPI cannot be obtained or a DEA number is found to not allow the drug DEA schedule.

Chrysler groups to participate in prior authorization program

Beginning Jan. 1, 2015, all Chrysler group segments will participate in the Medical Drug Prior Authorization Program.

Keep in mind that the prior authorization requirement does not apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

The list below reflects all the medications that are part of the Medical Drug Prior Authorization Program.

TheraMatrix will no longer handle administrative services for Ford Motor Company salaried employees

Beginning Jan. 1, 2015, Blue Cross Blue Shield of Michigan will assume responsibility of processing all claims and handling the administrative responsibilities from TheraMatrix for Ford Motor Company salaried members who receive outpatient physical therapy services.

In order for your claims to be paid, you must submit all outpatient physical therapy claims to Blue Cross for processing.

TheraMatrix previously administered all outpatient physical therapy services for Ford Motor Company salaried employees who live in Michigan. If you need to file a claim for a service performed prior to Jan. 1, 2015, please contact TheraMatrix.

If you have questions or need more information about this transition, please contact Provider Inquiry.