Blue Cross^® Premier Platinum Extra with Dental and Vision to launch in 2015

Blue Cross Blue Shield of Michigan will introduce a platinum qualified health plan — Blue Cross^® Premier Platinum Extra with Dental and Vision — on the BCBSM PPO network for our individual customers in 2015.

The plan offers our richest level of coverage available, and features our lowest deductible, coinsurance and out-of-pocket maximum. It also includes dental and vision benefits for all family members.

As part of the new plan, members will receive a platinum colored ID card. The look and feel of the card will be slightly different, so we want to make sure that our health care providers are familiar with this option. See example of the card below:

For more information about this plan or any other of our 2015 product offerings, visit bcbsm.com/platinum.

Embedded coinsurance maximum introduced for 2015

Beginning Jan. 1, 2015, group plan benefits may include something new — an embedded coinsurance maximum.

What exactly is an embedded coinsurance maximum?

Coinsurance is a percentage of the cost of a service that the member is responsible for paying. A coinsurance maximum provides a maximum dollar amount that the member will pay for coinsurance. Once the coinsurance maximum is reached, the member will no longer pay coinsurance for the rest of the benefit year, with the exception of certain services that are exempt from the coinsurance maximum.

The coinsurance maximum is considered to be “embedded” because one member on a two-person or family contract cannot contribute in excess of the individual maximum amount. The embedded coinsurance maximum will count toward the out-of-pocket maximum along with the deductible and all other cost-sharing, such as medical or prescription drug copays.

You’ll know whether a member has an embedded coinsurance maximum by looking at the medical benefits description page on web-DENIS. If the member has a coinsurance maximum, you’ll see “coinsurance maximum” listed, along with the specific dollar amounts for that contract and the list of exclusions noted below.

Services that may be exempt from the coinsurance maximum include:

• Deductible amounts
• Services with a flat dollar copayment
• Diabetic supplies
• Durable medical equipment
• Elective abortion (if covered)
• Infertility services
• Male mastectomy
• Male sterilization
• Orthognathic surgery
• Prosthetics and orthotics
• Reduction mammoplasty
• Temporomandibular joint dysfunction
• Weight reduction procedures

If you have any questions, contact your provider consultant.

New Blue Distinction^® Total Care program to include Blue Cross patient-centered medical home providers

In previous Record articles, we’ve discussed the Blue Cross and Blue Shield Association’s Blue Distinction^® Specialty Care Program, which focuses on delivering health care quality and value. In January 2015, the Association will formally launch the Blue Distinction^® Total Care program nationwide.

This new program, also known BDTC, will make value-based programs available in 35 states and 40 of the top 50 metropolitan statistical areas in the U.S. It will allow multistate employers to use locally tailored Blue programs designed to help improve patients’ health while managing costs.

BDTC programs are custom-designed to meet local market needs. But they also are required to meet nationally consistent standards set by the Association in these four impact-driven categories:

• Value-based reimbursement
• Accountability across the care continuum
• Patient-centered quality care
• Provider empowerment

Blue Cross Blue Shield of Michigan’s Patient-Centered Medical Home program and accountable care organizations meet these criteria for patient-centered, value-based care. As a result, national account members and their families will have access to these high-quality providers throughout the state of Michigan through the BDTC program.

Providers participating in BDTC are responsible for managing the patient care of a high-risk population, so Blue plans will equip them with the necessary information and resources. Blue plans use a combination of proprietary tools and best-in-class vendors to give providers the data they need to identify and close gaps in care.

The plans focus on two key areas to support providers:

• Supplying medical informatics
• Consultative support

A provider participating in the BDTC program may be located by following these steps:

• Go to bcbsa.com.
• Click on the Find a Doctor or Hospital tab at the top of the homepage. The search criteria will appear as indicated below.
• To find a specific provider, enter the required information in the “Search by” field. Or, for a list of BDTC providers, complete the location fields.

Once the initial search criteria are entered, users can either click on the Go button or click on Add Filter to see various links as indicated below. Use the Add Filter search function to customize your search results of BDTC providers.

To view a complete list of BDTC providers:

• Go to bcbsa.com.
• Click on the Find a Doctor or Hospital tab.
• Click on Add Filter.
• Click on Blue Distinction.
• Click on Blue Distinction Total Care in the drop-down menu (as shown above).
• Click on Select.
• Click on the Go button.

For more information, contact your provider consultant.

2015 Blue Cross formulary changes focus on high-risk medications for older adults

As of Jan. 1, 2015, changes to the Blue Cross Blue Shield of Michigan Medicare Part D drug formulary will take effect for certain high-risk medications in older adults.

Blue Cross made these formulary changes based on the American Geriatrics Society’s endorsed list of medications deemed potentially inappropriate for older adults. These changes align with the Centers for Medicare and Medicaid Services’ Five-Star Quality Rating System to improve the quality of patient care by decreasing the use of these medications in the Medicare population.

While some medications did not change tiers, they have added criteria which require a prior authorization. For example, amitriptyline is still a tier 2 drug, but it will only be covered if treatment failure occurs with an antidepressant that has fewer anticholinergic side effects.

Below is a summary of the 2015 Blue Cross formulary changes for high-risk medications. “PA” stands for prior authorization and “QL” stands for quantity limit.

Legal or court-ordered services are not considered Blue Cross Blue Shield of Michigan benefits

Services that are rendered due to legal or court-ordered actions and solely for the benefit of the court are not benefits for most Blue Cross Blue Shield of Michigan members. These types of claims should not be submitted to Blue Cross for processing.

Group-specific provisions may be applicable, as some groups may pay for some of these services for their members. Please verify group-specific benefits for coverage availability and guidelines.

For groups that cover these services, please submit those claims according to our current claims filing guidelines.

For more information, contact your provider consultant.

Reminder: Follow guidelines established for processing Medicare primary claims

Keep in mind that Blue Cross Blue Shield of Michigan changed how it processes Medicare primary claims, effective Oct. 13, 2013. The change aligns with the Blue Cross and Blue Shield Association’s policies.

The Blue Cross and Blue Shield Association requires a minimum 30-day waiting period after the Medicare remittance date before a Blue plan can accept or process provider-submitted supplemental claims that involve Medicare crossover.

Medicare primary claims are submitted to Medicare for processing and then forwarded to a secondary insurance carrier via a crossover arrangement for additional payment determinations.

Providers can identify Medicare crossover claims that have been sent to Blue Cross by looking for remittance advice remark codes MA18 and N89.

Providers can identify Medicare crossover claims that have been sent to BCBSM by remark codes MA18 and N89 returned on the Medicare Remittance Advice and electronic remittance (835).

Electronic claims submitted within the 30days will receive the following BCBSM EDI front end edits:

• P951  A3  516        SUPPLEMENTAL CLM RECD WITHIN 30 DAYS OF MEDICARE PROC DATE
• F716  A3  516        SUPPLEMENTAL CLM RECD WITHIN 30 DAYS OF MEDICARE PROC DATE

Edits will be returned in our 277CAP transactions and R277CAH and R277CAI edit reports. Edited claims cannot be resubmitted until the 30 days have lapsed.

If you have questions regarding the edits, contact the eBIG/EDI Business help desk at 1-800-542-0945.

For more information about this process, please see the September 2013 Record.

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

It’s important to properly document the status of cancer in the medical record to support the ICD-9-CM diagnosis code selected. Cancer should be documented as active cancer, as personal history of cancer or cancer in remission. Incorrectly coding a cancer diagnosis can be problematic for a patient in the future.

Definitions of each cancer status

• Active cancer: Cancer that is currently being treated. Various methods could include surgery, radiation, chemotherapy, drugs, alternative medicine or a combination of the various methods.

• Personal history of cancer: Cancer that has been excised or eradicated from its site. No further treatment is being directed at the site and there’s no evidence of any existing cancer.

• Cancer in remission: Cancer that has been removed; however, there may be cells that are still present but are currently undetectable. There are two kinds of remission: complete remissionand partial remission.

Active cancer status
The following is an example of coding for active cancer that’s currently being treated by the doctor:

The patient has active cancer of the upper lobe. His or her doctor discusses the treatments available, explains the risks and possible outcomes, and answers any questions the patient has regarding the diagnosis. If the patient decides to start treatment immediately, the doctor documents the assessment as 162.3 — Malignant neoplasm of bronchus and lung — as the diagnosis. The plan is the patient will begin chemotherapy in a week, with follow up as needed.

In instances such as this, where cancer has been diagnosed and is documented as currently receiving treatment, it should be coded using a current neoplasm code from “Neoplasms” chapter (Pages 140-239) in the ICD-9-CM Coding Guidelines.

Keep in mind that certain benign neoplasms, such as prostatic adenomas, may be found in the specific body system chapters.

Personal history of cancer status
When a patient has a personal history of cancer, and the cancer is no longer active and doesn’t need treatment, the doctor needs to specify that using the proper code.

For example, if a patient was diagnosed with prostate cancer five years ago and there’s no current treatment being directed at the prostate cancer, the doctor should use V-code V10.46 – Personal history of malignant neoplasm prostate. This indicates that the patient has a personal history of cancer and it’s no longer an active cancer that needs treatment directed towards it.

V-codes can be found in the “Classification of Factors Influencing Health Status and Contact with Health Service (Supplemental V01-V89)” section, located in volume 1 of the ICD-9-CM manual.

In most cases, doctors will still monitor the condition for a certain period of time due to the nature of the cancer. However, it’s incorrect to use an active cancer code (140-239) in cases where the doctor has indicated that there’s no evidence of the existing cancer and no treatment is being directed towards the site of the primary malignancy.

Remission status
There are two types of remission:

• Complete remission: There are no signs and symptoms that indicate the presence of cancer. 

• Partial remission: A large percentage of the signs and symptoms of cancer are gone, but some still remain.

According to the American Cancer Society, to qualify for either type of remission, the reduction in the size of the tumor must last for at least one month. When a person is in remission, there may be microscopic cancer cells that are unable to be identified by the current techniques and technologies available.

Complete remission is better because there’s a higher rate of recurrence with a partial remission. A person in remission, whether complete or partial, may experience a recurrence of cancer at some point in the future.

ICD-9-CM codes 203-209 Malignant Neoplasm of Lymphatic and Hematopoietic Tissue list remission codes which can be used if the doctor documents the condition as such. The fifth digit “1” indicates that the cancer is in remission.

If lymphoma is documented as in remission, it’s still assigned to the appropriate code from categories 200 to 202. Although lymphoma patients may be regarded in remission, they’re still considered to have lymphoma and should be assigned the appropriate code from categories 200-202.

Other types of cancer can be termed as in remission, but there aren’t specific codes designated like there are for lymphoma and leukemia. Whether to use an active cancer code or a personal history of cancer code for other types of cancer that a doctor documents as in remission, will depend on what the documentation states for that date of service. Keep in mind if there’s no treatment or adjuvant therapy being directed at the primary malignancy at that time, the doctor shouldn’t use an active cancer code.

It’s important to always review the ICD-9-CM Coding Guidelines (Section I.C.2 , Chapter 2: Neoplasms, codes 140-239) as well as any instructional notes under the codes in the tabular list of the ICD-9-CM manual in order to select the correct code, additional codes required and possible sequencing information as well.

For more information, contact your provider consultant.

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

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 linkat 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.

Online tutorial will walk you through our new individual plans with local networks

In last month’s issue, we announced our 2015 individual products. They include two new plans with localized provider networks:

• Blue Cross^® Metro Detroit EPO
• Blue Cross^® Metro Detroit HMO

The Metro Detroit EPO covers six counties: Livingston, Macomb, Oakland, St. Clair, Wayne and Washtenaw. The Metro Detroit HMO covers three counties: Macomb, Oakland and Wayne.

Residents of these counties can now purchase the plans that become effective as of Jan. 1, 2015.

To learn more about the Metro Detroit EPO and HMO, an online tutorial will be available on web-DENIS by Dec. 5, 2014. To view the presentation, log in to web-DENIS:

• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters & Resources.
• Go to the “What’s New” section and click on Training presentation: Blue Cross® Metro Detroit EPO and HMO local networks.

How this affects your practice
Other than eligible emergency services and accidental injuries, patients with these plans may not have coverage if they visit a doctor that is outside the network.

So it’s very important to know if you are in either network to provide services to patients with these health plans. Find out if you’re in the Metro Detroit EPO network, Metro Detroit HMO network or both. And be sure your office staff is also aware of which networks you are in.

Keep the following in mind:

• Before you provide a service, check your patient’s plan name and network.

• Refer members to health care providers and hospitals in their networks. You can use the Find a Doctor search feature on bcbsm.com to verify that a doctor or hospital is in this network. We’ve also created a flier with instructions on how to use this tool.

How we’re educating members
We want to ensure a smooth transition for the providers in the Metro Detroit EPO and HMO networks and our members who have these new plans.

To do that, we’re conducting ongoing outreach to educate members how the coverage works for our plans with localized networks. We’re highlighting the guidelines for their local network coverage and the importance of providing you with the complete name of their plan and network when making appointments and at the time of their services.

If you have questions about our local network plans, you can get additional information from your provider consultant.

CPT Category II codes, V codes help you monitor performance on key measures

It’s important to use available Current Procedural Terminology Category II and V codes to help you — and Blue Cross — monitor performance on key measures. Here’s what you need to know about these codes.

What are CPT Category II and V codes?
CPT Category II codes and V codes are tracking codes used to collect clinical data that help measure health care performance. CPT Category II codes describe components usually included in the evaluation and management of clinical services, such as test results or blood pressure, and are billed in the procedure code field just like CPT Category I codes. Alternatively, V codes are diagnosis codes which in general describe screening exam components included in the evaluation and management of clinical services.

Why should my practice use CPT Category II and V codes?
The use of CPT Category II and V codes enables your organization to monitor internal performance for key measures and eases the administrative burden of chart review for many HEDIS^® measures. You can then identify opportunities for improvement and address them throughout the year. Use of available CPT Category II and V codes also will enable us to measure and better manage the care Blues members receive, which helps meet key HEDIS and Centers for Medicare & Medicaid Services star measures. Using CPT codes will also decrease the amount of information Blue Cross may need to request in determining HEDIS performance.

When should my practice begin using CPT Category II and V codes?
Please start using the available CPT Category II and V codes on professional claims immediately. Doing so will help better track the management of members’ health risks and improve physician organization and provider performance on initiatives, such as evidence-based care tracking, Provider Recognition Program and Patient-Centered Medical Home designation.

What do I need to know about exclusions?
Members who have certain medical conditions may be excluded from a specific measure. Health care providers need to code for these exclusions to ensure that their performance on a measure is not affected by a member not receiving a specific service.

The following chart includes select HEDIS measures, descriptions and CPT Category II or V codes. For additional measures and reporting codes, refer to HEDIS Technical Specifications 2015, Volume 2.

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

Focus on HEDIS^®: Managing patients with high blood pressure

This is first in a series of articles focusing on key Healthcare Effectiveness Data and Information Set measures.

Hypertension is among the most common conditions seen in the primary care setting. If left untreated, it can lead to myocardial infarction, stroke, renal failure and even death.

Controlling your patient’s blood pressure is more than just a simple blood pressure reading. Encouraging and coaching your patient to adopt healthy lifestyle habits is an effective first step in both preventing and controlling high blood pressure.

The 2014 Eighth Joint National Committee released new evidence-based guidelines for the management of high blood pressure in adults.

Adequate blood pressure control is defined as:

• Patients age 18 to 59 whose blood pressure was under 140/90
• Patients age 60 to 85 years of age with a diagnosis of diabetes whose blood pressure was less than 140/90
• Patients age  60 to 85 without a diagnosis of diabetes whose BP was less than 150/90

Here are several important things to keep in mind when caring for your hypertensive patients:

• To confirm diagnosis of hypertension, notation of hypertension must appear in the medical record during an outpatient visit on or before June 30 of each year.
• Examples of notation include: Hypertension, HTN, High BP, Elevated BP, Borderline HTN, Intermittent HTN, History of HTN, Hypertensive vascular disease, Hyperpiesia and Hyperpiesis.
• A representative blood pressure is the most recent blood pressure reading taken during the measurement year (by Dec 31) and it occurs after the date of service in which the diagnosis of hypertension occurred. If multiple readings occur in a single visit, the lowest systolic and lowest diastolic is the representative blood pressure and determines blood pressure control.
• A blood pressure reading must have been taken and documented in the chart during the same visit in which you assessed the patient for hypertension and again at subsequent visits.
• Self-reported blood pressure readings taken by your patient are not considered accurate in diagnosing hypertension.

If lifestyle changes alone are not effective in keeping your diabetic patient’s blood pressure controlled, it may be necessary to add anti-hypertensive medications to your patient’s regimen.

• Initiate pharmacologic anti-hypertensive treatment that includes an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker.

Take the opportunity to educate your patient about the importance of taking their recommended medications regularly. You should also discuss medication side effects.

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

Blue Cross Blue Shield of Michigan announces changes to Traditional program participation criteria

Blue Cross Blue Shield of Michigan is making changes to the Traditional program participation criteria. As of Jan. 1, 2015, the criteria under which a practitioner may be refused participation in the BCBSM Traditional program include, but are not limited to, the following:

• Any felony or misdemeanor conviction, guilty plea, plea of nolo contendere or placement in a diversion program for any crime related to the payment or provision of health care involving BCBSM, Medicare, Medicaid or other health care insurers in the last five years

• Any felony or misdemeanor conviction, guilty plea, plea of nolo contendere or placement in a diversion program for any crime in the last three years

• Termination, suspension, revocation of licensure, certification, registration or accreditation in Michigan or in any other state in the last two years

• Reprimand, censure, restriction or reduction to probationary status of licensure, certification, registration or accreditation in Michigan or any other state in the last year

• Practitioners who have failed to reimburse BCBSM any amounts due and owing as a result of any overpayment or audit identified from previous affiliation with Blue Cross

• Practitioners who are currently on federal sanction list or have been on such a list within the last two years

• Practitioners who have been departicipated by BCBSM within the last five years after being on pre-payment utilization review for at least two years and who did not meet criteria to be removed from PPUR. 

If you have any questions about these changes, please call Provider Enrollment and Data Management at
1-800-822-2761.

Guidelines have changed for autism procedure code S5108 for applied behavior analysis

The billing and documentation guidelines for procedure code S5108 have changed. Board-certified behavior analysts may no longer bill for supervision of relatives or guardians performing skills training.

For more details about this change, refer to the Applied Behavior Analysis Billing Guidelines and Procedure Codes document. You can find it online using these steps:

• Log in to web-DENIS.
• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters & Resources.
• In the left-hand navigation under Other Resources, click on Clinical Criteria & Resources.
• Under Resources, click on Autism.
• Scroll to the bottom of the page and click on Applied Behavior Analysis Billing Guidelines and Procedure Codes.

The document is also available on BCN Provider Publications and Resources. Click on Autism.

For additional information, contact Provider Inquiry or your provider consultant.

2015 criteria for medically necessary mental health treatment available Jan. 1

Several medical necessity criteria for behavioral health treatment have recently been updated and will become effective on Jan. 1, 2015. At that time, you’ll be able to access them on web-DENIS.

For 2015, updates have been made to the following:

• The Magellan Behavioral Health Medical Necessity Criteria Guidelines,adapted for Blue Cross Blue Shield of Michigan. This document identifies the criteria for medically necessary psychiatric and substance abuse treatment.

• The BCBSM Behavioral Health Criteria Application Guidelines: These guidelines provide additional requirements and clarification for the use of the Magellan Behavior Health Medical Necessity Criteria and should be used in conjunction with these criteria where necessary.

• The medical necessity criteria for applied behavioral analysis and for repetitive transcranial magnetic stimulation.

As of Jan. 1, you can print or copy any of the above documents directly from web-DENIS. Follow these steps:

• Log in to web-DENIS.
• In the left-hand navigation, click on BCBSM Provider Publications and Resources.
• Click on Newsletters and Resources.
• Under “Other Resources,” click on Clinical Criteria & Resources.
• Scroll down to the Magellan Behavior Health Clinical Criteria section of the page and click on the document you wish to copy or print.

If you have any questions, please call Behavioral Health Services in the Ancillary Program Management department at 313-448-7745.

Register for upcoming freestanding radiology center webinars

As you’ve read in The Record over the past few months, the Blues are establishing a new freestanding radiology center provider type. This will create the capability to uniquely recognize and reimburse freestanding diagnostic imaging services providers.

On Dec. 10, 2014, we’ll be hosting webinars for diagnostic imaging providers interested in enrolling as a freestanding radiology center provider type. Two 30-minute webinars will be available at 10 a.m. and 1 p.m.

To register for one of the webinars, complete the registration form that you can download from web-DENIS:

• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters & Resources.
• Under “What’s New,” click on Register for a freestanding radiology center webinar.

For more information about the freestanding radiology center provider type, see the August and October issues of The Record. And If you have any questions about the webinars, please contact your provider consultant.

We’re making a change to our PPO radiology program for commercial and Medicare Advantage PPO products

Beginning Jan. 1, 2015, Blue Cross Blue Shield of Michigan PPO providers will have up to 60 days past the date of service to request retrospective authorizations through AIM Specialty Health for commercial and Medicare Advantage members participating in our Radiology Management Program.

This is a change from the current 30-day timeline. Although we have expanded this timeline, we still encourage providers to ensure an authorization is obtained prior to administering services.

We’d also like to clarify the roles of the ordering providers versus the rendering providers in requesting and making changes to authorizations. Although the ordering physician is responsible for obtaining a new authorization, there are instances when the rendering provider can request changes to that initial authorization directly from AIM.  These include:

• Change of location prior to the service being performe
• Modifying procedures performed on adjacent body parts from the original approved authorization.
  

Note:  A change in modality will require a new authorization to be requested by the ordering physician, even for the same body part.

Additionally, there are some situations that don’t require a change to the authorization because AIM approves procedures in the same grouping. For example, when the approved procedure is one with contrast but the rendering provider determines that it needs to be done without contrast, then no change is needed because both procedures fall within the same grouping.

To request an AIM authorization, call 1-800-728-8008 or visit AIMSpecialtyHealth.com**.

For more information about this change, please contact your provider consultant.

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

PPO Quality Improvement Program supports member care

At Blue Cross, we continually implement, monitor, measure and evaluate strategies to improve the quality of care delivered to our members. Through our data-driven PPO Quality Improvement Program, we’re able to understand our member population and identify opportunities to improve their health and satisfaction with their health care.

Our annual quality assessment includes:

• Access to care
• Continuity and coordination of care
• Member satisfaction
• Provider performance
• Clinical quality
• Utilization and medical management programs
• Delegation
• Patient safety

This evaluation is also supported through the compliance and health outcomes of:

• The Healthcare Effectiveness Data and Information Set, known as HEDIS^®
• Consumer Assessment of Healthcare Providers and Systems member satisfaction surveys, known as CAHPS^®

You can get more details abou Quality Improvement Program at bcbsm.com/importantinfo.

Blue Cross electronic qualification form available Jan. 1, 2015

The Blue Cross Blue Shield of Michigan Qualification Form will be posted on web-DENIS for Michigan health care providers on Jan. 1, 2015. Providers can now submit the qualification form electronically for BCBSM members who have a wellness plan that requires a form.

You can access the electronic qualification form by logging into BCBSM Provider Secured Services and clicking on BCBSM Electronic Qualification Form. We’ll also post detailed instructions for submitting the form on web-DENIS Jan. 1.

We strongly encourage you to submit BCBSM qualification forms electronically to speed up processing time.

Note: Providers should continue to use the BCN electronic qualification form for Blue Care Network members.

Reminder: Bill Medicare Supplemental claims electronically

Blue Cross Blue Shield of Michigan is committed to helping control health care costs. One of the ways we do this  is through our electronic claims submission initiatives.

As you may know, most of the claims submitted to Medicare automatically cross over to Blue Cross as supplemental claims. But Medicare supplemental claims that are submitted directly by providers should be submitted electronically whenever possible.

If you submit Medicare supplemental claims on paper, it could delay processing or require additional follow-up to ensure that the claims are handled properly.

If you aren’t currently submitting claims electronically and want to, contact your software vendor, practice management vendor or clearinghouse.

If you have questions or problems submitting claims electronically, call our Electronic Data Interchange department at 1-800-542-0945.

National drug code billing solution extended

Earlier this year, Blue Cross Blue Shield of Michigan implemented a solution to calculate the NDC quantity for medical drug claims until Nov. 1, 2014.

We’re extending this solution until Feb. 1, 2015, which will align changes with Blue Cross  fee schedule updates. The extension will also allow providers more time to update billing software and address billing issues.

On Feb. 1, 2015, we’ll require the correct NDC and NDC quantity information to be submitted. We’ll no longer calculate the NDC quantity of medical drugs as of Feb.1, 2015.

We’re changing billing instructions for prenatal visits

In the past, we asked you to bill the last prenatal visit in the “from” field on the claim form and the first prenatal visit in the “to” field. Going forward, if the billing is for prenatal care only, enter the date of the first prenatal visit in the “from” field and the last prenatal visit in the “to” field on the 1500 form.

Do not hold claims for non-returning patients who have not been seen by the attending physician or another physician within the same group practice within 60 days. Professional providers should submit claims prior to the filing limits (180 days) to avoid rejections.

Register for upcoming freestanding radiology center webinars

As you’ve read in The Record over the past few months, the Blues are establishing a new freestanding radiology center provider type. This will create the capability to uniquely recognize and reimburse freestanding diagnostic imaging services providers.

On Dec. 10, 2014, we’ll be hosting webinars for diagnostic imaging providers interested in enrolling as a freestanding radiology center provider type. Two 30-minute webinars will be available at 10 a.m. and 1 p.m.

To register for one of the webinars, complete the registration form that you can download from web-DENIS:

• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters & Resources.
• Under “What’s New,” click on Register for a freestanding radiology center webinar.

For more information about the freestanding radiology center provider type, see the August and October issues of The Record. And If you have any questions about the webinars, please contact your provider consultant.

We’re making a change to our PPO radiology program for commercial and Medicare Advantage PPO products

Beginning Jan. 1, 2015, Blue Cross Blue Shield of Michigan PPO providers will have up to 60 days past the date of service to request retrospective authorizations through AIM Specialty Health for commercial and Medicare Advantage members participating in our Radiology Management Program.

This is a change from the current 30-day timeline. Although we have expanded this timeline, we still encourage providers to ensure an authorization is obtained prior to administering services.

We’d also like to clarify the roles of the ordering providers versus the rendering providers in requesting and making changes to authorizations. Although the ordering physician is responsible for obtaining a new authorization, there are instances when the rendering provider can request changes to that initial authorization directly from AIM.  These include:

• Change of location prior to the service being performe
• Modifying procedures performed on adjacent body parts from the original approved authorization.
  

Note:  A change in modality will require a new authorization to be requested by the ordering physician, even for the same body part.

Additionally, there are some situations that don’t require a change to the authorization because AIM approves procedures in the same grouping. For example, when the approved procedure is one with contrast but the rendering provider determines that it needs to be done without contrast, then no change is needed because both procedures fall within the same grouping.

To request an AIM authorization, call 1-800-728-8008 or visit AIMSpecialtyHealth.com**.

For more information about this change, please contact your provider consultant.

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

Reimbursement amount changes for nonpayable codes covered by other plans

Keep in mind that we pay for covered services based on the lower of either your billed charges or the Blue Cross Blue Shield of Michigan approved amount. However, there are times when the member’s home plan may cover a service that Blue Cross considers nonpayable.

In these instances, we’ll base our approved amount on a percentage of your charged amount.  Ambulatory surgery facilities also will be paid based on a percent of charges, like codes currently listed on the fee schedule with a fee of "St % Chrgs." Hospital outpatient charges will be paid at a percentage of charges, like codes currently listed on the fee schedule with a fee of “Cost-based.”

Procedure codes paid under this methodology due to a member’s coverage from an out-of-state Blue plan will continue to show as nonpayable, or NP, on the fee schedule.

Reminder: Documents needed for a pharmacy audit

As a reminder, if your pharmacy is contacted to schedule an audit, you should keep the following  documentation requirements in mind. To ensure a smooth audit — and to avoid preventable findings —  be prepared to provide complete and accurate records.

Prescriptions. The pharmacy must furnish the original prescriptions for written and verbal orders, but may submit printed copies of electronic and faxed prescriptions. Scans of written and verbal prescriptions are not accepted. If the claim was submitted with a “compound 2” indicator, the pharmacy must also supply the compound record, including the national drug codes and the quantities used.

Dispensing histories. The pharmacy must provide a printout of the dispensing history of each prescription; i.e., the date of each dispense for the life of the prescription as well as the quantity dispensed. These can be listed on a printed spreadsheet or your pharmacy software may have a report. If your computer does not have this capacity, please record the dispensing history, including the quantities, on a photocopy or back of each prescription. Note:  If the medication, drug strength or quantity changed for any dispense, this information should also be documented.

Signature logs. All Blue Cross and Blue Care Network prescription drug programs require a signature from the member, their representative or their caregiver at the time of dispense to verify receipt of their medications. We accept a member’s, a representative’s or caregiver’s signature on a manual or electronic log, including signatures from drive-through customers, as proof that the member received the prescription. For prescriptions that pharmacies mail to members, the pharmacy should provide a dated “proof of delivery/receipt” signed by the member, their representative or their caregiver.

Members’ rights notice. Blue Cross is required to report to the Centers for Medicare & Medicaid Services whether network pharmacies are compliant with the requirement to give Medicare Part D patients a copy of the Medicare Prescription Drug Coverage and Your Rights Standardized Pharmacy Notice (CMS-10147/OMB 0938-0975) if the prescription cannot be filled. Please have this notice printed to show the auditor.

Record retention. As a reminder, the minimum time a pharmacy must keep prescription records for Blue Cross and Blue Care Network commercial is five years from the last date of service. Michigan   law requires that every prescription has to be preserved for at least five years. The federally administered Medicare plan requires that prescriptions be retained a minimum of 10 years after the last date of service.

If a pharmacy does not have the required documents as described above, monetarily recoverable findings may result.

Correction: Victoza^® billing information

An October Record article, titled “Are you billing correctly for these drugs,” contained incorrect information about the drug Victoza.  On Oct. 24, we sent out a corrected fax blast to pharmacies. Following is the correct information about Victoza.

URMBT benefit changes for 2015 announced

Effective Jan. 1, 2015, certain benefit changes take place for members who are covered under the UAW Retiree Medical Benefits Trust.

For detailed information, please check PARS or Benefit Explainer on web-DENIS.

Following are highlights of the group’s benefit changes.

Office visits

• Primary care office visits increased from four to six visits with a $25 copay for each visit.
  
  Note: This is applicable to all Traditional Care Network, non-Medicare members and dependents.

Enhanced urgent care coverage

• Urgent care facility fees are covered with a $50 copay.
• Retail health clinics are covered as an approved site of care with a $50 copay. Providers must bill with a place of service 17 (retail health clinic). Only locations listed on bcbsm.com and the Blue Cross and Blue Shield Association website (bcbsa.com) are participating retail health clinics.
  
  Note: These changes are applicable to all TCN and PPO plans.

Cost sharing

• Increases to cost-share amounts for both in-network and out-of-network services for URMBT members
  
  Note: This is applicable to the TCN and PPO plans, with the exception of Ford Protected plans.

Diagnostic eye exam or diabetic retinopathy test

• One diagnostic eye exam or diabetic retinopathy test is covered every 12 months.
• The first exam or test is covered with a $25 copay, whether the service is in-network or out-of-network. For Ford Protected plans, no in-network cost share or copay applies.

Benefit changes for Ford Motor Company salaried employees

Beginning Jan. 1, 2015, Ford Motor Company salaried members will have the following benefit changes:

Autism coverage
Blue Cross Blue Shield of Michigan will cover rehabilitation therapy and Applied Behavioral Analysis services for members who have been diagnosed with autism spectrum disorder. However, members must receive approval for these services through Magellan.

Ambulatory Infusion Centers are an approved provider for Infusion Therapy.
This is not a benefit change but rather an additional location for members to receive
infusion therapy.

TheraMatrix no longer handling outpatient physical therapy benefits  
Blue Cross Blue Shield of Michigan will assume responsibility of processing all claims and handling the administrative responsibilities from TheraMatrix for employees who receive outpatient physical therapy services. In order for your claims to be paid, you will have to submit outpatient physical therapy claims to Blue Cross for processing.

This change will affect Ford Motor Company salaried employees who have these group numbers:

• 87251
• 87252
• 87254
• 87261
• 87262
• 87264
• 87271
• 87272
• 87274
• 87281
• 87282
• 87284
• 87290 to 87297

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

Blue Cross expects all care to be based on medical necessity and functional outcomes, and will reimburse all services rendered by health care providers according to the member benefit packages and to Blue Cross’s reimbursement and medical policies.

Blue Cross continues to contract with Landmark Healthcare Inc. to manage use of physical therapy. Landmark, together with Blue Cross, reviews use for PPO physical therapy providers with at least 10 episodes of care and places them into A, B or C categories, based on risk adjustment and peer means.

For questions or more information about this transition, please contact Blue Cross Blue Shield of Michigan Network Management at 248-448-6371 or your provider consultant.

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

Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO 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 prior to 2013 as soon as possible, and no later than Dec. 29, 2014.

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

HDI audits
To avoid any claims processing problems associated with the HDI audits for claims with dates of service prior to 2013, be sure to submit any adjustment request(s) to your provider consultant as soon as possible.

As of Jan. 1, 2015, any HDI and/or PGBA outstanding claim issue (e.g., outpatient re-bills, Administrative Law Judge decisions) must be forwarded to your provider consultant for resolution outside the claims system. To expedite those inquiries, please provide the following information for research: 

• Patient name
• Patient contract number
• Patient medical record number
• Claim number
• Date of service
•  ALJ appeal number
• Amount

BCBSM will follow up on all HDI inquiries.

EDI
Electronic claims with dates of service prior to 2013 will receive the following front end edits from BCBSM EDI:

Professional

P285 A3 718 DATE OF SERVICE BEYOND TIMELY FILING LIMIT
P617 A3 718 ADJ CLAIM IS BEYOND TIMELY FILING, CONTACT MA PROV INQ

Institutional

F243 A3 718 STATEMENT DATE BEYOND TIMELY FILING LIMIT
F718 A3 718 ADJ CLAIM IS BEYOND TIMELY FILING, CONTACT MA PROV INQ

Edits will be returned in our 277CA reports and transactions. If you have questions regarding the edits, contact the eBIG/EDI Business help desk at 1-800-542-0945.