Blue Cross individual, small group customers getting expedited Rx review process in 2015

Effective Jan. 1, 2015, Blue Cross Blue Shield of Michigan will offer a 24-hour expedited review process for individual and small group customers requesting nonformulary or urgently needed prescription drugs. Prescription drug coverage is one of the 10 essential health benefits included in the health reform guidelines for 2015.

The Centers for Medicare & Medicaid Services, or CMS, expects health insurance carriers to update their certificates of coverage to notify members of the process. CMS also expects carriers to provide instructions on how to ensure the decision is communicated to pharmacies and the pharmacy benefit manager.

For 2015, individual and small group issuers of qualified health plans that provide essential health benefits can provide a 24-hour expedited review process based on urgent circumstances. Here are the circumstances needed to trigger a 24-hour response:

• A member, the member’s designee or the member’s prescribing doctor can request an expedited exception process based on urgent circumstances.
  
  Note: Blue Cross must be able to accept the information electronically, in writing or by telephone.
  
  
• The doctor must provide an oral or written statement explaining:
1. An urgency exists.
2. Harm could result to the member if the drug isn’t provided in the timeframe specified in the Blues standard drug exception process.
3. Justification supporting the need for the nonformulary drug to treat the member’s condition. One of the following statements must apply to all covered formulary drugs on any drug:
• The drug will be or has been ineffective.
• The drug would not be as effective as the nonformulary drug.
• The drug would have adverse effects.

CMS notes that carriers are not required to cover medication during the review process.  When circumstances are deemed to fall under the rule, Blue Cross must respond to the request within 24 hours and make sure that approved prescription drugs are made available to the member for the duration of the authorization period.

Once a decision to expedite is made, Blue Cross will:

• Verbally notify the member and the provider of Blue Cross’ decision.
• Send a written letter to the member about the decision.
• Send a fax or letter to the provider about the decision.

Do you know which Blues products you accept?

As 2015 health care plan coverage begins, it’s important to make sure that your office personnel know which Blues products you accept. That way, they can accurately answer questions from patients.

Here are the local network products and where to find more information:

• Blue Cross^® Metro Detroit EPO — New exclusive provider organization in Southeast Michigan
• Blue Cross^® Metro Detroit HMO — New local HMO in Southeast Michigan
• Blue Cross^® Partnered — Local HMO in West Michigan introduced last year
• Blue Cross^® Select or PCP Focus — Special HMO PCP network
• BCN Advantage^SM HMO ConnectedCare — New local Medicare Advantage HMO in Southeast Michigan and Kalamazoo
• BCN Advantage^SM HMO MyChoice Wellness — Local Medicare Advantage HMO in West Michigan introduced last year

Not sure which of these plans you participate in? Here are some ways to check:

• Check your listing by using our Find a Doctor feature. You’ll need to look up the Blue Cross Blue Shield of Michigan products separately from the BCN products. Finding your Blues plans and networks offers a step-by-step guide.
• Check with your practice administrator.
• Contact your Blues provider consultant.

Keep in mind that the Blues individual commercial products all have names that begin with “Blue Cross,” but some of them are actually BCN plans. Here’s how to know which plans are BCBSM vs. BCN.

Update: Metro Detroit EPO, HMO networks

We’ve recently learned the St. Joseph Mercy — Port Huron will not be a participating hospital in the Blue Cross^® Metro Detroit EPO and HMO networks. To reflect this change, we’ve updated the November Record and the November-December issue of BCN Provider News.

For your reference, below is a current list of participating hospitals and product names. We also want to let you know that our online tutorial on the Metro Detroit EPO and HMO networks is now available on web-DENIS. The tutorial will walk you through our new individual plans with these local networks.

To view the presentation, you can click on the link above. Or, when you log in to web-DENIS, follow these steps:

• Log in to Provider Secured Services.
• Click on 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.

You can also find it on these pages:

• In the navigation menu, go to Operations and Training and click on Products and networks. Then, click on Training presentation: Blue Cross Metro Detroit EPO and HMO local networks.

• In the navigation menu, go to Health Reform and click on Information. Scroll to Product information and click on Training presentation: Blue Cross Metro Detroit EPO and HMO local networks.

Blue Cross Metro Detroit EPO and HMO — Participating hospitals

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

• Oakwood Healthcare, now part of Beaumont Health*
• Oakwood Hospital and Medical Center, Dearborn
• Oakwood Hospital Southshore
• Oakwood Hospital Taylor
• Oakwood Hospital Wayne

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

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

• Botsford Hospital, now part of Beaumont Health*
• Garden City Hospital
• Stonecrest Center for Behavioral Health
• Straith Hospital for Special Surgery
  
  *Note: Beaumont Health campuses in Royal Oak, Troy and Grosse Pointe are not part of the EPO network.

Blue Cross Metro Detroit EPO and HMO — Product names

• 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

BCBSM coverage decisions on 2015 HCPCS codes available online

The 2015 Current Procedural Terminology codes were released in late August and the 2015 HCPCS codes were released mid-November. You may begin using these new codes on or after Jan. 1.

Blue Cross Blue Shield of Michigan will publish coverage decisions in PDF format on web-DENIS, in the BCBSM Provider Publications and Resources section, under BCBSM Resources. To request a copy of the PDF, please send an email to ProvComm@bcbsm.com.

We will also identify codes deleted for 2015. As you know, a 90-day grace period is no longer observed for any procedure code deleted as part of the update.

Our claims processing systems use HCPCS codes to allow health care providers to report services they performed. HCPCS is a two-level coding system. Providers should use the following resources to find the code that best describes the service provided:

• Level I codes are published in the Physicians' Current Procedural Terminology, CPT 2015 maintained by the American Medical Association. For a comprehensive list of 2015 changes, refer to Appendix B.
• Level II codes are the Centers for Medicare & Medicaid Services codes and apply to professional services, procedures, items and supplies. For a comprehensive list of CMS Level II code changes, refer to the HCPCS Level II Code Book.

The 2015 CPT and HCPCS manuals may be purchased from various sources, including:

American Medical Association
                     
To order by mail:
Order Department
American Medical Association
P.O. Box 930876
Atlanta, GA 31193-0876

To order online:
amabookstore.com

To order by phone:
1-800-621-8335

Practice Management Information Corporation

To order by mail:
PMIC
200 W. 22nd St. Ste. 253
Lombard, IL 60148

To order online:
pmiconline

To order by phone:
1-800-633-7467, ext. 2713

Coding Corner: Documentation is key when coding morbid obesity

With an increasing number of Americans becoming overweight or suffering from obesity, it’s important for physicians to recognize the degree to which obesity — and its ever-present complications — negatively impacts patient health.

Overweight, obesity and morbid obesity are distinct diagnoses that must be properly documented.

The Centers for Medicare & Medicaid Services includes morbid obesity (ICD-9-CM code 278.01) and its associated body mass index values (40 and above, ICD-9-CM code range; V85.41-V85.45) in its 2014 Hierarchical Condition Categories Model. This categorization impacts the way providers should document the condition.

From a coding perspective, documentation of morbid obesity in the medical record makes it easier to assign code 278.01 with an associated V code. A problem may arise when obesity is documented in the medical record, but evidence indicates that the patient is morbidly obese. For example, the patient has a body mass index of 40 with co-morbid conditions.
                                                                                       
Can a BMI value of 40 with co-morbid conditions be used to validate the HCC Model for morbid obesity when there is a different diagnosis? The answer is yes. Consider the following guidelines for making a morbid obesity diagnosis:

• Patients with a BMI greater than 35 who are seen with co-morbid conditions such as osteoarthritis, sleep apnea, diabetes, coronary artery disease, hypertension, hyperlipidemia and gastroesophageal reflux disease
• Patients with a BMI equal to or above 40

According to Dr. Laurrie Knight, associate medical director for Blue Cross Blue Shield of Michigan, you should capture all of the medical complications that are associated with an obesity diagnosis. These may include sleep apnea, uncontrolled diabetes, hypertension and hyperlipidemia, among others. “This will prompt you to define and document the specific clinical condition, such as morbid obesity,” she said.

The BMI value is one of the key elements to consider when assessing morbid obesity, Dr. Knight added. “Clinical complications should also be evaluated and treated,” she said. “Sometimes multiple interventions are required to evaluate and identify a clinical condition like morbid obesity. Observing the impact of weight on other medical conditions is often a clear indicator.”

A provider may recommend several interventions that could include a dietician, incorporating an exercise regiment and education about managing other co-morbidities that can impact the total health of the patient.

“Morbid obesity may not be documented early in the year as you may opt to evaluate the patient over time,” Dr. Knight continued. “However, once you’ve determined the patient to be morbidly obese, and you code it as such, the diagnosis must continue to be coded as morbid obesity on subsequent visits.”

Since documentation is key to coding morbid obesity, a coder must review the medical record thoroughly when obesity is documented with a BMI of 40 or above, with co-morbid conditions affecting the patient’s overall health. In such a situation, a code for the BMI (the same HCC as morbid obesity) should be used to support morbid obesity.

For more information, 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.

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

As you previously read in The Record, 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.

We anticipate that any disruption to FEP members will be minimal. For complete details, see the November Record.

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.

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.

There will be changes to autism benefit for 2015

Changes to the Blues’ coverage for autism spectrum disorder will become effective Jan, 1, 2015.

This benefit applies to Blue Cross Blue Shield of Michigan and Blue Care Network groups with underwritten plans, and self-funded groups on the Michigan Operating System. It does not apply to self-funded groups that elected to implement the multistate self-funded benefit.

Limitations on direct-line therapy removed
For the Blues’ standard autism treatment benefits, we’ve removed the current limit of 25 hours of direct-line therapy and skill training for applied behavior analysis (per member, per seven calendar days) for codes H2014 and H2019, as well as the three hours of supervision and caregiver training for codes S5108 and S5111.The treatment must be medically necessary and be preauthorized. Members will continue to be covered through the age of 18.

Remember to check member eligibility and benefits before providing services to ensure the member has autism coverage and to determine which of the limits applies for applied behavior analysis treatment.

Evaluations
For ABA treatment to be payable, the member must have an autism spectrum disorder diagnosis made or confirmed by a Blues-approved autism evaluation center (or a multidisciplinary evaluation for out-of-state members). The member must also obtain a treatment plan containing a comprehensive set of treatment recommendations for the member, including a recommendation for ABA, before treatment begins.

At this time, evaluations are only required for ABA services. Members receiving services other than ABA to treat autism spectrum disorder do not need to receive the ASD diagnosis from an approved autism evaluation center  or a multidisciplinary evaluation.

Visit limits
In 2015, all physical therapy, speech therapy and occupational therapy — when billed with ASD as the primary diagnosis — is covered for the treatment of autism. The treatment must be medically necessary, which is typically up to the age of 18. In addition, these visits do not count toward any plan limits.

Billing for ABA services
More information is available in the Applied Behavior Analysis Billing Guidelines and Procedure Codes on web-DENIS.

• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters & Resources.
• Under Other Resources, click on Clinical Criteria & Resources.
• Click on Autism.
• Scroll down to Board-Certified Behavior Analysts and click on Applied Behavior Analysis Billing Guidelines and Procedure Codes.

Board certification and accreditation required for TRUST providers performing sleep studies and polysomnography

As announced in the October Record, Blue Cross Blue Shield of Michigan’s new prior authorization requirement for sleep-testing services, effective Feb. 1, 2015, applies only to in-lab sleep testing. However, all sleep testing services for BCBSM commercial PPO members, whether an in-lab or home sleep test, must be performed and interpreted by a board-certified sleep medicine physician affiliated with an accredited sleep laboratory.

Providers in the TRUST network who do not meet BCBSM’s credentialing requirements as outlined below should not submit sleep study claims for PPO members. This violates the TRUST Provider Agreement, and such claims will be subject to audit and recovery. Providers who continue to submit such claims will be subject to termination of their TRUST contracts.

Physician board-certification requirement
TRUST physicians performing and/or interpreting polysomnography  services (*95810 -*95811-*95805- and *95808) and portable home sleep testing for Blue Cross PPO members are required to be board certified in sleep medicine. This requirement was effective April 1, 2010. TRUST physicians who do not have these credentials may perform the initial evaluation of patients suspected of having a sleep disorder (e.g., physical exam, medical and sleep history, etc.); however, they must refer their patients to board-certified sleep specialists in the TRUST network for all diagnostic sleep studies.

The sleep specialist is the physician responsible for determining and performing the most appropriate test(s) for the patient and obtaining preauthorization when required. It’s important that providers keep their certification information, including expiration dates, current with BCBSM in order to be able to submit preauthorization requests and perform such services.

Facility accreditation requirement
As another step in improving the quality and utilization of sleep services, beginning Feb. 1, 2016 all TRUST facilities performing polysomnography and home sleep testing for Blue Cross PPO members must be accredited by a BCBSM-designated accrediting body. 

For nonhospital-based sleep laboratories, Blue Cross requires accreditation by the American Academy of Sleep Medicine. Hospital-based sleep testing facilities must be accredited by AASM or an accreditation organization accepted under the Participating Hospital Agreement.

The offices of providers that only interpret polysomnography or other sleep testing results are not considered sleep laboratories and would not qualify for accreditation. To interpret polysomnography or home sleep test, however, the board-certified sleep specialist must be under the supervision of the director of a laboratory meeting BCBSM accreditation and board-certification requirements.

The 2016 effective date provides the opportunity for sleep-testing facilities that are not accredited to submit their application for accreditation. In the interim, providers not meeting this requirement may continue to provide services while working toward accreditation. Note: This accreditation requirement does not change the way BCBSM contracts with sleep-testing providers nor does it affect the billing location for services provided.

See October Record article
For additional information, please refer to the October 2014 Record article titled “Preauthorization required for in-lab sleep studies.”

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2013 American Medical Association.  All rights reserved.

We’re revising Prudent Laboratory Use qualification standards

Effective March 3, 2015, participating independent laboratories in the PLUS network must maintain either a current CLIA Certificate of Compliance or a current CLIA Certificate of Accreditation.

You can access the entire revised agreement from the Participation agreements link in the “Participation” chapter of the Independent Laboratory provider manual. You can view the manual on bcbsm.com:

• Log in to Provider Secured Services.
• Click on web-DENIS.
• Click on BCBSM Provider Publications and Resources.
• Click on Provider Manuals.
• Click on Provider type on the dashboard.
• Select Independent Laboratory in the drop-down list.
• Click on Search on the dashboard.
• Click on Prudent Laboratory Use (PLUS) Participation Agreement (effective 3/3/15).

Home infusion therapy guidelines for drug deliveries reinforced

Home infusion therapy drugs delivered to a patient shouldn’t exceed a seven-day supply. The Blue Cross HIT Provider Manual states that, “No more than a seven-day supply of drugs may be delivered to the patient or a 10-day supply for a holiday weekend.”

We understand that there will be situations when a patient needs a drug delivery quantity of more than the allowed seven days. The following drug delivery exceptions are acceptable as long as the pharmacist receives a verbal order from the physician to send an additional quantity:

• When the pharmacist delivers a three-day drug supply, the next delivery quantity during the same infusion week shouldn’t be more than four-day supply. This delivery combination would meet the seven-day drug supply requirement.
• During the first week of drug therapy, additional drug quantities can be added to the delivery to accommodate the provider’s delivery schedule.
• Because of the possibility of a drug reaction, providers who want to closely monitor a patient’s first dose might not want to deliver the entire week’s drug supply. In this case, the remainder of the drug delivery can be delayed until the next delivery date.
• When the length of drug therapy lasts more than seven days but less than 14 days, the delivery of the entire drug therapy is acceptable

Blue Cross also won’t recover payments from HIT providers for drugs under following circumstances:

• Drugs that remain in the home when the therapy is prematurely discontinued
• The patient is unexpectedly hospitalized after a drug delivery
• The drug is changed midweek following a drug delivery

If you have any additional questions or concerns about these guidelines refer to the current Blue Cross HIT Provider Manual.

HIT drug claims need National Drug Code information for billings

If you’re submitting a home infusion therapy drug claim, please report:

• The drug’s J code with the NDC dispensed by the pharmacist, plus the appropriate dose form code for the NDC
• Each NDC separately if more than one container of the same medication is dispensed and the additional containers have a different NDC
• The NDC using the dispensed quantity with appropriate drug measurement unit. Keep in mind that not all drugs are billed according to the number of vials; some are billed according to the amount of liquid in the vial; e.g., the number of millimeters.

Important information you should know when submitting a HIT drug claim:

• The dispensed drug quantity may have up to four whole numbers, a decimal point and decimal numbers. For example, XXXX.XX
• Not all drugs are assigned Health Care Procedure Coding Structure J codes. Some drugs are assigned Q or S codes.
• J3490 code can only be used when HCPCS hasn’t classified a drug.
• The date of service is the date the drug is shipped to the patient.

Blues’ RA Limited Choice program expands in 2015

Under the Affordable Care Act, an employer is not required to offer contraceptive coverage if it qualifies as a religiously accommodated group.

In 2015, Blue Cross Blue Shield of Michigan and Blue Care Network are expanding a program that allows members of these groups to have women’s contraceptive services with no cost sharing when services are obtained from an in-network Blues provider.

To obtain this coverage, members must enroll in Religious Accommodation Limited Choice coverage and use the RA Limited Choice ID card when obtaining contraceptive services.

What’s covered under the RA Limited Choice program?

Contraceptive coverage for members of a religiously accommodated group as defined above depends on whether the group’s plan covers one of the following:

• Medical services such as sterilization and intrauterine devices
• Medical services such as sterilization and intrauterine devices, and prescription contraceptive drugs

Note: A member is eligible for prescription drug coverage if that coverage is included in the group’s plan.

How do members enroll in RA Limited Choice coverage?

Here are the steps:

• We’ll send an RA Limited Choice enrollment form to members of religiously accommodated organizations in the late January to early February timeframe.
• Members can obtain coverage for women’s contraceptive services according to their group plan if they fill out the form and return it to us.
• Upon receipt of the completed form, we’ll send members an RA Limited Choice ID card.
• Members present the RA Limited Choice ID card when obtaining contraceptive services from an in-network provider, and the provider bills Blue Cross for payment of the claim using information on the card. The member won’t have to do anything further or make any kind of payment.

Note:

• The member must be enrolled in the RA Limited Choice program on the date of service to ensure the service is paid.
• If a member does not present the RA Limited Choice ID card when obtaining contraceptive services, claims for the services will be rejected when billed to the member’s group coverage. The services will then have to be billed again using the information on the RA Limited Choice card.

If services are billed using information from the member’s group coverage, the following message will be provided by the Provider Automated Response System, or PARS. (This interactive voice response system replaces CAREN.)

“Your patient’s health care plan doesn’t pay for this service. It’s not a benefit unless this member has coverage for women’s contraceptive services.  We suggest you ask the patient for another Blue Cross ID card.  If the patient has a Blue Cross ID card with benefits for this service, please send us a new claim with the other Enrollee ID.  If there are no benefits for this service, the member is liable.”

The RA Limited Choice ID card

The top ID card is for members who have coverage for medical contraceptive services only.

The bottom ID card is for members who have both medical and prescription contraceptive coverage. (The RxLimited logo, located on the bottom right corner of the card, indicates prescription coverage for contraceptives.)

Reimbursement program ending in 2015

A reimbursement program was in effect during 2014 for members of certain religious employer groups. These members paid up front for contraceptive services and sent the receipts to Blue Cross for reimbursement.

We encourage members to send Blue Cross these receipts so they can be paid.

Note: Members who have selected RA Limited Choice coverage and have the RA Limited Choice ID card cannot pay for contraceptive services and send the receipts to us for reimbursement.

2015 FEP benefits feature BRCA mutation testing for adult males, updated guidelines for transplants

New coverage for BRCA mutation testing is among the Federal Employee Program benefit changes for 2015. We've outlined other benefit changes for FEP members below.

The following changes apply to both the Standard Option and Basic Option benefit plans for services provided on or after Jan. 1, 2015:

Preventive care

• We now provide preventive care benefits for genetic counseling and evaluation services related to preventive BRCA testing for males age 18 and older. The males must have a family history associated with an increased risk for harmful mutations in BRCA1 or BRCA2 genes. Benefits are limited to one BRCA test per lifetime. (Previously, preventive care benefits for these services were not available for male members.)
• Preventive care benefits are now available for BRCA testing in males and females with a family history of both breast and fallopian tube cancer or breast and primary peritoneal cancer among first- and second-degree relatives. (Previously, the family history criteria for BRCA testing did not include the presence of fallopian tube or primary peritoneal cancer with breast cancer.)
• Prior approval for all BRCA testing is required before the test is performed, whether it is performed for preventive or diagnostic reasons. For preventive BRCA testing, the member must also receive genetic counseling and evaluation services before the test is performed. (Previously, BRCA testing was not subject to these requirements.)
• We now provide preventive care benefits to screen for diabetes mellitus in adults. (Previously, preventive benefits were available for related screening only when performed as part of a metabolic panel.)
• Preventive care benefits are now available for hepatitis C screening in adults.
• We now provide preventive care benefits for low-dose CT screenings for lung cancer in adults ages 55 to 80 with a history of tobacco use.

Women’s care

• Benefits for tocolytic therapy and related services are now limited to those services provided on an inpatient basis. (Previously, benefits were also available for in-home services.)
• We’ve updated our prescription drug benefits for tamoxifen and raloxifene. These generic drugs are now covered in full when they’re obtained from a Preferred pharmacy to reduce breast cancer risk for women ages 35 or older who have not been diagnosed with any form of breast cancer.

Blood, stem cell and organ transplants

• We now provide benefits for certain allogeneic blood or marrow stem cell transplants limited to select diagnoses and stages. This includes those transplants that are performed in a facility accredited by the Foundation for the Accreditation of Cellular Therapy, a Blue Distinction^® Center for Transplants or a cancer research facility. (Previously, these benefits were limited to transplant procedures performed at a Blue Distinction Center for Transplants.)
• We now reimburse members for eligible travel expenses related to covered transplants performed at designated Blue Distinction Centers for Transplants. The member must live 50 miles or more from the facility, and the reimbursement is subject to certain criteria.
• We provide benefits for covered organ transplants only when they are performed in facilities with a Medicare-approved transplant program for the type of transplant anticipated. This guideline does not apply to facilities where Medicare does not maintain an associated approved program. (Previously, benefits for organ transplants were not subject to this requirement.)
• Benefits are now available for implantation of an artificial heart as a bridge to transplant or destination therapy.
• Benefits for simultaneous liver and kidney transplants, single lung transplants, double lung transplants and pancreas transplants performed at Blue Distinction Centers for Transplants are now limited to adult members.

Medical facilities

• When members use a designated Blue Distinction Center for certain inpatient bariatric, hip, knee or spine surgeries, cost shares have been reduced to $150 per admission under the Standard Option and to $100 per day ($500 maximum) under the Basic Option.
• When members use a facility designated as a Blue Distinction Center for Bariatric Surgery for outpatient laparoscopic gastric banding surgery, the following copayments will now apply: $100 per day per facility under Standard Option and $25 per day per facility under Basic Option. Regular benefit levels apply to charges for the professional services, including surgery and anesthesia.
• When emergency room services related to an accidental injury or medical emergency are performed by Nonpreferred professional providers in a Preferred hospital, members are responsible for their cost share for those services. They’re also responsible for any difference between our allowance and the billed amount.
• We now provide benefits for outpatient facility mental health and substance abuse services when performed and billed by residential treatment centers.

Wellness incentives

Members who complete a Blue Health Assessment health risk questionnaire are eligible for a $50 health account to be used for qualified medical expenses. (Previously, members were eligible for a $40 health account. Please encourage your FEP patients to complete the Blue Health Assessment.)

The following changes only apply to Standard Option members for services provided on or after Jan. 1, 2015:

Medical facilities

• We’ve reduced the copayment for accidental injury or medical emergency care provided at a Preferred urgent care center to $30 per visit. (Previously, the copayment was $40 per visit.)
• The cost share for an inpatient admission to a nonparticipating hospital or other covered facility for mental health and substance abuse services is now 35 percent of the plan allowance and any remaining balance after the plan’s payment. (Previously, members were also responsible for a $350 per admission copayment for these services.)
• The cost chare for inpatient professional mental health and substance abuse services is now 35 percent of the plan allowance for participating and nonparticipating providers. When services are performed by nonparticipating providers, members are also responsible for the difference between the plan allowance and the billed amount. (Previously, members were also required to meet their calendar-year deductible for these services.)
• We now provide benefits for inpatient admissions to residential treatment centers for mental health and substance abuse services only for Standard Option members who have Medicare Part A coverage as their primary insurance.  (Previously, there were no benefits for this type of inpatient admission.)

The following changes only apply to Basic Option members for services provided on or after Jan. 1, 2015:

• For cardiovascular monitoring services performed by a Preferred professional or facility provider, a copayment of $40 is now applied. (For standard electrocardiograms, there is no copayment.)
• We’ve reduced the copayment for accidental injury or medical emergency care provided at a preferred urgent care center to $35 per visit. (Previously, the copayment was $50 per visit.)

Drugs added to the Medical Drug Prior Authorization Program, effective April 1, 2015

Beginning April 1, 2015, five additional specialty drugs administered by health care practitioners will require prior authorization from Blue Cross Blue Shield of Michigan before they will be covered under members’ medical benefits. The prior authorization is only a clinical review approval; it is not a guarantee of payment. Health care practitioners will need to verify the members’ coverage for medical benefits.   

This helps ensure proper use and address potential safety issues for these medications.

You can find medication request forms within the list of medications that require prior authorization on web-DENIS:

• Click on BCBSM Provider Publications and Resources.
• Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
• Click on Physician administered medications (on the right side under Frequently Used Forms).

We will not consider a request for authorization until we receive a physician-signed medication request form faxed or mailed to BCBSM or a request uploaded onto the online-based tool, NovoLogix. Standard processing time for review of a request is 15 days. An urgent request is reviewed within 72 hours.

The drugs in the following list** will require prior authorization starting April 1, 2015:

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

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

Prior authorization required for specialty drug Lemtrada™

The following medical specialty drug will require prior authorization starting Jan. 1, 2015:

Lemtrada™ — HCPCS code J3490/J3590

Blue Cross Blue Shield of Michigan reserves the right to add a medical specialty drug to the medical prior authorization program as a product becomes approved by the Food and Drug Administration. Blue Cross will continue to provide an update notification of any drug that will be added to the medical drug PA program.

Certain specialty drugs administered by health care practitioners require prior authorization before they can be covered under our members’ medical benefits. The prior authorization is only a clinical review approval; it is not a guarantee of payment. Health care practitioners will need to verify the member’s coverage for medical benefits.

This helps ensure proper use and addresses potential safety issues for specialty drugs.

You can find medication request forms within the list of medications that require prior authorization on web-DENIS:

• Click on BCBSM Provider Publications and Resources.
• Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
• Click on Physician administered medications (on the right side under Frequently Used Forms).

You must send the authorization request to us in one of the following ways:

• Fax or mail a physician-signed medical medication request form
• Upload your request using the online-based tool, NovoLogix.

Standard processing time for review of a request is 15 days. An urgent request is reviewed within 72 hours.

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

Board certification and accreditation required for TRUST providers performing sleep studies and polysomnography

As announced in the October Record, Blue Cross Blue Shield of Michigan’s new prior authorization requirement for sleep-testing services, effective Feb. 1, 2015, applies only to in-lab sleep testing. However, all sleep testing services for BCBSM commercial PPO members, whether an in-lab or home sleep test, must be performed and interpreted by a board-certified sleep medicine physician affiliated with an accredited sleep laboratory.

Providers in the TRUST network who do not meet BCBSM’s credentialing requirements as outlined below should not submit sleep study claims for PPO members. This violates the TRUST Provider Agreement, and such claims will be subject to audit and recovery. Providers who continue to submit such claims will be subject to termination of their TRUST contracts.

Physician board-certification requirement
TRUST physicians performing and/or interpreting polysomnography  services (*95810 -*95811-*95805- and *95808) and portable home sleep testing for Blue Cross PPO members are required to be board certified in sleep medicine. This requirement was effective April 1, 2010. TRUST physicians who do not have these credentials may perform the initial evaluation of patients suspected of having a sleep disorder (e.g., physical exam, medical and sleep history, etc.); however, they must refer their patients to board-certified sleep specialists in the TRUST network for all diagnostic sleep studies.

The sleep specialist is the physician responsible for determining and performing the most appropriate test(s) for the patient and obtaining preauthorization when required. It’s important that providers keep their certification information, including expiration dates, current with BCBSM in order to be able to submit preauthorization requests and perform such services.

Facility accreditation requirement
As another step in improving the quality and utilization of sleep services, beginning Feb. 1, 2016 all TRUST facilities performing polysomnography and home sleep testing for Blue Cross PPO members must be accredited by a BCBSM-designated accrediting body. 

For nonhospital-based sleep laboratories, Blue Cross requires accreditation by the American Academy of Sleep Medicine. Hospital-based sleep testing facilities must be accredited by AASM or an accreditation organization accepted under the Participating Hospital Agreement.

The offices of providers that only interpret polysomnography or other sleep testing results are not considered sleep laboratories and would not qualify for accreditation. To interpret polysomnography or home sleep test, however, the board-certified sleep specialist must be under the supervision of the director of a laboratory meeting BCBSM accreditation and board-certification requirements.

The 2016 effective date provides the opportunity for sleep-testing facilities that are not accredited to submit their application for accreditation. In the interim, providers not meeting this requirement may continue to provide services while working toward accreditation. Note: This accreditation requirement does not change the way BCBSM contracts with sleep-testing providers nor does it affect the billing location for services provided.

See October Record article
For additional information, please refer to the October 2014 Record article titled “Preauthorization required for in-lab sleep studies.”

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2013 American Medical Association.  All rights reserved.

Blues’ RA Limited Choice program expands in 2015

Under the Affordable Care Act, an employer is not required to offer contraceptive coverage if it qualifies as a religiously accommodated group.

In 2015, Blue Cross Blue Shield of Michigan and Blue Care Network are expanding a program that allows members of these groups to have women’s contraceptive services with no cost sharing when services are obtained from an in-network Blues provider.

To obtain this coverage, members must enroll in Religious Accommodation Limited Choice coverage and use the RA Limited Choice ID card when obtaining contraceptive services.

What’s covered under the RA Limited Choice program?

Contraceptive coverage for members of a religiously accommodated group as defined above depends on whether the group’s plan covers one of the following:

• Medical services such as sterilization and intrauterine devices
• Medical services such as sterilization and intrauterine devices, and prescription contraceptive drugs

Note: A member is eligible for prescription drug coverage if that coverage is included in the group’s plan.

How do members enroll in RA Limited Choice coverage?

Here are the steps:

• We’ll send an RA Limited Choice enrollment form to members of religiously accommodated organizations in the late January to early February timeframe.
• Members can obtain coverage for women’s contraceptive services according to their group plan if they fill out the form and return it to us.
• Upon receipt of the completed form, we’ll send members an RA Limited Choice ID card.
• Members present the RA Limited Choice ID card when obtaining contraceptive services from an in-network provider, and the provider bills Blue Cross for payment of the claim using information on the card. The member won’t have to do anything further or make any kind of payment.

Note:

• The member must be enrolled in the RA Limited Choice program on the date of service to ensure the service is paid.
• If a member does not present the RA Limited Choice ID card when obtaining contraceptive services, claims for the services will be rejected when billed to the member’s group coverage. The services will then have to be billed again using the information on the RA Limited Choice card.

If services are billed using information from the member’s group coverage, the following message will be provided by the Provider Automated Response System, or PARS. (This interactive voice response system replaces CAREN.)

“Your patient’s health care plan doesn’t pay for this service. It’s not a benefit unless this member has coverage for women’s contraceptive services.  We suggest you ask the patient for another Blue Cross ID card.  If the patient has a Blue Cross ID card with benefits for this service, please send us a new claim with the other Enrollee ID.  If there are no benefits for this service, the member is liable.”

The RA Limited Choice ID card

The top ID card is for members who have coverage for medical contraceptive services only.

The bottom ID card is for members who have both medical and prescription contraceptive coverage. (The RxLimited logo, located on the bottom right corner of the card, indicates prescription coverage for contraceptives.)

Reimbursement program ending in 2015

A reimbursement program was in effect during 2014 for members of certain religious employer groups. These members paid up front for contraceptive services and sent the receipts to Blue Cross for reimbursement.

We encourage members to send Blue Cross these receipts so they can be paid.

Note: Members who have selected RA Limited Choice coverage and have the RA Limited Choice ID card cannot pay for contraceptive services and send the receipts to us for reimbursement.

Billing change for observation services

Blue Cross Blue Shield of Michigan is changing the reporting guidelines for observation services that were previously published in March 2013.

If a patient is admitted for observation from settings other than the emergency room, report Healthcare Common Procedure Coding System code G0379 with a quantity of “1,” and report G0378 for additional observation hours. Keep in mind that 48 hours is the maximum number of hours that are payable.

For more information, contact your provider consultant.

2015 FEP benefits feature BRCA mutation testing for adult males, updated guidelines for transplants

New coverage for BRCA mutation testing is among the Federal Employee Program benefit changes for 2015. We've outlined other benefit changes for FEP members below.

The following changes apply to both the Standard Option and Basic Option benefit plans for services provided on or after Jan. 1, 2015:

Preventive care

• We now provide preventive care benefits for genetic counseling and evaluation services related to preventive BRCA testing for males age 18 and older. The males must have a family history associated with an increased risk for harmful mutations in BRCA1 or BRCA2 genes. Benefits are limited to one BRCA test per lifetime. (Previously, preventive care benefits for these services were not available for male members.)
• Preventive care benefits are now available for BRCA testing in males and females with a family history of both breast and fallopian tube cancer or breast and primary peritoneal cancer among first- and second-degree relatives. (Previously, the family history criteria for BRCA testing did not include the presence of fallopian tube or primary peritoneal cancer with breast cancer.)
• Prior approval for all BRCA testing is required before the test is performed, whether it is performed for preventive or diagnostic reasons. For preventive BRCA testing, the member must also receive genetic counseling and evaluation services before the test is performed. (Previously, BRCA testing was not subject to these requirements.)
• We now provide preventive care benefits to screen for diabetes mellitus in adults. (Previously, preventive benefits were available for related screening only when performed as part of a metabolic panel.)
• Preventive care benefits are now available for hepatitis C screening in adults.
• We now provide preventive care benefits for low-dose CT screenings for lung cancer in adults ages 55 to 80 with a history of tobacco use.

Women’s care

• Benefits for tocolytic therapy and related services are now limited to those services provided on an inpatient basis. (Previously, benefits were also available for in-home services.)
• We’ve updated our prescription drug benefits for tamoxifen and raloxifene. These generic drugs are now covered in full when they’re obtained from a Preferred pharmacy to reduce breast cancer risk for women ages 35 or older who have not been diagnosed with any form of breast cancer.

Blood, stem cell and organ transplants

• We now provide benefits for certain allogeneic blood or marrow stem cell transplants limited to select diagnoses and stages. This includes those transplants that are performed in a facility accredited by the Foundation for the Accreditation of Cellular Therapy, a Blue Distinction^® Center for Transplants or a cancer research facility. (Previously, these benefits were limited to transplant procedures performed at a Blue Distinction Center for Transplants.)
• We now reimburse members for eligible travel expenses related to covered transplants performed at designated Blue Distinction Centers for Transplants. The member must live 50 miles or more from the facility, and the reimbursement is subject to certain criteria.
• We provide benefits for covered organ transplants only when they are performed in facilities with a Medicare-approved transplant program for the type of transplant anticipated. This guideline does not apply to facilities where Medicare does not maintain an associated approved program. (Previously, benefits for organ transplants were not subject to this requirement.)
• Benefits are now available for implantation of an artificial heart as a bridge to transplant or destination therapy.
• Benefits for simultaneous liver and kidney transplants, single lung transplants, double lung transplants and pancreas transplants performed at Blue Distinction Centers for Transplants are now limited to adult members.

Medical facilities

• When members use a designated Blue Distinction Center for certain inpatient bariatric, hip, knee or spine surgeries, cost shares have been reduced to $150 per admission under the Standard Option and to $100 per day ($500 maximum) under the Basic Option.
• When members use a facility designated as a Blue Distinction Center for Bariatric Surgery for outpatient laparoscopic gastric banding surgery, the following copayments will now apply: $100 per day per facility under Standard Option and $25 per day per facility under Basic Option. Regular benefit levels apply to charges for the professional services, including surgery and anesthesia.
• When emergency room services related to an accidental injury or medical emergency are performed by Nonpreferred professional providers in a Preferred hospital, members are responsible for their cost share for those services. They’re also responsible for any difference between our allowance and the billed amount.
• We now provide benefits for outpatient facility mental health and substance abuse services when performed and billed by residential treatment centers.

Wellness incentives

Members who complete a Blue Health Assessment health risk questionnaire are eligible for a $50 health account to be used for qualified medical expenses. (Previously, members were eligible for a $40 health account. Please encourage your FEP patients to complete the Blue Health Assessment.)

The following changes only apply to Standard Option members for services provided on or after Jan. 1, 2015:

Medical facilities

• We’ve reduced the copayment for accidental injury or medical emergency care provided at a Preferred urgent care center to $30 per visit. (Previously, the copayment was $40 per visit.)
• The cost share for an inpatient admission to a nonparticipating hospital or other covered facility for mental health and substance abuse services is now 35 percent of the plan allowance and any remaining balance after the plan’s payment. (Previously, members were also responsible for a $350 per admission copayment for these services.)
• The cost chare for inpatient professional mental health and substance abuse services is now 35 percent of the plan allowance for participating and nonparticipating providers. When services are performed by nonparticipating providers, members are also responsible for the difference between the plan allowance and the billed amount. (Previously, members were also required to meet their calendar-year deductible for these services.)
• We now provide benefits for inpatient admissions to residential treatment centers for mental health and substance abuse services only for Standard Option members who have Medicare Part A coverage as their primary insurance.  (Previously, there were no benefits for this type of inpatient admission.)

The following changes only apply to Basic Option members for services provided on or after Jan. 1, 2015:

• For cardiovascular monitoring services performed by a Preferred professional or facility provider, a copayment of $40 is now applied. (For standard electrocardiograms, there is no copayment.)
• We’ve reduced the copayment for accidental injury or medical emergency care provided at a preferred urgent care center to $35 per visit. (Previously, the copayment was $50 per visit.)

Reminder: Ambulatory surgery facility audit process

Blue Cross Blue Shield of Michigan regularly conducts post-payment utilization review audits at ambulatory surgery facilities. During these audits, we review medical records and billing information to ensure that billed and paid services were ordered, rendered, medically necessary, documented, reported and covered under the patient’s contract according to Blue Cross guidelines.

When a facility is selected for audit, we obtain an audit sample that represents the patient population. The methodology we use for ASF audits is random sampling. The process places an equal probability of selection on every patient at a facility within a specific time frame. A computer selects the patients to be used in the audit.

The size of the audit sample is determined by two quantities: confidence and precision. These values determine the risk level associated with the sample estimates deviating from the true unknown population overpayment.

The acceptable values are 95 percent for confidence and 10 percent for precision. This means that Blue Cross wants to be 95 percent confident that the sample compliance error rate isn’t different from the population compliance error rate by more than 10 percent. This produces a sample size large enough that the estimates obtained through the audit accurately represent characteristics of the population.

After we have selected the audit sample, we’ll conduct an on-site audit at the facility or at a Blue Cross office. Once the auditor completes the review of the medical record and billing information, we’ll identify any overpayments due to billing errors and medical necessity determinations and then recover the payments. Any underpayments we identify will be offset against the overpayments. If there are no overpayments, we’ll instruct the facility to re-bill underpaid claims to Blue Cross. We’ll then send a detailed audit report to the facility.

Facilities can appeal the audit results. If the facility chooses to appeal, we’ll provide information for the next available level of appeal.

For more information, refer to the provider manual for ambulatory surgery facilities on web-DENIS.   

Reminder: Qualifying facilities can enroll to provide psychiatric residential treatment

We’d like to remind you that qualifying facilities can enroll as psychiatric residential treatment facilities. Blue Cross began covering psychiatric residential treatment on July 1, 2014, in alignment with the requirements of the federal mental health parity law.

Qualifying as a psychiatric residential treatment facility

To enroll with Blue Cross, a psychiatric residential facility must be licensed by the state of Michigan as a child caring institution, an adult foster-care facility or a nonhospital, psychiatric facility for individuals who:

• Require psychiatric treatment that is longer-term than the traditional inpatient program
• No longer require the intensity of service provided in a traditional psychiatric inpatient facility
• Require psychiatric treatment that is more intensive than outpatient psychiatric treatment
• Continue to require supervision 24 hours a day, seven days a week because they cannot safely be treated in a less restrictive setting, such as a day treatment program

The facility must also use the services of a multidisciplinary treatment team.

Treatment requirements

The facility must be able to provide supervision and treatment as outlined below, as well as room and board for patients:

• A face-to-face evaluation by the attending psychiatrist must occurwithin 72 hours of admission.
  
• Supervision is provided 24/7.
• Nursing care is on-site or on call and no more than 15 minutes away 24/7.
• A psychiatrist is on call 24/7.
• A psychiatrist is on-site a minimum of two days per week.
• An individualized plan of active psychiatric treatment and residential living support is provided in a timely manner. Initial treatment plan should be developed within 72 hours of admission and a more robust treatment plan should be developed by the end of week two. Treatment plans should be updated at least weekly.
  
  At minimum, the plan includes the following elements:
• A weekly face-to-face meeting must be scheduled with the patient and his or her caretaker, guardian, or family members unless there is an identified, valid reason why it is not clinically appropriate or feasible.
• Medication management by a board-certified psychiatrist must be provided a minimum of twice per week.
• There must be ongoing medical services to evaluate and manage co-morbid medical conditions.
• Integrated treatment, rehabilitation and support must be provided by a multidisciplinary team. There should be linkage and coordination with the patient’s community resources with the goal of returning the patient to his or her regular social environment as soon as possible.
• There should be individual therapy twice a week.
• Group therapy should comprise a minimum of 12.5 hours a week.
• Group sessions should be from 60 and 90 minutes in length.
• At least two group therapy sessions should be “psychological” sessions, such as process groups and dialectal behavior therapy.
• The remaining groups may be expressive, such as art, dance, psychodrama therapy and psycho-educational groups.
• Recreational activities should be available for those able to participate and there should be a minimum of four hours of treatment or activities planned each weekend day.
• Therapies such as equestrian therapy or “ropes” exercises may be included but not at an additional cost to the member. Wilderness programs are excluded.
• Clinical judgment should be used to determine whether the patient can tolerate the designated amount of group activity. If the patient is unable to participate to the extent described above, the reason should be documented in the chart for each activity.
• For children and adolescents, a certified school program must be provided.
• For geriatric facilities, the care is expected to include availability of activities and resources to meet the social needs of older patients with chronic mental illness. These needs would typically include, at a minimum, company (either external visitors or individuals inside the facility), daily activities and having a close confidant.

If you have questions regarding this program or how to enroll, contact Rose Zidzik at rzidzik@bcbsm.com. Also, check future issues of The Record and web-DENIS for updates.

Reminder: Be sure you’re billing correctly for therapy services

Our claims experience shows that hospital outpatient departments and freestanding outpatient physical therapy facilities are not billing correctly for physical, occupational and speech therapy services.

We shared the billing requirements in the November 2012 and July 2012 issues of The Record.

When these services are not billed correctly, your patients may reach their therapy benefit limits sooner than they should.

For each date of service, please report the following:

• Therapy services revenue code
• Health Care Common Procedure Coding System code
• Number of services provided

For more information, contact your provider consultant.

Pharmacies can qualify for direct payments for immunizations

We’d like to remind pharmacy providers that they can be directly reimbursed for administering certain vaccines as a participating pharmacy under our medical and surgical benefits.

How does this work?
As you read in the November Record, covered professional services qualify for reimbursement through Blue Cross Blue Shield of Michigan medical and surgical benefits — not under the pharmacy benefit — as long as the member has immunization coverage. Pharmacies must bill for vaccines and their administration on either the paper CMS-1500 claim or the 837 electronic CMS-1500 claim for BCBSM. Please see the September 2013 Record for direction on how to submit the national drug code and quantity on your claim.

Which pharmacies are eligible?
Each pharmacy must first be credentialed and approved to participate in the BCBSM pharmacy network before being eligible for reimbursement through the vaccine pharmacy network for professional medical and surgical benefit plan claims. Participating pharmacies that subsequently sign the vaccine network contracts will receive new Blues professional provider identification numbers. This will allow professional eligibility verification access through web-DENIS. Each pharmacy must use its national provider identifier number for billing these professional services.

If your pharmacy participates in our vaccine pharmacy network, we’ll send payments for covered professional services directly to your pharmacy. For consistent provider payment procedures, the Blues will allow pharmacies to designate other entities as payees.

To be eligible for reimbursement, pharmacies must meet the Blues qualification and reimbursement standards outlined in the Vaccine Affiliation Agreement.

A qualified pharmacy that wants to become eligible for direct reimbursement as a participating provider can apply for a Blues professional PIN by following these steps:

1. Become credentialed and approved as a participating BCBSM pharmacy.
   
   
2. Visit the Enrollment and Changes Web page at bcbsm.com/provider/enrollment.

• Under the Enrollment and Changes banner, click on Physicians and Professionals.
• Click on Next.
• Select Enroll a new provider.
• Click on Next.
• Select Vaccine Pharmacy.
• Click on Next, then follow the instructions to apply.

3. Complete the required immunization administration training. The Michigan Pharmacists Association offers a program. You may contact them at michiganpharmacists.org.**

Note: The pharmacy must register all immunizations with the Michigan Care Improvement Registry.

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

• The NDC must be submitted along with the applicable Healthcare Common Procedure Coding System or Current Procedural Terminology code.
• The NDC must follow the “5digit4digit2digit” format (11 numeric characters with no spaces or special characters). If the NDC on the package label is fewer than 11 digits, you must add leading zeroes to total 11 digits.
• The NDC must be active for the date of service.
• To submit electronic claims (ANSI 837P), report the following information:

• To submit paper claims, enter the NDC information in field 24 of the CMS-1500 claim. In the shaded portion of field 24A-24G, enter the qualifier “N4” left-justified, immediately followed by the national drug code. Next, enter the appropriate qualifier for the correct dispensing unit (GR, UN, ML or ME), followed by the quantity and the price per unit, as indicated in the example below.
• The format for billing should be:
  N4 + NDC code + 3 spaces+ unit of measure + quantity
  Example: N4555103026710 ML5.5

For BCN, please see previous notification on how to bill effectively.

Which members are covered?
This program applies to BCBSM commercial (non-Medicare) members with Traditional or PPO coverage, excluding Federal Employee Program members. Member benefits will vary by group for immunization coverage. The pharmacy should check eligibility through web-DENIS.

Vaccine code list
Blue Cross will pay eligible pharmacies directly for the following procedure codes for the vaccines and the administration services listed below.

Note: Vaccines will be paid at either 100 percent of the standard BCBSM fee schedule or the pharmacy’s retail charge (whichever is less), minus applicable member copayments and deductibles. Administration of vaccines will be paid at 85 percent of the standard Blues fee schedule or the pharmacy’s retail charge (whichever is less), minus applicable member copays and deductibles.

The retail charge is the pharmacy’s charge per vaccine to its cash-paying customers notwithstanding the billing terminology associated with such charge. In addition, any retail charge specific to certain demographic groups will also be given to BCBSM for similar members.

Additional codes, new vaccines
The following administration codes may apply: G0008, G0009, *90471, *90472, *90473 and *90474. The vaccine codes that were initially included in the program were *90655, *90656, *90657, *90658, *90660, *90663, *90732 and *90736. We will be including the following additional influenza vaccine codes: *90654, *90661, *90662, *90672, *90686, *90688, Q2034, Q2035, Q2036, Q2037 and Q2038 in the program. There are several new vaccines that will be now included in the program, effective April 1, 2015, as follows:

For more information, see the appropriate BCBSM payment schedules on web-DENIS.

**Blue Cross Blue Shield of Michigan and Blue Care Network do not control this website or endorse its general content.

Drugs added to the Medical Drug Prior Authorization Program, effective April 1, 2015

Beginning April 1, 2015, five additional specialty drugs administered by health care practitioners will require prior authorization from Blue Cross Blue Shield of Michigan before they will be covered under members’ medical benefits. The prior authorization is only a clinical review approval; it is not a guarantee of payment. Health care practitioners will need to verify the members’ coverage for medical benefits.   

This helps ensure proper use and address potential safety issues for these medications.

You can find medication request forms within the list of medications that require prior authorization on web-DENIS:

• Click on BCBSM Provider Publications and Resources.
• Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
• Click on Physician administered medications (on the right side under Frequently Used Forms).

We will not consider a request for authorization until we receive a physician-signed medication request form faxed or mailed to BCBSM or a request uploaded onto the online-based tool, NovoLogix. Standard processing time for review of a request is 15 days. An urgent request is reviewed within 72 hours.

The drugs in the following list** will require prior authorization starting April 1, 2015:

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

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

Prior authorization required for specialty drug Lemtrada™

The following medical specialty drug will require prior authorization starting Jan. 1, 2015:

Lemtrada™ — HCPCS code J3490/J3590

Blue Cross Blue Shield of Michigan reserves the right to add a medical specialty drug to the medical prior authorization program as a product becomes approved by the Food and Drug Administration. Blue Cross will continue to provide an update notification of any drug that will be added to the medical drug PA program.

Certain specialty drugs administered by health care practitioners require prior authorization before they can be covered under our members’ medical benefits. The prior authorization is only a clinical review approval; it is not a guarantee of payment. Health care practitioners will need to verify the member’s coverage for medical benefits.

This helps ensure proper use and addresses potential safety issues for specialty drugs.

You can find medication request forms within the list of medications that require prior authorization on web-DENIS:

• Click on BCBSM Provider Publications and Resources.
• Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
• Click on Physician administered medications (on the right side under Frequently Used Forms).

You must send the authorization request to us in one of the following ways:

• Fax or mail a physician-signed medical medication request form
• Upload your request using the online-based tool, NovoLogix.

Standard processing time for review of a request is 15 days. An urgent request is reviewed within 72 hours.

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

Drugs added to the Medical Drug Prior Authorization Program, effective April 1, 2015

Beginning April 1, 2015, five additional specialty drugs administered by health care practitioners will require prior authorization from Blue Cross Blue Shield of Michigan before they will be covered under members’ medical benefits. The prior authorization is only a clinical review approval; it is not a guarantee of payment. Health care practitioners will need to verify the members’ coverage for medical benefits.   

This helps ensure proper use and address potential safety issues for these medications.

You can find medication request forms within the list of medications that require prior authorization on web-DENIS:

• Click on BCBSM Provider Publications and Resources.
• Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
• Click on Physician administered medications (on the right side under Frequently Used Forms).

We will not consider a request for authorization until we receive a physician-signed medication request form faxed or mailed to BCBSM or a request uploaded onto the online-based tool, NovoLogix. Standard processing time for review of a request is 15 days. An urgent request is reviewed within 72 hours.

The drugs in the following list** will require prior authorization starting April 1, 2015:

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

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

Prior authorization required for specialty drug Lemtrada™

The following medical specialty drug will require prior authorization starting Jan. 1, 2015:

Lemtrada™ — HCPCS code J3490/J3590

Blue Cross Blue Shield of Michigan reserves the right to add a medical specialty drug to the medical prior authorization program as a product becomes approved by the Food and Drug Administration. Blue Cross will continue to provide an update notification of any drug that will be added to the medical drug PA program.

Certain specialty drugs administered by health care practitioners require prior authorization before they can be covered under our members’ medical benefits. The prior authorization is only a clinical review approval; it is not a guarantee of payment. Health care practitioners will need to verify the member’s coverage for medical benefits.

This helps ensure proper use and addresses potential safety issues for specialty drugs.

You can find medication request forms within the list of medications that require prior authorization on web-DENIS:

• Click on BCBSM Provider Publications and Resources.
• Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
• Click on Physician administered medications (on the right side under Frequently Used Forms).

You must send the authorization request to us in one of the following ways:

• Fax or mail a physician-signed medical medication request form
• Upload your request using the online-based tool, NovoLogix.

Standard processing time for review of a request is 15 days. An urgent request is reviewed within 72 hours.

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

Update: Dental coverage, physical therapy benefits for Ford employees

Starting Jan, 1, 2015, Ford Motor Company hourly employees will no longer be covered by Blue Cross Blue Shield of Michigan and Dental Network of America, also known as DNoA, for dental coverage. Delta Dental or another dental carrier will be picking up coverage for hourly members.

And for Ford salaried employees, we want to clarify information in the December 2014 Record article titled “TheraMatrix™ no longer handling outpatient physical therapy benefits.”

Starting Jan, 1, 2015, Blue Cross Blue Shield of Michigan will process all claims from TheraMatrix Physical Therapy Network, also known as TPTN, including handling administrative responsibilities. This means that TheraMatrix won’t be the claims processor or the sole administrator for Ford salaried employees. 

Employees are able to choose where they receive services as long as the provider participates with Blue Cross. Prior to 2015, Ford salaried employees were required to only use TheraMatrix.

This change won’t affect coverage for Ford or other Blue Cross members who receive outpatient physical therapy services at TheraMatrix outpatient physical therapy clinics.

Blue Cross Blue Shield of Michigan issues Medicare Plus Blue^SM claim overpayment recovery letters

In reviewing our records, we discovered that we overpaid some providers for services to our Medicare Plus Blue members. We will attempt to recover the overpayments by reducing future claim payments.

You will receive monthly reports beginning in March 2015 that identify outstanding overpayments until the balance due is recovered.  For overpayment balances that exceed 60 days, please send a copy of the claim detail report along with a refund check made payable to Medicare Plus Blue to:

            Blue Cross Blue Shield of Michigan
            Attn:  FBD COB, Recoveries & Collections
            P.O. Box 441187
            Detroit, MI  48226-1187

Any unpaid balances that exceed 120 days may be referred to collections.  Also, under federal regulations, we may be required to report this issue to the Centers for Medicare & Medicaid Services.

We apologize for any inconvenience this may cause. If you have any questions, please call our Medicare Advantage Provider Inquiry department at 1-866-309-1719 between 8 a.m. and 4:30 p.m., Monday through Friday.

To review our recovery and provider disputes process in more detail, please visit our Overpayment page on our provider website.

Below is an explanation of the detail report that you’ll receive.

1. Date — The date the report was generated
2. Provider Name — The provider name associated with the overpayment
3. Provider Address —  The provider address associated with the overpayment
4. NPI — The NPI associated with the overpayment
5. Member ID — Patient’s Blue Cross Medicare Advantage contract number
6. Patient Name — Patient name related to the overpayment
7. Claim Number — Original claim number associated with the overpayment
8. Adj. Date (Adjustment Date) — The date the overpayment was identified
9. Dates of Service — Beginning and ending (if available) dates of service on the overpayment
10. Charged Amount — The total charged amount on the overpayment
11. Overpayment Amt — The original amount of the overpayment
12. Received Amt  — The amount applied to the overpayment
13. Balance Due — The remaining amount due from the provider
14. Adj Rsn (adjustment reason code) — The reason for the overpayment
15. Age in Days — The number of days between the Adj Date (adjustment date) and the last day of the previous month. If this number is greater than 60 then please see instructions in the letter to send in payment.
16. New Claim No. if avail — If the original claim number was adjusted the new claim number would appear here.
17. Total Number of Claims — Total number of claims on the report
18. Totals in Dollars
1. Charged Amt — The amount charged for all claims on the report
2. Overpayment Amt — The amount Blue Cross overpaid for all claims on the report
3. Received Amt — The amount we received from the provider for all claims on the report
4. Balance Due —  The amount owed by the provider for all claims on the report
19. Reason For Overpayment — Detail description for the Adj Rsn (adjustment reason code)

Medicare Plus Blue^SM changes reimbursement for gradient compression stockings

Effective for claims with dates of service on or after March 8, 2015, Blue Cross Blue Shield of Michigan’s Medicare Plus Blue plan will reimburse 35 percent above the supplier invoice cost for unspecified gradient compression stockings (HCPCS code: A6549). 

You’ll need to submit the supplier invoice along with supporting documentation when submitting the claim. Claims received without the supplier invoice will be denied for payment. 

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