Medicare Advantage Diagnosis Closure Incentive program continues in 2015

Blue Cross Blue Shield of Michigan and Blue Care Network will continue the Medicare Advantage Diagnosis Closure Incentive program in 2015.

The incentive program again applies to Blues Medicare Advantage patients, including those with Blue Cross Medicare Plus Blue PPO^SM, Medicare Plus Blue Group^SM PPO, BCN Advantage HMO-POS^SM and BCN Advantage HMO^SM coverage.

Diagnosis Closure Incentive program
The incentive program rewards participating primary care doctors for having annual, face-to-face visits with Blues Medicare Advantage patients to evaluate, document and code diagnoses according to standards set by the Centers for Medicare & Medicaid Services. Doctors will receive a financial incentive for closing diagnosis gaps identified by the Blues.

A “gap” is a suspected or past condition that hasn’t been documented and coded in the current year.

The Diagnosis Evaluation Panel on MAPPO Health e-Blue^SM lists patients who are suspected of having a condition based on:

• Pharmacy claims
• Medical claims
• Other supplemental data sources
• Prior-year diagnoses

But the diagnoses for patients listed on the Diagnosis Evaluation panel haven’t been submitted to the Blues in the current year. The report will be refreshed monthly so doctors can track their progress in closing these identified diagnosis gaps.

The Blues will pay doctors $100 for each Medicare Advantage member with one or more gaps identified between Jan. 1, 2015, and Sept. 30, 2015, and for whom all gaps are closed during a face-to-face encounter by Dec. 31, 2015.

An identified gap can be closed following a face-to-face visit with the patient in 2015. During this visit, the doctor should manage, evaluate, assess or treat the condition, and the diagnosis should be documented in the patient’s medical record following CMS guidelines. The gap can then be closed through one of the following methods:

• Confirm the diagnosis code:
• By submitting a claim with the diagnosis code
• Through Health e-Blue
• By submitting a paper Member Diagnosis Evaluation and Treatment Opportunities Report (for those without access to Health e-Blue)
• By submitting a patient medical record

• Notify the Blues that the patient does not have the suspected condition:
• Through Health e-Blue
• By submitting a paper Member Diagnosis Evaluation and Treatment Opportunities Report (for those without access to Health e-Blue)

Note that a gap should not be closed solely for the reason that you are not actively treating the condition. A diagnosis gap should only be closed if you have conducted an office visit, addressed the condition and determined that the patient no longer has the condition or the suspected condition does not exist.

More information about this incentive program will be posted on Health e-Blue for Medicare Advantage primary care doctors in the first quarter 2015. If you don’t have access to Health e-Blue, sign up today on bcbsm.com/provider. Contact your provider consultant if you need assistance.

web-DENIS member care alerts
When checking patient eligibility and benefits on web-DENIS, be sure to check your member care alerts, which have been updated to include 2015 patient gaps in care.

These alerts are color-coded to help you identify patient needs quickly, and they display a printable list of diagnosis gaps and treatment opportunities for patients.

2014 incentive payment
If you participated in the 2014 Diagnosis Closure Incentive program, your incentive payment will be mailed to you by the end of the third quarter.

Training available
The Blues can provide training to doctors and their office staff on proper documentation and coding guidelines and the importance of closing gaps for Medicare Advantage patients. Contact your provider consultant for more information.

Ask your provider consultant for a set of tip cards for your office called Documentation and Coding Tips for Professional Offices. The tip cards are also available electronically on web-DENIS. From the web-DENIS home page:

• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters and Resources.
• Click on Patient Care Reporting.

Health e-Blue features 2015 Provider Recognition Program materials

Blue Cross Blue Shield of Michigan and Blue Care Network are providing you with 2015 Provider Recognition Program materials for the following products:

• BCN Commercial
• BCN Advantage^SM
• Blue Cross Medicare Advantage PPO^SM

To simplify the program, the Blues created one booklet that outlines the requirements for all three products. 

The 2015 program materials can be found on the home page of BCN Health e-Blue^SM or MAPPO Health e-Blue^SM under Incentive Documents. The material contains a one-page summary document that outlines the program. Use this as a reference tool to help provide quality care to our members.

The Blues’ philosophy toward our provider incentive programs is to make meaningful payments to encourage appropriate clinical outcomes. We also strive to increase HEDIS^® scores, also known as the Health Effectiveness Data and Information Set, and Centers for Medicare & Medicaid Services star ratings.

Remember that all data entered into Health e-Blue must be for services rendered, not just for ordered services or sent reminders.

Visit the home page on BCN Health e-Blue or MAPPO Health e-Blue for all 2015 program information.

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

HEDIS^® medical record reviews begin March 2015

Blue Cross Blue Shield of Michigan conducts Healthcare Effectiveness Data and Information Set medical record reviews annually from March through May. Inovalon™ will perform the HEDIS reviews on behalf of Blue Cross PPO and Medicare Plus Blue^SM members who received services in Michigan.

For the HEDIS reviews, Inovalon looks for details that may not have been captured in claims data, such as blood pressure readings, HbA1c lab results, colorectal screenings and body mass index. This information helps us enhance our member quality improvement initiatives.

Inovalon will contact you to schedule an appointment for a HEDIS review or request that you fax the necessary records. HEDIS requires proof of service documentation for data collected from a medical record. Blue Cross will reimburse you $5 for each chart requested and received.

Inovalon will continue to perform the risk adjustment medical record review on behalf of Blue Cross Medicare Plus Blue members who received services in Michigan. These reviews are in addition to the risk adjustment and HEDIS medical record review process performed by Verisk on behalf of the Blue Cross Blue Shield Association.

Here are HCPCS code changes that took effect Jan. 1

Here’s a look at the Healthcare Common Procedure Coding System codes that went into effect Jan. 1, 2015.

HCPCS update: Two new 2015 procedure codes

Two new vaccine-related procedure codes are effective Feb. 1, 2015.

You can find a list of HCPCS codes that became effective Jan. 1, 2015, in the BCBSM Provider Publications and Resources section of web-DENIS under BCBSM Resources.

Reminder: Metro Detroit EPO, HMO networks

As a reminder, the Blue Cross^® Metro Detroit EPO network covers six counties in Southeast Michigan (Livingston, Oakland, Macomb, St. Clair, Wayne, and Washtenaw), while the Blue Cross^® Metro Detroit HMO covers three counties (Macomb, Oakland and Wayne).

Other than eligible emergency services and accidental injuries, members who have enrolled in a Metro Detroit EPO do not have coverage if they visit a doctor or hospital that is outside the network. Be sure to always refer members to health care providers that are in the network.

For care outside the local Metro Detroit HMO network, keep the following guidelines in mind:

• If the service is in the statewide BCN provider network, standard BCN referral and clinical review requirements apply.
• If the service is outside the BCN provider network, BCN out-of-network rules apply. (Providers submit an authorization to BCN, and BCN conducts a clinical review before making a decision.)

The following hospitals participate in the Metro Detroit EPO network:

• Detroit Medical Center
• DMC Children’s Hospital (Wayne County)
• DMC Detroit Receiving (Wayne County)
• DMC Harper–Hutzel (Wayne County)
• DMC Huron Valley–Sinai (Oakland County)
• DMC Sinai Grace (Wayne County)
• DMC Rehabilitation Institute of Michigan (Wayne County)

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

• St. John Providence Health System
• Providence Hospital (Oakland County)
• Providence Park Hospital (Oakland County)
• St. John Hospital and Medical Center (Wayne County)
• St. John Macomb–Oakland Hospital Macomb Center (Macomb County)
• St. John Macomb–Oakland Hospital Oakland Center  (Oakland County)
• St. John River District Hospital (St. Clair County)

• Saint Joseph Mercy Health System/CHE Trinity Health
• St. Joseph Mercy Ann Arbor (Washtenaw County)
• St. Joseph Mercy Chelsea (Washtenaw County)
• St. Joseph Mercy Livingston (Livingston County)
• St. Joseph Mercy Oakland (Oakland County)
• St. Mary Mercy Hospital Livonia (Wayne County)

• Botsford Hospital, now part of Beaumont Health** (Oakland County)
• Garden City Hospital (Wayne County)
• Stonecrest Center for Behavioral Health (Wayne County)
• Straith Hospital for Special Surgery (Oakland County)

These hospitals participate in the Metro Detroit HMO network:

• Botsford Hospital, now part of Beaumont Health** (Oakland)
• Detroit Medical Center
• DMC Children’s Hospital of Michigan (Wayne County)
• DMC Detroit Receiving Hospital (Wayne County)
• DMC Huron Valley–Sinai Hospital (Oakland County)
• DMC Harper University/Hutzel Women’s Hospital (Wayne County)
• DMC Sinai–Grace Hospital (Wayne County)
• DMC Rehabilitation Institute of Michigan (Wayne County)

• Oakwood Healthcare System
• Oakwood Hospital Dearborn (Wayne County)
• Oakwood Hospital Southshore (Wayne County)
• Oakwood Hospital Taylor (Wayne County)
• Oakwood Hospital Wayne (Wayne County)

• St. John Providence Health/Ascension
• Providence Hospital (Oakland County)
• St. John Hospital and Medical Center (Wayne County)
• St. John Macomb–Oakland Hospital, Macomb Center (Macomb County)
• St. John Macomb–Oakland Hospital, Oakland Center (Oakland County)
• St. John River District Hospital (St. Clair County)

• Saint Joseph Mercy Health System
• St. Joseph Mercy Ann Arbor (Washtenaw County)
• St. Joseph Mercy Livingston (Livingston County)
• St. Joseph Mercy Oakland (Oakland County)
• St. Mary Mercy Livonia (Wayne County)

**Note: Beaumont Health campuses in Royal Oak, Troy and Grosse Pointe are not part of the EPO network.

Online tutorial
If you would like to learn more, please view our online tutorial located on web-DENIS. The tutorial will walk you through our Metro Detroit EPO and Metro Detroit HMO networks and individual plans. Here’s how you can find the tutorial:

• Log in to Provider Secured Services.
• Click on web-DENIS.
• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters & Resources.
• Scroll down to Blue Cross^® Metro Detroit EPO and HMO local networks resources.
• Click on Training presentation: Blue Cross® Metro Detroit EPO and HMO local networks.

Find a doctor
You can search for a participating doctor in the local networks using the Find a Doctor tool:

• Go to bcbsm.com/find-a-doctor.
• Click on Get Started.
• Click on Advanced Search.
• Select ZIP code, street address or city, state or county and type in the information.
• Go to “Please select your plan.” In the drop-down menu, click on Individual and Family plans (under 65).
• Go to “Please select your sub plan. In the drop-down menu, click on Blue Cross Metro Detroit (EPO) or Blue Cross Metro Detroit (HMO).
• Choose the provider type.
• Add additional search criteria (optional) or click Go.

Coding corner: Accurate coding of venous thrombosis and embolism

“Coding corner” is a series of coding tips that run in The Record each month.

With approximately 30 ICD-9 codes to choose from when diagnosing venous thrombosis and embolism, or VTE, there are many details that should be documented to support the proper choice of code.

These specifics can play a key role in selecting a code that will indicate medical necessity for the reimbursement of necessary treatment and services.

Codes for VTE can be found in Chapter 7, Diseases of the Circulatory System, indexed under category 453. The majority of the codes for VTE range from 453.0 through 453.9, with several codes in this range requiring a fifth digit to provide proper detail. There are also codes outside this range for VTE occurring during the peripartum period or in conjunction with other conditions.

The first specific that should be documented is the anatomic location of the VTE. It’s best practice to document the specific veins that are affected. In addition, documenting these other key factors will drive code selection:

• Deep or superficial vein
• Upper or lower extremity
• Distal or proximal portion of the extremity

Acuity of the condition should also be documented. Specific code selection will depend on whether the VTE is documented as:

• Acute
• Sub-acute
• Chronic or
• Past history

Typically, a chronic VTE is an old, previously diagnosed yet still present clot requiring continuation of anticoagulation therapy. While an acute clot is one that is newly diagnosed and requires treatment.

Code selection for sub-acute VTE should be classified to ICD-9 codes listed as acute. There are no set guidelines for when VTE is considered chronic, so the code selection for VTE will rely solely on the provider’s documentation. Coders should not assume that the clot is acute or chronic without documentation to support the code choice.

The phrase “history of” can have different meanings depending on its use. For example, “history of” as an old, active condition that is still being treated or “history of” as a past condition now treated prophylactically to prevent recurrence.

If an old VTE is present and requires further treatment, the codes for chronic VTE should be selected. If the patient has a past history of a thrombosis or embolism that is no longer present, and they’re being treated prophylactically, then the ICD-9 code V12.51, personal history of VTE, should be selected.

A patient’s medical record with documentation of “history of” VTE that does not provide specifics may require the coder to query the provider and request that they make appropriate documentation changes before the correct diagnosis can be applied.

The pending ICD-10 transition is scheduled for Oct. 1, 2015, and the importance of specific documentation will be more important than ever. ICD-9 provides approximately 30 codes for VTE, while ICD-10 increases that selection to more than 130 codes.

The additional ICD-10 codes will require coders to specify laterality as well as provide additional code choices to document veins affected by VTE.

For more information about this process, 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.

Blue Cross committed to improving your experience with BlueCard^® program

This is part of an ongoing series providing information about the BlueCard program.

Blue Cross Blue Shield of Michigan has reviewed the BlueCard provider satisfaction survey scores. The information and comments we gathered from this survey will help us improve your satisfaction and experience with the BlueCard program.

In 2015, we’ll focus on educating and collaborating with you on areas of the program that affect your business. Some of the areas identified as needing improvement include:

• Receiving prompt notifications for medical record requests
• Processing BlueCard adjustment claims in a timely and accurate manner
• Education on the BlueCard program and the online tools available to assist you

Medical record requests
It’s important to remember that the member’s home plan decides when to request medical records. The BlueCard department at Blue Cross works to expedite sending the request to you and then back to the plan. Ensuring we have your accurate contact information for these record requests will reduce the time it takes for you to be notified that records are needed. Once you receive the request, if the records are returned to us within 10 days of the home plan’s request, it can prevent the claim from rejecting.

If you need to update your contact information for medical record requests, please provide us with the correct address and fax number for the department responsible for processing your claims. A link to the form can be found in the BlueCard chapter of the online provider manuals located on web-DENIS. To find the manuals, log in to web-DENIS and click on BCBSM Provider Publications and Resources.

Online provider manuals
The BlueCard chapter of the provider manuals also includes a variety of links to other online tools that will assist you with the BlueCard program. Please refer to the chapter often as updates and additional information are added monthly.

When a change or additional information is added to the manuals, a web-DENIS broadcast message will alert you to the updated information in the chapter.

If you’re experiencing issues with the information provided in the chapter or any of the online tools — or if you’d like more information on a particular topic — let us know. You can send an email to ProvComm@bcbsm.com and put “BlueCard series” in the subject line.

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.

National drug code billing information required for medical drug claims

On Feb. 1, 2015, Blue Cross Blue Shield of Michigan will require the correct national drug code and national drug code quantity information to be submitted on medical drug claims. We’ll no longer calculate the NDC quantity of medical drugs as of this date. If the NDC and NDC quantity is not provided, the minimum fee schedule will apply.

Finding the NDC and unit of measure
The national drug code is found on a medication’s packaging. An asterisk may appear as a placeholder for any leading zeroes. The container label also displays the appropriate unit of measure for that drug. The unit of measure is by weight (grams: GR), volume (milliliter: ML) or count (unit: UN). Each dispensed dose must be converted into one of those units, following the manufacturer’s unit of measure. International units (F2) must be converted to standard measurements (GR, ML and UN).

• For drugs that come in a vial in powder form that need to be reconstituted before administration, bill each vial (UN).
• For drugs that comes in a vial in liquid form, bill in milliliters (ML).
• For topical forms of medicine (e.g., cream, ointment and bulk powder in a jar), bill in grams (GR).

Note:  We are not accepting milligrams (ME) as a unit of measure.

Submitting the NDC on claims
Here are some quick tips and general guidelines to help 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 or ML), 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: N400173044202   ML2

• Reimbursement for discarded drugs applies only to single use vials. Discarded amounts of drugs in multi-use vials are not eligible for payment.
• For home infusion therapy, ambulatory infusion center, hemophilia network and specialty pharmacy, health care providers must continue to submit claims with national drug code and National Council for Prescription Drug Programs quantities electronically.

CAQH updating Universal Provider Datasource^®

CAQH^® is updating its Universal Provider Datasource in February 2015.

In addition to adding new features, the name of the tool is changing to CAQH ProView™. Please make a note of the following:

• Unattested data won’t convert. Completed applications with current attestations will automatically migrate to CAQH ProView. Health Care providers with incomplete applications who did not complete and attest to any outstanding applications prior to the transition to ProView will not convert to CAQH ProView.
• An email address is required. CAQH ProView requires an email address for all providers as a primary method of contact. Providers should enter an email address in the tool as soon as possible.
• Paper applications will be discontinued. When CAQH ProView launches in February 2015, providers must enter and complete their information online. Paper versions of the credentialing application will no longer be accepted.
• The estimated release date for the upgrade is Feb. 23, 2015. Once it is released, the new CAQH website will be https://proview.caqh.org/pr.**

If you have questions, contact the CAQH ProView Provider Transition Support Center. Providers can send an email to proview@caqh.org or call 844-259-5347.

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

Reminder: How to access and use the BCBSM electronic qualification form

Effective Jan. 1, 2015, the Blue Cross Blue Shield of Michigan qualification form has been posted on Provider Secured Services for Michigan health care providers. Providers can now submit the form electronically for Blue Cross members who have a wellness plan that requires a qualification form.

To access the form and instructions:

1. Log in to the Provider Secured Services page at bcbsm.com.
2. Scroll down to the BCBSM Qualification Form section.
3. Click on the BCBSM Qualification Form link, which will send you to the online form.
4. For instructions for completing the form, click the BCBSM Qualification Form Instructions link located below the BCBSM Qualification Form link.
5. After completing the electronic qualification form for your patient, make sure you print two copies of the form.
6. Give one completed and signed copy to the patient for his or her records, and keep a copy of the form with the patient’s medical records.

We strongly encourage submitting BCBSM qualification forms electronically to improve processing time. Blue Cross does not reimburse providers separately for the submission of a qualification form because it is included in the well-visit reimbursement. Therefore, members should not be charged additionally for the completion and submission of an electronic qualification form.

For Blue Care Network members, providers can continue to submit the Blue Care Network electronic qualification form. BCN will continue to reimburse them for electronic submissions.

Monthly care management code not payable for Blue Cross commercial members

The new monthly care management code for non-face-to-face encounters, *99490, will not be payable for Blue Cross Blue Shield of Michigan commercial members in 2015.

However, *99490 will be payable for all BCBSM Medicare Advantage members. Care management services are subject to deductibles and coinsurance, according to plan guidelines.

Blue Cross will continue to assess various options for supporting provider delivery of care management services for commercial members. We will be gathering input about this topic from the provider community throughout 2015.

Behavioral health services to be managed by new company

As of April 1, 2015, Blue Cross Blue Shield of Michigan behavioral health services will be managed by New Directions Behavioral Health, replacing Magellan Behavioral, Inc.

New Directions will assume behavioral health management of 2.5 million Blue Cross commercial members nationwide. Services include preauthorization and case management for members who receive behavioral health through Blue Cross.

More information, including details about authorization, will be published in The Record at a later date.

Blue Cross designates partial hospitalization programs for patients with eating disorders

To help members identify psychiatric treatment programs that focus on eating disorders, Blue Cross Blue Shield of Michigan will designate eating disorders programs offering partial hospitalization programs that meet the requirements detailed below.

Eating disorders partial hospitalization programs provide comprehensive and intensive treatment while allowing patients to live at home and maintain some social activities and contacts. Partial hospitalization is ideal for patients with eating disorders who require treatment at a more intensive level than that provided in the outpatient setting.

Designated providers will be identified in our  Find a Doctor feature on bcbsm.com. The designation of eating disorders partial hospitalization programs will:

• Recognize and promote high quality programs
• Improve awareness and access to eating disorders partial hospitalization programs in Michigan
• Facilitate options for successful transitions from inpatient treatment to outpatient treatment
• Reduce the need for medical or psychiatric hospitalization by providing more intensive treatment than outpatient treatment
• Reduce the need for stays at residential treatment facilities
• Not impact current contract arrangements with partial hospitalization providers

Key designation requirements
Partial hospitalization programs must be licensed as a partial hospitalization program by the State of Michigan. A multidisciplinary staff is required, including a physician director, a psychiatrist (who may also be the physician director) or fully licensed psychologist, a master’s level social worker, a licensed registered nurse and a licensed dietician.

Partial hospitalization program components

• Six hours per day, at least five days per week
• Program components must include, at a minimum:
• Three physician visits per week, either medical or psychiatric (with at least one medical visit per week)
• Two therapy sessions per week, one of which must be with family or adult support
• Didactic presentations lasting 1- 1.5 hours per session, limited to 15 patients in a group, one per day
• Group psychotherapy lasting at least 1.5 hours per session, with a maximum of 12 members, one per day
• Two supervised meals per day
• Nutritional services provided by a dietician
• One of the following adjunctive services per day:
• Behavioral modification, occupational therapy, recreational therapy, goal oriented social groups, creative expressive therapy and community meetings
• Programs should use validated and well-recognized measures to track patients’ progress and should be able to provide information on program outcomes on an aggregate basis, including measures discussed above, readmission rates and follow-up data.

You can find more details about BCBSM designated eating disorder programs, including program criteria and application materials by visiting web-DENIS:

• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters and Resources.
• Click on Clinical Criteria and Resources.
• Click on Eating Disorders Program Resources.

Materials can also be obtained by sending an email to  ValuePartnerships@bcbsm.com.

UA Local 190 health and welfare plan added to Medical Drug Prior Authorization Program

Effective April 1, 2015, all groups enrolled in the UA Local 190 health and welfare plan will participate in the Medical Drug Prior Authorization Program.

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

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

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

Call for response: Research survey exploring physician and pharmacist collaboration

In November 2014, a short survey was developed to explore new ways to improve the quality, accessibility and affordability of patient care through the collaboration between pharmacists and physicians. The survey is part of a research project created by Mindy Prasad, Pharm.D., who is a PGY-1 managed care pharmacy resident. It was mailed to 4,000 randomly selected physicians within the Blue Cross Blue Shield of Michigan provider network.

This survey seeks physician opinions about pharmacists providing advanced patient care management. This information will help Blue Cross develop programs that can support the organization and improve collaboration between pharmacists and physicians.

• If you received the survey and haven’t responded yet, please do so by sending it to the fax number found on the survey.
• If you didn’t receive a survey, please email mprasad@bcbsm.com.

Responses will be collected through Feb. 28, 2015. Results will be presented at the Academy of Managed Care Pharmacy Annual Meeting & Expo in April 2015.

Blue Cross designates partial hospitalization programs for patients with eating disorders

To help members identify psychiatric treatment programs that focus on eating disorders, Blue Cross Blue Shield of Michigan will designate eating disorders programs offering partial hospitalization programs that meet the requirements detailed below.

Eating disorders partial hospitalization programs provide comprehensive and intensive treatment while allowing patients to live at home and maintain some social activities and contacts. Partial hospitalization is ideal for patients with eating disorders who require treatment at a more intensive level than that provided in the outpatient setting.

Designated providers will be identified in our  Find a Doctor feature on bcbsm.com. The designation of eating disorders partial hospitalization programs will:

• Recognize and promote high quality programs
• Improve awareness and access to eating disorders partial hospitalization programs in Michigan
• Facilitate options for successful transitions from inpatient treatment to outpatient treatment
• Reduce the need for medical or psychiatric hospitalization by providing more intensive treatment than outpatient treatment
• Reduce the need for stays at residential treatment facilities
• Not impact current contract arrangements with partial hospitalization providers

Key designation requirements
Partial hospitalization programs must be licensed as a partial hospitalization program by the State of Michigan. A multidisciplinary staff is required, including a physician director, a psychiatrist (who may also be the physician director) or fully licensed psychologist, a master’s level social worker, a licensed registered nurse and a licensed dietician.

Partial hospitalization program components

• Six hours per day, at least five days per week
• Program components must include, at a minimum:
• Three physician visits per week, either medical or psychiatric (with at least one medical visit per week)
• Two therapy sessions per week, one of which must be with family or adult support
• Didactic presentations lasting 1- 1.5 hours per session, limited to 15 patients in a group, one per day
• Group psychotherapy lasting at least 1.5 hours per session, with a maximum of 12 members, one per day
• Two supervised meals per day
• Nutritional services provided by a dietician
• One of the following adjunctive services per day:
• Behavioral modification, occupational therapy, recreational therapy, goal oriented social groups, creative expressive therapy and community meetings
• Programs should use validated and well-recognized measures to track patients’ progress and should be able to provide information on program outcomes on an aggregate basis, including measures discussed above, readmission rates and follow-up data.

You can find more details about BCBSM designated eating disorder programs, including program criteria and application materials by visiting web-DENIS:

• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters and Resources.
• Click on Clinical Criteria and Resources.
• Click on Eating Disorders Program Resources.

Materials can also be obtained by sending an email to  ValuePartnerships@bcbsm.com.

InterQual^® home health care criteria, format to change

McKesson InterQual home health criteria are changing for 2015 and will be released in a new question-and-answer format. Blue Cross Blue Shield of Michigan will begin using the new criteria — in the new format — in early August 2015.

The Q & A format was introduced a few years ago with InterQual’s care planning suite. The new format offers some significant advantages:

• The simple question-and-answer flow makes the format easier and more intuitive to use
• It allows for a single review that covers all the potential skilled disciplines instead of the currently required separate review of each service.

The new format also eliminates the physical copy of the Home Health Care InterQual book, making the home health care content only available electronically using InterQual View. This means that beginning with the March 2015 release, home care content won’t be included in the InterQual printed books or in the InterQual Mobile app.

InterQual View is an interface designed for customers who want direct access to InterQual criteria, without going to the internet, using a laptop or through an internal server.

Key features of InterQual View

• Quick searches for quality indicator checklists, transition plans and notes
• Ability to load InterQual historical criteria
• Ability to set larger font sizes for easier viewing
• Ability to print InterQual criteria or subsets from InterQual View

Accessing and using InterQual View
Before the new format is released, you can access the existing home care content through InterQual View at mhsinfo.mckesson.com/BCBSMIHomecare.** Organizations with multiple locations will need to sign up for each location.

After signing in, you’ll receive login information and a license key to download and unlock the content. You’ll also receive an invitation to a free webinar that will walk you through how to access and use the home care content through InterQual View. McKesson is working with Blue Cross to make the webinar available and will send your login information as soon as it’s available.

McKesson will be offering additional training on how to use the new Q & A format for home health care content once it becomes available in March. If you have any Blue Cross-specific questions, please contact your provider consultant.

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

Call for response: Research survey exploring physician and pharmacist collaboration

In November 2014, a short survey was developed to explore new ways to improve the quality, accessibility and affordability of patient care through the collaboration between pharmacists and physicians. The survey is part of a research project created by Mindy Prasad, Pharm.D., who is a PGY-1 managed care pharmacy resident. It was mailed to 4,000 randomly selected physicians within the Blue Cross Blue Shield of Michigan provider network.

This survey seeks physician opinions about pharmacists providing advanced patient care management. This information will help Blue Cross develop programs that can support the organization and improve collaboration between pharmacists and physicians.

• If you received the survey and haven’t responded yet, please do so by sending it to the fax number found on the survey.
• If you didn’t receive a survey, please email mprasad@bcbsm.com.

Responses will be collected through Feb. 28, 2015. Results will be presented at the Academy of Managed Care Pharmacy Annual Meeting & Expo in April 2015.

UA Local 190 health and welfare plan added to Medical Drug Prior Authorization Program

Effective April 1, 2015, all groups enrolled in the UA Local 190 health and welfare plan will participate in the Medical Drug Prior Authorization Program.

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

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

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

Medicare Plus Blue^SM adjusts molecular lab claim reimbursement

Effective for claims with dates of service on or after March 22, 2015, Blue Cross Blue Shield of Michigan’s Medicare Plus Blue plan will reimburse providers 65 percent of the charged amount for unlisted molecular pathology claims (procedure code *81479). A Medicare remittance advice will not be required for payment.

Currently, we reimburse at 25 percent without a remittance advice and 100 percent of the Medicare fee if the claim is submitted with a remittance advice.

Supporting documentation will still be required with all related claims to determine medical appropriateness and to ensure timely processing. When the necessary documentation is not attached, claims will be denied.

Required documentation includes but may not be limited to the following:

• Patient medical records
• Physician narrative
• Diagnosis and procedure code(s)
• Lab order
• Lab results

If you have any questions, contact your provider consultant.

Blue Cross updates its Medicare Plus Blue^SM enhanced hearing benefit policy paper

Blue Cross Blue Shield of Michigan updated its Medicare Plus Blue^SM enhanced hearing benefit policy paper, effective Jan. 1, 2015, to provide additional clarity. We previously notified you in a December 2014 web-DENIS message.

You can find the paper and other enhanced benefit papers online at bcbsm.com/provider/ma.

• Click on the Medicare Plus Blue PPO button.
• Click on the Provider Toolkit button.
• Click on Enhanced benefits under "Coverage details."
• Scroll down and click on Hearing services - 2015 NEW.

If you have any questions, contact your provider consultant.