Blue Cross Blue Shield of Michigan to change professional provider fees July 1

Blue Cross Blue Shield of Michigan will change practitioner fees, effective with dates of service on or after July 1, 2015, for services provided to our Traditional, TRUST, Blue Preferred Plus^SM and Blue Cross^® Metro Detroit EPO members, regardless of customer group.

Blue Cross will use the 2015 Medicare resource-based relative value scale for all relative value unit-priced procedures for dates of service on and after July 1. Most fees are currently priced using the 2014 values.

Changes in resource-based relative values can impact fees. Procedure code maximum fees will increase or decrease based on the new relative value units and Blue Cross’ conversion factors.

At the same time, the regional conversion factors for non-relative value, unit-based anesthesia services will remain unchanged, pending expected modifications later in 2015.

We conduct a comprehensive analysis of professional provider performance and current economic indicators annually to calculate practitioner fees, with consideration for corporate and customer cost concerns. Blue Cross remains committed to reviewing professional provider performance to determine the need for increases or decreases in our maximum payments.

Fee schedules with the new fees that are effective July 1, 2015, will be available on web-DENIS April 1. Click on Entire Fee Schedules and Fee Changes on the web-DENIS BCBSM Provider Publications and Resources page to find fee information. Only claims submitted with dates of service on or after July 1 will be reimbursed at the new rates.

Please note that the Physician Group Incentive Program physician organization reward component of professional fees remains the same this year.

For more information, contact your Blue Cross provider consultant.

Four specialty drugs added to prior authorization program July 1

Beginning July 1, 2015, four additional specialty drugs administered by health care practitioners will require prior authorization by Blue Cross Blue Shield of Michigan before they are covered by BCBSM members’ medical benefits.

The prior authorization is only a clinical review and approval, not a guarantee of payment. Health care practitioners will need to verify the necessary coverage for medical benefits. These updates will help ensure proper drug use while addressing potential safety issues.

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

• 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 tool, through NovoLogix^®. Standard processing time to review a request is 15 days. An urgent request can be reviewed within 72 hours.

Starting July 1, 2015, the following drugs will require prior authorization:

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

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

Here’s 2015 schedule for ICD-10 educational presentations

Blue Cross Blue Shield of Michigan will continue to offer ICD-10 educational presentations once a month in 2015 from April to September.

These sessions provide:

• An overview of ICD-10
• Differences between the ICD-9-CM and ICD-10-CM code sets
• Review of the top ten most frequently reported diagnosis codes
• Steps and resources for readiness and testing

All classes will be held at the New Hudson Conference Center, located at 53200 Grand River, New Hudson. The sessions take place from 9 to 11 a.m., with registration beginning at 8:30 a.m.

To register, send an email to Icd-10providerreadiness@bcbsm.com. Include your name, provider office name, address, phone number, email, PIN and the date of the class you wish to attend.

You’ll receive confirmation within 72 business hours of registering.

Here are the 2015 ICD-10 training dates:

• Thursday, April 9, in the Teal Conference Room
• Tuesday, May 5, in the Midnight Conference Room
• Tuesday, June 9, in the Midnight Conference Room
• Tuesday, July 14, in the Midnight Conference Room
• Tuesday, Aug. 11, in the Midnight Conference Room
• Thursday, Sept. 10, in the Midnight Conference Room

For ICD-10 provider readiness resources, visit cms.gov/icd10 or roadto10.org.**

Also, Blue Cross is providing a monthly ICD-10 provider readiness webinar. Registration for these webinars will be provided in web-DENIS the week before the webinar. The webinars are scheduled for the third Monday of the month from 1 to 2 p.m. through September.

If you’d like to view prior Precyse University presentations and download the presentations, click here.**

New this year is the ICD-10 Health Plan Collaborative, which includes Blue Cross, Priority Health, Humana, United HealthCare and Health Alliance Plan. The collaborative is offering a series of one-hour webinars every other Thursday at noon. The next one will be held April 2.

These webinars are focused on specific specialties. The topic and registration link will be provided via web-DENIS prior to the session.

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

Register now for April behavioral health webinar

Complete and submit the registration form to secure your spot in an April 2015 Blue Cross Blue Shield of Michigan and Blue Care Network behavioral health webinar.

The webinar is designed for behavioral health providers who serve Blue Cross and BCN members. There’s no need to travel; you can participate right at your desk.

The topics to be covered include:

• Enrollment
• System navigation and resources
• Billing and supervision guidelines
• BCN’s 2015 Behavioral Health Incentive Program

Select one of the following two dates:

• Tuesday, April 21, 2015, 10-11 a.m.
• Thursday, April 23, 2015, 10-11 a.m.

The same information will be covered on each webinar date.

Registration closes Friday, April 17, so you’ll want to submit your form as soon as possible. The instructions for submitting it are on the form.

Be sure to include your email address on the form. We will email you the instructions for signing in to the webinar a day or two prior to the webinar.

Will changing your PO affiliation affect relationships with patients or incentive rewards?

David Share, M.D., M.P.H., Blue Cross Blue Shield of Michigan senior vice president, Value Partnerships, and Allison Pollard, Blue Care Network vice president, Provider Affairs, sent a letter on Feb. 20 to physician organizations participating in the Physician Group Incentive Program to answer a question that was on the minds of some physicians

Physicians asked: “Does changing my physician organization affiliation affect my relationships with patients or disrupt any potential rewards I may receive through Blue Cross Blue Shield of Michigan incentive programs?” The short answer is “no.” For more details, see the text of the letter below:

In response to recent inquiries, Blue Cross Blue Shield of Michigan and Blue Care Network (BCBSM/BCN) would like to provide clarity about some of our policies and expectations for POs that partner with us in our various programs. BCBSM/BCN, for all products and pay-for-performance programs, allows patients to continue their medical care with their physician of choice even if their physician decides to change physician organizations.

Patients (members) attributed to or assigned to physicians in a PO are not bound to that PO. Physicians within POs may exercise their right to change POs, without concern about disruption in their relationships with their patients. Physician’s patients may elect to continue to seek care with the same physician when the physician joins a new PO, or may choose to seek care with a new physician. The decision regarding whether patients remain with a physician is not at the discretion of the physician organization.

Additionally, physicians will not be negatively affected in regard to potential rewards in BCBSM incentive programs if they change physician organization affiliation. Physician-specific incentives are not linked to the physician organization and should a physician change POs during an incentive program year, BCBSM will apportion earned incentives based on the performance of each PO and the proportion of the year the physician was in each PO. The performance recognition payments made by BCN, BCNA and MAPPO are based on the performance of the individual physician and will be paid to the physician (or physician’s employer) at their relationship at the time of the incentive is paid.

We are confident that each physician organization will continue to work collaboratively with physicians and patients to maintain positive relationships that foster our mission. Thank you for your continued contributions and partnership with Blue Cross Blue Shield of Michigan and Blue Care Network.

Please direct questions to the appropriate individual listed for assistance.

Donna LaGosh, BCBSM, Manager, PGIP Field Team, 313-448-6058
Michael VanPutten, BCN, Director, Contracting, 616-956-5734
Jill Torok, BCN, Provider Affairs Operations Manager, 734-887-5414

Thanks for your partnership and attention to this matter.

Maternity care billing: Here’s how to report antepartum care for a high-risk condition

When a practitioner is not performing all three components of global maternity care, antepartum visit code 59425 or 59426 should be reported with a quantity of one. Here are the three components of global maternity care:

• Antepartum visits
• Delivery
• Postpartum care 

Note: The code 59425 is used to report four to six visits, while code 59426 is used when there are seven or more visits.

When a practitioner provides the maternity care for a high-risk condition, an appropriate evaluation and management code with modifier 25 should be reported to indicate a significant separately identifiable E&M service was performed. The diagnosis code used in conjunction with the E&M code should support the high-risk condition for post-audit review.

Follow these guidelines to report bilateral services

When you’re reporting bilateral services on professional claims, the appropriate bilateral procedure code should be reported when services are performed on the exact same anatomical sites. This means aspects or organs on both sides of the body during the same session by the same physician.

Only use modifier 50 when the procedure code description doesn’t state the procedure is bilateral. Modifier 50 should be appended to the appropriate unilateral procedure code as a one-line entry on the claim with a quantity of one.

For more information or questions regarding this process, contact your provider consultant.

Are you coding adult BMI assessment correctly when reporting evaluation and management services?

It has come to our attention that some health care providers have been reporting the ICD-9 codes for adult body mass index assessment in the primary diagnosis location on claims, which may cause the claims to reject.

To capture information about BMI for your adult patients, use ICD-9 codes V85.0, V85.1, V85.21-25, V85.30-39 or V85.41-45. The BMI codes should only be reported as secondary diagnosis for evaluation and management services.

Adult BMI assessment is a key HEDIS^® measure**, so not documenting it correctly can affect HEDIS scores. These scores, as you may know, are tied to incentive payments through our Physician Group Incentive Program.

In addition to PGIP physician organizations being rewarded for their HEDIS improvement efforts (including adult BMI), PGIP participating primary care physicians are also eligible for a 5 percent fee uplift based on their overall quality performance on a variety of HEDIS metrics. Adult BMI is being added as one of the quality metrics contributing to this physician-level opportunity for elevated fees.

For more information on adult BMI assessment, see our tip sheet on this topic by clicking here.

Note: For evaluation and management services, V codes are collected for informational purposes only and are not directly reimbursable.

**HEDIS, which stands for Healthcare Effectiveness Data and Information Set, is a registered trademark of the National Committee for Quality Assurance.

Clarification: When speech pathologists, PTs, OTs and OPT facilities apply to participate before Medicare approval letter received

In the April 2014 Record, we announced that as of March 1, 2014, independent occupational therapists, independent physical therapists, independent speech language pathologists and outpatient physical therapist facilities may be considered for temporary participation with Blue Cross Blue Shield of Michigan and Blue Care Network.

The articles were titled “Speech pathologists, physical therapists, occupational therapists may apply to participate with BCBSM and BCN before Medicare approval letter received” and “OPTs may apply to participate with BCBSM and BCN before Medicare approval letter received.”

We wanted to clarify that the temporary participation we referred to does not apply to the Medicare Advantage PPO or BCN Advantage networks.

New rule requires prescribers to register with CMS if they write scripts for patients with Medicare Part D coverage

According to a new Centers for Medicare & Medicaid Services mandate, health care providers and other health care professionals who write prescriptions for Medicare Part D members have until June 1, 2015, to apply for an approved prescriber status or submit a valid opt-out affidavit. This is required of providers and other eligible health professionals to ensure continued prescription coverage under Medicare Part D for their patients.

Although these changes will not be enforced until Dec. 1, 2015, providers should submit their completed Medicare prescriber applications or opt-out affidavits to their Medicare administrative contractors on or before June 1, 2015. This will prevent their patients’ prescription drug claims from being denied by their Part D plans, beginning Dec. 1, 2015.

Part D requirements
For details on the Part D application requirements, visit the CMS website by clicking here.**

Medicare administrative contractor
If you have any questions, contact your Medicare administrative contractor, or MAC, at their toll-free number. You can find your Medicare administrative contractor by visiting the Review Contractor Directory Interactive Map.**

Applying for Medicare Part D approved provider status
You may submit your application electronically, using the Internet-based Provider Enrollment, Chain, and Ownership System,** or by completing the paper CMS-855I or CMS-855O application, which is available by accessing the CMS Forms List.** Note: An application fee is not required as part of your application submission.

Submitting an opt-out affidavit for Medicare Part D
If you want to opt out of Medicare, you must submit an opt-out affidavit to the MAC within your specific jurisdiction. Your opt-out information must be current. (An affidavit must be completed every two years and a National Provider Identifier is required.) For more information on the opt-out process, refer to article SE1311 in MLN Matters^®, titled “Opting out of Medicare,” by clicking here.**

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

Blue Cross Blue Shield of Michigan creates combined signature document for each provider type

As part of Provider Enrollment and Data Management’s commitment to assisting practitioners, we have combined the practitioner signature documents into a single document for each provider type.

That way, for example, a medical doctor would only need to sign one document, indicating what network or networks he or she wishes to participate in, rather than a separate document for each network. Signature documents have been created for each provider type.

To complete a combined signature document, the practitioner will need to indicate which network or networks he or she wants to apply for and sign the form. To see a copy of the new combined signature document for doctors, click here.

As of Feb. 23, 2015, combined signature documents were posted for M.D.s, D.O.s, chiropractors, podiatrists and dental and oral surgeons in the Provider Enrollment area of bcbsm.com/providers. New documents for other provider types will be available in the near future.

Don’t miss important Blue Care Network news coming in May

If you subscribe to BCN Provider News, you’ll get the most up-to-date Blue Care Network information in the May-June issue, including:

• Billing and claims news
• Clinical practice guidelines
• Pharmacy updates
• Referral and authorization requirements and updates
• Programs for quality management and disease management

BCN Provider News is published six times a year and contains helpful information for contracted providers of Blue Care Network, BCN Advantage HMO-POSSM and Blue Cross Complete. The newsletter is published exclusively as an electronic publication. Check out the current issue.

Subscribers receive an e-mail notification when each issue is posted. All you have to do is go to the BCN Provider News page, click on Subscribe and check the box next to BCN Provider News and BCN Alerts. The e-mail notification you receive will contain headlines specifically of interest to you if you select a BCN topic of interest when you subscribe.

If you are a BCN-contracted provider, sign up today.

HCPCS procedure code Q9975 replaces J7199 when billing for Eloctate™

Effective April 1, 2015, the Centers for Medicare & Medicaid Services has established a permanent procedure code for Eloctate, which is an antihemophilic (recombinant), Fc fusion protein.

That means that for services that occurred through March 31, 2015, you should continue to report code J7199. For services that take place on or after April 1, 2015, you should use the replacement code of Q9975.

Eloctate is a recombinant DNA derived, antihemophilic factor found in adults and children with hemophilia A, or congenital factor VIII deficiency, and is used for:

• Control and prevention of bleeding episodes
• Perioperative management (surgical prophylaxis)
• Routine prophylaxis to prevent or reduce the frequency of bleeding episodes

Note: Eloctate is not indicated for the treatment of von Willebrand disease.

HCPCS codes added, deleted

The Centers for Medicare & Medicaid Services recently added the following new HCPCS codes and deleted one code as part of its regular quarterly HCPCS updates.

Added

Deleted

BCBSM to update McKesson ClaimsXten for third quarter 2015

McKesson ClaimsXten, which uses the most current Common Procedure Terminology and Health Care Procedure Coding System codes, will be updated in July 2015.

As a result, we ask that you report the most current CPT and HCPCS codes on your claims. By reporting the most current codes, you will help us to process claims and send accurate reimbursement more quickly.

McKesson’s ClaimsXten is software that reviews procedure combination coding and compares CPT codes billed on claims against national rules to check for billing inconsistencies or errors. BCBSM uses ClaimsXten for clinical edits within our claim systems.

McKesson continually updates ClaimsXten information base using yearly CPT code updates, CMS guidelines, specialty society guidelines and information gathered from industry seminars and publications. In turn, BCBSM quarterly implements ClaimsXten updates in our claims system to ensure we are using current rules.

Watch upcoming issues of The Record for further ClaimsXten updates.

If you have questions, contact your provider consultant.

Online prescription drug lists updated

Blue Cross Blue Shield of Michigan just updated its prescription drug lists, otherwise known as formularies.

Blue Cross periodically updates these lists to help ensure patient safety and assist prescribers in selecting the most effective and affordable drug therapy for patients.

You can view the most recent prescription drug list updates, including updates to the Custom Select Drug List, at bcbsm.com/rxinfo. You can also view other pharmacy-related information at this link.

Our prescription drug lists can help prescribers make better-informed prescribing decisions that can lead to increased medication adherence and can help other providers explain prescription drug coverage to our members.

Coding corner: properly documenting asthma and chronic obstructive pulmonary disease

Asthma and chronic obstructive pulmonary disease are chronic, inflammatory airway obstructions that share similar symptoms, including shortness of breath, coughing and wheezing. These similarities can make it difficult to distinguish one condition from the other without concise documentation.

Complete and accurate documentation, to the greatest specificity possible, can play a crucial role in the continuum of care and appropriate reimbursement. It’s important to be specific when documenting current medical issues and to be clear if a condition still exists. Using the term “history of” can lead to the assumption that the condition no longer exists and is resolved.

When a patient who has asthma or COPD seeks medical attention for an acute condition, such as a sore throat or cough, it’s important that the physician documents their chronic conditions as well as their current status. This is important from a coding perspective as the documentation has an impact on the ICD-9-CM codes chosen by the coder.

Following is information that may be useful in properly coding these two conditions.

Asthma
Asthma is a chronic or long-term lung disease that inflames and narrows the airways. Codes for asthma fall under ICD-9 category 493 and the fourth and fifth digits are required for all codes in this category. The table on the right provides more detail for the codes in this category. Note that the fifth-digit sub-classifications don’t apply to 493.8, which have their own fifth-digit descriptions: 493.81 – exercise induced asthma, and 493.82 – cough variant asthma.

COPD
COPD is an umbrella term for a broad classification of disorders characterized by airway obstruction and airflow limitations.

Diseases that fall under the COPD classification include emphysema, chronic bronchitis and bronchiectasis. With COPD, the air sacs are permanently damaged, making it harder to move air in and out of the lungs.

Because of the wide range of ICD-9-CM codes, specific documentation from the physician assists the coder in selecting a code with the highest level of specificity.

Physician documentation makes a difference. For example, if documentation states “asthma,” the coder would select 493.90 (asthma, unspecified), while documentation of “intrinsic asthma” would be coded to 493.10 (intrinsic asthma, unspecified).

Documentation of “COPD” uses the code 496 (COPD, unspecified), while documentation of “exacerbation of COPD” uses code 491.21 (obstructive chronic bronchitis, with acute exacerbation). The fifth digit of an ICD-9-CM code is used to capture the specificity of the diagnosis, such as “unspecified, with or without exacerbations,” or “with or without status asthmaticus.”

Examples to substantiate validations in the medical record for asthma or COPD include:

• Medication given for the condition
• Pulmonary function testing
• Documentation of oxygen saturation (normal range 95 to 100 percent)
• Occupational exposure to dusts and chemicals
• Genetics

As you evaluate patients for asthma and COPD, this information is intended to help you understand the importance of documenting the diagnosis to the highest specificity. From a coding perspective, the medical record coder must be able to validate the condition documented by the physician.

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.

Training tips and opportunities: Resources to help make your job easier

This is part of a series designed to make you aware of the resources available to health care providers and how to access them. This month we’ll take a look at the Blue Cross Blue Shield of Michigan prior authorization forms for drugs paid under the pharmacy benefit and those paid under the medical benefit for our commercial members.

Pharmacy drug benefit

As part of our efforts to make the drug prior authorization process more efficient, we’re asking prescribers to use our Web-based system when prescribing drugs for commercial members. You can identify commercial members by one of the following Rx group codes on their ID cards: BCBSMAN or BCBSMRX1.

Follow these easy steps:

1. Log in to web-DENIS through the Provider section of bcbsm.com.
2. Click on Medication Prior Authorization.
3. Enter the drug requested in the Drug Search Form.
4. Click on the drug name.
5. Enter patient and physician information.
6. Answer a few questions related to the drug selected.
7. Click on Submit. (Once submitted, you will receive a tracking number for future reference).

Your request will be placed in the queue for review by a member of the clinical staff. You can go online and check the status of a request at any time.

Offices that don’t support online options can fax prior authorization requests to 1-866-601-4425 or call 1-800-437-3803.

Lists showing drugs included in our pharmacy programs can be found on our Web-based prior authorization system or at bcbsm.com/rxinfo.

Note: At this time, the online prior authorization system cannot be used when prescribing drugs for Federal Employee Program^® members. Call 1-800-624-5060 for information on how to handle drug prior authorization for FEP members.

Medical benefit: physician-administered medications

The physician-administered medication link on web-DENIS lists forms to request prior authorization for drugs administered by a health care professional and billed under a member’s medical benefit. By using this link, you can also find the list of groups that are not included in the BCBSM Medical Drug Prior Authorization Program.
To access the link, log in to web-DENIS.

• Click on BCBSM Provider Publications and Resources.
• Click on BCBSM Newsletters and Resources.
• Under “Frequently used forms,” click on Physician administered medications.

As with the pharmacy drug benefit, we encourage prescribers to register and use our Web-based system when prescribing drugs that are billed under the medical benefit for commercial members. This new application gives you the ability to submit forms electronically and look up the status of medical drug prior authorization requests. For more information, contact your provider consultant.

In order to be able to submit your prior authorization requests electronically, you will need to:

• Become a registered web-DENIS user.
• Complete the addendum P form in the Medical Drug Prior Authorization area of bcbsm.com/providers. Here’s how to get there:
• From the homepage of bcbsm.com/providers, scroll down and click on Provider Secured Services.
• Scroll down and click on the link that says: Medical drug prior authorization: physicians can make an online request for prior authorization of specialty drugs.

BlueCard^® connection: answer to a recent question

As part of our ongoing series on the BlueCard program, here’s the answer to a question we received.

I sent medical records to Blue Cross Blue Shield of Michigan regarding a BlueCard claim. Do I need to contact Provider Inquiry to request that the medical records be reviewed by a member’s home plan? 

No. If you are sending the records to us that the plan requested on the appropriate form, the records should automatically be routed to the member’s home plan for review. However, if you are unsure what information the plan is requesting, it is important that you confirm the information the plan has requested by contacting our Provider Inquiry department. This should be done before sending us medical records or any documentation on the medical record routing form for a BlueCard rejected claim. Unsolicited medical records will not be forwarded to another Blue plan.

A detailed process for determining when to send BlueCard medical records on a pending or rejected claim is included in the BlueCard chapter of every online provider manual. If you have any questions regarding the medical record process after referencing the BlueCard chapter of the online provider manual on web-DENIS, contact your provider consultant.

Note: Records should be sent directly to the Utilization Department at the member’s home plan — not BCBSM — if the plan requires medical documentation to determine the appropriateness of an admission. This applies to:

• Any inpatient authorization request
• An appeal of a retro-authorization
• An appeal of an authorization that was denied with the member’s home plan

If you’re experiencing issues with the information provided in the BlueCard chapter or any of the online tools — or if you’d like more information on a particular topic — contact your provider consultant. If you’d like to suggest a topic to be covered in a future issue of The Record, send an email to ProvCom@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 Record: what you need to know

Here are some tips for using The 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 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 &md 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.

Register today for annual hospital forum in Frankenmuth

The Blues invite you to the annual hospital forum sponsored by the Benefit Administration Committee. This year’s forum is scheduled for Tuesday, May 19, 2015, for all hospital billing staff, managers and directors.

The event includes information on web-DENIS, BlueCard^®, Medicare Advantage and ICD-10. The forum starts with an information fair during registration, followed by classroom-style presentations on a variety of important topics. A lunch featuring Frankenmuth’s famous chicken will be served following the event.

RSVP to jholzhausen@bcbsm.com by Friday, May 15. In the subject line, indicate “BAC Forum” and list your name, facility and the total number of people attending from your facility. Your response is also an RSVP for lunch.

If you have other agenda topic suggestions, please include them in your email, and we’ll attempt to address them at the forum.

2015 Michigan Hospital Networking sessions scheduled

Blue Cross Blue Shield of Michigan is hosting a series of networking sessions to give hospitals the information they need to do business with us. The sessions will address hospital billing, medical policy, Medicare Advantage, Blue Care Network, BlueCard and Medicaid.

They will be held from 10 a.m. to 2 p.m., with registration beginning at 9:30 a.m. Lunch will be provided. Each of the sessions will be held at our Lyon Meadows Conference Center, 53200 Grand River Avenue, New Hudson, MI 48165.

Here are the dates:

To register for the sessions, send an email to SEFacilityEducationRegistration@bcbsm.com. When registering, we encourage you to take the opportunity to suggest topics for discussion at future meetings.

Clarification: When speech pathologists, PTs, OTs and OPT facilities apply to participate before Medicare approval letter received

In the April 2014 Record, we announced that as of March 1, 2014, independent occupational therapists, independent physical therapists, independent speech language pathologists and outpatient physical therapist facilities may be considered for temporary participation with Blue Cross Blue Shield of Michigan and Blue Care Network.

The articles were titled “Speech pathologists, physical therapists, occupational therapists may apply to participate with BCBSM and BCN before Medicare approval letter received” and “OPTs may apply to participate with BCBSM and BCN before Medicare approval letter received.”

We wanted to clarify that the temporary participation we referred to does not apply to the Medicare Advantage PPO or BCN Advantage networks.

Four specialty drugs added to prior authorization program July 1

Beginning July 1, 2015, four additional specialty drugs administered by health care practitioners will require prior authorization by Blue Cross Blue Shield of Michigan before they are covered by BCBSM members’ medical benefits.

The prior authorization is only a clinical review and approval, not a guarantee of payment. Health care practitioners will need to verify the necessary coverage for medical benefits. These updates will help ensure proper drug use while addressing potential safety issues.

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

• 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 tool, through NovoLogix^®. Standard processing time to review a request is 15 days. An urgent request can be reviewed within 72 hours.

Starting July 1, 2015, the following drugs will require prior authorization:

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

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

Four specialty drugs added to prior authorization program July 1

Beginning July 1, 2015, four additional specialty drugs administered by health care practitioners will require prior authorization by Blue Cross Blue Shield of Michigan before they are covered by BCBSM members’ medical benefits.

The prior authorization is only a clinical review and approval, not a guarantee of payment. Health care practitioners will need to verify the necessary coverage for medical benefits. These updates will help ensure proper drug use while addressing potential safety issues.

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

• 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 tool, through NovoLogix^®. Standard processing time to review a request is 15 days. An urgent request can be reviewed within 72 hours.

Starting July 1, 2015, the following drugs will require prior authorization:

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

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

Medical, benefit and payment policy changes for certain recurring supplies

Effective March 1, 2015, Blue Cross Blue Shield of Michigan will align with the Centers for Medicare & Medicaid Services Billing Frequency Policy to allow suppliers to dispense more than a one-month supply at a time for recurring continuous positive airway pressure, nebulizer, urological and ostomy supplies.

Suppliers should continue to reference Benefit Explainer in web-DENIS for the usual maximum amount of supplies expected to be reasonable and necessary.

As a reminder, suppliers can’t dispense a quantity of supply that exceeds a member’s expected utilization amount. Suppliers must also be cognizant to changes or unusual utilization patterns by our members.

As a general rule, suppliers for durable medical equipment, prosthetics, orthotics and supplies must not dispense more than a three-month supply at a time. Our policy includes a five-day grace period. Suppliers should continue to reference Benefit Explainer in web-DENIS for usual maximum amount of supplies that meet Blue Cross quantity limitations.

Suppliers are required to follow the Blue Cross policy on refill requirements for DME POS medical supplies, which can be found in the June 2014 Record.

Note: This policy does not apply to MESSA members.

Reminder: Blue Cross’ DME Home Oxygen Equipment and Related Supplies Medical Policy

We’d like to remind you that, effective Jan. 1, 2015, Blue Cross Blue Shield of Michigan established a Home Oxygen Equipment and Related Medical Supplies Medical Policy that aligns closely with Medicare’s criteria, with the exception of the 36-month rental limit. Here’s what you need to know:

For more detailed descriptions of the Blue Cross policies for these procedures, 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.

Failure to follow these policies may result in monetary recoveries on retrospective audits.