We’re announcing the Michigan Skilled Nursing Facility Pay-for-Performance Program

On Jan. 1, 2016, Blue Cross Blue Shield of Michigan will launch its Skilled Nursing Facility Pay-for-Performance Program. The program will give incentive rewards to Michigan freestanding and hospital-based SNF providers that improve quality and meet health information exchange expectations.

The goal of the SNF P4P is to:

• Enhance the population-based model of health
• Promote a team-based approach
• Engage a strong commitment to the care continuum
• Help ensure that a patient’s caregivers receive timely notification of an admission, discharge, transfer or emergency room visit
• Improve coordination of care and outcomes
• Reduce the likelihood of an unplanned readmission

The Michigan Health Information Network, or MiHIN, has established a statewide notification service to help address the need for more timely information and:

• Give practitioners daily, all-payer ADT and ER census reports for their patients.
• Help practitioners better prepare for and support their patients when they’re discharged from an acute care hospital, SNF or ER to the home or another care setting.
• Improve the transition process.
• Help ensure a better health outcome for the patient.
• Reduce the likelihood of an unplanned readmission.

Program details and reward
In the program’s first year, we’ll recognize SNFs that are successful in:

• Electronically transmitting and receiving all-patient and all-payer ADT data into the statewide notification service administered by MiHIN daily
• Submitting a list of patients in order to electronically receive post-discharge notifications for the purpose of improving transitions of care

Providers achieving the program expectations and deadlines will be eligible to receive an additional 1 percent reward for either six or 12 months following the incentive’s effective date.

SNFs not meeting the SNF P4P program requirements or choosing not to participate will forfeit the incentive opportunity.

Important dates

Additional information

• Future program years may focus on enhanced health information exchange and quality measure reporting and performance.
• Program guides will be published and distributed to the SNF community in December, prior to the beginning of the program year.
• SNF performance will be evaluated twice per program year — once in February and again in August — with the corresponding incentive uplift applied in April and October 2016, respectively.

If you have questions, contact your provider consultant.

**Skilled nursing facility providers must meet Blue Cross’ participating provider criteria at least six months before the performance deadline to be eligible for P4P incentives.

HCPCS codes added for fourth quarter 2015, CPT codes added for early release 2016

The Centers for Medicare & Medicaid Services has added four new HCPCS codes, as part of its regular quarterly HCPCS updates, and some new CPT codes for 2016.

The new HCPCS codes are listed below:

Following are the 2016 early release CPT codes:

Procedure code Q9979 replaces J3490 and J3590 when billing for Lemtrada™

Effective Oct. 1, 2015, the Centers for Medicare & Medicaid Services has established a permanent procedure code for the specialty drug Lemtrada (alemtuzumab).

All services performed before Oct. 1, 2015, should be reported with code J3490 or J3590, with NDC number 58468-0200-01. Services performed on and after Oct. 1, 2015, must be reported with procedure code Q9979.

Prior authorization is required for all groups except for those that opted out of the Specialty Pharmacy Prior Authorization Program.

Online prescription drug lists updated for fourth quarter

Blue Cross Blue Shield of Michigan recently updated its prescription drug lists, also called formularies. Blue Cross updates these lists every quarter to help ensure patient safety and to help prescribers select the most effective and affordable drug therapy for patients.

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

These drug lists can help prescribers make better-informed decisions. This can lead to increased medication adherence and help providers explain prescription drug coverage to members.

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

As you read in The Record previously, health care providers and other health care professionals who write prescriptions for Medicare Part D members had until June 1, 2015, to apply for an approved prescriber status or submit a valid opt-out affidavit, according to a Centers for Medicare & Medicaid Services mandate. This was required of providers and other eligible health professionals to ensure continued prescription coverage under Medicare Part D for their patients.

Recently, CMS announced that it will delay enforcement until June 1, 2016. Providers should submit their completed Medicare prescriber applications or opt-out affidavits to their Medicare administrative contractors before Jan. 1, 2016. This will prevent their patients’ prescription drug claims from being denied by their Part D plans, beginning June 1, 2016.

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 own or control the content of this website.

BlueCard^® connection: Learn about our policy for appealing claims

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

Does Blue Cross Blue Shield of Michigan’s claims appeals policy apply to BlueCard claims?

Yes, because you’re a Blue Cross-contracted provider, our claims appeal policy applies to the BlueCard claims you submit to us. Before sending us a written claim appeal, you must first follow the routine inquiry steps for having a claim reconsidered. The entire process was recently updated to make it easier for you to understand. Refer to the “Appeals” chapter specific to your provider type.

Also, a link to the claims appeals section is included in the BlueCard chapter of every online provider manual. For BlueCard claims, remember that:

• BlueCard claims that are processed through Blue Cross Blue Shield of Michigan must be appealed through us, as documented in the BlueCard chapter of the online provider manuals. Do not send claim appeals directly to out-of-state plans.

• For BlueCard, you can appeal a claim on behalf of your patient with the patient’s written consent to do so. Some plans may require that the member complete a specific claim appeal form authorizing you to appeal on the member's behalf. The patient would need to provide that information to you.

For more information on the BlueCard program, including links and articles on online tools, reference the BlueCard chapter of the online provider manuals.

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 ProvComm@bcbsm.com and put “BlueCard series” in the subject line.

Coding corner: Improve medical record documentation for chronic hepatitis

ICD-10-CM coding guidelines state that chronic conditions treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the conditions.

According to an article on chronic hepatitis in Harvard Health Publications, chronic hepatitis is liver inflammation that continues for more than six months. It often doesn’t cause early symptoms and is frequently discovered during a routine blood test.

Since hepatitis can be categorized in many ways such as chronic or acute, viral or bacterial, alcoholic or non-alcohol documentation that includes specificity is important and required in order to capture the correct diagnosis code. We encourage providers to remember the acronym “M.E.A.T.,” which stands for manage, evaluate, assess or treat, in their documentation for all diagnoses.

To properly assign medical codes for hepatitis, continue to provide specificity of the condition and clear documentation of the assessment, findings or ongoing treatment. This specificity is preferred rather than only documenting the condition in past medical history.

For example, a patient came to the office with chronic hepatitis C and continues to display signs of jaundice and abdominal tenderness. The patient will need to continue treatment with antiviral medications.

Documentation with specificity is crucial for accurate patient care and coding. You can see from the table below how codes change, based on the level of specificity. For example, notice how chronic viral hepatitis B or C uses the B18 category of codes, while unspecified viral hepatitis B or C uses the B19 category.

Providers that document conditions such as chronic hepatitis C with specificity and M.E.A.T. help to pinpoint the patient’s specific condition, thereby enhancing the quality of patient care.

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.

Coding corner update: proper use of placeholders and seventh characters in ICD-10

Beginning Oct. 1, 2015, the transition to ICD-10-CM will affect every provider of health care. Many codes contain much greater specificity. This article includes the proper use of placeholders and seventh characters to align with the transition to ICD-10-CM.

ICD-10-CM has expanded from a maximum of five characters in ICD-9-CM to up to seven characters. The seventh character will be used to identify the treatment stage (which visit in a series) of an injury, such as fracture care, the relationship to an original injury or which fetus in a pregnancy is affected by a specific condition. Although there are many seventh characters, the most frequently used are:

There may be times when a diagnosis code isn’t a full six characters in length and a seventh character, is required. When this occurs, one to three placeholder “X”s must be used to fill in the empty characters when a seventh character extension is required. If a seventh character is required, these characters must be used in order for the code to be considered complete and valid. Blue Cross Blue Shield of Michigan will only process claims based on valid code submission. Seventh characters are used in the following chapters:

• Chapter 13 — Diseases of the Musculoskeletal System and Connective Tissue
• Chapter 15 — Pregnancy, Childbirth and the Puerperium
• Chapter 18 — Symptoms, Signs and Abnormal Clinical and Laboratory Findings
• Chapter 19 — Injury, Poisoning and certain other Consequences of External Causes
• Chapter 20 — External Causes of Morbidity

Because the seventh character values vary significantly for different ICD-10-CM chapters, it’s important to always use your coding resource for guidance in code selection. ICD-10-CM is divided into two main parts: The Index, an alphabetical listing of terms and their corresponding code, and the Tabular list, a sequential, alphanumeric listing of codes divided into chapters based on body system or condition. The Tabular section will identify if a placeholder is needed and what applicable seventh characters may be needed.

Below is an example, using the Tabular section of the ICD-10-CM manual and creating a valid code for the initial presentation for a crushing injury of right ankle (S97.01XA).

Tabular instructions:

• S97 Crushing injury of ankle and foot
• Use additional code(s) for all associated injuries

A: Initial encounter
B: Subsequent encounter
S: Sequela

S97.0 — Crushing injury of ankle
S97.01 — Crushing injury of right ankle

S97.01X — Because the code subcategory has only five characters (S97.01), placeholder “X” is inserted once before the seventh character.
S97.01XA — The seventh character “A” is added to report this as an initial encounter.

As always, ICD-10-CM/PCS coding for all conditions should follow coding conventions, chapter-specific guidelines and official coding guidelines.

If you have questions or need 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.

Last call: Win a prize for giving input on our provider manuals

If you haven’t already done so, complete our online survey by Oct. 15 and you could win one of three $25 gift certificates.

Participation in the survey is not necessary to win. The drawing is open to all active Blue Cross Blue Shield of Michigan or Blue Care Network providers. Enter by completing the survey no later than Oct. 15, 2015, or by sending an email with your name, phone number and the words “Survey drawing” in the subject line to ProviderOutreach@bcbsm.com by Oct. 15, 2015.

Three winners will be selected in a random drawing from among all eligible entries. Each winner will receive a $25 gift certificate. The drawing will take place by the end of October. Winners will be notified by telephone or email following the drawing.

There are four provider manuals included in the survey.
Blue Cross and BCN have several manuals in different formats. By participating in our online survey, you can tell us which ones you prefer.

• Blue Cross
• Go to bcbsm.com and log in to Provider Secured Services.
• Click on web-DENIS.
• Click on BCBSM Provider Publications and Resources.
• Click on Provider Manual.
• BCN
• Follow the steps above to access web-DENIS.
• Click on BCN Provider Publications and Resources.
• Click on Provider Manual.
• BCBSM Medicare Plus BlueSM PPO (Medicare Advantage)
• Blue Cross Complete (Medicaid)

Billing chart
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.

All Blue Cross-contracted providers should refer members to other participating providers

Health care providers who participate in our TRUST PPO network are required to refer their patients to other providers contracted with Blue Cross Blue Shield of Michigan for nonemergency services. However, all participating providers should be following this rule.

Referring patients to nonparticipating Blue Cross providers increases the member’s risk for greater out-of-pocket costs. Aside from potential out-of-network benefit sanctions, members are responsible for any amount charged by the nonparticipating provider that exceeds Blue Cross’ rate. This practice of balance billing can leave members with a significant and often avoidable financial liability.

In many cases, patients rely on their referring provider’s recommendations for such services as diagnostic testing, laboratory services, physical therapy, ambulance services and durable medical equipment. That’s why providers should make sure that all of their referrals for nonemergency services are to other Blue Cross-contracted providers.

You can find a list of Blue Cross-participating providers within a specified geographic area by going to bcbsm.com and clicking on Find a Doctor.

New requirement: Plans must contact providers monthly

Beginning in 2016, the Centers for Medicare & Medicaid Services will require plans to contact health care providers monthly to determine their availability and find out whether they are accepting new patients. This effort is designed to improve the information found in online directories.

CMS is also requiring contracted providers to inform the plan of any changes to their address, phone number, office hours or anything else that affects availability.

While Blue Cross Blue Shield of Michigan and Blue Care Network work on a process to comply with this new requirement, we’re asking professional providers to use our Provider Enrollment and Change Self-Service tool to identify any discrepancies in their information and the information of affiliated providers. The online application within Provider Secured Services allows you to add or remove practice locations, mailing or remittance addresses and to submit requests to update group information with Blue Cross and BCN electronically.

To use Provider Enrollment and Change Self-Service, you’ll need to log in to Provider Secured Services at bcbsm.com/providers and then follow these steps:

• Click on the Help tab.
• Click on FAQs from the drop-down menu.
• Click on Provider Enrollment and Change Self-Service for professional groups and allied providers and follow the instructions.

Please continue using the self-service tool on a monthly basis to ensure all changes are made to your records in a timely manner.

Blue Cross and BCN have contracted with American Well^® to provide online doctor visits

Blue Cross Blue Shield of Michigan and Blue Care Network have contracted with American Well^®, a best-in-class telehealth company, to provide online doctor visits for our members.

Initially, this benefit will be available only to Blue Cross ASC groups with 50 or more enrolled contracts and all BCN fully insured groups, beginning Jan. 1, 2016. We’ll offer this benefit to Blue Cross’ fully insured groups and individual members at a later date.

As consumers bear more responsibility for health care costs, they demand lower-cost, convenient access to care. This initiative for online doctor visits improves access to care and drives lower out-of-pocket costs for our members.

Members with this benefit will be able to talk to one of American Well’s extensive group of board-certified doctors from their laptop, tablet or smartphone. They can talk to a doctor 24 hours a day, seven days a week for common illnesses such as a cold, flu, fever, skin rash and ear infections.

This secure, online video visit gives members a trustworthy, reliable option to higher-cost urgent and emergency care when their own doctors aren’t available.

Online visits aren’t intended to replace a member’s relationship with his or her primary doctor. They’re an alternative way to seek treatment for acute illness when the member’s primary doctor isn’t available or urgent care isn’t convenient.

We’ll provide more details about online doctor visits in the November Record.

Direct reimbursement available to licensed professional counselors beginning Jan. 1

Licensed professional counselors will have the opportunity to participate in Blue Cross Blue Shield of Michigan’s Traditional, TRUST (PPO) and Mental Health and Substance Abuse Managed Care networks, starting Jan. 1, 2016. Participating LPCs will receive direct reimbursement for covered mental health services within the scope of their licensure.

Covered mental health services within the LPC scope of licensure will be reimbursed at 80 percent of the Traditional, TRUST and MHSAMC practitioner fee schedule, less any member deductibles and copayments.

This change affects Blue Cross benefit plans that cover mental health services that LPCs are licensed to provide. Note: Not all plans will cover LPC services or services billed directly by an LPC. To find out if a patient has coverage, check web-DENIS for member benefits and eligibility or call PARS at 1-800-344-8525.

If an LPC registers as a nonparticipating provider for Traditional plans, we’ll send payment for covered services to the member.

Starting in October, LPCs can find the Traditional, TRUST and MHSAMC practitioner agreements and enrollment forms on bcbsm.com. To find enrollment information, click on Providers, and then on Join the Blues Network and Enrollment and Changes. Specific qualification requirements are identified within each agreement. Qualified LPCs may apply for a Blue Cross provider identification number by completing the enrollment applications available on the site.

All applicants to the TRUST and MHSAMC networks must pass a credentialing review before participation. We’ll notify applicants in writing of their approval status.

With these changes, LPCs have the opportunity to participate in three Blue Cross networks: Traditional, TRUST and MHSAMC.

For more information, contact Provider Inquiry or your Blue Cross provider consultant.

Resolving your issues: Requirements for processing written inquiries will change Nov. 1

An August Record article titled “Do I call or do I write?” offered some guidance on whether to call Provider Inquiry or write to us when you have a question. We let you know that, in the future, we’ll only be processing written inquiries for these reasons:

• Preauthorization for Blue Cross Blue Shield of Michigan-enrolled members. (For more details, see the June 2012 article on requesting medical reviews.)

• Ten or more claims regarding the same issue, including refund requests

The date that this change will take place has moved to Nov. 1, 2015. We’ve updated the article accordingly, and you can view the entire revised article by clicking here.

The Federal Employee Program^® and Medicare Advantage contracts are excluded from this process change.

Self-service tools and resources

We’d like to remind you that several self-service tools and resources are available to provide you with the answers you need:

• Web-DENIS — This resource provides information on medical policies, fees, claims and benefits, and Clear Claim Connection

• Provider Automated Response System — PARS offers information on eligibility, benefits, deductibles, cost share by voice response, fax and email.

• Provider manuals — Customized provider manuals are available for each provider type. To learn how to use them more effectively, see the March Record article, part of our “Training Tips and Opportunities” series.

• Training and online resources — For an overview of learning opportunities and online resources, see the May Record article, part of our “Training Tips and Opportunities” series.

UA Local 357 and UA Local 174 will participate in medical drug prior authorization program

Beginning Jan. 1, 2016, Plumbers & Pipefitters Local 357 and West Michigan Plumbers & Pipefitters Local 174 will participate in the medical drug prior authorization program.

Keep in mind that the prior authorization requirement doesn’t 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.

Reminder: There’s still time to register for a provider forum this fall

As you’ve read in The Record previously, we scheduled a series of forums for professional providers across the state this fall. Nine of them are still available for the October through November time frame.

Billing and office managers and their staff are strongly encouraged to attend one of the forums. The classes will cover such key topics as:

• ICD-10 (professional)
• Medicare Advantage
• Provider Inquiry
• BlueCard^®
• EviCore healthcare (formerly CareCore/Med Solutions Inc.)
• Transparency
• Provider enrollment

Here’s a schedule of events:

• Half-day classes start at 9 a.m. and end at noon, with registration at 8:30 a.m.
• To accommodate driving schedules to the Upper Peninsula, classes there will begin one hour later than usual. Registration for the Marquette and Sault Ste. Marie classes will be at 9:30 a.m., with the class starting at 10 a.m. (These times are for Upper Peninsula classes only.)
• Continental breakfast will be served.

Following is a list of remaining forums. To register, click on the link next to the event you’d like to attend.

If you have questions, contact your provider consultant.

Reminder: Flu shots, other vaccines

Flu shots and other vaccines administered to non-Medicare members should be submitted as medical, not pharmacy claims. For complete details, see the September Record article.

Correction: Self-service tools can help

An article in the September Record, titled “Self-service tools can help,” contained some incorrect information about the Provider Automated Response System. We’ve updated the article with this information about PARS:

Provider Automated Response System — PARS offers information on eligibility, benefits, deductibles and cost share by voice response, fax and email.

You can view the entire revised article by clicking here.

All Blue Cross-contracted providers should refer members to other participating providers

Health care providers who participate in our TRUST PPO network are required to refer their patients to other providers contracted with Blue Cross Blue Shield of Michigan for nonemergency services. However, all participating providers should be following this rule.

Referring patients to nonparticipating Blue Cross providers increases the member’s risk for greater out-of-pocket costs. Aside from potential out-of-network benefit sanctions, members are responsible for any amount charged by the nonparticipating provider that exceeds Blue Cross’ rate. This practice of balance billing can leave members with a significant and often avoidable financial liability.

In many cases, patients rely on their referring provider’s recommendations for such services as diagnostic testing, laboratory services, physical therapy, ambulance services and durable medical equipment. That’s why providers should make sure that all of their referrals for nonemergency services are to other Blue Cross-contracted providers.

You can find a list of Blue Cross-participating providers within a specified geographic area by going to bcbsm.com and clicking on Find a Doctor.

Resolving your issues: Requirements for processing written inquiries will change Nov. 1

An August Record article titled “Do I call or do I write?” offered some guidance on whether to call Provider Inquiry or write to us when you have a question. We let you know that, in the future, we’ll only be processing written inquiries for these reasons:

• Preauthorization for Blue Cross Blue Shield of Michigan-enrolled members. (For more details, see the June 2012 article on requesting medical reviews.)

• Ten or more claims regarding the same issue, including refund requests

The date that this change will take place has moved to Nov. 1, 2015. We’ve updated the article accordingly, and you can view the entire revised article by clicking here.

The Federal Employee Program^® and Medicare Advantage contracts are excluded from this process change.

Self-service tools and resources

We’d like to remind you that several self-service tools and resources are available to provide you with the answers you need:

• Web-DENIS — This resource provides information on medical policies, fees, claims and benefits, and Clear Claim Connection

• Provider Automated Response System — PARS offers information on eligibility, benefits, deductibles, cost share by voice response, fax and email.

• Provider manuals — Customized provider manuals are available for each provider type. To learn how to use them more effectively, see the March Record article, part of our “Training Tips and Opportunities” series.

• Training and online resources — For an overview of learning opportunities and online resources, see the May Record article, part of our “Training Tips and Opportunities” series.

Blue Cross changes billing and reimbursement for partial hospitalization program and electroconvulsive therapy

Effective for claims with dates of service Jan. 1, 2016, and after, Blue Cross Blue Shield of Michigan will change the requirements for hospitals billing for the partial hospitalization program and electroconvulsive therapy services.

The partial hospitalization program will be billed by a licensed PHP provider as an outpatient service only and electroconvulsive therapy can be billed as an inpatient or outpatient service. These changes will help to simplify billing and standardize reimbursement for these services across the state.

As a result of this change, effective for claims with dates of service Jan. 1, 2016, and after:

• Revenue code 0912 will be rejected if billed on an inpatient claim.
• Revenue codes 0901 and 0912:
• Should be billed on an outpatient facility claim
• Must be billed with a valid HCPCS code on an outpatient facility claim
• Revenue code 0901 should be billed with HCPCS 90870, and revenue code 0912 should be billed with S0201 on an outpatient facility claim
• The change impacts all PHP and ECT facility claims submitted by a Michigan facility for:
• Michigan members
• FEP^® members
• Host members
• Michigan “as par” members
• Flexlink members
• Revenue code 0901 must be billed with a room revenue code when billed as an inpatient service.
• When revenue code 0901 is billed as a service on an inpatient claim, the inpatient reimbursement policy will continue to apply.
• An inpatient claim with revenue code 0901 without a room revenue code will be rejected as provider liability.
• Revenue codes 0901 and 0912 must be billed as follows:
• One service date per line (no ranges)
• One unit per service date
• Different dates of service are allowed on the same claim.
• Facilities should complete preauthorization for PHP services billed with revenue code 0912 with the exception of the Federal Employee Program and Medicare Advantage.
• Pre-authorization is not required for ECT services billed with revenue code 0901 on a facility outpatient claim.
• The fees for payable HCPCS codes applicable to revenue codes 0901 and 0912 will be published 90 days in advance of the effective date.

For more information, contact your provider consultant.

Preauthorization expansion to outpatient facilities begins Jan. 1, 2016

Blue Cross Blue Shield of Michigan is expanding its utilization management program to include medical drugs administered in hospital outpatient facilities. The following drugs will require prior authorization, starting Jan. 1, 2016:

These drugs need to be administered (injection or infusion) by a physician or other health care professional.

To be eligible for payment for these medications subject to prior authorization, the ordering provider is responsible for getting the authorization and verifying the patient’s benefit. If prior authorization is not obtained before services are rendered, the claim will be rejected. The ordering provider can request an authorization after the patient receives medications. However, the patient still needs to meet all of the requirements and have the necessary coverage in order for the claim to be payable.

We won’t consider a request for coverage until we receive a physician-signed medication authorization request form either faxed to Blue Cross or a request uploaded to the online-based tool NovoLogix^®. Standard processing time for review of a request is 15 days. An urgent request is reviewed within 72 hours.

You can find the form linked within the current list of medications that require prior authorization, as well as a list of groups that have opted out, on web-DENIS:

• Click on BCBSM Provider Publications and Resources.
• Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
• From this page, click on Pharmacy prior authorization/Step Therapy forms link at the top of the page
• Click on Physician administered medications link

Our Blue Cross clinical team will continue to review requests against our clinical criteria. Ordering physicians can get real-time status on prior authorizations and immediate approvals for certain medications when patients meet the criteria by using the secure online tool, NovoLogix^®.

We’ve included criteria for authorization and the medication request forms on the medical router for in- and out-of-state physicians. In-state physicians only can also view it on web-DENIS.

We suggest that outpatient facilities contact the physician who ordered the drugs — and received the authorization — to obtain an approval date and authorization number. The authorization number should be documented on the claim form.

When additional medications are included in the program, we’ll update the forms list and alert providers through web-DENIS.

We’ll provide more details in The Record later this year.

Blue Cross and BCN have contracted with American Well^® to provide online doctor visits

Blue Cross Blue Shield of Michigan and Blue Care Network have contracted with American Well^®, a best-in-class telehealth company, to provide online doctor visits for our members.

Initially, this benefit will be available only to Blue Cross ASC groups with 50 or more enrolled contracts and all BCN fully insured groups, beginning Jan. 1, 2016. We’ll offer this benefit to Blue Cross’ fully insured groups and individual members at a later date.

As consumers bear more responsibility for health care costs, they demand lower-cost, convenient access to care. This initiative for online doctor visits improves access to care and drives lower out-of-pocket costs for our members.

Members with this benefit will be able to talk to one of American Well’s extensive group of board-certified doctors from their laptop, tablet or smartphone. They can talk to a doctor 24 hours a day, seven days a week for common illnesses such as a cold, flu, fever, skin rash and ear infections.

This secure, online video visit gives members a trustworthy, reliable option to higher-cost urgent and emergency care when their own doctors aren’t available.

Online visits aren’t intended to replace a member’s relationship with his or her primary doctor. They’re an alternative way to seek treatment for acute illness when the member’s primary doctor isn’t available or urgent care isn’t convenient.

We’ll provide more details about online doctor visits in the November Record.

UA Local 357 and UA Local 174 will participate in medical drug prior authorization program

Beginning Jan. 1, 2016, Plumbers & Pipefitters Local 357 and West Michigan Plumbers & Pipefitters Local 174 will participate in the medical drug prior authorization program.

Keep in mind that the prior authorization requirement doesn’t 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.

Reminder: Flu shots, other vaccines

Flu shots and other vaccines administered to non-Medicare members should be submitted as medical, not pharmacy claims. For complete details, see the September Record article.

Are you billing correctly for these drugs?

The following drugs are often billed with incorrect quantities under the prescription drug benefit. We've indicated below the correct quantities for these drugs so your claims can be processed more accurately and in a timely manner.

Make sure you submit the appropriate quantities on claims for all medications. We’ve identified these drugs by their names and strength, and have listed the correct quantity that should be billed to Blue Cross Blue Shield of Michigan.

Following are medications often associated with an incorrect days supply:

Brimonidine tartrate

Brimonidine tartrate ophthalmic solution = # drops in bottle/# drops prescribed per day = day supply

Rebif^®

Restasis^®

Victoza^®

If you have questions about how to submit claims, contact our claims processor, Express Scripts, at 1-800-922-1557. For any unresolved issues or questions regarding information in this article, contact our Pharmacy Services Clinical Help Desk at 1-800-437-3803.

Use AIM Specialty Health to obtain preauthorization for proton beam therapy services

Our auto customers are now required to use AIM Specialty Health for preauthorization for both in- and out-of-state providers for proton beam therapy services.

This will affect procedure codes *77520, *77522, *77523 and *77525, and revenue code 0333. The referring health care provider will need to submit a written request and include the following information:

• Dates of service
• Radiology report and rationale to support medical necessity
• Diagnosis codes
• Procedure codes
• Charges
• Planned duration of treatment

For dates of service on or after Sept. 1, 2015, you must call AIM at 1-800-728-8008 for preauthorization requests. AIM will review the requests and Provider Inquiry will respond to the provider with a letter explaining what the preauthorization covers. The provider must follow the terms of the letter.

The preauthorization process will verify that Blue Cross criteria are met and, where appropriate, to explore the proper use of alternative therapies.

To refer to the Charged-Particle (Proton or Helium Ion) Radiation Therapy Policy, click here.

Note: The listed preauthorization requirements do not apply to URMBT, Federal Employee Program^® and State of Michigan members.

Anti-rheumatic drug benefit changes for Medicare Plus Blue^SM and Prescription Blue^SM PDP members

Starting May 1, 2015, Blue Cross made the following changes to its Medicare Advantage formulary:

• Hydroxychloroquine and sulfasalazine are now Tier 1 preferred generic drugs, offering the lowest cost-sharing for members.
• Oral methotrexate is also now a Tier 1 preferred generic. The Centers for Medicare & Medicaid Services requires a coverage determination to establish if the drug should be paid under Medicare Part B or Medicare Part D. Coverage determinations can be completed by calling 1-800-437-3803 to obtain a fax form and faxing requests to 1-866-601-4428.
• Enbrel^® (etanercept) and Humira^® (adalimumab) no longer require prior authorization. Enbrel^® and Humira^® are considered Tier 5 specialty drugs, the highest cost-sharing medication tier. This tier may be cost-prohibitive for some patients.

You can help patients by recognizing the early signs and symptoms of rheumatoid arthritis. You may want to consider prescribing a disease-modifying anti-rheumatic drug or providing an early referral to a rheumatologist. For more information, check out the current American College of Rheumatology guideline** on rheumatoid arthritis.

Keep in mind that patients receiving a disease-modifying anti-rheumatic drug should be regularly monitored for early detection and management of adverse events that are associated with a specific drug or biologic agent.

Medicare Plus Blue and Prescription Blue members can fill prescriptions for specialty drugs at a retail pharmacy, but not all pharmacies dispense specialty drugs. You’ll want to advise Medicare Plus Blue and Prescription Blue members to call their pharmacy to verify that the prescribed specialty drug can be filled there.

Members can also call the customer service number on the back of their Blue Cross ID card for help.

Did you know?
The Blue Cross Blue Shield of Michigan Performance Recognition Program provides participating primary care physicians $50 for each Medicare Plus Blue member with RA who fills at least one prescription for a disease-modifying anti-rheumatic drug each calendar year.

**Blue Cross Blue Shield of Michigan does not own or control the content of this website.