Coming soon: Blue Cross^® Personal Choice PPO

Blue Cross Blue Shield of Michigan is offering a new, innovative product called Blue Cross Personal Choice PPO. This PPO product offers members unique access to Organized Systems of Care (similar to accountable care organizations) and the broader Blue Cross PPO network. Personal Choice PPO provides members with the opportunity to select a plan that meets their specific health care needs while keeping affordability in mind.

Here are a few key dates:

• Summer 2016: Provider training begins.
• Summer 2016: Member enrollment begins.
• Oct. 1, 2016: The first effective date of coverage.

For questions or additional information, contact your provider consultant or log in at bcbsm.com/providers.

Annual notice: What you need to know about our programs

At Blue Cross Blue Shield of Michigan, we continually implement, monitor, measure and evaluate strategies to improve the quality of care delivered to our members. Some improvements we’re proud of include:

• We successfully maintained accreditation with a Commendable rating from the National Committee for Quality Assurance.
• Member satisfaction with providers remains high. Members’ personal doctor satisfaction once again scored in the 90th percentile, based on 2015 Consumer Assessment of Healthcare Providers and Systems member satisfaction surveys.
• We exceeded annual goals for volumes of identified, reached and engaged members for both case management and chronic condition management.
• We established a pharmacy program with 24-hour turnaround time frames. The program helps make coverage decisions for non-formulary drugs in urgent circumstances.
• Sixty-nine Michigan hospitals have signed a value-based contract.
• A total of 1,551 practices have been designated as patient-centered medical homes.

We annually update information about the following:

• Behavioral health care benefits
• Clinical practice guidelines
• Comprehensive care management
• Criteria used for utilization management decisions
• Members rights and responsibilities
• Pharmacy management
• Statement about incentives
• Translation services
• Utilization management staff availability

Here’s a brief rundown:
Behavioral health care benefits
New Directions Behavioral Health is an independent company administering behavioral health benefits on behalf of Blue Cross for our members. Contact information:

• Commercial PPO and Traditional programs: 1-800-762-2382
• Federal Employee Program^®: 1-800-342-5849

For a summary of New Directions annual quality improvement initiatives and outcomes, click here.

Clinical practice guidelines
For medical and behavioral health care, Blue Cross follows Michigan Quality Improvement Consortium guidelines, which can be found at mqic.org.**

Federal Employee Program: In addition to MQIC guidelines, FEP uses Accordant clinical practice guidelines for treating chronic disease. Those guidelines can be found at accordant.com.** Note: User name and password are required; provided by Accordant.

Comprehensive care management
To learn about Blue Cross comprehensive care management, use your online provider manual or go to bcbsm.com and click on the For Members tab. Under Health & Wellness, choose either Case Management or Chronic Condition Management and click on Learn More.

Criteria used for level of care utilization management decisions
InterQual^® criteria: For hospitals and facilities, Blue Cross uses InterQual criteria to assess medical necessity and the appropriate level of care. Criteria encompasses acute care (adult and pediatric), rehabilitation (adult and pediatric), long-term acute care, skilled nursing facility and home health care. For questions about InterQual, email Blue Cross at InterQualCriteria@bcbsm.com

Behavioral health program: New Directions criteria are available for download at ndbh.com.** Medical necessity criteria are reviewed annually and updated as needed. You may call New Directions at 1-800-528-5763 to request a printed copy.

Federal Employee Program: Criteria for FEP utilization management decision-making can be found at fepblue.org.

Additional medical policies: To review additional Blue Cross medical policies, go to bcbsm.com/providers and click Quick Links, then on Medical Policy and Pre-Cert/Pre-Auth Router.

Member rights and responsibilities
Blue Cross Blue Shield of Michigan members have the right to:

• Receive clear and understandable written information about Blue Cross Blue Shield of Michigan, its services, practitioners and providers, and their member rights and responsibilities
• Receive easy-to-understand information about their care
• Receive medically necessary care as outlined in the New Member Handbook and Summary of Benefits and Coverage
• Receive considerate and courteous care with respect to their privacy and human dignity
• Candidly discuss appropriate medically necessary treatment options for their health conditions, regardless of cost or benefit coverage
• Participate in decision-making regarding their health care
• Expect confidentiality regarding their care and know that Blue Cross Blue Shield of Michigan adheres to strict internal and external guidelines concerning their personal health information. This includes the use, access and disclosure of that information or any other information that is of a confidential nature.
• Refuse treatment to the extent permitted by law and be informed of the consequences of their actions
• Voice concerns or complaints about their health care by contacting the Customer Service department or submitting a formal, written grievance through the Blue Cross Blue Shield of Michigan appeals process
• Review their medical records at your office by scheduling an appointment during regular business hours
• Make recommendations regarding the member rights and responsibilities policies of Blue Cross Blue Shield of Michigan
• Request the following information from Blue Cross Blue Shield of Michigan:
• The current provider network in their region
• The professional credentials of the health care practitioners who are participating with Blue Cross Blue Shield of Michigan, including participating practitioners who are board-certified in the specialty of pain medicine and the evaluation and treatment of pain
• The names of participating hospitals where individual participating physicians have privileges for treatment
• How to contact the appropriate Michigan agency to obtain information about complaints or disciplinary actions against a health care practitioner
• Any prior authorization requirement and limitation, restriction or exclusion by service, benefit or type of drug
• Information about the financial relationships between Blue Cross Blue Shield of Michigan and a participating practitioner

Blue Cross members have the responsibility to:

• Read all Blue Cross Blue Shield of Michigan materials provided for members, and call our Customer Service department with any questions
• Coordinate all nonemergency care through their primary care doctors
• Use the Blue Cross Blue Shield of Michigan provider network unless otherwise approved by Blue Cross and their primary care physicians
• Comply with the plans and instructions for care that they agreed to with their providers
• Provide, to the extent possible, complete and accurate information that Blue Cross Blue Shield of Michigan and its providers need in order to provide care
• Make and keep appointments for nonemergency medical care. They must call their doctor’s offices if they need to cancel an appointment.
• Participate in the medical decisions regarding their health
• Be considerate and courteous to practitioners, providers, their staff and other patients
• Notify Blue Cross Blue Shield of Michigan of address changes and additions or deletions of dependents covered by their contracts
• Protect their identification cards against misuse and contact Customer Service immediately if their cards are lost or stolen
• Report all other health care coverage or insurance programs that cover their health and their family’s health
• Participate in understanding their health problems and the development of mutually agreed upon treatment

Behavioral health: For members’ behavioral health service rights and responsibilities, click here.

Pharmacy management
We recommend you visit bcbsm.com/pharmacy at least quarterly and click on Drug Lists or call 1-800-437-3803 for the most up-to-date pharmaceutical information.

Federal Employee Program: CVS/caremark™ provides pharmacy management services for the Federal Employee Program. Below are the links to the FEP drug lists for the FEP Basic Option and FEP Standard Option:

• Basic Option: Click here.
• Standard Option: Click here.

Statement about incentives

• Medical decisions are based only on appropriateness of care and service and existence of coverage.
• Blue Cross Blue Shield of Michigan doesn’t specifically reward doctors or other individuals for issuing denials of coverage.
• Financial incentives for doctors and other health professionals don’t encourage decisions that limit treatment for our members.

Behavioral health: Decisions about utilization of behavioral health services are made only on the basis of eligibility, coverage and appropriateness of care and service. New Directions doesn’t specifically reward, hire, promote or terminate practitioners or other individuals for issuing denials of coverage. Utilization decision-makers don't receive incentives that would result in under-utilization.

Translation services
Members who need language assistance can call the Customer Service number on the back of their ID card. TTY users should dial 711.

Utilization Management staff availability
Blue Cross provides access to Utilization Management staff for members and practitioners seeking information about UM process and authorization of care. Department telephone numbers and hours are shown in the Utilization Management Decisions chart in the Appeals section of your provider manual.

For more information

• Information about our programs and additional resources are available at bcbsm.com/importantinfo.
• To request a printed copy of any of the information contained in this article, contact Vicki Boyle, director of Quality Management and Accreditation, at 313-448-6145.
• If you have any questions about this article or the information in it, contact your provider consultant.

**Blue Cross Blue Shield of Michigan doesn’t own or control the content of this website.

Check bcbsm.com to view the most recent prescription drug lists

Blue Cross Blue Shield of Michigan recently updated its 2016 online prescription drug lists, or formularies.

We update these lists periodically 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.

Blue Cross updating ClaimsXten™ for third-quarter 2016

McKesson ClaimsXten software, which uses the most current Common Procedure Terminology and Health Care Procedure Coding System codes to determine clinical edits, is periodically updated. This ensures that the most current CPT code updates, Centers for Medicare & Medicaid guidelines, specialty society guidelines and information gathered from industry seminars and publications are being used.

Blue Cross Blue Shield of Michigan is updating ClaimsXten for the third quarter of 2016, so it’s important that you report the most current CPT and HCPCS codes on your claims. Doing so will help us process claims and send accurate reimbursements more quickly and efficiently.

Blue Cross works to make sure that ClaimsXten is also aligned with any unique Blue Cross payment policy. Blue Cross reserves the right to make changes or corrections when additional changes are required or new information becomes available. In some instances, changes to ClaimsXten may be applied retroactively.

BlueCard^® connection: Why don’t I always see my BlueCard replacement claim on web-DENIS?

When we receive a replacement claim from you for a BlueCard member, your replacement claim appears on web-DENIS as a pending adjustment to your original claim and not under a new ICN. This occurs because of an automated process Blue Cross Blue Shield of Michigan established in September 2015 to improve the processing of replacement claims.

Please note: Replacement claims can no longer be viewed in web-DENIS as a unique ICN but can be viewed as an adjustment to your original claim.

Home plans may deny our request to process replacement claims because they require additional information. If the BlueCard claims department has the information required or if the claim was denied in error, the department will automatically work with the home plan to reprocess your claim. Once finalized, your replacement claim will be posted on web-DENIS as an adjustment to your original claim.

If your replacement claim wasn’t billed correctly or the plan maintains its denial, you’ll receive written communication with the details. You may contact Provider Inquiry for questions on the claim and for assistance with details of the claim denial.

Here are some helpful tips in preventing a BlueCard replacement claim from denying:

• Ensure your original claim is finalized before sending a replacement claim.
• Ensure all patient demographics on the replacement claim are the same as reported on the voucher of the finalized original claim.
• Include the 14-digit ICN from the original claim. (The ICN can be obtained from the original claim information on web-DENIS.)
• Include all the charges for services you’re billing on the claim and not just your changes. The replacement claim replaces your original claim in its entirety.

Blue Cross Blue Shield of Michigan and other Blue plans are addressing this automation process with the Blue Cross and Blue Shield Association. Changes that may occur as result of these discussions will be communicated in a future Record article.

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 of the online manual — or if you’d like more information on a particular topic — contact your provider consultant.

Want to suggest a topic to be covered in this series? Send an email to ProvComm@bcbsm.com and put “BlueCard series” in the subject line.

Reminder: Prominently display HIPAA Notice of Privacy Practices on your website home page

This is a reminder to health care providers and other covered entities that maintain websites that they are required by the Health Insurance Portability and Accountability Act to prominently display their Notice of Privacy Practices on the home page of their website.

In addition to physicians and other health care providers, covered entities include hospital systems, urgent care centers and vendors, such as VSP^® Vision Care.

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.

Here's what you need to know about participating in Value Partnerships quality programs

The Value Partnerships team at Blue Cross Blue Shield of Michigan develops and maintains quality programs to better align provider reimbursement with quality of care standards, improve health outcomes and control health care costs for Blue Cross customers. We refer to reimbursement earned through our quality programs as “value-based reimbursement,” formerly called “fee uplifts.”

Select primary care and specialist physicians who participate in the Physician Group Incentive Program and meet the standards of particular quality programs developed under PGIP will, for a designated period, be eligible for reimbursement in accordance with the Value-Based Reimbursement Fee Schedule. The VBR Fee Schedule sets reimbursement rates for particular codes at greater than 100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules, or Standard Fee Schedules. The VBR Fee Schedule rates apply to commercial payments only.
The following are participation guidelines for quality programs. Providers who have questions about participating in a quality program, or who would like more information about the opportunities described in this article, should contact their provider consultant, provider organization or email valuepartnerships@bcbsm.com. All requirements are subject to change annually.

Primary care physicians

There are four ways a primary care physician can participate in Blue Cross’ quality programs and be eligible to earn reimbursement in accordance with the VBR Fee Schedule.

1. Primary care physicians designated as a Patient-Centered Medical Home are eligible for reimbursement at the rates applicable to such designations on the VBR Fee Schedule. Primary care physicians can receive designation as a PCMH by demonstrating the following:
• Nomination from their physician organization
• Meeting the PCMH minimum capability requirement. PCMH capabilities are tasks medical practices undertake to change their care processes and become more patient-centered. Examples of PCMH capabilities include providing 24-hour access to a clinical decision-maker so patients can avoid emergency room visits, creating patient registries or offering access to patient web portals. In 2016, the capability requirement for PCMH designation requires 50 out of 145 PCMH capabilities. The extent to which a provider has implemented PCMH capabilities represents 50 percent of the PCMH designation score.
• Meeting the minimum PCMH percentile ranking for quality and use criteria. Quality and use criteria are analyzed using claims data from the prior calendar year for a doctor’s attributed patient population, and the metrics include 17 adult quality metrics, eight pediatric/adolescent quality metrics, high- and low-tech radiology use, and primary care sensitive emergency room visits. In 2016, the minimum percentile ranking was 20 percent. This represents 50 percent of the designation score.
2. Primary care physicians with PCMH designation who are also part of a physician organization that meets Blue Cross’ cost-benchmarking criteria are eligible for reimbursement at the rates for such designations on the VBR Fee Schedule. For 2016, cost benchmark performers are defined as sub-physician organizations or Organized Systems of Care that are in the top 15 percent for total per member per month cost or trend, or groups that have combined cost and trend performance above a certain threshold, based on Blue Cross claims data. Specific cost-benchmarking metrics include:
• Cost of care
• Overall cost of care per member per month for the previous calendar year
• Overall monthly trend in cost of care per member per month for the calendar year two years prior
• Combined performance measure for cost of care per member per month and monthly trend in cost of care per member per month

• This year, PCMH designated primary care physicians who attest to having a qualified care manager in the office, a provider who is engaged in care management and willing to refer patients to care management, and staff working to close gaps in care, in addition to delivering care management services to a proportion of their eligible, attributed patient population, will receive reimbursement for Provider Delivered Care Management according to the VBR Fee Schedule.

4. PCMH designated and non-PCMH designated primary care physicians who Blue Cross determines are performing well on measures of clinical quality performance related to preventive service use, chronic condition management and medication adherence are eligible for reimbursement at rates for such designations on the VBR Fee Schedule. There are 27 measures in this value-based reimbursement opportunity, based on the Healthcare Effectiveness Data and Information Set measures of the National Committee on Quality Assurance. Not all measures apply to each type of primary care practice. The adult measures are used for internal medicine practitioners, the pediatric measures are used for pediatricians, and a combination of adult and pediatric measures is used for family practitioners. All measures use claims data from the prior calendar year for the providers’ attributed patient population.

Specialists
Specialists are eligible for the VBR Fee Schedule if they meet all of the following:

1. Are a physician, chiropractor, podiatrist or fully licensed psychologist
2. Are a member of a PGIP physician organization for at least one year
• Every PGIP-participating doctor is entered into a database by his or her PO. At regular intervals, Blue Cross takes a snapshot of the database. For value-based reimbursement, a specialist is considered to be in a PGIP physician organization for at least one year if the doctor is listed on the winter and summer snapshot of the year before the quality program year. In the 2016 quality program year only, anesthesiologists are exempt from the one-year requirement.
3. Are nominated by and have a signed a primary care-specialist agreement with his or her member PO. Blue Cross has a template agreement but doesn’t require its use. Standard employment agreements don’t constitute primary care-specialist agreements. Also, if a substantial proportion of the specialist’s patients are attributed to a PO other than his or her member PO, the specialist must be nominated by and have a signed primary care-specialist agreement with the non-member PO (in other words, a principal partner PO).
• Each PO establishes its own criteria for nominating member and principal partner specialist practices within broad parameters set by Blue Cross. Nominated member practices must be actively engaged with their nominating member PO. Active engagement can be demonstrated by progress toward one or more of the following:
• Involvement in managing the use of services and optimizing the quality of care
• Collaboration with primary care physicians to develop and improve shared processes of care
• Collaboration on efforts to coordinate care across settings and over time
• Implementing Patient-Centered Medical Home-Neighbor capabilities in the specialist practice

Note: The PO’s criteria for principal partner practices may be the same as or different than those for member practices. All specialist practices — regardless of their membership status — must have an equal opportunity to be considered for nomination. Each PO must document the nomination criteria and process in writing and disclose it to the other physician organizations on the shared PO website maintained by Blue Cross. And, POs must make the documented process available to practices upon request. Blue Cross reviews the documented nomination criteria and process to make sure it’s fair to principal partner practices.

4. Meet the performance rankings on measures of quality, cost and efficiency set by Blue Cross.
• Blue Cross uses primarily population-based measures of quality, cost and efficiency to evaluate and rank nominated practices. Each performance measure is assigned a weight. Within each specialty type and within all pediatric specialties, specialist practices are ranked based on the weighted average of the relevant performance measures. For specialists who treat adult patients, the top two-thirds of nominated specialists who have been in PGIP for one year are eligible for reimbursement at the rates for such designation on the VBR Fee Schedule. For specialists who primarily serve pediatric patients, all nominated specialists who have been in PGIP for one year are eligible for reimbursement at the rates for such designation on the VBR Fee Schedule.
  
  In 2016, Blue Cross used three population-based performance measures to determine eligibility for VBR Fee Schedule reimbursement for all specialty types:
• A population-level per member per month cost measure
• A population-level cost difference measure (the change in population-level cost from the prior measurement year)
• A population-level global quality index, a single composite score based on numerous measures of quality of care

Also, Blue Cross has developed additional specialty-specific performance measures for 13 specialties: allergy, cardiology, emergency medicine, endocrinology, gastroenterology, nephrology, neurology, obstetrics and gynecology, oncology, orthopedics, otolaryngology, pulmonology and rheumatology.

We’re making some changes to the Value-Based Reimbursement Fee Schedule, effective July 1, 2016

Value-based reimbursement is one of the ways Blue Cross Blue Shield of Michigan is working with health care professionals to create value for health care users. There have been some changes to the VBR Fee Schedule since we communicated about it in the December 2015 Record. Following is a detailed description of the VBR Fee Schedule that goes into effect July 1, 2016.

Primary care physicians

Primary care physicians in the Physician Group Incentive Program are eligible for reimbursement according to the VBR Fee Schedule. The VBR Fee Schedule sets reimbursement rates for specific codes at more than 100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules, or Standard Fee Schedules. Primary care physicians can receive value-based reimbursement at 105 percent to 140 percent of the Standard Fee Schedules for certain procedure codes,* depending on the program(s) in which they participate and the criteria they meet. Previously, primary care physicians could receive value-based reimbursement at 105 percent to 130 percent of the Standard Fee Schedules.

Effective July 1, 2016, through June 30, 2017 (based on performance in 2015), three tiers of clinical quality value-based reimbursement will be available to primary care physicians. Previously, only one tier was available.

Primary care practices without Patient-Centered Medical Home designation that:

• Rank in the 95th to 100th percentile for clinical quality performance can receive 115 percent of the Standard Fee Schedules for the following procedure codes:
• 99201-99215
• 99381-99397
• Rank in the 85th to 94.99th percentile for clinical quality performance can receive 110 percent of the Standard Fee Schedules for the procedure codes above
• Rank in the 80th to 84.99th percentile for clinical quality performance can receive 105 percent of the Standard Fee Schedules for the procedure codes above

Primary care physicians with PCMH designation receive 110 percent of the Standard Fee Schedules for the procedure codes above. Primary care physicians with PCMH designation can receive additional value-based reimbursement.

PCMH designated practices that:

• Rank in the 95th to 100th percentile for clinical quality performance can receive an additional 15 percent of the Standard Fee Schedules for the procedure codes above
• Rank in the 85th to 94.99th percentile for clinical quality performance can receive an additional 10 percent of the Standard Fee Schedules for the procedure codes above
• Rank in the 80th to 84.99th percentile for clinical quality performance can receive an additional 5 percent of the Standard Fee Schedules for the procedure codes above
• Belong to a physician organization that meets Blue Cross’ cost-benchmarking criteria can receive an additional 10 percent of the Standard Fee Schedules for the procedure codes above.
• Participate in Provider-Delivered Care Management can receive an additional 5 percent of the Standard Fee Schedules for the procedure codes above and for the following procedure codes:

• G9001-G9002
• 98961-98962
• 98966-98968
• G9007
• 99487
• 99489
• S0257

The total amount of value-based reimbursement depends upon the programs in which the primary care physicians participate and the criteria they meet. For instance, primary care physicians who are PCMH designated, are a member of a physician organization that meets Blue Cross’ cost benchmark criteria, participate in PDCM and perform in the highest tier on measures of clinical quality will receive reimbursement at 140 percent of the Standard Fee Schedules.

The table below summarizes the potential value-based reimbursement available under the VBR Fee Schedule to primary care physicians for the procedure codes indicated above.

Specialists

Specialists in PGIP are also eligible for reimbursement in accordance with the VBR Fee Schedule. Specialists will, depending on their ranking, receive value-based reimbursement at 105 percent or 110 percent of the Standard Fee Schedules for all relative value unit-based procedure codes and the time and base codes. (Relative value unit codes are most procedure codes billed by specialists, except those for ambulance service, durable medical equipment, prosthetics and orthotics, immunizations, hearing, routine vision services, lab, dental and most injections.)

Reimbursement for specialists treating adult members and ranked in the top third will be 110 percent of the Standard Fee Schedules for the codes described above. Those ranked in the second third will receive 105 percent of the Standard Fee Schedules for the codes described above.

Reimbursement for specialists treating primarily pediatric members and ranked in the top half of pediatric practices will be 110 percent of the Standard Fee Schedules for the codes described above. Those ranked in the second half will receive 105 percent of the Standard Fee Schedules for the codes described above.

The tables below illustrate how reimbursement works for specialists in non-pediatric practices and pediatric practices:

Specialists — non-pediatric practices

Note: If fewer than 20 percent of the Blue Cross participating specialists of a particular specialty type are in PGIP, practices ranking in the top two-fifths can receive 110 percent of the standard fee schedule, and practices ranking in the next two-fifths can receive 105 percent of the standard fee schedule.

Specialists — pediatric practices

Blue Cross changing practitioner fees July 1

Blue Cross Blue Shield of Michigan will change practitioner fees, effective with dates of service on or after July 1, 2016. This change applies to 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 2016 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 2015 values.

Changes in resource-based relative values can affect 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 conversion factor used to calculate anesthesia base units for anesthesia procedures will increase and be aligned at $58 throughout Michigan. Also effective July 1, the percentage weight for the QK or QY modifier will be adjusted from 60 percent to 56 percent, and the QX modifier will be adjusted from 40 percent to 44 percent.

We conducted 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 effective July 1 will be available on web-DENIS on 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 allocation (formerly known as the physician organization component) of professional fees remain the same this year.

For more information, contact your provider consultant.

More tips on correct billing for certain drugs

In the March 2016 Record, we gave you tips on how to calculate national drug code units. The additional NDCs listed in the table below are often billed with the incorrect quantities under the medical drug benefit. To ensure that the payment received is what’s expected, make sure you submit the appropriate quantities on claims for all NDCs.

Make sure you share the following information with your biller or billing company.

** Billable units can be found on the injections minimum fee schedule on web-DENIS.

*** To be billed in CTP segment for electronic claims (ANSI 837P).

For more quick tips and general guidelines on proper submissions, please reference the February 2015 Record.

We have changed vendors for Medicare risk adjustment medical record retrievals

Blue Cross Blue Shield of Michigan and Blue Care Network, in partnership with Data Driven Delivery Systems, will use CIOX Health to perform medical record retrieval for risk adjustment services for Medicare Advantage members. This service was previously performed by Inovalon. DDDS will manage the partnership and review and code medical records at sites that don’t permit scanning or copying of records. The retrieval process starts April 2016.

“We’re excited about our alliance with DDDS and CIOX Health,” said Tracy Korczyk, Blue Cross director of performance management and enterprise risk adjustment. “We’re working to minimize disruption at hospitals and provider offices.”

Inovalon will continue serving as the vendor of Blue Cross for in-state Healthcare Effectiveness Data and Information Set, or HEDIS, medical record retrievals for Blue Cross PPO and Medicare Advantage PPO members from March through May each year.

Verisk Health will remain the medical record retrieval vendor for in-state commercial risk adjustment business and continue to partner with other Blue plans for out-of-state risk adjustment and HEDIS chart retrieval services.

Blue Cross and BCN request medical records every year to meet the Centers for Medicare & Medicaid Services’ standards for data submission and coding accuracy, and CMS’ and Health and Human Services’ regulations and quality standards for patient care.

DDDS and CIOX Health, formerly known as Enterprise Consulting Services, or ECS, are contractually bound to preserve the confidentiality of members’ protected health information obtained from medical records, in accordance with the Health Insurance Portability and Accountability Act of 1996.

You won’t need to submit patient-authorized information releases to comply with medical records requests when both the provider and health care plan have a relationship with the patient, and the information relates to this relationship [45 CFR 164.506(c)(4)]. For more information about privacy rules, go to hhs.gov/ocr/privacy.**

If you have any questions, contact one of the following Blue Cross provider outreach consultants:

• Sue Brinich at 313-225-8981
• Tom Rybarczyk at 313-225-0445
• Corinne Vignali at 313-225-7782

DDDS, CIOX Health, Inovalon and Verisk Health are independent companies that do not provide Blue Cross Blue Shield of Michigan products or services.

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

Provider informational forums coming to a town near you

Blue Cross Blue Shield of Michigan and Blue Care Network are coming to you this summer. We’ve scheduled a series of forums focusing on our professional providers across the state. The classes will cover key topics such as:

• Risk, coding and documentation (AM session)
• HEDIS^® updates and Medicare star ratings information (AM session)
• Improving patient satisfaction (AM session)
• Incentive programs (AM session)
• ICD 10 update (AM session)
• Documentation and coding (AM session)
• Telemedicine (PM session)
• Claim attachment enhancement (PM session)
• Provider Inquiry (PM session)
• New products (PM session)
• Clinical edit updates (PM session)

Here’s a schedule of events:

• Classes are scheduled for the entire day. You have the option to register for the entire day, the AM ONLY or the PM ONLY. Lunch is provided for those attending both the AM and PM sessions.
• Registration begins at 7:30 a.m. The AM session begins at 8 a.m. and includes a continental breakfast. The PM session begins at noon.

To register, click on the link next to the event you’d like to attend. If you have questions, contact your provider consultant.

Training classes set for Upper Peninsula

We’ve scheduled facility and professional training classes in Marquette and Houghton this June.

Facility

The full-day facility class will cover such topics as billing tips, web-DENIS and Medicare Advantage, and include plenty of time for questions and answers. It will run from 7:30 a.m. to 5 p.m.

Professional

Classes are scheduled for the entire day. You have the option to register for the entire day, the AM session ONLY or the PM session ONLY. Lunch is provided for those attending both the AM and PM sessions.

Registration begins at 7:30 a.m. The AM session begins at 8 a.m. and includes a continental breakfast. The PM session begins at noon.

The classes will cover key topics such as:

• Risk, coding and documentation (AM session)
• HEDIS^® updates and Medicare star ratings information (AM session)
• Improving patient satisfaction (AM session)
• Incentive programs (AM session)
• ICD 10 update (AM session)
• Documentation and coding (AM session)
• Telemedicine (PM session)
• Claim attachment enhancement (PM session)
• Provider Inquiry (PM session)
• New products (PM session)
• Clinical edit updates (PM session)

Following are the dates of the sessions, the class location and registration information.

To register, click on the appropriate link. Because the AM and PM professional classes might appeal to different personnel, you have the ability to attend BOTH sessions or just the AM or PM session based on your interests.

You’ll receive a confirmation on registering. It’s important that you register so we have an accurate headcount for meals.

For more information, contact your provider consultant.

For residents: Get an early start with credentialing

Practitioners completing their residency this summer are welcome to submit their Blue Cross Blue Shield of Michigan provider enrollment application 60-days before their training completion date. The CAQH ProView application must be completed to begin the credentialing process with Blue Cross.

Visit the CAQH ProView website** for more information.

**Blue Cross Blue Shield of Michigan doesn’t own or control the content of this website.

Reminder: Practitioners, professional groups and facilities that don’t submit claims within a 24-month period could be terminated

The Blue Cross Blue Shield of Michigan and Blue Care Network provider records for practitioners, professional groups and facilities that don’t submit claims to us within a 24-month period will be considered inactive and could be terminated. If a terminated individual or group needs to be reinstated, the provider or group is required to apply to Blue Cross or BCN as a new enrollee and will also need to be credentialed by Blue Cross or BCN.

Message on provider voucher updated

Effective Feb. 17, we no longer use the term PO component on the provider voucher for message Z587. Instead, we say PGIP Allocation.

This update improves the message’s clarity, and it won’t affect the outcome or the timely processing of your claims.

The new message now says:

“WE APPROVED THE APPLICABLE FEE SCHEDULE AMOUNT, OF WHICH [$X.XX] IS THE PGIP ALLOCATION AMOUNT. THE MEMBER’S LIABILITY IS SHOWN ABOVE. (Z587)”

HCPCS and CPT Category III codes added

The Centers for Medicare & Medicaid Services has added 20 HCPCS and nine CPT Category III codes. The new codes are listed below.

Effective date changed for 2 HCPCS codes

These codes are now effective Feb. 5, 2015. They were revised from an erroneous effective date of Jan. 1, 2016:

G0296 — Counseling visit to discuss need for lung cancer screening using low dose CT scan (service is for eligibility determination and shared decision-making)

G0297 — Low dose CT scan for lung cancer screening

CAQH reattesting reminder: Include Type 2 NPI information for each of your affiliated groups

Every three months, the Council for Affordable Quality Healthcare will ask you to reattest your credentialing application to make sure your information is up to date and accurate. Here’s an important reminder about that process:

When reattesting your application with the CAQH, you must include Type 2 NPI information for each provider group you’re affiliated with. If you don’t, you won’t be included in our provider directories for organizations that aren’t listed in your information.

So when you’re reattesting with CAQH, don’t forget to include all Type 2 NPI information for each provider group you’re affiliated with.

Policy update: Percutaneous left atrial appendage closure device

Blue Cross Blue Shield of Michigan and Blue Care Network have updated the medical policy regarding the use of an Food and Drug Administration-approved percutaneous left atrial appendage closure device (e.g., the Watchman™).

The safety and effectiveness of this device for stroke prevention in patients with atrial fibrillation has been established. The policy was effective Jan. 1, 2016.

This procedure (CPT code *0281T) may be performed in the inpatient or outpatient facility setting. The performing physician determines the most appropriate setting, depending on factors such as co-morbidities or the risk of complications.

To read the full medical policy, click here.

Training classes set for Upper Peninsula

We’ve scheduled facility and professional training classes in Marquette and Houghton this June.

Facility

The full-day facility class will cover such topics as billing tips, web-DENIS and Medicare Advantage, and include plenty of time for questions and answers. It will run from 7:30 a.m. to 5 p.m.

Professional

Classes are scheduled for the entire day. You have the option to register for the entire day, the AM session ONLY or the PM session ONLY. Lunch is provided for those attending both the AM and PM sessions.

Registration begins at 7:30 a.m. The AM session begins at 8 a.m. and includes a continental breakfast. The PM session begins at noon.

The classes will cover key topics such as:

• Risk, coding and documentation (AM session)
• HEDIS^® updates and Medicare star ratings information (AM session)
• Improving patient satisfaction (AM session)
• Incentive programs (AM session)
• ICD 10 update (AM session)
• Documentation and coding (AM session)
• Telemedicine (PM session)
• Claim attachment enhancement (PM session)
• Provider Inquiry (PM session)
• New products (PM session)
• Clinical edit updates (PM session)

Following are the dates of the sessions, the class location and registration information.

To register, click on the appropriate link. Because the AM and PM professional classes might appeal to different personnel, you have the ability to attend BOTH sessions or just the AM or PM session based on your interests.

You’ll receive a confirmation on registering. It’s important that you register so we have an accurate headcount for meals.

For more information, contact your provider consultant.

HCPCS and CPT Category III codes added

The Centers for Medicare & Medicaid Services has added 20 HCPCS and nine CPT Category III codes. The new codes are listed below.

Effective date changed for 2 HCPCS codes

These codes are now effective Feb. 5, 2015. They were revised from an erroneous effective date of Jan. 1, 2016:

G0296 — Counseling visit to discuss need for lung cancer screening using low dose CT scan (service is for eligibility determination and shared decision-making)

G0297 — Low dose CT scan for lung cancer screening

Reminder: Register today for annual hospital forum in Frankenmuth

Blue Cross Blue Shield of Michigan invites you to attend the annual hospital morning forum, sponsored by the Benefit Administration Committee. This year’s forum is Tuesday, May 17, 2016.

The event will include information on web-DENIS, BlueCard^®, AIM and Medicare Advantage. The forum starts with an information fair during registration, followed by classroom-style presentations. A lunch featuring Frankenmuth’s famous chicken will be served after the event. Immediately after lunch, from 1 to 2 p.m., there will be optional training on AIM.

To register, click here.

RSVP by clicking the link above by Thursday, May 12. Your response is also an RSVP for lunch.

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

Here is a quick review of our hospital Readmission Audit Program

Blue Cross Blue Shield of Michigan conducts audits for patients readmitted to a hospital within 14 days of a previous discharge. There are two types of readmission audits:

• Desk — The facility submits a patient’s health information record to Blue Cross by secure, electronic media, disc or paper for the review.
• Onsite — The readmission team members are on-site at the facility and review the patient’s record.

Key steps in the readmission audit process:

• At the beginning of the year, the hospital will be notified by mail it’s selected for an audit.
• About 30 days before the audit, the lead auditor will contact you to confirm the audit date and hospital contact information.
• After confirming the audit appointment, you’ll receive the case list of readmissions identified for the audit. Once you’ve receive the case list, no adjustments should be made to the patients’ claims.
• When the audit is complete, the lead auditor will forward a copy of the audit report, which includes the approval and non-approval readmission report, to the designated hospital contacts.
• Decide whether to appeal, or not, and submit your response to Blue Cross.

Hospitals may appeal cases in writing no later than 50 days from the receipt of the audit report. Send your written appeal to:

Utilization Review Appeals
Attn: Rhonda Thomas, Manager
Mail Code 616A
Blue Cross Blue Shield of Michigan
600 E. Lafayette Blvd, Detroit, MI 48226

If your facility decides not to appeal, please send notification within five days of receiving your audit report letter, by fax, to our Utilization Review department at 1-877-276-3920.

For more information, see your online provider manual.

There are radiology authorization updates for PPO commercial, Medicare Advantage

Beginning April 1, 2016, the following authorization process updates will apply for Blue Cross Blue Shield of Michigan PPO commercial and Medicare Advantage radiology patients:

For Radiology Management Program providers:

• You’ll have up to 90 days past the date of service (on or after Jan. 1, 2016) to request retrospective authorizations through AIM Specialty Health. This is a change from the current 60-day timeline. We still encourage providers to obtain an authorization before administering services (this can be confirmed on the AIM Web portal).

For rendering-facility providers:

• You may now request prospective authorization through AIM (by phone or the AIM Web portal) for dates of service on or after April 1, 2016.
• The facility requesting prospective or retrospective authorizations will be responsible for selecting the correct “ordering” provider’s name.

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

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

**Blue Cross Blue Shield of Michigan doesn’t own or control the content of this website.

TheraMatrix to administer PT benefits for active bargaining unit FCA members

Effective March 1, 2016, TheraMatrix will administer outpatient physical therapy benefits for all active bargaining unit FCA members.

The affected group numbers are:

• 82300
• 82400

If you have questions about eligibility, coverage, benefits or the TheraMatrix provider network, call TheraMatrix at 1-888-638-8786 or go to theramatrix.com.**

**Blue Cross Blue Shield of Michigan doesn’t own or control the content of this website.

Claim rejection prevention complete for CPAP humidifiers

Blue Cross Blue Shield of Michigan has made system changes to prevent claim rejections for purchases of humidifiers used with CPAP devices when Medicare Exact Fill or complementary crossover claims are received for secondary payments.

The changes are for claims with dates of service on or after Jan. 1, 2016.

If you have questions, contact your provider consultant.

Covered procedure codes for prosthetic socks

Procedure code L8470 may be covered as a stand-alone item when reported with procedure code L8420. Additionally, procedure code L8480 may be covered as a stand-alone item when reported with procedure code L8430. Below are the procedure codes and what they cover:

• L8420 — Prosthetic sock, multiple ply, below knee, each
• L8430 — Prosthetic sock, multiple ply, above knee, each
• L8470 — Prosthetic sock, single ply, fitting, below knee, each
• L8480 — Prosthetic sock, single ply, fitting, above knee, each

Blue Cross, BCN retain Mobile Medical Examination Services Inc.™ for home health reviews

Blue Cross Blue Shield of Michigan and Blue Care Network will once again retain an independent company to conduct Home Health Reviews, formerly known as in-home assessments, for eligible Blue Cross and BCN Medicare Advantage members. Home Health Reviews began in March and will run through Dec. 31, 2016.

The home health reviews are part of our members’ coverage and are completely voluntary.

Licensed health care professionals from Mobile Medical Examination Services Inc., or MedXM, will provide the personalized Home Health Reviews. These reviews will include a medical history review, brief physical exams and documentation of any existing medical conditions. They won’t replace any care members receive from their physicians. Also, the MedXM health professional can’t access a member’s medical history or write prescriptions.

This type of outreach helps support our members’ health and your ongoing care. It also provides documentation of any current medical conditions, helping to guide our care management programs.

We’ll provide information obtained from these reviews to the Centers for Medicare & Medicaid Services as part of our risk-adjustment initiatives. We’ll also share it with you to support your patient care efforts.

Please place a copy of these reviews in your patients’ medical records. You may also want to encourage patients to schedule an office visit following a Home Health Review to discuss the review with them.

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