Claim attachment enhancement coming in August

As we wrote in the December 2015 Record, Blue Cross Blue Shield of Michigan will be enhancing its claims processing systems to systematically link faxed or mailed additional documentation to a corresponding professional or institutional electronic claim.

This enhancement, effective Aug. 5, will allow us to process your claim, along with the documentation, more quickly. It will also help us prepare for the anticipated electronic claim attachment federal mandate.

Blue Care Network, Federal Employee Program^®, Medicare Advantage and BlueCard^® claims are excluded from these changes. However, FEP will participate in the use of the Medical Record Routing Form.

What’s a claim attachment?
A claim attachment is additional documentation (e.g., medical records) that Blue Cross requires when there's a need to determine if the service reported is a covered benefit. Although the required additional documentation can't be sent as part of or within an electronic claim (the 837 transaction), Blue Cross can accept the documentation by fax or mail.

Blue Cross requires additional documentation for the following:

• Individual consideration procedure codes. Examples include surgical notes or detailed descriptions.
• Not-otherwise-classified procedure codes. Provide additional documentation when the procedure code description data element (Loop 2400 SV101-7/SV202-7) of the electronic claim only provides a partial explanation of procedure performed.
• Procedure code with modifier 22. Requires documentation to describe increased procedural services when the work performed is substantially greater than typically required.
• Procedure code with modifier 62. Requires documentation to describe when two surgeons work together as primary surgeons performing distinct parts of a procedure.
• Procedure code with modifier 66. Requires documentation to describe the collaboration of more than two surgeons for team surgery (surgical report).
• Air ambulance. Includes procedure codes A0424, A0430, A0431, A0435 and A0436; requires the ambulance run report and medical records that support the need for air transport versus ground transport.
• Hearing claims with modifier SC: Medically necessary service or supply requires support documentation regarding the service provided.
• Cosmetic service claims: Some procedures may be considered either cosmetic or reconstructive based on the indications for surgery; additional documentation is required to support the statement of medical necessity that justifies the surgery as reconstructive.

To ensure your additional documentation is linked to your claim:

• The electronic claim (837 transaction) should indicate that medical records are being sent. This is accomplished through the use of the PWK segment, or paperwork segment. If the electronic claim doesn’t indicate that additional documentation is being sent, the service will automatically be rejected.
• The documentation must be received within seven days of the electronic claim receipt. If the medical records aren't received within seven days, the service will be rejected.
• The updated Medical Record Routing Form must be used as the cover sheet for the additional documentation being faxed or mailed to us. The updated form includes the required information needed to link the additional documentation with your electronic claim in our system. The revised form will also continue to be used when submitting medical records to request review of a previously paid or denied claim. Following is an example of a completed original electronic claim form:

• Be sure to type in the required information on the form and print it so that claim attachments are linked to your claim. The information shouldn't be handwritten. Also, a paper claim should never be included with the form and documentation. When using the form to submit additional information required for a claim, choose the option on the form that states that the documentation is for an original electronic claim. The claim information provided on the Medical Record Routing Form must match the information you sent in the original electronic claim. Including:
• Patient information — the patient’s first name, subscriber’s last name and contract number. The number must begin with a three-digit alpha prefix or be an FEP contract number (R with eight digits).
• Date of service — If the service date includes a range of dates, use the first date of service.
• Billing NPI — This is the 10-digit national provider identifier of the health care provider that’s doing the billing.
• Patient control number — Either the patient account number or the claim number assigned by the billing submitter’s practice management system (maximum length of 20 characters). This should be provided, if available, but isn’t required.
• Attachment control number — This is the billing submitter’s unique document identification number; it should be different than the patient control number (maximum length of 50 characters). This should be provided, if available, but isn’t required.

Information regarding this enhancement will be shared at the upcoming provider informational forums. For more information on the forums, see the following two articles, also in this issue.

• Reminder: Provider informational forums coming to a city near you
• Reminder: Provider informational forums set for Upper Peninsula

Once the enhancement occurs, an online provider training resource will be added to web-DENIS. We’ll also include more information about this new capability in a future issue of The Record, and the online provider manuals will be updated to include a list of services that always require additional information.

Thanks to your feedback, we’ve improved Blue Cross provider manuals

We’ve updated the Blue Cross Blue Shield of Michigan provider manuals to make information easier to find and use. The changes are based on suggestions from providers who participated in provider manual usability testing or the provider manual survey in 2015.

Here are the changes:

• Several chapters have been combined:
• The “Blue Distinction Centers for Specialty Care” chapter has been folded into the “Value Partnerships” chapter.
• The “Best Practices” chapter has been folded into the “Medical-Surgical Services” chapter.
• The “Cardiac Rehabilitation Services” chapter has been folded into the “Hospital Services” chapter of the Outpatient Hospital manual.
• The “Problem Resolution” chapter has been folded into the “Appeals” chapter, which was renamed “Appeals and Problem Resolution.”
• The “ID Card” chapter has been folded into the “Patient Eligibility” chapter.

• The chapters have been reorganized into what we hope is a more logical and usable sequence:

• Most frequently accessed:
• Introduction
• Blue Pages Directory
• Claims
• Valid Modifiers
• Patient Eligibility
• Preapproval of Services
• Appeals and Problem Resolution
• Documentation Guidelines

• Provider-specific chapters (services) in alphabetical order
  (This includes “Physician Office Lab List” and “Radiology Management Program Procedure Codes” where applicable.)
  
  
• Supporting chapters:
• Audits and Other Post-Service Reviews
• Blue Cross Health and Wellness
• BlueCard Program
• Blue Preferred Plus
• Coordination of Benefits
• Exclusive Provider Organization
• General Limitations and Exclusions
• Participation
• Patient Copayment and Deductible Requirements
• PPO Policies
• Value Partnerships (where applicable)

What do you think?
If you have suggestions for making Blue Cross provider manuals easier to use, let us know. You can contact us at ProviderManuals@bcbsm.com.

Here’s a new, quick way to access our provider manuals, publications and resources online

We’re making it easier for you to find the information you need on Provider Secured Services. When you log in to your provider account on bcbsm.com, you’ll see new hyperlinks on the provider home page that will quickly take you to important information.

You may already be familiar with a blue box located on the right side of the screen. The box features hyperlinks to the current issues of Blue Cross Blue Shield of Michigan and Blue Care Network provider newsletters. Now we’ve added more hyperlinks directly below the box that you may find helpful.

These new hyperlinks are:

• BCBSM Provider Publications and Resources
  
  This online resource has Blue Cross fee schedules, the Blue Cross provider manuals, pharmacy forms, newsletter archives and many additional resources, such as provider training and clinical criteria.

• BCN Provider Publications and Resources
  
  This online resource has information on Blue Care Network billing, authorizations and referrals, the BCN provider manual, forms, learning opportunities and many other resources.

• Provider Manuals
  
  This is a new page that links to all four of the Blue Cross and BCN provider manuals for medical providers. It’s a one-stop shop to find information on guidelines for claims submission, authorization requests, appeals and many other topics. Just select the manual you need according to the patient’s coverage: Blue Cross, BCN, Blue Cross Medicare Plus Blue^SM PPO or Blue Cross Complete.

These Web pages are also still available within web-DENIS, but now you can find hyperlinks on the Provider Secured Services home screen that will save you time.

New Medicare star ratings measure: Medication reconciliation post-discharge

We want to let you know about the medical record documentation requirements for a new star ratings measure: Medication reconciliation post-discharge.

About the measure
The measure assesses patients age 18 and older who were discharged from an acute or non-acute inpatient stay between Jan. 1 and Dec. 1 of the measurement year. It looks at patients whose medications were reconciled from the date of discharge through 30 days after discharge (31 days total).

What is medication reconciliation?
Medication reconciliation is a review in which the discharge medications are reconciled with the most recent medication list in the outpatient record. It helps prevent adverse drug reactions and other medication-related issues that can occur after hospitalization. Medication reconciliation should be conducted by a prescribing practitioner, clinical pharmacist or registered nurse.

Medical record documentation requirements
Health care providers must meet certain criteria when documenting evidence of medication reconciliation in Medicare patients’ medical records for the reconciliation to count toward this measure. Documentation in the medical record must include evidence of medication reconciliation and the date it was performed. Any of the following meets documentation criteria:

• A note from the provider that current and discharge medications were reconciled
• The current medication list with a notation that references the discharge medications (for example, no changes in medication since discharge, same medications at discharge, discontinue all discharge medications)
• Current medication list with a notation that the discharge medications were reviewed
• Documentation of a current medication list, a discharge medication list and notation that both lists were reviewed on the same date of service
• Notation that no medications were prescribed or ordered upon discharge

Only documentation in the outpatient chart meets the intent of the measure; an outpatient visit isn’t required. Medication reconciliation can also be done by phone.

Improving quality performance

• Talk to your patients about the importance of maintaining an accurate and up-to-date record of all active medications. Medications can often change between settings and the list of medications can be inaccurate or outdated.
• Encourage your patients to keep a copy of the updated medication list and bring it to all appointments. A comprehensive list of medications should include all prescription medications, herbal supplements, vitamins, nutritional supplements, over-the-counter drugs, vaccines, diagnostic and contrast agents, radioactive medications, parenteral nutrition, blood derivatives and intravenous solutions.
• Explain to your patients that this reconciliation is done to avoid medication errors as they relate to such matters as duplications, omissions, dose, timing and adverse drug interactions.
• Establish a process asking patients to bring their medication bottles, including all over-the-counter preparations, to every health care encounter.
• A computer order entry system should be used when possible. It reduces errors and confusion caused by illegible handwriting.
• The updated hospital medication list and discharge instructions are printed for education and review with the patient before he or she leaves the hospital. Request the medication list to better assist in your review and update of the chart during post-discharge medication reconciliation.
• Always include medication reconciliation in your post-discharge visit note, whether you see your patient during an outpatient visit or you review medications over the phone with your patient.

Using correct procedure codes
CPT codes must be billed on the same date of service.

Note: CPT coding guidelines must be followed. Refer to detailed coding guidelines for the codes *99495 and *99496.

Here’s some new information about CMS training on compliance, fraud, waste and abuse

As we’ve told you before, the Centers for Medicare & Medicaid Services requires that health care providers who provide services for patients with Medicare must complete annual compliance, fraud, waste and abuse training.

What’s new
We’ve recently learned that the only way for providers to generate a certificate of completion for this year’s annual compliance training is to take it using the modules available at the Medicare Learning Network.

To fulfill the requirements for compliance training and generate a certificate of completion, you must do the following:

1. Click to open the Medicare Learning Network^® (MLN) Learning Management System.
   
   
2. Log in. (If you’re a first-time user, you must create an account.)
   
   
3. Complete the following two training modules:
   
• Medicare Parts C and D General Compliance Training
• Combating Medicare Parts C and D Fraud, Waste and Abuse
4. Generate a certificate of completion for each module.

Each employee, contractor, volunteer, governing body member or downstream entity that provides health or administrative services for Medicare Advantage must have a certificate of completion on file from each training section (fraud, waste and abuse training and general compliance training; two certificates in total).

Your staff must complete the training within 90 days of hire or contract and annually thereafter.

Exception
If you’re enrolled in Medicare Parts A or B, you’re “deemed” to have satisfied the fraud, waste and abuse training requirement and you're not required to take additional fraud, waste and abuse training. However, you must still complete the general compliance training section and maintain a certificate as evidence of training completion.

Alternative training option
Providers who wish to use their own training program must incorporate the content from both the Medicare Parts C and D Fraud, Waste and Abuse Training and the Medicare Parts C and D General Compliance Training modules into their training materials without any changes. Regardless of the training option you choose, the certificates of completion you generate or other evidence of training completion must be kept on file for 10 years following the expiration of the contract.

Background
As a reminder, CMS requires Medicare Plus Blue^SM, which receives payment from Medicare, to implement an effective general compliance program. To satisfy CMS guidelines, this program must meet the minimum requirements established by federal statutes that pertain to Medicare Parts C & D. According to these guidelines, providers are required by CMS to take CMS-specific training about fraud, waste, abuse and compliance.

Look for new standardized paper prior authorization form, coming July 1

On July 1, 2016, Blue Cross Blue Shield of Michigan will begin using the new State of Michigan paper prior authorization form. It will help standardize the way doctors and insurers request and receive prior authorizations for prescription drug benefits.

Michigan Public Act 30 of 2013 amended the insurance code to require the creation of a single prior authorization form for use by health providers when a patient’s health plan requires prior authorization for prescription drug benefits.

This law applies to Blue Cross commercial members only, not Medicare members or drugs provided under the medical benefit. Also, a different process will be used for Blue Care Network and Medicare Part D members.

Prescribers can either submit an electronic preauthorization form online or request the paper form by calling the Clinical Help Desk at 1-800-437-3803.

Electronic submission
Blue Cross includes electronic prior authorization forms on bcbsm.com/providers for commercial members. Submitting electronically offers many advantages, including the following:

• Ability to request prior authorizations 24 hours a day, seven days a week at your convenience
• Convenience of starting a prior authorization, saving it if interrupted and then returning to it later without losing any entered data
• Elimination of the need to wait on hold, make multiple calls or deal with multiple faxes relating to drug prior authorization requests
• The ability of prescribers to look up the status of a drug prior authorization request.

New standardized paper submission
The new paper form doesn’t include all information that may be needed for a review or determination. However, the new law allows insurers to request additional information, including the following:

• Diagnosis
• Chart notes
• Lab information
• Genetic tests
• Information necessary for the approval of the prior authorization request under plan criteria
• Drug-specific information, including medication history, duration and treatment use

Coding corner: Best practices for documenting peripheral vascular disease and deep vein thrombosis

Delivering high-quality treatment and care to members is a high priority for Blue Cross Blue Shield of Michigan. And proper clinical documentation is crucial, as it ensures complete, consistent and accurate information about a patient encounter. For all medical conditions, including vascular disease, it’s necessary to follow the ICD-10-CM guidelines before assigning the appropriate code.

About vascular disease
Vascular disease is an abnormal condition of the blood cells and includes conditions affecting the circulatory system. The vascular system is the body’s network of blood vessels. It includes the arteries, veins and capillaries that carry blood to and from the heart.

Deep vein thrombosis
Deep vein thrombosis, or DVT, is a condition that occurs when a blood clot forms in one or more of the deep veins in your body — most often in the legs. DVT can develop if you have risk factors, keep legs fully flexed or haven’t moved for long periods of time, such as when traveling or bedridden.

DVT can develop if you have certain medical conditions that affect how your blood clots. It can be a serious condition because blood clots in your veins can break loose, travel through your blood stream and potentially lodge in your lungs, causing a pulmonary embolism. Use the following guidelines when documenting DVT:

• Code assignment is based solely on the provider’s specific description of the condition in the medical record.
• Code only confirmed cases of acute or current or chronic DVT using category I82.4 –.
• The condition in the medical record should be identified as acute or chronic:
  • I82.401 — Acute embolism and thrombosis of unspecified deep veins of right lower extremity
  • I82.501 — Chronic embolism and thrombosis of unspecified deep veins of right lower extremity
• A specific anatomic site where the thrombus is located should be identified (for example, right, left, bilateral, femoral vein, iliac vein, popliteal vein, tibial vein or other specified):
• I82.491 — Acute embolism and thrombosis of other specified deep vein of right lower extremity
• I82.702 — Chronic embolism and thrombosis of other specified deep vein of left upper extremity
• When DVT is completely resolved and the provider documentation indicates past history of DVT, assign a personal history code:
• Z86.718 — Personal history of other venous thrombosis and embolism
• Medical coders shouldn’t assign a code for DVT if the patient doesn’t have the condition.

Pulmonary embolism
An embolus is a blood clot that can occur in the veins of a body part, most commonly the legs. Emboli can dislodge and travel to other organs in the body. A pulmonary embolism is a clot that lodges in the lungs, blocking the pulmonary arteries and reducing blood flow to the lungs and heart. Document pulmonary embolisms as:

• I26.929 — Saddle embolus of pulmonary artery without acute cor pulmonale. Other pulmonary embolism without acute cor pulmonale
• This code includes acute pulmonary embolism and pulmonary embolism NOS.

Peripheral vascular disease
“Peripheral vascular disease” and “peripheral artery disease” are two terms used interchangeably. Provider progress notes may reference a physical exam of the lower extremity pulses or the ankle-brachial index, also known as ABI. Supporting documentation may also consist of claudication, pain, cramping or wounds that aren’t healing. Treatment may include anti-platelet medications, a walking exercise plan or surgical interventions. PVD is coded as:

• I73.9 — Peripheral vascular disease, unspecified

Tobacco use, diabetes, obesity, cardiovascular disease, hypertension, hyper lipidemia and physical inactivity are a few examples of risk factors and should also be clearly documented when present. When PVD is a manifestation of diabetes, it’s important the documentation ties the conditions together; assigning the correct combination code is equally important. Review the route below to find the proper diagnosis code using the ICD-10-CM:

• Locate the term “disease.”
• Locate the sub-term “vascular.”
• Under the sub-term, locate “peripheral.”
• In “diabetes mellitus,” see E08 to E13 with .51.

When coding conditions of the circulatory system, it’s important to review all documentation and follow the ICD-10-CM guidelines before assigning the appropriate code.

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.

BlueCard^® connection: Are Blue Cross providers contracted to treat members of other Blue plans?

As a Blue Cross Blue Shield of Michigan participating health care provider, you’re contracted for services you bill through Blue Cross for members enrolled in other Blue plans.

Blue Cross’ contracted services and policies include:

• Timely filing
• Claims reporting
• Reimbursement
• Not balance-billing a patient for an amount more than Blue Cross Blue Shield of Michigan allows for a service covered under the patient’s home plan

For Tennessee Medicaid members whose plan prefix is ZEC, all providers are required by the State of Tennessee to register with TennCare. Unregistered providers won’t be reimbursed for services reported for TennCare patients.

If you need assistance with a claim for a patient enrolled in another Blue plan, including Medicare crossover, ancillary claims or air ambulance claims, contact our Provider Inquiry department. The representative in Michigan can assist you and will work with the patient’s home plan on your behalf when necessary.

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.

Clarification: BCN’s telemedicine policy

In previous issues of The Record, we’ve written about our policy for reimbursing health care providers for telemedicine services. We’d like to clarify what Blue Care Network provider types are eligible for reimbursement.

BCN’s medical policy provides coverage for certain telemedicine services. The policy applies to both commercial members and BCN Advantage^SM. (Online visits billed with *99444 are not covered for BCN Advantage.)

Telemedicine visits include voice-only or audio-visual communication and must take place at an originating site; for example, a doctor’s office. Eligible providers may include: M.D.s, D.O.s, certified nurse midwives, clinical nurse practitioners, clinical psychologists, clinical social workers, physician assistants and licensed professional counselors.

For more details on BCN’s telemedicine policy, see this article in the March - April issue of BCN Provider News.

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.

Case Management Program helps your patients with complex needs

Blue Cross Blue Shield of Michigan works hard to develop programs that help our members manage their health care conditions while controlling health care costs. One such program is the Case Management Program. Designed to support the doctor-patient relationship, it provides our members who have difficult-to-manage conditions with additional resources.

Note: This program doesn’t apply to MESSA members.

As a Blue Cross participating practitioner, you can play a key role in educating and referring members with complex health needs to our program. Here’s what you need to know:

• Your patients with Blue Cross insurance need to determine if they’re eligible for this type of service. One way they can do that is by calling the Customer Service number on the back of their ID card.
• You can refer Blue Cross members to our complex case management program by calling 1-800-845-5982.

In addition to your referrals, we identify members who may benefit from case management through:

• Health information telephone referrals
• Our disease management program
• Information from discharge planners
• Our utilization management program
• Information from the member or caregiver

How it works
Our nurse case managers assess the member’s situation and develop a care plan that includes the member, caregiver, doctor and specialists. The plan incorporates:

• The member’s goals
• Actions to help them achieve their goals
• Progress monitoring

Blue Cross tracks the outcomes of our Case Management Program on a quarterly basis and reports results annually. We’re proud of our program’s achievements on several key measures, based on 2015 data. Here are two examples:

• Members with diabetes who participate in our program closed the HbA1c testing gap.
• Members with heart failure, coronary artery disease or diabetes who participate in our program received LDL testing.

This year, we’re focused on making improvements on the following measure: Connecting members discharged from an inpatient admission with a practitioner within seven days of discharge.

This measure is important to ensuring that at-risk members receive the care and services they need to get and stay healthy. We appreciate your support in helping us achieve this goal. If you have any questions about this program, contact our provider consultant.

Surveys show satisfaction with Blue Cross stays about the same

Overall satisfaction with Blue Cross Blue Shield of Michigan remains about the same as it was in 2013, according to the recently released results of the 2015 Physician Office Staff Satisfaction Study and the Hospital Patient Account Manager Satisfaction Study.

The physician office staff survey was conducted in November 2015, while the hospital survey was conducted from Oct. 26 through Dec. 16, 2015. An independent research firm, DSS Research, administered the surveys.

Here are highlights of the survey findings:

Physician staff

• Overall satisfaction with Blue Cross (77 percent) is on par with 2013 levels, but trails Priority Health and Medicare.
• Satisfaction with web-DENIS has improved significantly from 2013 (from 64 percent to 68 percent). Satisfaction with ease of submitting BlueCard^® claims also improved.
• Blue Cross has improved its score for resolving major claims accurately within 30 days but still lags behind HAP, Medicare and Priority Health.

Hospital administrators

• There has been directional improvement in overall satisfaction since 2013.
• At least three-quarters of hospital administrators are satisfied with the overall quality of service, the ease of doing business and their overall relationship with Blue Cross.
• There was directional improvement for Blue Care Network overall, from 57 percent to 67 percent.

Challenges to address
The surveys showed we have work to do in the following areas:

• Ease of reaching Provider Inquiry representatives by phone
• Ease of understanding payment rules
• Ease of resubmitting problem claims, accuracy of payment and timeliness of payments
• Accuracy of BlueCard claims payments
• Access to and experience with provider consultants

As we develop initiatives to improve provider satisfaction with Blue Cross, we’ll share details in The Record.

InterQual 2016 criteria delayed

InterQual^® 2016 criteria for all levels of care have been delayed.

As published in the Feb. 23, 2016, issue of The Journal of the American Medical Association, McKesson Health Solutions announced it’s incorporating some new criteria on sepsis. As a result, the publication and mailing of the acute hospital, skilled nursing, rehabilitation and long-term acute levels of care criteria books, as well as the home health care electronic criteria, will occur later than usual.

The new criteria are expected to be available before Blue Cross Blue Shield of Michigan implements the new criteria on Aug. 1, 2016.

Keep your profile up to date: Atlas Systems will help collect information

As one of our network providers, you’re required to keep your practice’s provider information records updated. Having correct information for the Blue Cross Blue Shield of Michigan and Blue Care Network provider directories is also helpful to our members — your patients — when they’re looking for care.

To help you, we’ve contracted with Atlas Systems to work with enrolled provider groups. Atlas Systems will be contacting professional providers periodically across the state via mail, phone and fax. Gathering provider information is required by the Centers for Medicare & Medicaid Services.

Please respond to their requests, even if you have no changes. If you don’t respond, it could result in termination from our network. Also, continue to make enrollment changes through CAQH. Providers are required to re-attest through CAQH every 90 days, using ProView.

Beacon Health helps members schedule doctor visits

On March 1, 2016, Beacon Health Options, the UAW Trust’s behavioral health manager, began helping members schedule visits with a primary care physician. Visiting a primary care physician after discharge from a behavioral health facility plays a big role in keeping members healthy while ensuring their care is coordinated.

If a patient has been admitted to a behavioral health facility, your office may be contacted by a Beacon Health representative to set up an appointment for that patient following discharge. If you have any questions about this process, call Beacon Health at 1-877-228-3912.

Ford Motor Company hourly employees to participate in Medical Drug Prior Authorization Program

Beginning July 1, 2016, Ford Motor Company hourly employees group will participate in the Medical Drug Prior Authorization Program. Keep in mind that the prior authorization requirement does not apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

The list below reflects all medications that are part of the Medical Drug Prior Authorization Program in alphabetical order:

Blue Cross setting new quantity limits for Enbrel^®, Humira^®, Actemra^® and Cimzia^®

On June 1, 2016, Blue Cross Blue Shield of Michigan will implement new quantity limits for the following drugs:

**Starter packs are limited to a maximum of two packages per year.

The quantity limits only affect our commercial (non-Medicare) members who have Blue Cross pharmacy benefits that include quantity limits. They don’t apply to MESSA members.

If necessary, you can request an override of the quantity limits for your patients. The request should include documentation stating that the amount prescribed is medically necessary. To get a form for a quantity limit override, log in as a provider at bcbsm.com or call the Pharmacy Services Clinical Help Desk at 1-800-437-3803.

Our goal is to provide our members with safe, high-quality prescription drug therapies. Enbrel^®, Humira^®, Actemra^® and Cimzia^® are high-cost specialty medications. To help our members maintain lower premiums, we’re attempting to limit waste or overutilization of expensive medications. The quantity limits align with dosing guidelines approved by the U.S. Food and Drug Administration to minimize potentially unsafe drug use by our members.

We sent letters in April to notify members who may be affected by these quantity limit changes. The letters encourage members to discuss treatment options with their physicians.

If you have any questions about this program, call the Pharmacy Services Clinical Help Desk at 1-800-437-3803.

More tips on billing correctly for certain medical drugs

During the previous two issues of The Record, we’ve offered tips on how to calculate national drug code units. We’re offering some additional tips this month.

The national drug codes listed in the table below are often billed with the incorrect quantities under the medical drug benefit. To help ensure that the payment you receive is what you’re expecting, submit the appropriate quantities for all NDCs. See the far right column in the chart below for the appropriate NDC quantity for the following drugs.

Share the following information with your biller or billing company.

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

*** For billing purposes, these quantities should be entered into the CTP segment for electronic claims (ANSI 837P).

See the April 2016 Record for tips on submitting electronic claims. For tips on submitting paper claims, see the February 2015 Record.

Note: We highly recommend billing electronically for faster claims processing.

Reminder: Follow billing guidelines when purchasing or administering medical drugs

When professional health care providers purchase and administer a medical drug for a Blue Cross Blue Shield of Michigan member, they should bill for both the drug and its administration. They should only bill the national drug code on the drug’s service line. The code shouldn’t be placed on the administration service line.

See the example below:

When professional providers administer a drug they didn’t purchase, they should bill for the administration code only and not include an NDC code.

See the example below:

For additional information on billing, refer to the online provider manual.

Reminder: We’ve changed vendors for Medicare risk adjustment medical record retrievals

Blue Cross Blue Shield of Michigan and Blue Care Network, working with Data Driven Delivery Systems, will use CIOX Health/Enterprise Consulting Solutions, or ECS, to perform medical record retrieval for risk adjustment services for Michigan Medicare Advantage members. This service was previously performed by Inovalon.

DDDS will review and code medical records at sites that don’t permit scanning or copying of records. The retrieval process started in April 2016.

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

**HEDIS is a registered trademark of the National Committee for Quality Assurance.

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

Reminder: Provider informational forums coming to a city 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 such key topics 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 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.

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

Reminder: Provider informational forums 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, 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 of registering 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. For professional classes, you have the option of attending for the entire day, the AM session or the PM session.

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.

Surveys show satisfaction with Blue Cross stays about the same

Overall satisfaction with Blue Cross Blue Shield of Michigan remains about the same as it was in 2013, according to the recently released results of the 2015 Physician Office Staff Satisfaction Study and the Hospital Patient Account Manager Satisfaction Study.

The physician office staff survey was conducted in November 2015, while the hospital survey was conducted from Oct. 26 through Dec. 16, 2015. An independent research firm, DSS Research, administered the surveys.

Here are highlights of the survey findings:

Physician staff

• Overall satisfaction with Blue Cross (77 percent) is on par with 2013 levels, but trails Priority Health and Medicare.
• Satisfaction with web-DENIS has improved significantly from 2013 (from 64 percent to 68 percent). Satisfaction with ease of submitting BlueCard^® claims also improved.
• Blue Cross has improved its score for resolving major claims accurately within 30 days but still lags behind HAP, Medicare and Priority Health.

Hospital administrators

• There has been directional improvement in overall satisfaction since 2013.
• At least three-quarters of hospital administrators are satisfied with the overall quality of service, the ease of doing business and their overall relationship with Blue Cross.
• There was directional improvement for Blue Care Network overall, from 57 percent to 67 percent.

Challenges to address
The surveys showed we have work to do in the following areas:

• Ease of reaching Provider Inquiry representatives by phone
• Ease of understanding payment rules
• Ease of resubmitting problem claims, accuracy of payment and timeliness of payments
• Accuracy of BlueCard claims payments
• Access to and experience with provider consultants

As we develop initiatives to improve provider satisfaction with Blue Cross, we’ll share details in The Record.

InterQual 2016 criteria delayed

InterQual^® 2016 criteria for all levels of care have been delayed.

As published in the Feb. 23, 2016, issue of The Journal of the American Medical Association, McKesson Health Solutions announced it’s incorporating some new criteria on sepsis. As a result, the publication and mailing of the acute hospital, skilled nursing, rehabilitation and long-term acute levels of care criteria books, as well as the home health care electronic criteria, will occur later than usual.

The new criteria are expected to be available before Blue Cross Blue Shield of Michigan implements the new criteria on Aug. 1, 2016.

Reminder: We’ve changed vendors for Medicare risk adjustment medical record retrievals

Blue Cross Blue Shield of Michigan and Blue Care Network, working with Data Driven Delivery Systems, will use CIOX Health/Enterprise Consulting Solutions, or ECS, to perform medical record retrieval for risk adjustment services for Michigan Medicare Advantage members. This service was previously performed by Inovalon.

DDDS will review and code medical records at sites that don’t permit scanning or copying of records. The retrieval process started in April 2016.

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

**HEDIS is a registered trademark of the National Committee for Quality Assurance.

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

Reminder: Provider informational forums 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, 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 of registering 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. For professional classes, you have the option of attending for the entire day, the AM session or the PM session.

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.

Resolving your issues: Do I call or do I write?

In the August 2015 Record, we ran an article on this topic aimed at professional providers. We’ve repurposed the article for our facility providers.

We’re committed to resolving your inquiries as soon as possible and making it easier for you to do business with us. That’s why we want to let you know that many of your inquiries can be handled more quickly and efficiently by calling Provider Inquiry rather than by writing to us.

When you need to write
To improve your service experience, beginning May 1, 2016, we’ll only process written inquiries for the following reasons:

• Preauthorizations for Blue Cross Blue Shield of Michigan members. (For more details, see the June 2012 article on requesting medical reviews.)
• If you have 10 or more claims regarding the same issue. This includes refund requests.

When you can call
Below is a list of inquiries that will be handled by phone (list isn’t all-inclusive):

• Benefit and eligibility questions that can’t be answered by PARS
• Duplicate rejections
• Benefit rejections
• Incorrect claim rejections
• Precertification rejections
• BlueCard rejections that don’t require medical documentation
• Provider affiliation rejections
• Claims processed after Medicare has paid or rejected
• Issues related to quantities billed (e.g., number of procedures, amount of drugs)
• In- or out-of-network payments
• Refund requests
• Requests for additional payment
• Payment discrepancies
• Questions regarding patient benefits and claims
• COB claim inquiries

A provider service representative will review your claim and determine how to best resolve the issue. If the issue requires further investigation, the representative will document your concerns and forward your inquiry for review and resolution.

Here’s how to keep home health care records in tip-top shape

Our auditors review home health care facility documentation to verify services billed. They check for whether:

• Services were actually performed, billed and paid correctly.
• Care was reasonable and medically necessary.

Here’s a checklist for ensuring that your home health care records are correct and provide us with the information we need:

• Complete documentation as soon as possible after your visit or observation of the patient.
• Use legible handwriting on documents.
• Sign and date documents according to Blue Cross’ requirements.
• Be sure that patient records contain:
• Patient identification information
• The patient’s homebound status
• Signed and dated physician orders
• Pertinent medical and social history
• Physical assessment and medication reports
• Plan of treatment, care and evaluation
• Visit notes for all services provided with documentation to support the InterQual^® criteria application
• Ensure that treatment plans:
• Specify the particular service order
• Are signed and dated by the ordering physician within the patient’s certification recertification period
• Document verbal orders from the physician for changes in the plan of care. They must be documented, signed and dated on the date they are received.

None of the information in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with applicable state and federal laws and regulations.

Reminder: 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.

The event will include information on web-DENIS, BlueCard^®, AIM and Medicare Advantage. If you have any other agenda topic suggestions, please include them in your registration and we’ll attempt to address them at the forum.

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 presentations. Immediately following lunch, from 1 to 2 p.m., there will be optional training on AIM.

To register, click here.

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

Reminder: ClaimsXten tracking outpatient facility quantity reporting

Effective April 25, 2016, ClaimsXten began determining the clinically recommended daily quantity allowance for specific outpatient facility services.

Quantity reporting is the total number of times a specific procedure code is considered to be clinically appropriate to perform on a single date of service for the same patient.

When reporting services with a quantity greater than one, make sure the total charge reflects the total number of times a service was performed. If a procedure is billed for more than the clinically recommended daily allowance, the charge will be divided by the quantity billed and processed accordingly.

Ford Motor Company hourly employees to participate in Medical Drug Prior Authorization Program

Beginning July 1, 2016, Ford Motor Company hourly employees group will participate in the Medical Drug Prior Authorization Program. Keep in mind that the prior authorization requirement does not apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

The list below reflects all medications that are part of the Medical Drug Prior Authorization Program in alphabetical order:

Blue Cross setting new quantity limits for Enbrel^®, Humira^®, Actemra^® and Cimzia^®

On June 1, 2016, Blue Cross Blue Shield of Michigan will implement new quantity limits for the following drugs:

**Starter packs are limited to a maximum of two packages per year.

The quantity limits only affect our commercial (non-Medicare) members who have Blue Cross pharmacy benefits that include quantity limits. They don’t apply to MESSA members.

If necessary, you can request an override of the quantity limits for your patients. The request should include documentation stating that the amount prescribed is medically necessary. To get a form for a quantity limit override, log in as a provider at bcbsm.com or call the Pharmacy Services Clinical Help Desk at 1-800-437-3803.

Our goal is to provide our members with safe, high-quality prescription drug therapies. Enbrel^®, Humira^®, Actemra^® and Cimzia^® are high-cost specialty medications. To help our members maintain lower premiums, we’re attempting to limit waste or overutilization of expensive medications. The quantity limits align with dosing guidelines approved by the U.S. Food and Drug Administration to minimize potentially unsafe drug use by our members.

We sent letters in April to notify members who may be affected by these quantity limit changes. The letters encourage members to discuss treatment options with their physicians.

If you have any questions about this program, call the Pharmacy Services Clinical Help Desk at 1-800-437-3803.

Medicare Plus Blue^SM post-acute care prior authorization process changing June 1

Effective June 1, 2016, prior authorization for inpatient admissions to skilled nursing facilities, long-term, acute care facilities and inpatient rehabilitation facilities for Medicare Plus Blue members will be handled by eviCore healthcare.

EviCore healthcare is a national specialty benefit management company that focuses on managing quality and use for individual patients.

Note: This process is for Blue Cross Blue Shield of Michigan providers and members for post-acute care services provided in Michigan.

For dates of service on or after June 1, 2016, providers will need to contact eviCore at 1-877-917-2583 (BLUE) to request prior authorization for skilled nursing facility, long-term acute care or inpatient rehabilitation facility admissions. EviCore healthcare will authorize the admission and length of stay.

Any admissions that takes place before June 1 will be handled according to the current process.

In the case that a prior authorization request is denied, you’ll have an opportunity for a peer-to-peer conversation. If you have any questions, contact your provider consultant.

Training on the new process will be announced on web-DENIS soon.

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

Medicare Plus Blue^SM has sent letters to health care providers regarding overpayment for services provided to Medicare Plus Blue members. As soon as overpayments are identified, we attempt to recover by reducing other payments.

For unpaid balances over 90 days we will attempt to collect the balance due by reducing current claims payments based on your tax identification number or though a collection agency. Also, under federal regulations, we may be required to report this issue to the Centers for Medicare & Medicaid Services.

If you have outstanding balances that exceed 90 days, and would prefer to pay by check rather than through claims offset, send a refund check, made payable to Medicare Plus Blue, within 30 days to:

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

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

To review our recovery and provider disputes process in more detail, visit our Overpayment page on bcbsm.com/providers.

If you have questions about this policy, contact your provider consultant.