Haven’t joined PGIP yet? Here’s your chance!

Blue Cross Blue Shield of Michigan health care practitioners can help change the face of health care in Michigan — and earn higher levels of reimbursement — by participating in our Physician Group Incentive Program.

Here’s how it works:

• PGIP rewards physician organizations for improving health care delivery by working with its member practitioners on more than 20 initiatives.
• PGIP practitioners have the opportunity to be reimbursed in accordance with the Value-Based Reimbursement Fee Schedule. The fee schedule reimburses at greater than 100 percent of the standard fee schedules.

Program requirements

Practitioners

To be eligible to participate in PGIP, a practitioner must:

• Participate in the Blue Cross PPO (TRUST network) or Traditional lines of business.
• Be a medical doctor, doctor of osteopathy, doctor of chiropractic or doctor of podiatric medicine. Fully licensed psychologists are also eligible to participate in the program.

Primary and specialty care practitioners must join a PGIP participating physician organization to be eligible for the program.

Currently, there are more than 40 POs throughout the state participating in PGIP. Here’s a current list of PGIP physician organizations. Practitioners should contact a physician organization directly to discuss its specific criteria.

If you’re an individual practitioner with questions, contact your provider consultant. Not sure who your provider consultant is? Visit our Contact Us page to find out.

New physician organizations

To be eligible to join PGIP as a PO, you must:

• Be composed of 75 or more Blue Cross participating practitioners. Fifty of those practitioners must practice as primary care physicians, i.e., internal medicine, pediatrics, family practice or general practice.
• Be able to coordinate and facilitate practice improvements and program administration on behalf of its member practitioners.
• Be a partnership, association, corporation, individual practice association or other legal entity with its own taxpayer identification number.
• Be able to receive and distribute income via electronic fund transfer.
• Have contractual authority to represent your practitioners for this program.

 Applying for consideration as a PO

To participate in the 2017 program year as a new PO, you must submit a completed application by Aug. 31, 2016.

To learn more about PGIP, visit bcbsm.com/providers and valuepartnerships.com.

Physician Group Incentive Program to accept applications for new organized systems of care

We’d like to invite newly formed organized systems of care to apply to become PGIP-contracted OSCs. Applications will be accepted from July 1, 2016, through Aug. 31, 2016. OSCs whose applications are approved will become PGIP-contracted OSCs, effective Dec. 1, 2016.

About OSCs
An organized system of care is a community of caregivers with a shared commitment to quality and cost-effective health care delivery for a specific population. OSCs are responsible for the care and treatment provided to a patient population attributed to the community’s primary care physicians.

OSCs use coordinated care processes to achieve benchmark performance in quality and cost. They identify the populations they serve, tracking and assessing performance and establishing performance goals. Each OSC will work to coordinate services across the health care continuum for a defined patient population.

Why join?
Participating in our Organized Systems of Care program gives you the opportunity to earn financial rewards by participating in initiatives that lead to the development of integrated care processes and an OSC infrastructure. PGIP-contracted OSCs also will be eligible to participate in the new Blue Cross Blue Shield of Michigan tiered Blue Cross^® Personal Choice PPO product that launches late this year.

How to apply
To request the OSC application packet, send an email to valuepartnerships@bcbsm.com.

Here’s what you need to know about the Hospital Blue^SM product and referral process

Some self-funded Michigan hospitals have a specific type of PPO coverage for their employees called Hospital Blue. Hospital Blue allows an employer to create a provider network for his or her employees.

The product consists of three cost-share tiers — domestic, in network (PPO) and out of network (non-PPO). The domestic tier is made up of select providers designated by the hospital employer to process at the tier 1 benefit level. These providers are generally employed by or through the hospital. All PPO participating providers fall into the tier 2 category and non-PPO providers are tier 3.

Under certain circumstances, some of these employers allow their members to go outside of their domestic network for services without a financial penalty. For example, during a medical emergency or if a member needs specialized treatment unavailable within their domestic network. These situations require a Hospital Blue referral form signed by the member’s domestic provider. Currently, a few of the Hospital Blue policies offer this referral benefit.

To get the Hospital Blue referral benefit from a tier 2 or 3 provider, an eligible member would obtain the Hospital Blue referral form and take it to his or her domestic, or tier 1, provider. If the domestic provider agrees to the referral, the Hospital Blue referral form should be completed and signed by the domestic provider. The member then presents the form to the non-domestic provider.

The non-domestic provider should include the domestic provider’s information as the referring physician on any claims submitted for the Hospital Blue member. For paper claims, the information should be submitted in field 17 of a 1500 Health Insurance Claim Form. For electronic claims, the information should be submitted in loop 2310A. This allows claims to process at the correct benefit level when they are initially submitted while reducing the need for reprocessing.

New Medicare star ratings measure: Hospitalization for potentially preventable complications

We want to provide you with information about a new star ratings measure: Hospitalization for potentially preventable complications, also called HPC.

About the measure
The HPC measure evaluates patients age 67 and older with a diagnosis of an ambulatory care-sensitive condition that occurred during an inpatient visit. ACSCs are acute or chronic health conditions that can be managed or treated in an ambulatory setting.

Hospital inpatient data is used to assess the health care system as a whole, evaluating the quality of ambulatory care in preventing medical complications. This provides valuable information in determining how well a system of care helps older adults with chronic and acute conditions.

High rates of hospitalizations for ACSCs could indicate that our Medicare Advantage members aren’t receiving high-quality ambulatory care. Because some complications are unavoidable, members with ambulatory care-sensitive conditions may be hospitalized. Measuring ACSC admissions can provide information for our health care providers that will help them improve outpatient care.

What do providers need to know?
Providers manage and treat patients with ACSCs on an outpatient basis to help them avoid hospitalization. Older adults can develop serious complications as a result of hospitalization.

Access to high-quality care and care coordination, a focus on chronic disease self-management and connection to community resources can reduce the chance that individuals with these chronic and acute conditions will develop complications resulting in hospitalization.

Ambulatory care sensitive conditions included in the measure**

To comply with Centers for Medicare & Medicaid Services star reporting, Blue Cross Blue Shield of Michigan will report MA PPO member hospitalizations for ACSCs in accordance with HEDIS^® specifications.

**Exclusions apply. These include traumatic amputations, cystic fibrosis, congestive heart failure or hypertensive patients with a cardiac procedure or diagnosis of Stage 1 to Stage 4 kidney disease with a dialysis procedure, and patients who reside in a skilled nursing facility for 100 days or more during the measurement year.

Select procedures no longer need preauthorization

This is the first article in a series about procedures no longer needing Blue Cross Blue Shield of Michigan preauthorization.

After June 15, 2016, the following procedures that meet clinical criteria and are covered by the member’s benefits will no longer require preauthorization:

For the list of procedures above, we’ll return preauthorization requests and remind you to check the medical criteria to determine if a patient needs approval.

Cosmetic versus reconstructive surgery:

We define reconstructive surgery as a service that involves the restoration of a patient to his or her normal functional status. It can also be a service to repair a defect arising from illness, traumatic injury or surgery to return the patient’s appearance to its previous state.

Cosmetic surgery is a service performed solely to preserve or enhance appearance or self-esteem. It’s not considered medically necessary. For more information, check out this May 2015 Record article.

How to check web-DENIS for medical criteria:
Check the medical criteria to determine if a patient needs approval before you provide services. Here’s how:

1. Go to bcbsm.com and log in to Provider Secured Services.
2. Click on web-DENIS.
3. Click on BCBSM Provider Publications and Resources.
4. Click on Medical Policy and Pre-cert/Pre-Auth Router.
5. Click Medical Policies.
6. Insert search criteria in Keyword/Phrase and click Search.

Only request medical reviews when cases don’t meet criteria

By submitting the case for a medical review, you have identified the member does not meet criteria. Submit a copy of the patient’s relevant medical records with the letter requesting a medical consultant’s review. The letter should include the specific clinical findings or patient conditions that support medical necessity for the service and why special consideration is justified. We’ll give you our response within 15 days, which begins when we receive your letter along with the documentation for review.

To find routine benefit information
You may obtain benefit information, as well as medical policy and payment policy information, from Benefit Explainer online. To search for this benefit information on web-DENIS:

1. Open the web-DENIS tool.
2. Click Subscriber Info in the left navigation menu, then click Benefit Search. This link takes you to Explainer, our benefit research tool.
3. Click the BPR tab. (BPR stands for Benefit Package Report.)
4. Complete the required search criteria to view benefit policy rules that describe whether a code is payable for a group or member and any limitations that may apply.

To find policy and payment information
If you’re looking for our medical policy and payment policy information, you can find that while you’re already in Explainer:

1. Click the Medical/Payment Policy tab.
2. Complete the required search criteria to view Blue Cross’ general (not group-specific) medical and payment policy rules for a specific time frame.

To search for medical policy and payment policy information when you first log in to web-DENIS:

1. Click on BCBSM Provider Publications and Resources in the left navigation menu.
2. Click on Benefit Policy for a code. This link takes you directly to the Explainer, Medical/Payment Policy tab.

For patients in the groups listed below, call or write for approval of services.

**If criteria aren’t met, submit your request in writing to:

MESSA
1475 Kendale Blvd.
P.O. Box 2560
East Lansing, MI 48826-2560

Reminder: New standardized paper prior authorization form for prescription drugs, coming July 1

Last month, Blue Cross Blue Shield of Michigan announced that beginning July 1, 2016, we will use the new state of Michigan paper prior authorization form. It’ll 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 submit an electronic preauthorization form online located on the Michigan Department of Insurance and Financial Services website: michigan.gov/difs**. Also, you can request the paper form by calling the Pharmacy Clinical Help Desk at 1-800-437-3803 or faxing it to 1-866-601-4425.

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

• The ability to request prior authorizations 24 hours a day, seven days a week at your convenience.
• The convenience of starting a prior authorization, saving it if interrupted and then returning to it later without losing any entered data.
• The 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

Blue Cross Pharmacy Services will soon be sending a short survey about prior authorization forms to prescribers. We greatly appreciate your response.

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

Automated Medicare recovery process being updated

Blue Cross Blue Shield of Michigan is updating its automated Medicare recovery process, effective Sept. 1, 2016.

Blue Cross only pursues recovery of claims that fall within Medicare’s timely filing guidelines of 365 days from the date of service. Currently, Blue Cross recovers claims with dates of service that are within 10 months of the date. Our updated process will recover dates of service within 11 months of the date of the member’s change in eligibility. This change will be effective Sept. 1, 2016.

This doesn’t apply to Medicare Advantage recovery efforts.

The current recovery process is:

• If a recovery is necessary, Blue Cross will create an account receivable for the money due.
• Providers will receive an account receivable notice on their weekly vouchers if recoveries are needed, indicating our intent to recover the claims payments.
• Providers will need to rebill the claims to Medicare within the time frame specified by Medicare to receive the primary payments.
• If necessary, providers can work with their provider consultants to resolve any disputed recoveries.

Note to hospitals: For hospitals receiving weekly Blue Cross interim payments, or BIPs, an Account Receivables Created section will appear on their vouchers and will serve as notification of payment reductions. Reductions should be applied when the account receivable is created, as these adjustments won’t be deducted or reported in the Account Receivables Applied section of future vouchers.

We’ve simplified language in reimbursement addendums for our network agreements

At Blue Cross Blue Shield of Michigan, we’re committed to being clear and simple in our communications to all stakeholders, including our participating health care practitioners. As part of that effort, we’ve revised the language in the reimbursement addendums for the following:

• Blue Cross Practitioner Traditional Participation Agreement, or TRAD Agreement
• TRUST Network Practitioner Affiliation Agreement, or TRUST Agreement
• Local Network Participation Agreement, or Local Network Agreement

These updated addendums don’t reflect any substantive changes to how we reimburse practitioners for covered services provided to members. We’re simply providing a clearer look at our reimbursement policies and methodology. For example, we’ve provided additional detail about a practitioner’s opportunity to participate in our Value Partnerships program and be reimbursed in accordance with the Value-Based Reimbursement Fee Schedule.

To check out the updated addendums, click on the links below. We’ve bolded the areas where the language was updated for your reference:

• Addendum A — Reimbursement policies
• Addendum A — Reimbursement policies TRUST network
• Addendum B — Reimbursement methodology

The revised addendums are being posted on the Provider Enrollment section of bcbsm.com/providers.

Ensure that patients with diabetes have regular screenings for eye and kidney disease

Patients with diabetes require consistent medical care and monitoring to reduce the risk of complications and improve outcomes. Clinical interventions go far beyond glycemic control.

That’s why we were surprised to see the results of a recent analysis of clinical data on Blue Cross Blue Shield of Michigan members with diabetes:

• Thirty percent of diabetic Medicare Advantage PPO members didn’t receive an eye exam in 2015.
• Fifteen percent diabetic Medicare Advantage PPO members didn’t have nephropathy screening in 2015.

As you know, annual screening for eye disease can prevent or delay blindness. And urine microalbumin screens for early renal failure in patients with diabetes and hypertension can identify renal disease several years before it becomes significant enough to cause symptoms and affect management decisions.

What do providers need to do?
Providers should ensure that all diabetic patients have annual screenings for eye and kidney diseases to prevent or delay blindness and end-stage renal disease.

Retinal eye exam
Encourage diabetic patients to get annual eye exams. Ensure that they are referred to an eye care professional (optometrist or ophthalmologist) and let them know you need to receive a copy of the eye exam report. Follow up with the patient at every visit until you receive it.

Nephropathy screening and treatment
The National Kidney Foundation recommends annual microalbumin screening for diabetic patients. When you order an A1c test or other lab tests for your patients, make sure you include a urine microalbumin test.

A visit with a nephrologist or a prescription for an angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker therapy counts as treatment for nephropathy.

Use correct procedure codes when billing
Not all Blue Cross Medicare Advantage PPO members have Blue Cross pharmacy coverage so evidence of treatment with ACE or ARB medications isn’t always available to us. If your diabetic patient is taking an ACE inhibitor or ARB, be sure to include procedure code *4010F on their office visit claims.

If your patient is being treated for renal disease or has been treated by a nephrologist, include procedure code *3066F on their office visit claims. See chart below.

Did you know?... Individuals with diabetes have a two times higher risk of depression than those without diabetes. According to Richard L. Kravitz, M.D., professor of research at the University of California, Davis, “Diabetic patients with depression have more diabetic complications, more adverse long-term outcomes, and don’t engage as actively in self care.”

Coding corner: Best practices for documenting diabetes

With the implementation of ICD-10-CM and coding classification changes, documenting the nuances of diabetes is more important than ever.

Providers either report Type 1 diabetes for patients who don’t produce insulin or Type 2 diabetes for patients who produce insulin but their bodies don’t use it correctly.

To improve documentation and coding practices, it’s essential that medical records provide details on all diabetes-related conditions to the highest level of specificity known.

When documenting diabetes, consider the following:

• Specify whether it’s Type 1 or Type 2 diabetes.
• Is the diabetes due to a condition or a drug? If it’s due to a drug, indicate which one.
• Is this a secondary type of diabetes? If so, what’s the cause?
• Specify when diabetes is gestational.
• Was there an incidence of underdosing or overdosing (poisoning)? For example: Did the patient receive too much or not enough insulin?

How to improve progress notes
Only providers can diagnose a patient’s medical condition, making documentation even more important. Even if a medical coder can recognize the inference of a condition, only what is documented can be coded.

For instance, if a patient has two medical conditions that are linked, then his or her provider needs to document that the conditions are related. This allows coders to use a combination code, which is a single code used to describe two diagnoses (a diagnosis with either an associated manifestation or complication).

Example: Type 1 diabetic mellitus with severe nonproliferative diabetic retinopathy with macula edema

Here are three examples of when a report lacks documentation or doesn’t properly link two conditions:

1. A patient visits his podiatrist for an annual diabetic exam. The podiatrist documents a prescription for new shoes. The assessment shows the patient is instructed to return in one year.

What’s wrong with this documentation?

• The medical coder can’t code the patient’s medical condition as diabetes because the provider didn’t document the patient as being diabetic.

• The annual diabetic exam may have only been for monitoring purposes; it doesn’t prove the patient has the condition.

2. A patient visits his podiatrist for an annual diabetes exam. The podiatrist documents a prescription for new shoes. The assessment shows the patient understands the importance of checking his feet, because his diabetic condition makes his feet prone to other health issues.

What’s wrong with this documentation?

• The provider’s note only states the patient is diabetic.

• The documentation needs to state any linked or additional diagnoses. Peripheral neuropathy maybe suspected based on the prescription for diabetic shoes, but the provider didn’t document that condition.

3. A patient visits his podiatrist for an annual diabetes exam. The podiatrist documents a prescription for new shoes. The assessment shows peripheral neuropathy and that the patient understands the importance of checking his feet, because his diabetic condition makes his feet prone to other health issues.

What’s wrong with this documentation?

• The documentation supports two separate diagnoses; therefore a combination code can’t be used.

• To link two medical conditions together, there needs to be verbiage in the record such as “with,” “due to” or “associated with.”

It’s equally important for everyone involved in the patient’s care to understand the relationship of the conditions found in the progress notes. Documenting the cause and effect of a condition in the medical record provides a complete picture of the patient’s office visit.

The ICD-10 code assignment is crucial in determining the correct reimbursement for these face-to-face encounters and for tracking health care services provided for a diabetic condition.

Requirements for reporting diabetes mellitus and its associated illnesses are located in the ICD-10-CM coding book, “Chapter 4: Endocrine, Nutritional, and Metabolic Diseases (E00 — E89).”

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: Why am I being contacted to provide referring provider information on my claim?

Blue plans may need to contact the referring provider if they require additional information to determine the medical necessity for services reported on your claim. If the referring provider name and national provider identifier aren’t included on your claim, we’ll contact you by phone. Providing the information during the call when it’s available to you will prevent delays in processing your claim.

Although the referring provider name and NPI aren’t required fields on a UB-04 claim form, providing the information when it’s available will assist in processing your claim. The information will also expedite requests for medical records that an out-of-area plan may require to determine the patient’s contracted benefits.

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: Depo^®-Testosterone requires prior authorization

The prescription drug Depo^®-Testosterone requires a medical drug prior authorization for all Blue Cross Blue Shield of Michigan members.

As of July 1, 2015, the following testosterone replacement therapy medications were added to the prior authorization program:

Subscribe to email version of The Record to get information more quickly, easily

It’s come to our attention that some health care practitioners don’t know that they can subscribe to the email version of The Record and have it delivered to whatever email address they provide. It’s easier and faster to subscribe and have the newsletter arrive in your inbox as soon as it’s published.

You can access The Record by clicking on the Our Provider Newsletters tab on bcbsm.com/providers. But we email the newsletter directly to subscribers when we publish it on the last business day of the month before the issue date. For example, the July Record will be released June 30.

To subscribe, go to bcbsm.com/providernews and fill out the required information. You’ll have the opportunity to select your main area of interest (professional, facility, pharmacy, etc.), and that information will be featured at the top of your customized version of the newsletter.

While there, you can also subscribe to The Record’s companion publication, Hospital and Physician Update. This newsletter provides useful information to participating physicians and hospital executives.

Following are other newsletters you can subscribe to on the site:

• BCN Provider News (for information on our HMO products)
• Value Partnerships Update (for participants in the Physician Group Incentive Program)
• Dental Care News

If you encounter any technical difficulties when subscribing, send an email to provcomm@bcbsm.com.

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.

Let patients know that Blue Cross doesn’t cover digital breast tomosynthesis

We continue to receive a large number of member appeals related to digital breast tomosynthesis, also known as 3D mammography.

Be sure to let your patients know that Blue Cross Blue Shield of Michigan doesn’t cover this procedure for its members, with the exception of Medicare Advantage, Federal Employee Program^® and MESSA members. Blue Cross members who choose to have the procedure when it’s not covered should sign a waiver stating that they understand they will be financially responsible for the cost.

Digital breast tomosynthesis uses modified digital mammography equipment to obtain additional radiographic data to reconstruct cross-sectional “slices” of breast tissue. Conventional mammography produces 2D images of the breast.

Blue Cross considers digital breast tomosynthesis experimental for both the screening and diagnosis of breast cancer, and our contracts with providers exclude coverage for experimental services or procedures. Most other plans also consider the procedure to be experimental or investigational.

Keep in mind that if you determine that additional imaging is necessary for a patient, Blue Cross reimburses for other imaging procedures beyond conventional mammography.

We’ll continue to review the policy on digital breast tomosynthesis on an ongoing basis. If the policy changes, we’ll notify you through The Record.

Blue Cross providers can find out whether a procedure is experimental (not a covered benefit) by following these steps:

• Go to bcbsm.com.
• Log in as a provider.
• Click on web-DENIS.
• Click on BCBSM Provider Publications and Resources.
• Click on Provider Manual.
• Go to Benefit Explainer and enter the necessary information.

Here are more tips on correct billing for medical drugs

This is number four in a series of Record articles on how to properly calculate national drug code units.

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 accurate, 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.

For your convenience, here’s a list of all codes that have been identified and sorted by NDC.

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

**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).

None of the information included herein 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 all applicable state and federal laws and regulations.

Reminder: Update your Provider Authorization form when changes occur

Blue Cross Blue Shield of Michigan is dedicated to safeguarding the protected health information of our members. These safeguards include completion of a Trading Partner Agreement and Provider Authorization form as part of the electronic data interchange setup process. All EDI trading partners must complete a TPA and Provider Authorization before they can exchange protected health information electronically with Blue Cross.

Terms of the TPA require you to notify Blue Cross of any changes in your trading partner information. If you switch service bureaus (clearinghouses), software vendors, billing services or the recipient for your 835 files, you must update your Provider Authorization form. Updating the form ensures information is routed to the appropriate destination. You don’t need to update the Provider Authorization if your submitter and Trading Partner IDs don’t change.

Keep the following items in mind when changes occur. You should review your Provider Authorization information if you’ve:

• Joined a new group practice
• Left a group practice and now bill using your own NPI
• Hired a new billing service
• Started submitting claims through a clearinghouse or you’ve changed clearinghouses
• Decided you no longer want to receive 835 remittance files
• Selected a new destination for your 835s

You must update your Provider Authorization if you will send claims using a different submitter ID or route your 835s to a different unique receiver/Trading Partner ID. To make changes to your EDI setup, visit bcbsm.com.

• Click on Quick Links
• Click on Electronic Connectivity (EDI)
• Click on Update your Provider Authorization Form under EDI Agreements.

For questions about EDI enrollment, contact our help desk at 1-800-542-0945. For assistance with TPA and Provider Authorization forms, select the TPA option.

Reporting correct frequency code can prevent your claim from rejecting

With automated processing of replacement, late charge and void claims, you must report the correct bill frequency code for the type of claim you’re submitting. Failure to report the correct bill type and frequency code will result in a denial of your claim.

Here’s a look at the automated types of bills and the frequency codes that should be used:

Applies to reporting facility claims only:

• Late charge claim — Frequency code 5 should be used to report a late charge or charges on a facility claim. Frequency code 5 doesn’t apply to professional claims reporting. A facility late charge represents a service that wasn’t reported on your original claim. Only report the revenue code or codes and any required procedure codes that represent the late charges requested. A late charge claim won’t replace your original claim, but it will adjust your original claim to include payment consideration for the late charges reported.

Applies to reporting professional and facility claims:

• Replacement claim — Frequency code 7 is used when an original claim has been processed but needs to be replaced in its entirety.
• Void or cancellation of a prior claim — Frequency code 8 is used to request that we void your originally paid claim in its entirety.

The following reporting guidelines apply:

• The original claim has to be finalized before a late charge, replacement or void claim is reported.
• Report the 14-digit internal claim number from the original claim on your replacement or void claim. The internal claim number isn’t required on a late charge claim.
• All patient and provider demographics on your replacement, late charge or void claim must be reported exactly as you reported them on your original claim. For example, for a replacement claim (frequency code 7), if your request is to change the patient’s name or the national provider identifier on the claim, you should request a void of the original claim and report the correct patient or provider demographics as a new original claim.  
• If your original claim rejects because of a provider billing error, you can’t correct the claim by using frequency code 7. The rejection will instruct you to report a new original.
• Don’t attach a copy of a claim when submitting medical records to us. Instead, attach any supporting documentation to the Medical Records Routing Form. You can find this form by logging on to web-DENIS and following these steps:
• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters & Resources.
• Click on Clinical Criteria & Resources.
• Click on Medical Records Routing Form under the Clinical criteria section.
• Professional replacement claims can be billed electronically and shouldn’t be reported on a paper 1500 claim form when the original claim was billed electronically. All facility claims must be reported electronically or by using our Internet Claims Tool.  
• A facility claim that was previously reported as an inpatient service can’t be changed to an outpatient claim using a replacement claim (frequency code 7). Request a void of the paid inpatient claim and bill the outpatient claim as a new original.
• Facility providers who choose to report late charges using frequency code 7 — replacing their original claim in its entirety — must be sure to include all the charges for services rendered to the patient and not just the late charges.

For additional information on the automation of facility and professional claims, see previously published Record articles from January 2016 and September 2015.

For more information on claims reporting, see the “Billing and Claims” chapter of the online provider manuals.

If you need information on the status of a claim you submitted, contact Provider Inquiry.

We’re changing the categorization process for physical therapy

Blue Cross Blue Shield of Michigan is changing its categorization process for physical therapy. The changes will be implemented in fall 2016 and will include physical therapy claims from Blue Cross Medicare Advantage PPO and Blue Cross commercial PPO plans. Blue Cross will also be extending the categorization to include outpatient occupational therapy services.

Physical therapists will continue to be assigned to three tiers identified as categories A, B and C. Providers will continue to have 15 days from receipt of their categorization reports to request reconsideration. The categorization will continue to be done by eviCore healthcare. Independent occupational therapists will default to Category B.

Due to the changes in the categorization process, profile reports scheduled for July 2016 will be omitted and replaced with the updated profile reports in September 2016. Going forward, profile reports will be available in October and April, instead of January and July. Notifications will go out to providers Nov. 1 and May 1.

Here’s what you need to know about the Private Duty Nursing Program

Blue Cross Blue Shield of Michigan has created a Private Duty Nursing document to help you understand if you qualify as a private duty nursing provider and how the program works.

The Private Duty Nursing document is available on web-DENIS. Here’s how to find it:

• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters & Resources.
• Click on Clinical Criteria & Resources in the left-hand column.

The document is also linked from our online provider manual for home health agencies in the “Home Health Care Services” chapter, as well as from our hospital outpatient manual in the “Hospital Services” chapter.

Private duty nursing doesn’t cover services provided by, or within the scope of practice of, a medical assistant, nurse’s aide, home health aide or other non-nurse caregivers.

Private duty nursing can be provided to individuals who have this benefit and who have a skilled care need as identified by “InterQual Skilled Nursing” criteria. (Custodial care doesn’t qualify for PDN.) As always, you can check a member’s benefits through Benefit Explainer on web-DENIS.
Private duty nursing is considered medically necessary when specific criteria are met. Criteria include the following:

• The member’s condition requires intense, individualized, continual 24-hour on-site services extending beyond the basic home health care benefit.
• At least eight hours of PDN are required to meet the needs of the patient. (During transition from inpatient to home care, up to 16 hours per day of private duty nursing may be required.)
• At least two trained caregivers (family or friend, etc.) must be trained and competent to give care when the nurse isn’t in attendance.
• The family caregivers must provide at least eight hours of skilled care per day.
• The PDN services must be ordered by an M.D. or D.O. who is involved in the ongoing care of the patient, inclusive of home health certification with the plan of care or treatment plan.
• Private duty nursing services don’t require Blue Cross preauthorization or Blue Cross precertification.
• Continual assessment, observation and monitoring of a complex or fragile clinical condition and hourly documentation of the clinical information and services performed is required.
• Training and teaching activities by the skilled nurse to teach the patient, family or caregivers how to manage the treatment regimen is required and considered a skilled nursing service.
• Criteria and documentation requirements for specific conditions, if present, in addition to the medically complex or fragile condition of the patient, may include:
• Tracheostomy tube suctioning
• Ventilator management and oxygen saturation measuring with hourly observations
• Management of tube drainage, complex wounds and cavities
• Complex medication administration
• Tube feedings that require frequent changes in formulation or administration rate

Refer to the Private Duty Nursing document to view the full set of criteria and rules.

Required billing documentation submission rules
Invoicing and documentation for new private duty nursing patients** is required after the first seven to 10 days of services to ensure that PDN criteria is met. After that, billing should be monthly. Here are other rules:

• Don’t overlap months on the invoice.
• An invoice and notes must be included for the service dates billed.
• Each agency must submit an invoice and notes separately (don’t combine agencies).
• Invoices and medical records or documentation must be submitted in the following order:
• The Private duty nursing submission form must be completed and used as a cover sheet with each monthly invoice. The form is posted on the new Forms page on web-DENIS.
• Invoice — The invoice should include the following:
• Nurse’s name, level of degree and license number. (If not included on the invoice, it should be on a typed form following the invoice.)
• Tax ID and contract number
• Total hours or units for each level of care for each date billed (S9123 for an R.N. and S9124 for an L.P.N. Indicate charge per hour or unit (1 unit = 1 hour) and total charges for each date.
• Current home health certification with plan of care or treatment plan
• Physician’s letter of medical necessity or prescription
• Daily nursing notes with nursing flow sheets (date the notes and place in consecutive order)
• Additional documentation supporting services rendered

Refer to the Private Duty Nursing document for a full list of the criteria. Invoices and records should be mailed to the following address, with the Private duty nursing submission form included as a cover sheet:

Blue Cross Blue Shield of Michigan
P.O. Box 32597
Private Duty Nursing
Detroit, MI 48232-0597

Note: Mailing this information to any other address or omitting any required documentation will result in processing delays (returned invoices) or claim rejections.

** This is a pay-subscriber benefit, which means that benefits are paid directly to the subscriber by Blue Cross. If there are any invoicing or medical record issues, the member will need to assign permission for you to speak to Customer Service on their behalf. Otherwise, the member can call Customer Service directly, using the appropriate number on the back of their Blue Cross ID card.

Home infusion therapy benefit increases length of time subcutaneous immune globulin can be delivered

Blue Cross Blue Shield of Michigan’s home infusion therapy benefit currently allows a seven-day supply of medication and a 10-day supply if there’s a holiday weekend. Blue Cross recently changed the maximum number of supply days of subcutaneous immune globulin to a patient’s home.

Starting Jan. 1, 2016, a two-week supply of subcutaneous immune globulin can be delivered to an established home infusion patient.

However, Blue Cross will require a minimum of four weeks of weekly deliveries for all start-up patients receiving subcutaneous immune globulin. The weekly delivery will continue until there is supporting documentation that the patient has been on subcutaneous immune globulin for all four weeks without interruption from side effects.

In addition, the patient or caregiver needs to be independent from the administration of subcutaneous immune globulin therapy.

The bi-weekly deliveries apply only to subcutaneous immune globulin. The bi-weekly delivery doesn’t apply to any other immunotherapy. Once a patient receives two weeks of subcutaneous immune globulin, later deliveries may be made no sooner than 12 to 14 days after the previous delivery.

Due to the high cost of subcutaneous immune globulin, Blue Cross expects the home infusion therapy providers to perform frequent supply inventory checks with the patient to prevent the stock piling of the drug in the home. This is important for patients who have been hospitalized or have compliance issues with administration.

Specialty drug to be added to Medical Drug Prior Authorization program June 1

Beginning June 1, 2016, an additional specialty drug will require prior authorization by Blue Cross Blue Shield of Michigan before it’s covered under a member’s medical benefits.

Prior authorization is just a clinical review approval, not a guarantee of payment. Providers will need to verify the necessary coverage for this medical benefit.

Starting June 1, 2016, the following drug will need prior authorization:

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

• Click on BCBSM Provider Publications and Resources.
• Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
• Click on Physician administered medications (on the right side under Frequently Used Forms).

We won’t consider a request for coverage until we receive a physician-signed medication request form faxed or mailed to Blue Cross, or a request uploaded onto NovoLogix, an online-based tool. Standard processing time for request review is 15 days. An urgent request can be reviewed within 72 hours.

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

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

Note: The prior authorization requirement doesn’t apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

Reminder: What to do when home infusion therapy catheter care coverage goes on hold

The Blue Cross Blue Shield Michigan home infusion therapy benefit only covers catheter care when the infusion therapy, provided by the home infusion provider, is temporarily placed on hold.

This hold shouldn’t go beyond four weeks. There must be supporting documentation on why the therapy has been suspended and why the central line is being maintained. For example, the patient develops a rash from an antibiotic he or she is receiving. And you’re planning to evaluate the treatment and start a different antibiotic once the rash subsides.

The home infusion therapy benefit for central venous catheter care doesn’t apply when a patient has been discharged from the hospital with a central venous catheter and therapy wasn’t provided in the home setting. The Blue Cross home infusion therapy benefit for catheter care only applies when the home infusion therapy provider provides a therapy that can be later placed on hold. The catheter care ends when the infusion therapy is discontinued.

We’ve also observed that some providers are billing the durable medical equipment benefit for flushes and supplies, while billing the home infusion therapy benefit for catheter care. The DME benefit shouldn’t be billed at the same time as the home infusion therapy benefit for catheter care. The supplies and flushes are part of the catheter care S codes.

Bill FEP dental anesthesia codes on one line

Claims for Federal Employee Program^® members with dental anesthesia procedure codes *D9223 and *D9243 must be billed on one line with the quantity maximum.

FEP will reject the claim lines when multiple claims lines are billed for these procedure codes. If the provider has a quantity of three for either procedure code D9223 or D9243, use one claim line with the procedure code and the numeral “3” in the quantity field.

Home Infusion Therapy claims for FEP Basic Option members need separate lines

Home Infusion Therapy services for Federal Employee Program^® Basic Option members must be billed line by line for each date.

Basic Option members have a per-day copayment. Each date of service must be on a separate line so the system can accurately apply the copayment.

For example, if service dates run from April 1, 2016, through April 5, 2016, each date must have a separate line. April 1, April 2, April 3, April 4 and April 5 should each be on a separate line.

This only applies to Basic Option contracts with enrollment codes 111, 112 and 113.

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 topics such 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.

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 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 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.

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

Let patients know that Blue Cross doesn’t cover digital breast tomosynthesis

We continue to receive a large number of member appeals related to digital breast tomosynthesis, also known as 3D mammography.

Be sure to let your patients know that Blue Cross Blue Shield of Michigan doesn’t cover this procedure for its members, with the exception of Medicare Advantage, Federal Employee Program^® and MESSA members. Blue Cross members who choose to have the procedure when it’s not covered should sign a waiver stating that they understand they will be financially responsible for the cost.

Digital breast tomosynthesis uses modified digital mammography equipment to obtain additional radiographic data to reconstruct cross-sectional “slices” of breast tissue. Conventional mammography produces 2D images of the breast.

Blue Cross considers digital breast tomosynthesis experimental for both the screening and diagnosis of breast cancer, and our contracts with providers exclude coverage for experimental services or procedures. Most other plans also consider the procedure to be experimental or investigational.

Keep in mind that if you determine that additional imaging is necessary for a patient, Blue Cross reimburses for other imaging procedures beyond conventional mammography.

We’ll continue to review the policy on digital breast tomosynthesis on an ongoing basis. If the policy changes, we’ll notify you through The Record.

Blue Cross providers can find out whether a procedure is experimental (not a covered benefit) by following these steps:

• Go to bcbsm.com.
• Log in as a provider.
• Click on web-DENIS.
• Click on BCBSM Provider Publications and Resources.
• Click on Provider Manual.
• Go to Benefit Explainer and enter the necessary information.

Reporting correct frequency code can prevent your claim from rejecting

With automated processing of replacement, late charge and void claims, you must report the correct bill frequency code for the type of claim you’re submitting. Failure to report the correct bill type and frequency code will result in a denial of your claim.

Here’s a look at the automated types of bills and the frequency codes that should be used:

Applies to reporting facility claims only:

• Late charge claim — Frequency code 5 should be used to report a late charge or charges on a facility claim. Frequency code 5 doesn’t apply to professional claims reporting. A facility late charge represents a service that wasn’t reported on your original claim. Only report the revenue code or codes and any required procedure codes that represent the late charges requested. A late charge claim won’t replace your original claim, but it will adjust your original claim to include payment consideration for the late charges reported.

Applies to reporting professional and facility claims:

• Replacement claim — Frequency code 7 is used when an original claim has been processed but needs to be replaced in its entirety.
• Void or cancellation of a prior claim — Frequency code 8 is used to request that we void your originally paid claim in its entirety.

The following reporting guidelines apply:

• The original claim has to be finalized before a late charge, replacement or void claim is reported.
• Report the 14-digit internal claim number from the original claim on your replacement or void claim. The internal claim number isn’t required on a late charge claim.
• All patient and provider demographics on your replacement, late charge or void claim must be reported exactly as you reported them on your original claim. For example, for a replacement claim (frequency code 7), if your request is to change the patient’s name or the national provider identifier on the claim, you should request a void of the original claim and report the correct patient or provider demographics as a new original claim.  
• If your original claim rejects because of a provider billing error, you can’t correct the claim by using frequency code 7. The rejection will instruct you to report a new original.
• Don’t attach a copy of a claim when submitting medical records to us. Instead, attach any supporting documentation to the Medical Records Routing Form. You can find this form by logging on to web-DENIS and following these steps:
• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters & Resources.
• Click on Clinical Criteria & Resources.
• Click on Medical Records Routing Form under the Clinical criteria section.
• Professional replacement claims can be billed electronically and shouldn’t be reported on a paper 1500 claim form when the original claim was billed electronically. All facility claims must be reported electronically or by using our Internet Claims Tool.  
• A facility claim that was previously reported as an inpatient service can’t be changed to an outpatient claim using a replacement claim (frequency code 7). Request a void of the paid inpatient claim and bill the outpatient claim as a new original.
• Facility providers who choose to report late charges using frequency code 7 — replacing their original claim in its entirety — must be sure to include all the charges for services rendered to the patient and not just the late charges.

For additional information on the automation of facility and professional claims, see previously published Record articles from January 2016 and September 2015.

For more information on claims reporting, see the “Billing and Claims” chapter of the online provider manuals.

If you need information on the status of a claim you submitted, contact Provider Inquiry.

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 topics such 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.

Reminder: Supporting documentation must meet criteria for consideration during audit appeals

Blue Cross Blue Shield of Michigan accepts only supporting documentation relevant to a dispute when hospitals appeal audit decisions.

Blue Cross will accept additional information during an appeal process that is “specific to the area of dispute” with “an explanation of its relevance.” Only additional information that meets both criteria will be used in evaluating the disputed adjustment of audited claims.

The additional information will be evaluated against these criteria as part of the internal appeal process. No new information can be provided at the external appeal.

Blue Cross audits hospital claims after payment to ensure accuracy and appropriateness of the claims. A claim that lacks the necessary Blue Cross supporting documentation may be adjusted. Hospitals have the right to appeal these decisions and provide supporting documentation at that time.

Please see Exhibit D of the Participating Hospital Agreement for more information about the appeals process.

Here’s how to handle reporting on claims when Medicare benefits are exhausted

We’re seeing an increase in the volume of incorrectly reported inpatient claims for admissions when a Medicare primary non-Federal Employee Program^® member has exhausted his or her Medicare benefits before, after or during an admission.

Hospitals are required to apply InterQual criteria and prenote in-patient admissions when a patient exhausts Medicare benefits, and Blue Cross Blue Shield of Michigan is billed in full after Medicare days are exhausted.
Here are two scenarios to keep in mind:

1. Medicare benefits are exhausted during an admission.

You’re required to report two separate claims:

• One for the balance after the Medicare payment (coinsurance, deductible and lifetime reserve days).
• One for the days not covered by Medicare.

On the first claim to Blue Cross, report the days you would’ve reported to Medicare for the deductible, coinsurance or lifetime reserve days.

On this second claim, report the days after Medicare is exhausted on the UB-04 as follows:

• Report type of bill as 0111 in form locator 4.
• Report in Statement Covers Period in form locator 6. This is the first day after Medicare is exhausted, through the end of the admission that you’re billing.
• Report the admission date in form locator 12. This is the date that should be the day after Medicare is exhausted.
• Report occurrence code A3 with the date Medicare benefits are exhausted in form locator 31.
• Report value code 01 with room rate and value code B3 with total charges in form locator 39-41.
• Report in form locator 50 with the appropriate Medicare payer code on line “A” and Blue Cross payer code on line “B”.
• Don’t report a Medicare payment in form locator 54.
• This admission must meet InterQual criteria and be prenoted beginning the first day Medicare benefits become exhausted.

2. Medicare benefits are exhausted before admission.

Only one claim is reported to Blue Cross. On this claim, report the entire admission as full days when Medicare is exhausted on the UB-04 as follows:

• Report type of bill as 0111 in form locator 4.
• Report in Statement Covers Period in form locator 6, the dates for the entire admission that you’re billing full days Medicare exhaust.
• Report the admission date in form locator 12. This date should be the day after Medicare is exhausted.
• Report occurrence code A3, with the date Medicare benefits were exhausted, in form Locator 31.
• Report value code 01, with room rate and value code B3 with total charges, in form locator 39-41.
• Report in form locator 50 the appropriate Medicare payer code on line “A” and Blue Cross payer code on line “B.”
• Don’t report a Medicare payment for locator 54.
• This admission must meet InterQual criteria and can be prenoted.

UB-04 claim examples and reporting instructions are available in the “Claims” chapter of the Hospital Inpatient online provider manual.

To access the "Claims" chapter of the online provider manual, log on to web-DENIS and then:

• Click on BCBSM Provider Publications and Resources.
• Click on Provider Manuals (you will connect to Benefit Explainer).
• Click on Provider Type (Inpatient Hospital).
• Choose the Claims Chapter.

For more information on completing the UB-04 claim, follow the instructions in the Uniform Billing Manual. If you don’t have a UB-04 Manual, you can get one through the National Uniform Billing Committee website at nubc.org**.

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

Specialty drug to be added to Medical Drug Prior Authorization program June 1

Beginning June 1, 2016, an additional specialty drug will require prior authorization by Blue Cross Blue Shield of Michigan before it’s covered under a member’s medical benefits.

Prior authorization is just a clinical review approval, not a guarantee of payment. Providers will need to verify the necessary coverage for this medical benefit.

Starting June 1, 2016, the following drug will need prior authorization:

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

• Click on BCBSM Provider Publications and Resources.
• Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
• Click on Physician administered medications (on the right side under Frequently Used Forms).

We won’t consider a request for coverage until we receive a physician-signed medication request form faxed or mailed to Blue Cross, or a request uploaded onto NovoLogix, an online-based tool. Standard processing time for request review is 15 days. An urgent request can be reviewed within 72 hours.

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

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

Note: The prior authorization requirement doesn’t apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

Update: Coverage of home blood glucose monitors

Effective Oct. 1, 2015, home blood glucose monitors with special features (procedure codes E2100 and E2101) are covered when basic coverage criteria are met and the treating physician certifies that the member has a severe visual impairment requiring use of this special monitoring system. We consider severe visual impairment to be a visual acuity of 20/200 or worse in both eyes when corrected.

Code E2101 is also covered for those with impairment of manual dexterity when the basic coverage criteria are met and the treating physician certifies that the member has an impairment of manual dexterity severe enough to require the use of this special monitoring system. Coverage of E2101 for beneficiaries with manual dexterity impairments isn’t dependent upon a visual impairment.

The quantity of test strips (A4253) and lancets (A4259) that are covered depends on the usual medical needs of the member and whether or not the member is being treated with insulin, regardless of his or her diagnostic classification as having Type 1 or Type 2 diabetes mellitus. Coverage of testing supplies is based on the following guidelines**:

• Usual utilization
• For a member who isn’t currently being treated with insulin injections, up to 100 test strips and up to 100 lancets every three months are covered if the basic coverage criteria are met.
• For a member who is currently being treated with insulin injections, up to 300 test strips and up to 300 lancets every three months are covered if basic coverage criteria are met.
• High utilization
• For a member who isn’t currently being treated with insulin injections, more than 100 test strips and more than 100 lancets every three months are covered if criteria a–c below are met.
• For a member who is currently being treated with insulin injections, more than 300 test strips and more than 300 lancets every three months are covered if criteria a-c below are met.

1. Basic coverage criteria for all home glucose monitors and related accessories and supplies are met and each of the following:
• The member has diabetes.
• The member’s physician has concluded that the member or the member’s caregiver has sufficient training using the particular device prescribed as evidenced by providing a prescription for the appropriate supplies and frequency of blood glucose testing.
2. The treating physician has seen the member, evaluated his or her diabetes control within six months before ordering quantities of strips and lancets that exceed the utilization guidelines and has documented in the member’s medical record the specific reason for the additional materials for that particular member.
3. If refills of quantities of supplies that exceed the utilization guidelines are dispensed, there must be documentation in the physician’s records (for example, a specific narrative statement that adequately documents the frequency at which the member is actually testing or a copy of the member’s log) that the member is actually testing at a frequency that corroborates the quantity of supplies that have been dispensed. If the member is regularly using quantities of supplies that exceed the utilization guidelines, new documentation must be present at least every six months.

If neither basic coverage criterion is met, all testing supplies will be denied as not reasonable and necessary. If quantities of test strips or lancets that exceed the utilization guidelines are provided and criteria a–c aren’t met, the amount in excess will be denied as not reasonable and necessary.

Refill requirements

For DMEPOS provided on a recurring basis, billing must be based on prospective, not retrospective use. For DMEPOS products A4233-A4236, A4253, A4256, A4258 and A4259 that are supplied as refills to the original order, suppliers must contact the member before dispensing the refill and not automatically ship on a predetermined basis, even if authorized by the members.

This shall be done to ensure that the refilled item remains reasonable and necessary, existing supplies are approaching exhaustion and to confirm any changes or modifications to the order.

Contact with the member or designee regarding refills must take place no sooner than 14 calendar days before the delivery and shipping date. For delivery of refills, the supplier must deliver the DMEPOS product no sooner than 10 calendar days before the end of usage for the current product. This is regardless of which delivery method is utilized. (CMS Program Integrity Manual, Internet-Only Manual, CMS Pub. 100-08, Chapter 5, Section 5.2.6.)

For all DMEPOS items that are provided on a recurring basis, suppliers are required to have contact with the member, caregiver or designee before dispensing a new supply of items. Suppliers must not deliver refills without a refill request from a member. Items delivered without a valid, documented refill request will be denied as not reasonable and necessary.

Suppliers must not dispense a quantity of supplies exceeding a member’s expected utilization. Suppliers must stay attuned to changed or atypical utilization patterns on the part of their clients. Suppliers must verify with the ordering physicians that any changed or atypical utilization is warranted. Regardless of utilization, a supplier must not dispense more than a three-month quantity at a time.

For all glucose monitors and related accessories and supplies, if the basic coverage criteria aren’t met, the items will be denied as not reasonable and necessary**.

**These guidelines don’t apply to MESSA.

Reminder: Documentation requirements for recurring durable medical equipment, prosthetic, orthotics and medical supply needs

For all durable medical equipment, prosthetic, orthotics and medical supply items that are provided on a recurring basis, suppliers must contact the member, caregiver or designee before dispensing a new supply of items. Suppliers must not deliver refills without a refill request from a member. Items delivered without a valid, documented refill request will be denied as not reasonable and necessary.

Suppliers must not dispense a quantity of supplies exceeding a member’s expected use. Suppliers must be aware of changed or unusual use patterns on the part of their clients. Suppliers must verify with ordering physicians that any changed or unusual use is necessary. Regardless of use, a supplier must not dispense more than the approved monthly allowed quantity at a time.

Documentation requirements

A new prescription isn’t required for routine refill during a valid 12 month period. A new prescription is needed when:

• There’s a change of supplier.
• There’s a change in treating physician.
• There’s a change in the items, frequency of use or amount prescribed.
• There’s a change in the length of need or a previously established length of need expires.
• State law requires a prescription renewal.

For items the patient obtains in person at a retail store, the signed delivery slip or copy of itemized sales receipt is sufficient documentation of a request for refill.

For items delivered to the patient, documentation of a request for refill must be either a written document received from the member or a written record of a phone conversation or contact between the supplier and member. The refill request must occur and be documented before shipment. A past documentation statement by the supplier or member isn’t sufficient.

The refill record must include:

• The member’s name or authorized representative if different than the member.
• A description of each item being requested.
• The date of the refill request.
• The quantity of each item the member still has remaining.

This information must be kept on file and be available upon request.

Reminder: 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.

This process is for Blue Cross Blue Shield of Michigan members residing in Michigan using Michigan providers for post-acute care services.

Process change
For dates of service on or after June 1, 2016, hospitals 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.

The fax form is located on the eviCore implementation site for Blue Cross**, along with a list of frequently asked questions. The fax number is 1-844-407-5293. Program and training information is located on the implementation site under Provider Resources.

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.

Web orientation sessions
To attend an online Web orientation session, you need to register in advance. Each session is free and will last around one hour. The orientation sessions, which continue in June, are below.

• 8 a.m. Wednesday, June 1
• Noon Thursday, June 2
• 4 p.m. Friday, June 3
• 4 p.m. Tuesday, June 7
• 8 a.m. Wednesday, June 8
• Noon Friday, June 10

All session times are Eastern time. Note: WebEx may display Central time.

For complete instructions on training for the new process, click here.

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

Here are guidelines for treating patients with rheumatoid arthritis

It’s important for providers to follow national guidelines when treating patients diagnosed with rheumatoid arthritis, or RA, to prevent long-term damage and disability. Review of clinical quality data from Blue Cross Blue Shield of Michigan revealed that 20 percent of Blue Cross Medicare Advantage PPO members with RA aren’t being treated properly with Disease Modifying Antirheumatic Drug, or DMARD, therapy.

Why DMARD therapy?
Several major studies documented the benefits of early aggressive treatment for RA. DMARD therapy increases the quality of life more effectively than other treatment strategies.

The American College of Rheumatology recommends that all RA patients be prescribed a DMARD regardless of how active or severe their RA is. Appropriate DMARD treatment can reduce a patient’s disability potential by more than 60 percent.

According to the American College of Rheumatology, correctly diagnosed RA patients should be treated with a DMARD unless indicated otherwise. Once an RA diagnosis has been made, ensure all RA patients are treated according to accepted clinical practice guidelines.

They must receive at least one DMARD prescription each year and be referred to a rheumatologist. Keep in mind that patients receiving a DMARD should be regularly monitored for early detection and management of adverse events that are associated with a specific drug or biologic agent.

Please remember formulary enhancements have been made for DMARD therapy. These include the removal of prior authorization requirements for Humira^® and Enbrel^®, and that there is a lower member cost share for three other DMARD drugs. Refer to the article “Anti-rheumatic drug benefit changes for Medicare Plus Blue^SM and Prescription Blue^SM PDP members” in the October 2015 issue of The Record for more information.

Ensuring accurate diagnosis and coding
Members’ claims for RA are sometimes coded inaccurately when they have joint pain or other signs and symptoms that require workup. A claim for RA shouldn’t be submitted unless it’s a confirmed diagnosis. Note that ICD-10 coding guidelines state:

• Don’t code diagnoses that are probable, suspected, questionable, rule-out, working diagnosis or similar terms indicating uncertainty. Code conditions to the highest degree of certainty for the encounter such as symptoms, signs, abnormal test results or other reason for the visit.
• Codes that describe symptoms and signs as opposed to diagnoses are acceptable for reporting purposes when a related definitive diagnosis hasn’t been established (confirmed) by the provider.

Joint pain or arthritis isn’t always considered rheumatoid arthritis. The clinical criteria for RA are chronic inflammatory disorder for more than six weeks with four of the following symptoms:

• Affecting three or more joints
• Erosion showing on X-ray of joints
• Metacarpophalangeal, or MCP, and proximal interphalangeal, or PIP, joint involvement
• Morning stiffness
• Positive test results for cyclic citrullinated peptide, or CCP, or rheumatology factor, or RF
• Rheumatoid nodules
• Symmetrical joint pain

Chronic Condition Management Program has new remote monitoring services vendor

Blue Cross Blue Shield of Michigan’s Chronic Condition Management Program will be using a new vendor — AMC Health — for remote monitoring services for our Medicare Advantage PPO members, beginning July 1, 2016.

AMC Health’s TeleCare Management program will provide remote monitoring services to qualifying Medicare Advantage PPO members who’ve been diagnosed with chronic obstructive pulmonary disease, chronic heart failure and diabetes.

The contract with our current vendor, Alere, ends June 30, 2016. Alere delivered a chronic condition management program by phone, as well as remote monitoring services to members diagnosed with chronic obstructive pulmonary disease, or COPD, congestive heart failure, coronary artery disease or diabetes. The chronic condition management program provided by Alere will transition to Blue Cross’ Chronic Condition Management Program. This program is available for Medicare Advantage PPO members with CHF, COPD, CAD and diabetes effective May 1, 2016.

AMC Health’s remote monitoring program is similar to Alere’s program, but has some key distinctions and enhancements compared to Alere’s remote monitoring intervention.

The new vendor’s benefits include:

• COPD intervention, including monitoring of controller adherence and frequency of rescue inhaler use
• Blood pressure monitoring for patients with CHF and diabetes patients

AMC Health won’t be monitoring patients with coronary artery disease at this time.

Did you know?... Patients with chronic conditions often suffer from depression. In fact, more than 80 percent of patients with depression have a medical comorbidity, according to the Institute for Clinical Systems Improvement. That’s why depression screening and considering a referral to a behavioral health specialist are two approaches often taken by primary care physicians to improve a patient’s overall care.