Value Partnerships: Focusing on measuring and addressing the patient care experience

Improving patient care has always been a primary goal of Blue Cross Blue Shield of Michigan’s Value Partnerships program. Patients not only want to receive the best health care possible when receiving care at a doctor’s office — they want the best experience when receiving that care.

Value Partnerships has teamed with our Customer Experience department to provide support to physician organizations and their practices to measure and improve the patient care experience. Their efforts include:

• Capabilities built into the Patient-Centered Medical Home Neighbor and Organized Systems of Care programs (e.g., PCMH-N capabilities 4.4, 11.4 and 14.9 and OSC capability 16.6). These are capabilities that support practices in their efforts to measure and improve patient experience of care. Physician Group Incentive Program participating physician organizations and Organized Systems of Care can receive rewards for implementing PCMH-N and OSC capabilities. For more on the capabilities, click here.
  
  
• Michigan Patient Experience of Care, or MiPEC, workgroup — Launched in 2014, the workgroup is a voluntary, statewide collaborative initiative established to help support the measuring, reporting and improving of the patient care experience in a doctor’s practice. The hope is to have one standardized, statewide plan to measure, report and improve patient care experience. MiPEC is led by the Greater Detroit Area Health Council. Blue Cross — through the PGIP — is a participant in the workgroup, along with other Michigan health care plans. Currently, there are 16 participating physician organizations. Others interested in participating have an opportunity to join MiPEC during the recruitment period at the beginning of the year.
  
  
• Patient Care Experience Initiative — Launched by Blue Cross’ Customer Experience as a pilot program in 2015, the goal is to engage practices through physician organizations by using tools designed to identify areas to focus on and take actions for the improvement of the patient care experience. This initiative was designed to address areas for Blue Cross health plan improvements in member experience of care with their doctors based on the 2015 Consumer Assessment of Healthcare Providers and Systems survey. Those areas for improvement included getting care quickly, getting needed care and coordination of care.

Stay tuned because Value Partnerships is also developing other ways to support the measurement and improvement of a patient’s care experience through new PCMH-N and OSC capabilities.

For more information, contact Robin Mitchell, manager, Value Partnerships, at rmitchell@bcbsm.com or 313-448-7015. You can also contact Laurie Latvis, director of Provider Consulting Services, at llatvis@bcbsm.com or 313-225-7778.

Use our new provider manual page to find updates

We want to make it easier for you to get the information you need quickly. That’s why we’re now giving Blue Cross Blue Shield of Michigan manual updates on our new provider page online.

To access updates on the new provider page, follow these easy steps:

1. Go to bcbsm.com and log in as a provider with your ID and password.
2. Click on BCBSM Provider Publications and Resources in the lower right section of the page.
3. Click on Newsletters & Resources.
4. Click on Provider Manuals.

Here’s what you’ll find on the new page:

• Updates to the manuals
  We’ve created a list called BCBSM Provider Manuals Changes for 2016. The list is organized alphabetically by chapter and, within each chapter, changes are summarized by the effective date of the change.
  Use this list if you’ve already read through a chapter and just want to know if there are any recent changes.

• Learn about the manuals
  Here you’ll find tips on how to use the manual and search for the answers you need. This is a great resource if you’re new to using the BCBSM Provider Manuals.

• Access the manuals
  You can also access the BCBSM Provider Manual dashboard and links to the other Blue Cross and BCN provider manuals.

Don’t forget about CTRL + F
In a July Record article we shared how using the Ctrl + F keys on your keyboard can help you search the provider manuals, (Mac computeres use Command + F). Ctrl + F works on any web page or PDF document to help you with a simple keyword search. Give it a try to help you quickly find what you need.

Claim attachment enhancement effective Aug. 5

Starting Aug. 5, 2016, Blue Cross Blue Shield of Michigan will be able to systematically link faxed or mailed required additional documentation to a corresponding professional or institutional electronic claim.

We’re making this enhancement to:

• Improve claims processing for services that always require documentation.
• Prepare for the anticipated federal electronic claim attachment mandate.

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

We’ve shared information about this enhanced process with you over the past couple of months through Record articles in December and May, provider informational forums, Michigan Hospital Networking quarterly meetings and Benefit Action Committee meetings. Here are some of the most commonly asked questions at these meetings:

Frequently asked questions

What is a claim attachment?
A claim attachment is additional documentation (for example, medical records) required by Blue Cross when the supporting medical records are required to determine if the service reported is a covered benefit of the patient’s contract.

How will we know which services always require additional documentation?
The May 2016 Record article on the claim attachment enhancement included a list of services that always require supporting documentation and this list of services will be added to the Claims section of the Blue Cross online provider manuals on Aug. 5, 2016.

What are the electronic requirements to ensure that the required additional documentation is linked to the electronic claim?
The PWK segment (paperwork segment) of the electronic claim (837 transaction) must indicate that medical records are being sent by fax or mail. If the PWK segment doesn’t indicate that additional documentation is being sent — and supporting documentation is required — the service will automatically be rejected for the required documentation.

How do I send the required additional information (medical records) to Blue Cross if I'm reporting the claim electronically?
Attach the medical records to the updated Medical Record Routing Form, which will be posted on the new Forms page on web-DENIS on Aug. 5. Click on the appropriate button at the top of the form to indicate whether the documentation submission relates to a “previously paid or denied claim” or an original electronic claim. Complete the form as required (information regarding completing the form can be found on the first page), print it and use the form as the cover sheet to fax the records to Blue Cross.

How quickly should I send in the required medical records after releasing the electronic claim?
The required additional documentation must be received within seven calendar days of the electronic claim receipt. Release the claim and complete, print and fax the completed Medical Record Routing Form, along with the required medical records totaling 100 pages or less, to 1-866-617-9917. If the medical record documentation totals more than 100 pages, mail the completed routing form and the documentation to the address on the bottom of the form.

What happens when Blue Cross requires additional documentation and the electronic claim doesn't indicate documentation is being sent?
When a service requires additional documentation and the electronic claim doesn't indicate that additional documentation is being sent (by completing the PWK segment), the service will automatically reject, requesting the additional information.

What will occur when Blue Cross requires additional documentation and the faxed or mailed Medical Record Routing Form is not accurately completed (for example, the form is handwritten or the information on the medical record routing form doesn't match the information submitted on the electronic claim)?
In order to link the documentation to the electronic claim, the system must be able to match the following medical record routing data fields with the data submitted on the electronic claim: patient first name, subscriber last name, contract number, date of service and billing NPI. If these data fields are not legible on the Medical Record Routing Form or the data on the form (e.g., contract number, patient first name, subscriber last name, date of service) is different from what was submitted on the electronic claim, linkage can't occur and the service will automatically reject, requesting the additional information.

Can I use the Medical Record Routing Form to submit medical records on a rejected claim?
Yes. In a July 2016 Record article, we explained how the Medical Record Routing Form should be used as a cover sheet when sending supporting medical records to request review of a rejected claim. After the claims attachment enhancement starts on Aug. 5, you’ll choose the appropriate button to indicate the reason the documentation is being sent (e.g., a “previously paid or denied claim” or an “original electronic claim”).

Where can I find additional information regarding how to link documentation to a claim?
Blue Cross offers an online provider training resource through web-DENIS. You can find the resource by following these steps:

• Go to BCBSM Provider Publications and Resources.
• Click on Newsletters and Resources.
• Click on Provider Training.
• Choose the Claim Attachment Process.

Register for AIM Specialty Health Prior Authorization Program webinar

We invite you to take part in the Blue Cross Blue Shield of Michigan and AIM Specialty Health Prior Authorization Program webinar at 10 a.m. Sept. 27, 2016. AIM handles our commercial and Medicare Advantage outpatient PPO prior authorizations for high-tech radiology, echo cardiology and sleep therapy.

This webinar will give you an overview of the AIM prior authorization program, and it will help you understand program enhancements since 2015. Some topics include:

• Impacted groups and services
• How to get and verify authorizations
• Prior authorization guidelines
• How to register on AIM’s provider website
• An overview of AIM's provider website enhancements for verifying authorizations

Click here to register. After registering, you'll receive a confirmation email and instructions for joining the WebEx webinar. Note: WebEx training isn't available on Mac operating systems.

Correction: *17380 considered investigational service

In the July Record billing chart, under the Transgender Services medical policy, procedure code *17380 was listed as a covered service in error.

Procedure code 17380 is considered investigational.

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.

Coding corner: Medical record documentation for COPD and associated respiratory conditions

With the increased specificity required by ICD-10-CM, accurate and detailed medical record documentation is more important than ever. Chronic obstructive pulmonary disease and associated respiratory conditions need to be properly documented in the medical record to support the correct ICD-10-CM diagnosis code.

What is COPD?
Chronic obstructive pulmonary disease is a common and progressive disease that causes airflow from the lungs to be obstructed. Common symptoms include a productive cough, wheezing, shortness of breath and chest tightness. The two main forms of COPD are emphysema and chronic bronchitis. However, many patients with COPD have both emphysema and chronic bronchitis.

What causes COPD?
Smoking tobacco and exposure to tobacco smoke are the leading causes of COPD. According to the Centers for Disease Control and Prevention, smoking also accounts for as many as eight out of 10 COPD-related deaths. However, as many as one out of four people in the U.S. who have COPD never smoked cigarettes. Other causes include long-term exposure to lung irritants such as air pollution, chemical fumes and dust.

Tips to remember

• When coding for COPD, bronchitis (acute, chronic), asthmatic bronchitis (acute, chronic), emphysema and other associated respiratory conditions indicate through coding whether or not the condition is acute, chronic or in acute exacerbation.
• Since COPD-related conditions can be coded in a variety of ways, the final code selection must take into account all the specific details of a patient’s condition, as documented by the health care provider.
• ICD-10-CM code J44.9 (chronic obstructive pulmonary disease, unspecified) should only be used if the type of COPD being treated is not specified in the medical record.
• Always document and code to the highest specificity. For example, if the provider documents “acute bronchitis” or “chronic bronchitis” (both unspecified), then report ICD-10-CM codes J20.9 and J42.0, respectively. However if the provider does not indicate whether the bronchitis is acute or chronic, then the appropriate ICD-10-CM code would be J40 (Bronchitis not specified as acute or chronic).
• When COPD with an acute exacerbation is documented without acute bronchitis, then report ICD-10-CM code J44.1 (chronic obstructive pulmonary disease with acute exacerbation).
• Code J44.0 (chronic obstructive pulmonary disease with acute lower respiratory infection)when the medical record supports acute bronchitis and COPD. Use an additional code to identify the infection.

It’s important to review the ICD-10-CM Coding Guidelines (Chapter 10: Diseases of Respiratory System J00-J99), as well as any instructional notes under the various COPD subcategories and codes in the tabular list of the ICD-10-CM manual to select the correct code. In addition to the codes listed above, you may need to use additional codes to identify current or previous tobacco usage and dependence or other environmental exposure.

Note: ICD-10-CM coding for all conditions should follow coding conventions, chapter specific guidelines and general coding guidelines.

If you have questions or need more information, contact your provider consultant.

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

BlueCard^® connection: Which Blue plan do I contact to request an authorization?

All providers should contact the Blue plan where the member is enrolled to request:

• A required authorization

• Prior approval for any admission, service or treatment plan

When calling the toll-free BlueCard number (1-800-676-2583), you’ll be asked to provide the member’s three-letter alpha prefix found on his or her ID card. This alpha prefix will route you to the member’s home plan.

The first prompt includes information on your patient’s eligibility and benefits. The second prompt provides information on services that require an authorization and the option to initiate the authorization.

The authorization prompt should also be used:

• When a provider requests prior approval for a service or treatment plan that may not be required but is requested by the provider

• To request a retro-authorization or to appeal the plan’s decision or to extend a stay or treatment plan

Plans also make available to all providers the option to initiate an electronic authorization via the Electronic Prior Authorization tool when an electronic authorization is available to providers in their home plan. In Michigan, the Electronic Prior Authorization link is available on our secured provider portal.

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.

Here’s what you need to know about Blue Cross^® Personal Choice PPO

As you read in the April Record, we’re launching an innovative product called Blue Cross Personal Choice PPO.

The product gives members high-quality care and an opportunity for lower out-of-pocket costs when they work through our Organized Systems of Care program. It also offers access to the broader PPO network.

Members began enrolling June 1, with coverage beginning Oct. 1, 2016.

Training opportunities
To make sure you know all you need to know about this new plan, we’re offering a wide range of training opportunities. They include the following initiatives:

• Provider consultants will visit individual practices throughout August and September.
• You can participate in a Personal Choice PPO webinar (details below).
• If you can’t make one of the webinars, you can watch an e-learning video at a time that is convenient for you. Starting in mid-August, you'll be able to access it at brainshark.com/bcbsm/personal-choice-ppo or by going to ereferrals.bcbsm.com, clicking on Blue Cross and then on Blue Cross Personal Choice PPO.

Webinars
Webinars will be held at 10 a.m. or 1 p.m. on Sept. 20, Sept. 28 and Oct. 6. The webinar registration form has been posted on web-DENIS on the Provider Training page and on the e-referral website. You can get more information about the webinars and access the webinar invitation by clicking here or by following these steps:

• Go to ereferrals.bcbsm.com.
• Click on Blue Cross.
• Click on Blue Cross Personal Choice PPO.

 e-referral process
As part of the plan, members who select a primary care doctor who affiliates with a Level 1 OSC and who use other health care providers associated with that OSC receive high-quality, coordinated care at the lowest out-of-pocket cost. Members who have selected a primary care doctor in a Level 1 OSC but who seek services from other doctors and hospitals outside of that OSC will need to seek a referral from their primary care doctor in order to stay at the Level 1 cost share.

An e-referral process has been developed to help manage your referrals electronically. If you already use the e-referral system for your Blue Care Network patients, you already have access to the new Blue Cross Blue Shield of Michigan e-referral system. If e-referral is new to you, here’s how it works:

Requesting access to e-referral

• Go to the Sign Up or Change a User page at ereferrals.bcbsm.com.

Submitting referrals

• Go to ereferrals.bcbsm.com and click on Login.
• Click on BCBSM e-referral.
• Choose Submit Referral from the Referrals/Authorization drop-down menu at the top.
• Fill in all required fields.
• Click Submit.

For more information

• By mid-August, you'll be able to download an e-referral user guide with detailed information about e-referrals for Blue Cross Personal Choice PPO.
• For more information about the product, see the article in the July – August issue of Hospital and Physician Update.
• If you have any additional questions, contact your provider consultant.

Focus on HEDIS^®: Managing patients with high blood pressure

Hypertension is among the most common conditions seen in the primary care setting. If left untreated, it can lead to myocardial infarction, stroke, renal failure and even death.

Controlling your patient’s blood pressure involves more than taking regular blood pressure readings. Encouraging and coaching your patient to adopt healthy lifestyle habits is an important part of both preventing and controlling high blood pressure.

Adequate blood pressure control is defined as:

• Patients age 18 to 59 whose blood pressure was under 140/90
• Patients age 60 to 85 years of age with a diagnosis of diabetes whose blood pressure was less than 140/90
• Patients age 60 to 85 without a diagnosis of diabetes whose blood pressure was less than 150/90

Do not round manual blood pressure readings. Rounding just a few points can make a patient cross the line from controlled to uncontrolled.

Here are several important things to keep in mind when caring for your hypertensive patients:

• To confirm diagnosis of hypertension, a notation of hypertension must appear in the medical record during an outpatient visit on or before June 30 of each year.
  
• Examples of notation include: Hypertension, HTN, High BP, Elevated BP, Borderline HTN, Intermittent HTN, History of HTN, Hypertensive vascular disease, Hyperpiesia or Hyperpiesis.
• A representative blood pressure is the most recent blood pressure reading taken during the measurement year (by Dec. 31) and it occurs after the date of service in which the diagnosis of hypertension occurred. If multiple readings occur in a single visit, the lowest systolic and lowest diastolic is the representative blood pressure and determines blood pressure control.
  
  
• A blood pressure reading must have been taken and documented in the chart during the same visit in which you assessed the patient for hypertension and again at subsequent visits.
  
  
• Self-reported blood pressure readings taken by your patient aren’t considered acceptable for a diagnosis of hypertension.

For diabetic patients:

If lifestyle changes alone aren’t effective in keeping your diabetic patient’s blood pressure controlled, it may be necessary to add anti-hypertensive medications to the patient’s regimen. Best practice for patients who have hypertension associated with diabetes is to initiate pharmacologic anti-hypertensive treatment that includes an angiotensin converting enzyme inhibitor or angiotensin receptor blocker if no specific contraindications.

Be sure to educate your patient about the importance of taking their recommended medications regularly. You should also discuss possible medication side effects.

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

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.

How to bill CPT initial administration codes

Recent Blue Cross Blue Shield of Michigan audits of physician office infusion therapies revealed a need to clarify the correct way to bill Current Procedural Technology initial administration codes.

Only one initial administration code is billable. The CPT manual states: “When administering multiple infusions, injections, or combinations, only one ‘initial’ service code should be reported for a given date, unless protocol requires that two separate IV sites must be used.” The manual also states that “the ‘initial’ code that best describes the key or primary reason for the encounter should always be reported irrespective of the order in which the infusions or injections occur.”

It’s important to remember that the order in which the drug is administered doesn’t determine the initial code. For example, if the primary focus of the encounter is for the administration of chemotherapy, the sequential code should be applied for premeds given before the administration of that same chemotherapy.

For more information about initial code billing, refer to the CPT manual.

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.

Board certification and accreditation required for providers performing sleep studies and polysomnography

In the January 2015 Record, we let you know that TRUST providers need to comply with accreditation requirements for performing sleep studies and polysomnography. We subsequently informed you via web-DENIS that Traditional providers must also comply. We’ve revised the original article to include this additional information and are providing it here for your reference.

Blue Cross Blue Shield of Michigan’s prior authorization requirement for sleep-testing services, effective Feb. 1, 2015, applies only to in-lab sleep testing. However, all sleep testing services for Blue Cross members, whether an in-lab or home sleep test, must be performed and interpreted by a board-certified sleep medicine physician affiliated with an accredited sleep laboratory.

Providers in the TRUST or Traditional networks who don’t meet Blue Cross’ credentialing requirements as outlined below shouldn’t submit sleep study claims for members. This violates our provider agreements, and such claims will be subject to audit and recovery. Providers who continue to submit such claims will be subject to termination of their contracts.

Physician board-certification requirement
Physicians performing or interpreting polysomnography services and portable home sleep testing for Blue Cross members are required to be board-certified in sleep medicine. This requirement was effective April 1, 2010. Physicians who don’t have these credentials may perform the initial evaluation of patients suspected of having a sleep disorder (e.g., physical exam, medical and sleep history, etc.); however, they must refer their patients to board-certified sleep specialists in our networks for all diagnostic sleep studies.

The sleep specialist is the physician responsible for determining and performing the most appropriate test(s) for the patient and obtaining preauthorization when required. It’s important that providers keep their certification information, including expiration dates, current with Blue Cross to be able to submit preauthorization requests and perform such services.

Facility accreditation requirement
As another step in improving the quality and utilization of sleep services, beginning Feb. 1, 2016, all facilities performing polysomnography and home sleep testing for Blue Cross members must be accredited by a Blue Cross-designated accrediting body.

For nonhospital-based sleep laboratories, Blue Cross requires accreditation by the American Academy of Sleep Medicine. Hospital-based sleep testing facilities must be accredited by AASM or an accreditation organization accepted under the participating hospital agreement.

The offices of providers that only interpret polysomnography or other sleep testing results aren’t considered sleep laboratories and wouldn’t qualify for accreditation. To interpret polysomnography or home sleep test, however, the board-certified sleep specialist must be under the supervision of the director of a laboratory meeting Blue Cross accreditation and board-certification requirements.

Note: This accreditation requirement doesn’t change the way Blue Cross contracts with sleep-testing providers nor does it affect the billing location for services provided.

Be sure to follow intravenous solution billing requirements

For physician office infusion therapy, providers must follow the Current Procedural Terminology coding system and Blue Cross Blue Shield of Michigan requirements regarding the billing of IV solutions.

The J-codes for IV solutions are only billable when the infusion is for actual hydration. Any IV solutions used to administer or prepare medication are considered inclusive and not paid separately. IV solutions used to keep the vein open for pre- or post-therapy administration are considered incidental and not paid separately.

Be sure you adhere to these requirements.

Blue Cross updating ClaimsXten™ for fourth-quarter 2016

Blue Cross Blue Shield of Michigan is updating ClaimsXten for the fourth quarter of 2016. This ensures that the most current CPT code updates, Centers for Medicare & Medicaid guidelines, specialty society guidelines and information gathered from industry seminars and publications are being used.

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

Blue Cross members can get vaccines at participating pharmacies starting Oct. 1.

Starting Oct. 1, 2016, Blue Cross Blue Shield of Michigan (non-Medicare) commercial members will have vaccine coverage under their pharmacy benefits plan. This will allow select vaccines to be given at Blue Cross participating pharmacies and billed through the pharmacy claims processing system. This program will cover the same vaccines listed in the Vaccine Affiliation Program.

Below is a list of frequently asked questions.

Can I process Blue Cross members’ vaccines under both their prescription and medical plans?

Yes, but only bill one plan per claim. Both plans require a qualified administrator at a Blue Cross participating pharmacy or medical office give the vaccine.

• Qualified pharmacists giving the vaccine can bill the member’s pharmacy benefits plan or medical plan.
• Participating medical offices giving the vaccine should bill the member’s medical plan.

Note: All medical and pharmacy claims are subject to monitoring.

Who can receive vaccinations at participating retail pharmacies using their prescription drug plan?

Most Blue Cross commercial (non-Medicare) members with prescription drug coverage are eligible. The vaccine will be covered with no cost share to members if their benefits meet the coverage criteria. Note: Not all members are eligible so you’ll need to check the members’ benefits.

• Check to make sure the vaccine is payable under the member’s medical plan or pharmacy benefits
• Check the age requirements for the vaccine. If a member doesn’t meet the age requirement the claim won’t be covered.

Sample Blue Cross membership cards with the pharmacy benefits plan:

MOS     Rx Grp: BCBSMRX1	NASCO     Rx Grp: BCBSMAN

What is the message for rejected pharmacy claims?

The message for rejected pharmacy claims is 70 for Product-Service Not Covered if there is no age requirement.

If the age requirement is not met, the message is 60 for Product-Service Not Covered for patient age.

What vaccines can be processed under the Blue Cross prescription drug plan?

Listed below are the vaccines and age requirements covered under the pharmacy benefits plan.

Note: Members’ coverage for vaccines may vary, so check their benefits to make sure which vaccines are covered.

Can a member get a vaccine before Oct. 1, 2016?

Yes, if the member has vaccine coverage under his or her medical benefits.

How should pharmacy vaccines be billed for Blue Cross commercial members?

The vaccines are billed like any other pharmacy claim:

• Bill the metric quantity administered (for example, bill 0.5 ml; don’t bill quantity of 1)
• Follow state regulations when administering vaccines
• Use the National Council for Prescription Drug Programs format to submit the vaccines

Vaccines must be prescribed by a licensed prescriber or doctor to be covered. Standing physician orders are also acceptable. Pharmacies should refer to Schedule B of the Restated and Amended Preferred Rx Participation Agreement and Traditional Rx Participation Agreement we sent you.

All standard claims should include the following:

Does this new process pertain to Blue Care Network or Medicare Part D members?

No. You should continue to process BCN and Medicare Part D members’ vaccine claims as usual.

What should the pharmacy do if it has Blue Cross vaccine billing issues?
If you have any questions or billing issues, call Express Scripts^® Pharmacy Technical Help Desk at 1-800-922-1557, 24 hours a day, seven days a week.

Here’s what you need to know about Blue Cross^® Personal Choice PPO

As you read in the April Record, we’re launching an innovative product called Blue Cross Personal Choice PPO.

The product gives members high-quality care and an opportunity for lower out-of-pocket costs when they work through our Organized Systems of Care program. It also offers access to the broader PPO network.

Members began enrolling June 1, with coverage beginning Oct. 1, 2016.

Training opportunities
To make sure you know all you need to know about this new plan, we’re offering a wide range of training opportunities. They include the following initiatives:

• Provider consultants will visit individual practices throughout August and September.
• You can participate in a Personal Choice PPO webinar (details below).
• If you can’t make one of the webinars, you can watch an e-learning video at a time that is convenient for you. Starting in mid-August, you'll be able to access it at brainshark.com/bcbsm/personal-choice-ppo or by going to ereferrals.bcbsm.com, clicking on Blue Cross and then on Blue Cross Personal Choice PPO.

Webinars
Webinars will be held at 10 a.m. or 1 p.m. on Sept. 20, Sept. 28 and Oct. 6. The webinar registration form has been posted on web-DENIS on the Provider Training page and on the e-referral website. You can get more information about the webinars and access the webinar invitation by clicking here or by following these steps:

• Go to ereferrals.bcbsm.com.
• Click on Blue Cross.
• Click on Blue Cross Personal Choice PPO.

 e-referral process
As part of the plan, members who select a primary care doctor who affiliates with a Level 1 OSC and who use other health care providers associated with that OSC receive high-quality, coordinated care at the lowest out-of-pocket cost. Members who have selected a primary care doctor in a Level 1 OSC but who seek services from other doctors and hospitals outside of that OSC will need to seek a referral from their primary care doctor in order to stay at the Level 1 cost share.

An e-referral process has been developed to help manage your referrals electronically. If you already use the e-referral system for your Blue Care Network patients, you already have access to the new Blue Cross Blue Shield of Michigan e-referral system. If e-referral is new to you, here’s how it works:

Requesting access to e-referral

• Go to the Sign Up or Change a User page at ereferrals.bcbsm.com.

Submitting referrals

• Go to ereferrals.bcbsm.com and click on Login.
• Click on BCBSM e-referral.
• Choose Submit Referral from the Referrals/Authorization drop-down menu at the top.
• Fill in all required fields.
• Click Submit.

For more information

• By mid-August, you'll be able to download an e-referral user guide with detailed information about e-referrals for Blue Cross Personal Choice PPO.
• For more information about the product, see the article in the July – August issue of Hospital and Physician Update.
• If you have any additional questions, contact your provider consultant.

Blue Cross updating ClaimsXten™ for fourth-quarter 2016

Blue Cross Blue Shield of Michigan is updating ClaimsXten for the fourth quarter of 2016. This ensures that the most current CPT code updates, Centers for Medicare & Medicaid guidelines, specialty society guidelines and information gathered from industry seminars and publications are being used.

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

Collection of copays for ER visits: An important component of benefit management

Blue Cross Blue Shield of Michigan’s hospital participation agreements require that hospitals request payment for copays, deductibles and amounts not paid or expected to be paid by Blue Cross at the time services are provided. An exception to this rule is if a case can be made for a patient’s financial hardship. Hospitals should also have a well-defined copay collection policy.

Collecting copays and deductibles is an important part of Blue Cross’ benefit management strategy — and that of its customers as well — meant to encourage appropriate emergency room usage. Keep in mind that when someone visits the ER, they’re receiving care in one of the most expensive health care settings. And if they visit the ER for a nonemergency condition, they’re not only incurring unnecessary costs, but they’re not availing themselves of the coordinated care their primary care doctor can offer.

Blue Cross recognizes the challenges of collection in an ER environment, but we urge hospitals to make every effort to collect copays and deductibles from patients. Otherwise, members may be inclined to use ERs for nonemergency conditions and hospitals will contribute to their bad debt.

If you have any questions about developing a patient billing and collection policy, talk with your provider consultant.

Providers receive reimbursement for conducting medication reconciliation post-discharge for MA PPO members

As of July 11, 2016, Blue Cross Blue Shield of Michigan is reimbursing health care providers who conduct medication reconciliation during an office visit within 30 days of a hospital discharge for Medicare Advantage PPO members. Medication reconciliation post-discharge is a new Medicare star ratings measure that we announced in the May Record.

Why conduct medication reconciliation?
Hospital admissions are associated with unintentional discontinuation of medications for chronic conditions, and significant changes can occur to a patient’s medication during hospitalization.

Performing a routine medication reconciliation after every discharge is an important step to ensure that medication errors are addressed and that patients understand their new medications, as well as medications that should no longer be taken.

The post-hospitalization follow-up visit provides an opportunity to address the condition that caused the hospitalization and to review the patient’s medications.

How to receive reimbursement for medication reconciliation post-discharge
When Medicare Advantage PPO members are discharged after a hospital stay, schedule a post-discharge office visit as soon as possible and perform medication reconciliation during the visit.

• The outpatient medical record must state that the “current and discharge medications were reconciled.”
• Bill *1111F with the post-discharge office visit claim within 30 days of the discharge.
• Medication reconciliation should be performed after every inpatient discharge.

CPT 2 code *1111F states, “Discharge medications reconciled with the current medication list in outpatient medical record.”

In addition to the office visit, Blue Cross will reimburse providers an additional $10 for billing 1111F within 30 days of a patient’s discharge.

For more information about this measure, refer to the May 2016 Record article, which describes the measure in detail and provides specific documentation requirements.

Here’s some additional information about the Medicare Plus Blue^SM PPO prior authorization expansion

As you read in the July Record, Blue Cross Blue Shield of Michigan will expand its prior authorization program later this year to include three additional types of services for our Medicare Plus Blue^SM PPO members who reside in Michigan and use Michigan providers.

The expansion is intended to eliminate the unnecessary use of certain procedures to improve patient care and manage health care costs. Following are the three additional types of services, the purpose of prior authorization for these services and the effective dates.

Starting Sept. 1, 2016:

• Inpatient and outpatient lumbar spinal fusion surgery — Manage the utilization of spinal fusion surgeries to ensure clinical appropriateness
• Outpatient interventional pain management — Manage the use of outpatient interventional pain procedures, including epidural injections, facet block and radiofrequency ablations, to help eliminate inappropriate delivery of such procedures

Starting Nov. 1, 2016:

• Outpatient radiation oncology — Manage the use of radiation therapy inclusive of modalities, dosing, coding and treatment goals, while reducing expenditures and the patient’s exposure to radiation therapy

EviCore healthcare will administer prior authorization for these services. EviCore is a national specialty benefit management company that focuses on managing quality and individual patients.

To request a prior authorization and to locate the clinical worksheets and CPT code list for the mentioned services:

• Access the eviCore implementation site: https://www.carecorenational.com/page/bcbsm-implementation.aspx, or
• Go to the Blue Cross website at www.bcbsm.com, click on Provider Secured Services, then log in to web-DENIS to find the authorization information.

The clinical worksheets will help guide you with the necessary information to request a prior authorization. The eviCore implementation site also includes Frequently Asked Questions, a Quick Reference Guide, national guidelines and information on webinars that will be available before the start date.

Although the recommended way and quickest way to obtain authorizations is online, you can call eviCore at 1-877-917-2583 (BLUE) to submit requests. If a prior authorization isn’t obtained for the above services, claims will be denied and providers will be responsible for the costs.

EviCore will be sending letters with a schedule of online orientation sessions to affected physician specialties.

We’ll provide more details about these changes in future issues of The Record. We’ll also announce opportunities for training on the prior authorization expansion through web-DENIS broadcast messages.