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October 2016

All Providers

BCBSM Provider Manuals search tool is easier to use

To make information easier for you to find and use, we've made some changes to Benefit Explainer's BCBSM Provider Manuals search tool. The changes are a result of suggestions from providers who participated in provider manual usability testing in 2015 as well as those who participated in the 2015 provider manual survey.

One of the changes is the ability to set a provider type as a favorite so that each time you open the provider manuals in Benefit Explainer, your chosen provider type appears in the dashboard.

Here’s how to set a favorite provider type:

  1. Log in to Benefit Explainer.
  2. Click the BCBSM Provider Manuals tab.
  3. Click the Provider Type link on the dashboard.
  4. Click Make Selection within the Search for Provider Type dialog box.

1

  1. Clicking the star to the left of the provider type that you selected ensures that every time you open Benefit Explainer from now on (or until you choose a new favorite provider type), that provider type will be populated in the dashboard.

1

  1. After you click the star, you’ll see a message in green below the dashboard that reads: “Selected provider type has been updated as your favorite provider type.”

3

  1. Set all of your other search criteria in the dashboard and then click the Search button.

What do you think?
If you have additional thoughts on what would make the Blue Cross provider manuals easier to use, please let us know. You can contact us at providermanuals@bcbsm.com.


Do you know about the Provider Enrollment and Change Self-Service tool?

Our Provider Enrollment and Change Self-Service tool makes it easier for professional group administrators to update group information and enroll new practitioners within their group.

Some of the benefits include:

  • The application is electronic and makes it easy to keep your group records up to date.
  • Your enrollment and change requests will be processed more quickly.
  • Your data remains secure.

Transactions that can be performed with the self-service application include:

  • Group location maintenance — Update your practice, remittance information and mailing addresses
  • Networks and demographics: Update your name, tax information and network participation
  • Terminate groups: Terminate groups and remove them from our active rosters
  • Group practitioner management: Enroll new practitioners and add or remove practitioners from your groups

Want to register?

Click here to access a flier on the Provider Enrollment and Change Self-Service tool, detailing the benefits and steps to register for it.


New mobile app for members helps improve productivity and patient experience

Blue Cross Blue Shield of Michigan’s new mobile app, which conveniently connects our members securely to their health care plan information from their smartphones, can help your office run more smoothly and improve patient satisfaction ratings.

Ask them to tap the app
When Blue Cross members are at your reception desk and don’t have their member ID card or don’t know their copayment, deductible or prescription information, you can tell them how to access the Blue Cross app. Then patients have their information readily available during office visits.

Using their smartphones, patients can:

  • Download the Blue Cross app from the Apple App Store® or Google Play™ using key word BCBSM**
  • Create an account to gain access to medical information

The ID card feature on the app allows your patients to look up and confirm details such as:

  • Contract and group number
  • Customer Service numbers
  • Copayments for office, urgent care and emergency room

No electronic health records?
No problem. The app also gives members full and instant access to their previous claims, including procedure codes so you can update records at point of service rather than having to follow up later with phone calls and letters.

It also helps you:

  • Save time by eliminating the need to look up phone numbers or call Provider Inquiry
  • Refer patients to providers and their contact information through the app's Find a Doctor search option
  • Improve your patients’ experiences by keeping them informed and in control of their medical information
  • Boost your Blue Cross quality ratings by encouraging patients to use the app to endorse your excellent service

Check it out

See what our mobile app can do at bcbsm.com/app.

**The app isn’t available for tablets yet and only available on certain operating systems.


Here’s what you need to know to enroll in our retail health center network

As announced in the September Record, Blue Cross Blue Shield of Michigan is developing a retail health center network and creating a unique provider type for these centers. This network is effective Jan. 1, 2017.

Enrollment information will be available in the Enrollment and Changes section of bcbsm.com/providers on Oct. 1, 2016. Click on the following:

  • Join our Network
  • Enrollment and Changes
  • Provider Enrollment
  • Physician and Professionals
  • Enroll a New Provider
  • Allied Providers, Retail Health Centers

Retail Health Centers must pass the credentialing review process. Specific requirements are identified in the Retail Health Center agreement.

If you’re currently contracted with us as another provider type, you will need to sign a new agreement to be designated as a retail health center.

Additional information about the network will be communicated in future Record articles.


Are you billing correctly for these drugs?

For the following drugs, we often receive bills with incorrect quantities under the prescription drug benefit. To help you submit the appropriate quantities on claims for these medications, we've listed the correct quantities below. We can process your claims more accurately and quickly when you provide accurate quantities.

Drug name

Incorrectly billed quantity

Correctly billed quantity

Avonex®
Example: 30 mcg/0.5 mL
(4 syringes)

4 syringes

2 mL = total volume
(4 x 0.5 mL)

Chorionic gonadotropin
Example: 10,000 USP units per 10 mL vial

20 mL

2 vials

Enbrel®
Example: 50 mg/0.98 mL
(4 syringes)

4 syringes

3.92 = total volume
(4 x 0.98 mL)

Premarin® vaginal cream
Example: 0.625 mg/gm; 30gm tube

42.50 gm

30 gm

Enoxaparin

Drug name

Incorrectly billed quantity

Correctly billed quantity

Enoxaparin
Example: 40 mg/0.4 mL
(1 syringe)

60 syringes

24 mL = total volume
(60 x 0.4 mL)

Enoxaparin
Example: 40 mg/0.4 mL
(1 syringe)

30 syringes

12 mL=total volume
(30 x 0.4 mL)

Medications often associated with incorrect days' supply:

Alrex 0.2% eye drops

Dosing

Package size
(bill by volume)

Quantity of drops per bottle

0.2%

5 mL

5 mL x 20 drops/mL = 100 drops in bottle

0.2%

10 mL

10 mL x 20 drops/mL = 200 drops in bottle

Alrex 0.2% ophthalmic suspension=

Number drops in bottle

= day supply

Number drops prescribed per day

Victoza®

Dose

Days' supply per pen

Package
(bill by volume)

Days’ supply per package

0.6 mg per day

30

6 mL (2 pens)

60

9 mL (3 pens)

90

1.2 mg per day

15

6 mL (2 pens)

30

9 mL (3 pens)

45

1.8 mg per day

10

6 mL (2 pens)

20

9 mL (3 pens)

30

Questions?
Call our claims processor, Express Scripts, at 1-800-922-1557. If you need additional support, call our Pharmacy Services Clinical Help Desk at 1-800-437-3803.


ICD-10-CM and PCS code updates for 2017 fiscal year now available

ICD-10-CM and Procedure Coding System updates for fiscal year 2017, effective with dates of service on or after Oct. 1, 2016, are now available on the Centers for Medicare & Medicaid Services website. You can access the site by clicking here.

This year’s updates include:

  • 5,801 new ICD-10-CM and PCS codes
  • 1,163 ICD-10-CM and PCS code revisions
  • 323 ICD-10-CM and PCS deletions

As this is the first code update since ICD-10-CM and PCS codes were implemented on Oct. 1, 2015, we at Blue Cross Blue Shield of Michigan want to make sure you’re aware of these changes.


Organ recipient’s insurance to cover live donor charges for basic transplants

Starting Jan. 1, 2017, an organ recipient’s health insurance will cover the cost of a living donor’s services if the recipient is a member of Blue Cross Blue Shield of Michigan.

The donor’s type of health coverage or lack thereof is irrelevant. This billing change applies to basic organ transplantation of bone marrow, kidney, cornea and skin, currently covered under basic benefits.

This change doesn’t apply to the following groups:

  • UAW Retiree Medical Benefits Trust
  • General Motors
  • Ford Hourly
  • Fiat Chrysler Automobiles

There are no changes to the Specified Organ Transplantation Program.

Look for additional details and billing instructions in future issues of The Record.


HCPCS update: Codes added, deleted

The Centers for Medicare & Medicaid Services has added 13 HCPCS codes and deleted three as part of its regular quarterly HCPCS updates.

Added

Code

Change

Coverage comments

Effective date

C9139

Added

Not covered

Oct. 1, 2016

C9481

Added

Not covered

Oct. 1, 2016

C9482

Added

Not covered

Oct. 1, 2016

C9483

Added

Not covered

Oct. 1, 2016

C9744

Added

Not covered

Oct. 1, 2016

G0490

Added

Covered for facility only

Oct. 1, 2016

G9679

Added

Not covered

Oct. 1, 2016

G9680

Added

Not covered

Oct. 1, 2016

G9681

Added

Not covered

Oct. 1, 2016

G9682

Added

Not covered

Oct. 1, 2016

G9683

Added

Not covered

Oct. 1, 2016

G9684

Added

Not covered

Oct. 1, 2016

G9685

Added

Not covered

Oct. 1, 2016

Deleted

Code

Change

Effective date

G0436

Deleted

Oct. 1, 2016

G0437

Deleted

Oct. 1, 2016

S8032

Deleted

Oct. 1, 2016


Coding corner: Morbid obesity

“Once morbid obesity is diagnosed and coded as such, it’s important the diagnosis is coded the same during each visit. In order to provide the best quality of care for these patients, accurate and consistent coding plays a key role in helping identify appropriate disease and care management programs for morbidly obese patients.”

  • Dr. Raymond Hobbs, Blue Cross medical consultant

“Coding corner” is an ongoing column highlighting the importance of accurate documentation and coding for various health conditions.

With increasing numbers of our population suffering from obesity, it’s crucial for doctors to recognize the degree to which obesity and its accompanying complications can negatively affect a patient’s health.

“Overweight,” “obesity” and “morbid obesity” are distinct diagnoses that should be properly documented.

The Centers for Medicare & Medicaid Services includes morbid obesity (ICD-10-CM code E66.01) and its associated body mass index values (40 and above: ICD-10-CM code range Z68.41-Z68.45) in its ICD-10 Hierarchical Condition Categories for calendar year 2016. This categorization makes a big difference in how providers should document the condition.

From a coding perspective, documentation indicating morbid obesity in the medical record makes it easy to assign code E66.01 with an associated Z-code.

A potential coding issue occurs when only “obesity” is noted in the medical record, but there’s sufficient evidence to indicate that the patient is actually morbidly obese. For example, if the patient has a BMI over 40 and has a comorbid condition, such as osteoarthritis, sleep apnea, diabetes, coronary artery disease, hypertension, hyperlipidemia or gastroesophageal reflux disease, you should code for morbid obesity.

Can a BMI value of 40 with comorbid conditions and no mention of morbid obesity in the medical record still be used to code for morbid obesity? Yes.

According to Dr. Raymond Hobbs, Blue Cross Blue Shield of Michigan medical consultant, capturing all the medical complications associated with an obesity diagnosis helps define and document the specific clinical condition (morbid obesity).

“Because obesity is a serious health condition that often includes comorbidities, the BMI value is an important factor in identifying and treating this condition,” Dr. Hobbs said. “The impact of weight on other medical conditions can be significant, so it’s important that all clinical complications be evaluated as part of the patient’s diagnosis and treatment.”

The health care provider might not document morbid obesity in its early stages as he or she may decide to evaluate the patient over time and recommend several interventions that could help reverse the trend. These may include referral to a dietitian, helping the patient incorporate an exercise regimen into his or her daily routine or education about how the condition can affect overall health.

To sum up, documentation is key to coding morbid obesity. A coder must review the medical record thoroughly when only obesity is documented but the patient has a BMI of 40 or above, along with comorbid conditions affecting the patient’s overall health. In these circumstances, code for morbid obesity.

To access a flier on this topic, click here.

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: Clarification on claims in web-DENIS with 17-digit numbers in ICN field

In a July 2016 Record article, we responded to a question about why claims in web-DENIS have a 17-digit number in the ICN field.

Our internal control number is 14 digits. But sometimes you’ll see our “710” Michigan plan code at the end of the ICN when you’re viewing claims in web-DENIS and on your ANSI 835 electronic claims receipt.

In July, we advised you to never include the “710” Michigan plan code when reporting the ICN on a replacement or void claim, or when completing the Medical Record Routing Form.

But since that time, we’ve learned that adding the Michigan plan code at the end of the ICN won’t affect how your claim or medical records are processed. The claims section of our online provider manuals have been updated to state that the ICN number can be reported with or without the “710” Michigan plan code.

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.


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.
Code* BCBSM changes to:
Basic Benefit and Medical Policy, Group
Variations Payment Policy, Guidelines
UPDATES TO PAYABLE PROCEDURES

J3490

Basic benefit and medical policy

Akovaz covered for approved indication

The FDA-approved Akovaz is covered under NOC J3490 for its approved indication. Akovaz is approved for hypotension in surgical setting. This policy was effective May 4, 2016.

00635, 01936, 01991, 00520, 00740, 00810, 96373, 96374

Basic benefit and medical policy

Use of monitored anesthesia care

The monitored anesthesia care for endoscopic, surgical and other diagnostic and therapeutic procedures policy is established. This policy was effective Sept. 1, 2016.

Medical policy statement
Use of monitored anesthesia care may be considered established for gastrointestinal endoscopy procedures when there is documentation by the proceduralist or anesthesiologist that specific risk factors or significant medical conditions are present supporting the opinion that the procedure can’t be done successfully or safely in the absence of monitored anesthesia care.

Inclusions:

Monitored anesthesia care is considered medically necessary for patients with risk factors or significant medical conditions that increase the risk of sedation, including any of the following:

  • Increased risk for complications due to severe comorbidity (ASA P3* or greater)
  • Morbid obesity (body mass index greater than 40)
  • Documented sleep apnea
  • Inability to follow simple commands (cognitive dysfunction, intoxication, or psychological impairment)
  • Spasticity or movement disorder complicating procedure
  • History or anticipated intolerance to standard sedatives, such as:
    • Chronic opioid use
    • Chronic benzodiazepine use
  • Patients with active medical problems related to drug or alcohol abuse
  • Patients younger than age 12 or age 70 or older
  • Patients who are pregnant
  • Patients with increased risk for airway obstruction due to anatomic variation, such as:
    • History of stridor
    • Dysmorphic facial features
    • Oral abnormalities (e.g., macroglossia)
    • Neck abnormalities (e.g., neck mass)
    • Jaw abnormalities (e.g., micrognathia)
  • Acutely agitated, uncooperative patients
  • Prolonged or therapeutic gastrointestinal endoscopy procedures requiring deep sedation (e.g., endoscopic retrograde cholangiopancreatography, transduodenal biopsy, double balloon enteroscopy).

Exclusions:

Monitored anesthesia care is considered not medically necessary for gastrointestinal endoscopic, bronchoscopic or interventional pain procedures in patients at average risk for anesthesia and sedation.

POLICY CLARIFICATIONS

81206, 81207, 81208, 81170, 81401

Basic benefit and medical policy

Genetic testing for BCR/ABL1

The safety and effectiveness of genetic testing for BCR/ABL1 in patients with chronic myelogenous leukemia and acute lymphoblastic leukemia have been established. It may be considered a useful tool when indicated, effective Sept. 1, 2016.

GROUP BENEFIT CHANGES

Amcor

Amcor, group number 71737, will join Blue Cross Blue Shield of Michigan, effective Jan. 1, 2017.

Group number: 71737 
Alpha prefixes: PPO (KOR)
Platform: NASCO

Plans offered:
PPO, medical/surgical
Hearing
CDH – HSA and FSA

Irvin Automotive Inc.

Irvin Automotive Inc., group number 71739, will join Blue Cross Blue Shield of Michigan, effective Oct. 1, 2016.

Group number: 71739
Alpha prefixes: PPO (IAE)
Platform: NASCO

Plans offered:
PPO, medical/surgical
Dental
Prescription drugs


Professionals

We’re resuming distribution of value-based reimbursement reports

Select primary care physicians and specialists who participate in the Physician Group Incentive Program and meet the standards of specific PGIP quality programs are eligible for reimbursement under the Value-Based Reimbursement Fee Schedule. We wrote about the VBR fee schedule in the April Record.

The VBR Fee Schedule sets reimbursement rates for specific codes at greater than 100 percent of the TRUST/Traditional/BPP/EPO Maximum Fee Schedules, also called Standard Fee Schedules. We refer to reimbursement earned through our quality programs as “value-based reimbursement.”

In response to requests from PGIP physicians and physician organizations, we’re pleased to announce that we’re resuming distribution of reports of the estimated amount of value-based reimbursement received by practitioners. On an annual basis, each PO will receive a report of the estimated amount of value-based reimbursement received by each of the PGIP practitioners within the PO for the previous calendar year.

The next report will be distributed this month (October). The POs may share practitioner-specific information with the individual practitioners in the PO if they choose to.

For more information about PGIP and value-based reimbursement, check out the Value Partnerships Overview page of bcbsm.com/providers.


Find out how we resolve overpayments and incorrect payments

If we overpay you on a claim, you’ll receive two vouchers from us within three weeks after the overpayment.

  • The first voucher, the Accounts Created Voucher, advises you that a deduction will be taken on a future voucher. It shows the overpayment amount, your patient account number and an accounts receivable number.
  • The second voucher, the Accounts Applied Voucher, deducts the overpayment amount. It shows any accounts receivable balances from previous vouchers and the actual cash deductions that have been applied to correct the overpayments.

After our notification, if you disagree that you were overpaid, you may appeal. For more information, see the “Appeals and Problem Resolution” chapter of your provider manual. If you’re receiving weekly income from Blue Cross Blue Shield of Michigan, the Accounts Receivable will automatically deduct from future payments; no action is needed from you. Please don’t send a check to Blue Cross for overpayments except in the following instances:

  • If date of service is greater than two years, then you must submit a check to Blue Cross for the overpayment:
    • No Accounts Receivable will be set up.
    • Include the patient name, document number, date of service and contract number. With that information, we can ensure that the money is properly applied.
  • If the provider identification number that the original claim was paid on is no longer in use:
    • Send in a check or, after 90 days, letters will be sent out. If no payment is received after six months, Blue Cross will recover the funds using a different PIN that falls under the same tax ID as the original PIN as long as another PIN is available.
  • If you receive a misdirected check or a check for services you didn’t provide:
    • Write a personal check in the amount of the incorrect payment.
    • Underline the error on a copy of the voucher.
    • Attach the voucher to your check with a note of explanation, including the patient's name, address, date of birth, date of service and the Blue Cross check number.

      Send the check or voucher and note of explanation to:
      Blue Cross Blue Shield of Michigan
      P.O. Box 366
      Detroit, MI 48231-0366

After our notification, if you disagree that you were overpaid, you may appeal. For more information, see the “Appeals and Problem Resolution” chapter of your online provider manual.

If you need more information, review this frequently asked questions document.


Automated system designed to improve processing of replacement and void claims for professional providers

Blue Cross Blue Shield of Michigan implemented an automated process, starting Feb. 19, 2016, to improve the processing of replacement and void professional claims, including Federal Employee Program® and BlueCard® claims.

Following are the claim frequency codes for these types of claims and a description of each:

Type of claim

Claim frequency code

Replacement of prior claim

7

Voided/canceled claim

8

Claim Frequency Code 7 – A replacement claim replaces the entire original claim. The original claim that was previously processed is replaced with the frequency code 7 claim you report. Replacement claims should be reported when adding or deleting lines on the claim, changing quantities or changes on the claim.

Claim Frequency Code 8 – Void/cancel reflects the elimination in its entirety of a previously submitted bill for a specific provider, patient, subscriber and payer for a statement coverage period. The void/cancel claim must be billed exactly as the original claim you’re asking us to void.

Void/cancel claims are reported when you ask that we cancel the claim that we previously processed. If you report a void/cancel claim because you reported the incorrect provider or patient information on the original claim, the corrected claim must be reported as a new original claim.

Professional providers should follow these steps when submitting an electronic replacement or void/cancel 837 claims or a paper CMS-1500 claim form:

  1. Include the appropriate claim frequency code in the 837 file to indicate that the claim is an adjustment of a previously approved or denied claim. Enter the code in the CLM05-3 segment of loop 2300. For paper claims, these values should be reported in field 22 on the CMS-1500 form.
  2. In the REF*F8 segment of loop 2300, include the 14- or 17- character internal claim number that was returned on the original claim. For paper claims, these values should be reported in field 22 on the CMS-1500 form.
  3. Report the same provider NPI and billing information that was reported on the original claim for both replacement and void/cancel claims.
  4. Report the same contract number of the original, finalized claim.

Example: A claim was previously submitted with procedure codes *99214, *70052 and *99213, but procedure codes *70052 and *99213 were submitted in error. An electronic replacement claim should be submitted with frequency code 7 and procedure code *99214. This claim will then be adjusted to remove *70052 and *99213 so that the claim will be processed with procedure code *99214 alone.

Note:  Don’t report a replacement or void claim until your original claim has been finalized.

Claims reporting contact information

  • If you have questions on the electronic reporting of an 837 health care claim, contact the Electronic Data Interchange help desk at 1-800-542-0945.
  • For assistance with the electronic reporting of claims for your office, contact your software vendor or clearinghouse.
  • If you have questions about a claim you have billed, call Provider Inquiry.
  • If you have any additional concerns that can’t be addressed by Provider Inquiry, contact your provider consultant.

Seminars, webinars scheduled for Physical Therapy Use Management Program

Beginning Jan. 1, 2017, preauthorization by eviCore healthcare will be required for Medicare Plus BlueSM PPO members who reside in Michigan and use Michigan providers for outpatient physical and occupational therapy services.

eviCore is an independent company that manages preauthorization for Blue Cross Blue Shield of Michigan.

Blue Cross and eviCore will host two seminars and multiple webinars about the Physical Therapy Use Management Program for Medicare Advantage PPO providers. Seminar and webinar topics will include:

  • The practice profile
  • The preauthorization process
  • Self-monitoring expectations
  • The corrective action process
  • The disaffiliation process
  • A review of the tools available to help providers

Seminars
There will be two seminars on Nov. 7, one in the morning and one in the afternoon as follows:

Time

Date

Place

9 to 11 a.m.

Monday, Nov. 7, 2016

Blue Cross Lyon Meadows Conference Center
53200 Grand River Ave.
New Hudson, MI 48165

1 to 3 p.m.

Monday, Nov. 7, 2016

Blue Cross Lyon Meadows Conference Center
53200 Grand River Ave.
New Hudson, MI 48165

To sign up for an onsite seminar, please email Deb Marvay at dmarvay@bcbsm.com and provide the following information:

  • Indicate which session (a.m. or p.m.)
  • Your name
  • Provider name
  • Address

You can also sign up for a webinar. Webinars are 90 minutes, except for the Nov. 7 webinars, which will be conducted along with the onsite seminars.

Webinars

Time

Date

9 a.m.

Monday, Nov. 7, 2016

1 p.m.

Monday, Nov. 7, 2016

11 a.m.

Wednesday, Nov. 9, 2016

1 p.m.

Wednesday, Nov. 16, 2016

3 p.m.

Thursday, Nov. 17, 2016

2 p.m.

Tuesday, Nov. 29, 2016

11 a.m.

Wednesday, Nov. 30, 2016

9 a.m.

Tuesday, Dec. 6, 2016

11 a.m.

Thursday, Dec. 8, 2016

You can sign up for webinars at medsolutions.webex.com**

  • Click on the Training Center tab at the top of the page.
  • Click on the Upcoming tab, then find the date and time of the session you want to attend.
  • Click on Register and enter the registration information.

If you have questions about the seminars or webinars, call Blue Cross at 313-448-6371.


New modifier for habilitative services, benefit limit changes for habilitative and rehabilitative care

To comply with an Affordable Care Act mandate, effective Jan. 1, 2017, Blue Cross Blue Shield of Michigan is making changes regarding the reporting of habilitative services and the benefit limits of both habilitative and rehabilitative services for individual business and some groups.

Habilitative services and how they differ from rehabilitative services

  • Habilitative services: Health care services that help members keep, learn or improve skills and functioning for daily living.
  • Rehabilitative services: Health care services that help members keep, recover or improve skills and functioning for daily living. These skills and functioning have been lost or impaired because members were sick, hurt or disabled.

New modifier needed for habilitative services
Health care providers must use the SZ modifier to identify any physical therapy, occupational therapy or speech-language pathology codes for habilitative services. The SZ modifier identifies habilitative services and allows us to track when habilitative (versus rehabilitative) services are reported.

Benefit limit changes
The benefit limits for rehabilitative and habilitative services for individual business and some groups will change, effective for plan years beginning on or after Jan. 1, 2017:

Habilitative services

Benefit limit per calendar year

Any combination of physical therapy, occupational therapy (excludes chiropractic and osteopathic manipulation)

30 visits

Speech therapy

30 visits

 

Rehabilitative services

Benefit limit per calendar year

Any combination of physical therapy, occupational therapy, chiropractic manipulation and osteopathic manipulation

30 visits

Speech therapy

30 visits

Note: The benefit limit varies by group. Remember to always verify patient’s eligibility for benefits.


We’re updating our obstetrical ultrasound policy

Blue Cross Blue Shield of Michigan covers the first three obstetrical ultrasounds during a pregnancy. Additional obstetrical ultrasounds must be billed with the KX modifier. This modifier indicates that appropriate documentation is on file to show that the additional services were medically necessary in case there is an audit.


We're setting new quantity limits for Suboxone®

On Nov. 1, 2016, Blue Cross Blue Shield of Michigan will implement new quantity limits for Suboxone®. Suboxone is a combination product containing buprenorphine and naloxone. The product is approved by the Food and Drug Administration for the treatment of opioid dependence.

The new quantity limits are 90 films per 30 days and 270 films per 90 days. These limits:

  • Align with FDA-approved dosing guidelines to minimize potentially unsafe drug use by our members
  • Affect only commercial or non-Medicare Advantage members who have Blue Cross pharmacy benefits with quantity limits
  • Apply to both brand and generic forms of Suboxone
  • Don’t apply to auto group members

Our goal is to provide our members with safe, high-quality prescription drugs. In September, we sent letters to members who may be affected and encouraged them to discuss treatment options their doctors.

If necessary, you can request an override of the new quantity limits for your patients. Your request should include documentation, such as chart notes, to support that the amount prescribed is medically necessary.

To get a form for a quantity limit override:

  • Log in to web-DENIS.
  • Click BCBSM Provider Publications and Resources on the left.
  • Click Commercial Pharmacy Prior Authorization and Step Therapy forms on the right.
  • Click Quantity Limit Request form.

You can also call the Pharmacy Services Clinical Help Desk at 1-800-437-3803 to get a form or if you have questions about this change.


Facility

Seminars, webinars scheduled for Physical Therapy Use Management Program

Beginning Jan. 1, 2017, preauthorization by eviCore healthcare will be required for Medicare Plus BlueSM PPO members who reside in Michigan and use Michigan providers for outpatient physical and occupational therapy services.

eviCore is an independent company that manages preauthorization for Blue Cross Blue Shield of Michigan.

Blue Cross and eviCore will host two seminars and multiple webinars about the Physical Therapy Use Management Program for Medicare Advantage PPO providers. Seminar and webinar topics will include:

  • The practice profile
  • The preauthorization process
  • Self-monitoring expectations
  • The corrective action process
  • The disaffiliation process
  • A review of the tools available to help providers

Seminars
There will be two seminars on Nov. 7, one in the morning and one in the afternoon as follows:

Time

Date

Place

9 to 11 a.m.

Monday, Nov. 7, 2016

Blue Cross Lyon Meadows Conference Center
53200 Grand River Ave.
New Hudson, MI 48165

1 to 3 p.m.

Monday, Nov. 7, 2016

Blue Cross Lyon Meadows Conference Center
53200 Grand River Ave.
New Hudson, MI 48165

To sign up for an onsite seminar, please email Deb Marvay at dmarvay@bcbsm.com and provide the following information:

  • Indicate which session (a.m. or p.m.)
  • Your name
  • Provider name
  • Address

You can also sign up for a webinar. Webinars are 90 minutes, except for the Nov. 7 webinars, which will be conducted along with the onsite seminars.

Webinars

Time

Date

9 a.m.

Monday, Nov. 7, 2016

1 p.m.

Monday, Nov. 7, 2016

11 a.m.

Wednesday, Nov. 9, 2016

1 p.m.

Wednesday, Nov. 16, 2016

3 p.m.

Thursday, Nov. 17, 2016

2 p.m.

Tuesday, Nov. 29, 2016

11 a.m.

Wednesday, Nov. 30, 2016

9 a.m.

Tuesday, Dec. 6, 2016

11 a.m.

Thursday, Dec. 8, 2016

You can sign up for webinars at medsolutions.webex.com**

  • Click on the Training Center tab at the top of the page.
  • Click on the Upcoming tab, then find the date and time of the session you want to attend.
  • Click on Register and enter the registration information.

If you have questions about the seminars or webinars, call Blue Cross at 313-448-6371.


New modifier for habilitative services, benefit limit changes for habilitative and rehabilitative care

To comply with an Affordable Care Act mandate, effective Jan. 1, 2017, Blue Cross Blue Shield of Michigan is making changes regarding the reporting of habilitative services and the benefit limits of both habilitative and rehabilitative services for individual business and some groups.

Habilitative services and how they differ from rehabilitative services

  • Habilitative services: Health care services that help members keep, learn or improve skills and functioning for daily living.
  • Rehabilitative services: Health care services that help members keep, recover or improve skills and functioning for daily living. These skills and functioning have been lost or impaired because members were sick, hurt or disabled.

New modifier needed for habilitative services
Health care providers must use the SZ modifier to identify any physical therapy, occupational therapy or speech-language pathology codes for habilitative services. The SZ modifier identifies habilitative services and allows us to track when habilitative (versus rehabilitative) services are reported.

Benefit limit changes
The benefit limits for rehabilitative and habilitative services for individual business and some groups will change, effective for plan years beginning on or after Jan. 1, 2017:

Habilitative services

Benefit limit per calendar year

Any combination of physical therapy, occupational therapy (excludes chiropractic and osteopathic manipulation)

30 visits

Speech therapy

30 visits

 

Rehabilitative services

Benefit limit per calendar year

Any combination of physical therapy, occupational therapy, chiropractic manipulation and osteopathic manipulation

30 visits

Speech therapy

30 visits

Note: The benefit limit varies by group. Remember to always verify patient’s eligibility for benefits.


Pharmacy

Reminder: Here are requirements for prescription billing

Pharmacies are required to follow important billing procedures when submitting Blue Cross Blue Shield of Michigan and Blue Care Network prescription drug program claims.

Our reimbursements for prescription drug claims are based on the lesser of the:

  • Average wholesale price, minus the contractual percent discount
  • Pharmacy’s submitted ingredient cost
  • Pharmacy’s usual and customary charge (retail charge)
  • Maximum allowable cost price, where applicable

It’s your responsibility to submit these amounts in accordance with your provider agreement requirements.

The retail charge is the pharmacy’s charge per prescription for cash-paying customers. Any retail charge specific to certain groups will be given to Blue Cross or BCN for similar enrollees. When reimbursement is based upon the retail charge, Blue Cross or BCN doesn’t pay a dispensing fee.

For details, please refer to your Blue Cross and BCN Pharmacy Participation Agreement.

Note: Some of our members are part of demographic groups that qualify for a special price drug program — for example, the federal 340B program. In those instances, the pharmacy’s retail charge submitted on the claim for the member must reflect the special drug price of that program.

Blue Cross or BCN will seek recoveries following an audit for claims that don’t follow the Pharmacy Participation Agreement billing requirements. We appreciate your cooperation in complying with this contractual requirement.


DME

Procedure codes E8000, E8001 and E8002 no longer require individual consideration review

On June 1, 2016, Blue Cross Blue Shield of Michigan began processing procedure codes E8000, E8001 and E8002 for payment at the assigned fee and no longer require individual consideration review.

These codes relate to pediatric gait trainers and all accessories and components. Group specific benefits may apply.


Medicare Advantage

Seminars, webinars scheduled for Physical Therapy Use Management Program

Beginning Jan. 1, 2017, preauthorization by eviCore healthcare will be required for Medicare Plus BlueSM PPO members who reside in Michigan and use Michigan providers for outpatient physical and occupational therapy services.

eviCore is an independent company that manages preauthorization for Blue Cross Blue Shield of Michigan.

Blue Cross and eviCore will host two seminars and multiple webinars about the Physical Therapy Use Management Program for Medicare Advantage PPO providers. Seminar and webinar topics will include:

  • The practice profile
  • The preauthorization process
  • Self-monitoring expectations
  • The corrective action process
  • The disaffiliation process
  • A review of the tools available to help providers

Seminars
There will be two seminars on Nov. 7, one in the morning and one in the afternoon as follows:

Time

Date

Place

9 to 11 a.m.

Monday, Nov. 7, 2016

Blue Cross Lyon Meadows Conference Center
53200 Grand River Ave.
New Hudson, MI 48165

1 to 3 p.m.

Monday, Nov. 7, 2016

Blue Cross Lyon Meadows Conference Center
53200 Grand River Ave.
New Hudson, MI 48165

To sign up for an onsite seminar, please email Deb Marvay at dmarvay@bcbsm.com and provide the following information:

  • Indicate which session (a.m. or p.m.)
  • Your name
  • Provider name
  • Address

You can also sign up for a webinar. Webinars are 90 minutes, except for the Nov. 7 webinars, which will be conducted along with the onsite seminars.

Webinars

Time

Date

9 a.m.

Monday, Nov. 7, 2016

1 p.m.

Monday, Nov. 7, 2016

11 a.m.

Wednesday, Nov. 9, 2016

1 p.m.

Wednesday, Nov. 16, 2016

3 p.m.

Thursday, Nov. 17, 2016

2 p.m.

Tuesday, Nov. 29, 2016

11 a.m.

Wednesday, Nov. 30, 2016

9 a.m.

Tuesday, Dec. 6, 2016

11 a.m.

Thursday, Dec. 8, 2016

You can sign up for webinars at medsolutions.webex.com**

  • Click on the Training Center tab at the top of the page.
  • Click on the Upcoming tab, then find the date and time of the session you want to attend.
  • Click on Register and enter the registration information.

If you have questions about the seminars or webinars, call Blue Cross at 313-448-6371.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2015 American Medical Association. All rights reserved.