Blue Cross customers can opt for reference-based benefit designs

As part of our ongoing commitment to helping our customers and members better manage the cost of their health care, Blue Cross Blue Shield of Michigan is launching reference-based benefit designs.

These benefit designs, sometimes referred to as RBB, can be chosen by customers to supplement their current plans. They encourage members to gain as much information about certain services as possible, allowing them to take a more active role in their health care decisions.

Jan. 1, 2017, is the start date for the first customer group that has chosen this new option.
Here’s how it works:

1. Employers select certain services and “reference prices” for those services. These prices are the costs established for an episode of care based on claims data received by Blue Cross from their providers.
2. Information about these services and reference prices is shared with the employees of a particular group (the Blue Cross member).
3. When members need a service that is selected for RBB, they’ll use a vendor tool that helps them understand the cost involved and then go to a health care provider for the service.
4. Health care providers charge for the service the same way they do today.
5. Blue Cross pays up to a certain amount for the service.
6. If the health care provider offers the service at or below the reference price, Blue Cross pays the allowed amount plus any member liability.
7. If the health care provider charges an amount that exceeds the reference price, the member is responsible for the difference between the selected reference price and additional amount, plus any existing liability.

It’s important to note that RBB doesn’t modify rates or change the amount that health care providers charge for their services. Health care providers can expect to receive contracted rates on all procedures. It does, however, affect member cost share.

Example: If a member has a reference cost of $500 for an MRI of the spine and the allowable amount is $700, then Blue Cross pays up to $500 for the procedure and the member is responsible for $200.

Members with RBB will know the amount they owe by using consumer transparency tools that are part of the RBB. Providers will know the member cost share by checking web-DENIS.

As customer groups choose RBB for their members, we’ll include this information in the monthly billing chart in The Record, and we’ll also include the information in Benefit Explainer. In addition, we’ll post an RBB presentation on web-DENIS in mid-November and provide you with more details in the December Record.

Frequently asked questions about RBB

How are reference costs established?

Reference costs are established for a specific episode of care based on claims data received by Blue Cross from their providers.

How will I get paid?

Reference-based benefits won’t modify the current contract amount. Providers can expect to receive their contract rate on all procedures where reference-based benefits apply.

How will I know if a member is covered under reference-based benefits?

You can check the member’s benefits and eligibility on web-DENIS.

Do reference-based benefits apply to emergency services?

No. Reference-based benefits aren’t applicable to any service that is urgent or emergent.

How does the member identify services that are at or below the reference cost?

This information will be provided to members by their employer group. Members with reference-based benefits will be given access to consumer transparency tools to determine the cost of services.

What if members covered under reference-based benefits ask me for additional information about their benefits?

You can direct members to the transparency tools provided by their employer. Members who enroll in reference-based benefits will receive a welcome packet that gives them the tools they need to determine the cost of a particular episode of care.

Blue Cross to cover medical and pharmaceutical services for gender transition

Blue Cross Blue Shield of Michigan already provides gender transition benefits to many of its groups. Starting on Jan. 1, 2017, Blue Cross will extend these benefits to individuals and groups that currently have none or only some of them.

New benefits may include:

• Gender reassignment surgery
• Hormone therapy
• Psychotherapy and counseling
• Mastectomy for female to male transitions

Some surgical procedures will continue to require preauthorization. Always check a member’s eligibility and benefits.

Why are benefits for gender transition changing?

We’re changing our gender transition benefits in response to a final rule under Section 1557 of the Affordable Care Act. The rule, issued this year by the Department of Health and Human Services, prohibits discrimination on the basis of race, color, national origin, sex, age or disability in health programs or activities that receive federal financial assistance.

According to the rule, discrimination on the basis of sex includes discrimination based on gender identity. Protections for those seeking gender transition services are outlined in the rule.

This is the first time gender transition benefits have been mandated for health care coverage. This rule requires that gender transition benefits be available in health care plans starting on and after Jan. 1, 2017.

How will Blue Cross meet the requirements of the federal rule?

Blue Cross has been working to ensure its members will have access to these services no later than the start of their plan years, beginning on or after Jan. 1, 2017. Blue Cross groups and individuals will receive their enhanced benefits on Jan. 1, 2017, with the exception of NASCO Classic groups, which will receive them at the start of their 2017 plan year.

We’re streamlining EFT process

As of 9 p.m. Dec. 1, 2016, Blue Cross Blue Shield of Michigan will no longer require the use of an internal provider identification number, or PIN, when registering for electronic funds transfer, updating existing EFT bank information or canceling an EFT payment. Health care providers will be able to use their National Provider Identifier, or NPI, and the corresponding tax identification number instead.

Once a provider enters the NPI and tax ID number to register or make a necessary change, Blue Cross will systematically update all internal PINs and banking information affiliated with the NPI and tax ID.

Look for additional information about the updated EFT process in future web-DENIS messages and the December Record.

Here’s our policy on ‘DAW’ or ‘dispense as written’

Blue Cross Blue Shield of Michigan follows the Michigan Public Health Code, which states that the prescribing health care provider must enter the initials “DAW” or the words “dispense as written” on the prescription in his or her own handwriting.

Our policy doesn’t allow payment for a multisource brand-name drug when the DAW indicator is preprinted or stamped, circled or checked off. DAW must also be appropriately noted on a phone order and initialed by the receiving pharmacist.

Each prescription stands on its own merit. This means that DAW indications on previous prescriptions don’t permit the dispensing of a brand-name drug when DAW isn’t present on another prescription for the same drug.

Member requesting a brand-name drug
If the member requests a brand-name drug, you must report a DAW 2 and inform the member that he or she will be responsible for the difference between the generic and the brand-name drug, plus any applicable copay amount. This is also true when the member requests a brand-name drug on the Maximum Allowable Cost program drug list and DAW is not indicated by the prescriber.

Audit
As stated above, preprinted DAW indicators aren’t acceptable. The pharmacists who dispense brand-name drugs for prescriptions with preprinted DAW indicators are entitled to the price of the generic drug only. When this error is found during an onsite audit, the pharmacy will incur a monetary sanction that amounts to the difference between the cost of the brand-name drug and the generic. This will be extrapolated. Auditors also routinely contact prescribing physicians to verify the authenticity of DAWs on prescriptions.

Electronically transmitted prescriptions
An electronic prescription allows the prescriber to instruct the pharmacist to dispense a brand-name drug product provided that the prescription includes both of the following:

• The indication that no substitute is allowed, such as “dispense as written” or “DAW”
• The indication that no substitute is allowed and that it is a unique element in the prescription

For more information
DAW may only be requested by the prescriber, not by the member, to justify reporting a dispensing indicator of “1.” If a member requests a brand-name drug when a generic alternative is available, a dispensing indicator of “2” should be reported.

You can find more information about DAW and the Maximum Allowable Cost program in the BCBSM/BCN Guide for Pharmacists.

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, documentation and prescriptions are done in accordance with applicable state and federal laws and regulations.

2017 early-release CPT codes issued

The American Medical Association has issued a series of early-release Current Procedural Terminology codes for 2017 as follows. Only one code listed below is a Blue Cross Blue Shield of Michigan-covered benefit.

Surgery

Medicine

Medicine
Vaccines/Toxoids

Blue Cross to update McKesson ClaimsXten™ in January 2017

Blue Cross Blue Shield of Michigan will perform its quarterly ClaimsXten update in January 2017 to ensure that you have the most up-to-date codes to use on your claims.

ClaimsXten is clinical editing software that provides the most current Health Care Procedure Coding System codes, including Current Procedural Terminology codes. Using the most current procedure codes on your claims is important as it helps us process your claims and send accurate reimbursements quickly and efficiently.

Blue Cross works to ensure that ClaimsXten is aligned with all of our payment policies. We reserve the right to make changes or corrections as required or new information becomes available. In some instances, changes to ClaimsXten may be applied retroactively.

Note: Be sure to check out the January Record for information on new, revised or deleted procedure codes for 2017. We’ll include an article that will tell you how to find the “2017 HCPCS Update” on web-DENIS.

‘Provider consent to change’ option no longer available when calling Provider Inquiry

With the automation of both professional and facility replacement and void/cancel claims, we have removed the “provider consent to change” option from Provider Inquiry. If you have changes to a previously reported claim, report them on a claim form using the appropriate frequency codes: 7 for a replacement claim; 8 to void or cancel a claim.

Refer to the October Record for additional information on the appropriate reporting of replacement and void/cancel claims.

Provider Inquiry will continue to help you initiate an adjustment if you reported a valid and accurate claim but the claim did not process as expected. Examples include:

• Facility dual diagnosis claims (screening versus diagnostic) when only the screening or diagnostic service was processed
• Claims affected by a Blue Cross Blue Shield of Michigan system or processing issue

You may continue to receive calls from Customer Service on dual diagnosis facility claims or on a professional claim when we require additional information from you. We’re committed to resolving claim inquiries received from both providers and members on the first call if possible. If you can provide the information requested during the call — and a claim adjustment is appropriate — we’ll initiate it immediately on your behalf.

For more information on claim reporting, including links and articles to claim examples, reference the Claims chapter of the online provider manuals.

PARS to provide information on members’ remaining visits and days

Starting in December 2016, the Provider Automated Response System, or PARS, will be enhanced to provide members’ remaining number of visits and days in the benefit period for chiropractic services, cardiac rehabilitation services and physical therapy.

This enhancement will allow health care providers to obtain even more information about their patients by using the system. We’ll provide additional details in future communications.

Coding corner reminder: Best practices for documenting diabetes

With the implementation of ICD-10-CM and coding classification changes, there are now combination codes for diabetes and its associated conditions and manifestations. Specificity of documentation 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. When the type isn’t documented in the medical record, the default code would be for Type 2 diabetes mellitus.
• 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?
• Document current status on the diabetes and all associated conditions.

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.

Example: Type 2 diabetes mellitus with macular edema

1. It is necessary to also document retinopathy; “Diabetes, retinopathy, with macular edema” - E11.311

For instance, if a patient has two medical conditions that are linked, then his or her provider should 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 should 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 doesn’t support a relationship between the two conditions. Therefore, they would be coded as two separate diagnoses instead of diabetes with a manifestation or complication.
• 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.

It’s the health care provider’s responsibility to document when diabetes mellitus is not the underlying cause of other conditions. The fact that a patient has two or more conditions that commonly occur together doesn’t necessarily mean they are related.

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).”

References: Coding Clinic, First and Second Quarter Issues, 2016

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 was my claim for a Medicaid-enrolled member rejected?

Claims for Medicaid-enrolled members must be billed according to Medicaid reporting requirements. When a member is enrolled in a Medicaid plan in another state — and the Medicaid plan is administered by a Blue plan — your claim will be routed to the plan where the member is enrolled. The member’s three-letter alpha-prefix identifies the plan and state where the patient is enrolled.

Plans may also require you to register as a Medicaid provider with their plans before approving reimbursement on the claim. To ensure you’re billing the claim accurately and have met the plan’s state Medicaid requirements, be sure to verify your patient’s eligibility and benefits. Failure to report the claim according to Medicaid requirements could result in a request from the plan for additional information or a claim denial.

For more information on the BlueCard program, including links and articles on online tools, reference the BlueCard chapter of the online provider manuals.

Have a question you’d like answered?
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.

Commercial prescription drug plans will have out-of-pocket maximum when paired with Medicare supplement products

Effective Jan. 1, 2017, group members with commercial prescription drug plans will have a $7,150 out-of-pocket maximum applied to their plans when they’re paired with Blue Cross Blue Shield of Michigan Medicare supplement products or BCN 65. Members who reach their out-of-pocket maximum will have their prescription drugs covered in full for the rest of their plan year.

The new out-of-pocket maximum applies only to prescription coverage. The change doesn’t apply to grandfathered or retiree-only groups.

Keep the following in mind:

• A Blue Cross Medicare supplement plan is a commercial PPO product that is secondary to Medicare. It can be paired with a commercial prescription drug plan.

• BCN 65 is a commercial HMO product that is secondary to Medicare. BCN 65 covers Medicare copayments, coinsurance and deductibles, and provides some additional benefits such as preventive care.

Certain high-cost products to treat skin conditions won’t be covered due to comparable alternatives

As you read in the September Record, Blue Cross Blue Shield of Michigan commercial plans don’t cover select high-cost, FDA-approved drugs for which more cost-effective therapeutic alternatives are available. This is part of an ongoing effort to address the high cost of drugs and provide the best possible value for our members.

Ultravate^®-X kits, Ultravate^® lotion, Cordran^® lotion, flurandrenolide lotion and Locoid^® lotion, which are topical products used to treat corticosteroid-responsive skin conditions, have been targeted for exclusion, effective Oct. 7, 2016. Members currently using these drugs can continue to fill prescriptions for them through Dec. 31, 2016.

The following table includes the approximate cost of the targeted drugs and the associated therapeutic alternatives:

**Approximate cost for a 30-day supply based on the average wholesale price.

In some cases, members’ out-of-pocket costs for these brand-name drugs may be lower than their copay due to manufacturer savings cards. However, the high cost of these drugs will be reflected in future premium rates and the overall claims experience for members and plans.

As part of this ongoing initiative, Blue Cross will continue to identify select high-cost drugs and will stop covering them when there are more cost-effective alternatives available for our commercial members.

Assess, compare your chiropractic clinical performance with Optum™ WebAssist

Blue Cross Blue Shield of Michigan is committed to transparency when it comes to sharing performance data and helping clinicians provide care that is well-aligned with current, evidence-based best practices.

That’s why we’re working with our chiropractic partner, Optum, to help you maximize the valuable resources found on the secure Optum^® WebAssist provider portal.** The vast library of resources available to you 24 hours a day, seven days a week features a personalized clinical profile that compares your performance against same-specialty peers within the Blue Cross network.

This article includes answers to two questions we hear frequently from our participating chiropractors:

• What information is available to me in my profile?
• What’s the best way to review the data?

Here’s what you need to know about the WebAssist provider portal:

• It allows for a review of the current year and the previous three calendar years.
• Data can be reviewed by quarter, year or at six-month intervals.
• Data is updated monthly; with the date of refresh indicated on the site.
• Data is aggregated by health plan.
• It offers comparisons to same-specialty peers treating patients from the same health plan during the same time frame.
• It features “run charts” and “bubble charts” for most key performance indicators.
• Run charts contain the mean and standard deviation for high-volume peers treating patients from the same health plan, as well as the specific provider trend.
• Bubble charts allow a provider to view their performance against a specific metric in comparison to other network providers.
• It includes literature and guidelines related to key performance indicators.
• It allows you to review various reports regarding treatment, coding, therapy use and demographics. The summary and treatment reports will give you a general overview of multiple clinical parameters.

Tips for using WebAssist

• Viewing quarterly interval data from your profile is useful for seeing the most recent changes you’ve made in your practice.
• If you want to see how your clinical performance is progressing for the calendar year, check out the annual time interval.
• You can’t focus solely on the quarterly results and then add each quarter up — or use them independently — to determine your annual performance because you may be treating the same patient in multiple quarters.
• Only the annual report will display your performance for patients treated across the entire calendar year to date.

You’ll need your Optum provider ID and password to access your data on the Optum provider portal. If you haven’t received your Optum provider ID or password — or if you you need this information resent to you — contact Optum at 1-800-873-4575.

If you have any questions or want to discuss your clinical profile, call 1-800-873-4575 and ask to speak with your assigned Optum support clinician. Or call them direct at 1-952-205-3121 or 1-952-202-3496.

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

We’ve made some changes to our allergy antigens policy

Our allergy antigens policy has been updated since we communicated about it in the March 2016 Record. Please refer to the information that follows for details on our allergy antigens policy.

When billing procedure code *95165 for allergy antigens preparations, health care providers are required to specify the number of anticipated doses to prepare as units.

A dose, or unit, won’t be defined as one cubic centimeter. It will be defined as the amount of serum injected into the patient at the time of treatment.

Procedure code *95165 should be billed on a separate line for each multi-dose vial prepared with the number of anticipated doses at the time of preparation.

Providers may bill for:

• Preparation of a reasonable supply of allergy antigen at one time
• No more than a 12-month supply
• Unused prepared antigen left over after the patient begins treatment

Patients may ask that the antigen is mixed in preparation of immunotherapy. However, if the patient doesn’t begin the treatment, the patient is responsible for the cost of the preparation and provision of the antigen.

Patients should be notified of any potential liability at the time they request treatment. Providers should use the Advance Notice of Member Responsibility form to document that they have informed patients of this potential liability.

To sum up, Blue Cross shouldn’t be billed for an antigen that isn’t administered to the patient.

FluMist^® not covered for 2016-17 flu season

Effective Oct. 1, 2016, Blue Cross Blue Shield of Michigan is not covering the FluMist nasal spray vaccine for the 2016-17 flu season. The corresponding procedure codes are *90660 and *90672.

This decision is based on a recommendation from the Centers for Disease Control and Prevention. Data has shown that the nasal spray is less effective than flu shots in protecting against the flu.

We encourage our members to get an annual flu vaccination.

Michigan BAC and MPSERS members to participate in Medical Drug Prior Authorization Program

Beginning Jan. 1, 2017, members of the Michigan Bricklayers and Allied Crafts Health Care Fund, or Michigan BAC, and the Michigan Public School Employees Retirement System, or MPSERS, will participate in the Medical Drug Prior Authorization Program.

This program does not apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

The chart below lists the medications that are part of the Medical Drug Prior Authorization Program.

Drug names

Vitamins B6, B12 shots should only be given when medically necessary

Vitamin B6 and vitamin B12 injections and infusions should only be billed when medically necessary for patients who have a documented deficiency.

Doctors must clearly document the reason for giving vitamin B6 and vitamin B12 injections and infusions in the patient’s medical record.

We will not pay for these procedures when given for weight reduction purposes.

We’ll monitor use of 2 frequently misused E&M codes

Blue Cross Blue Shield of Michigan will closely monitor the use of two evaluation and management procedure codes that are frequently misused — office visits *99214 and *99215.

A review of how these codes are used revealed they are often based on the stored patient history in electronic medical records rather than on the services that were actually rendered. This can result in a higher-level service being billed when a lower-level service is warranted, sometimes called upcoding.

To avoid clinical inquires about E&M services you provide, be sure to carefully document and code each service according to the national coding guidelines. The CMS Evaluation and Management Services Guide is a good resource for coding guidelines.

Coverage for procedure code *61630 ending in 2017

Starting Jan. 1, 2017, Blue Cross Blue Shield of Michigan will no longer provide coverage for procedure code *61630.

Refer to the medical policy for Endovascular Procedures for Intracranial Arterial Disease (Atherosclerosis and Aneurysms), dated Nov. 1, 2016, for a list of related procedures and services that may be covered.

Reminder: Procedure codes for transitional care management

As we wrote in the August 2015 Record, procedure code *99495 is not payable for Blue Cross Blue Shield of Michigan contracts, with the exception of Federal Employee Program^® members, and procedure code *99496 is payable for all cases of transitional care management.

The provider must communicate directly with the patient or caregiver by phone, text, fax or email within two days of discharge from:

• An inpatient hospital
• A skilled nursing facility
• A community mental health center
• An outpatient observation
• A partial hospitalization

A face-to-face visit must occur within seven business days of the patient’s discharge.

Services performed during the face-to-face visit must take place in conjunction with the appropriate non-face-to-face transitional care management services outlined within the Transitional Care Management Services section of the CPT manual.

Bill new corrected original when reporting a modifier change on outpatient psychiatric claim

A replacement claim (frequency code 7) cannot be reported when changing the modifier on an OPC claim.

The modifier or the absence of a modifier on a claim identifies the level of therapist rendering the service to your patient. This changes the provider’s demographics on the claim.

As we explained in a June 2016 Record article, any change to patient or provider demographics, NPI, provider PIN or taxonomy code requires that you void or cancel your original paid claim, and report the member or provider change in a new, corrected original.

To avoid canceling your original claim, be sure you report the correct modifier on the original CMS-1500 claim form. Use field 24D-PROCEDURES OR SUPPLIES to identify the level of therapist who provided the service. Correct therapist-level codes are:

Note: For board-certified or board eligible psychiatrists, leave the code area blank.

On the CMS-1500 claim form, in field 24J - RENDERING PROVIDER ID, leave both the shaded and unshaded areas blank.

A replacement claim (frequency code 7) should be reported when changing a procedure code, charge or quantity on the claim.

Want to learn more?

For more information on outpatient psychiatric care claims, including helpful articles, examples and links, go to the Claims chapter of the OPC online provider manual.

2016 HCPCS maintenance

The Centers for Medicare & Medicaid Services recently released the following 2016 HCPCS code, retroactive to Jan. 1, 2016:

Chemo Admin

Certain high-cost products to treat skin conditions won’t be covered due to comparable alternatives

As you read in the September Record, Blue Cross Blue Shield of Michigan commercial plans don’t cover select high-cost, FDA-approved drugs for which more cost-effective therapeutic alternatives are available. This is part of an ongoing effort to address the high cost of drugs and provide the best possible value for our members.

Ultravate^®-X kits, Ultravate^® lotion, Cordran^® lotion, flurandrenolide lotion and Locoid^® lotion, which are topical products used to treat corticosteroid-responsive skin conditions, have been targeted for exclusion, effective Oct. 7, 2016. Members currently using these drugs can continue to fill prescriptions for them through Dec. 31, 2016.

The following table includes the approximate cost of the targeted drugs and the associated therapeutic alternatives:

**Approximate cost for a 30-day supply based on the average wholesale price.

In some cases, members’ out-of-pocket costs for these brand-name drugs may be lower than their copay due to manufacturer savings cards. However, the high cost of these drugs will be reflected in future premium rates and the overall claims experience for members and plans.

As part of this ongoing initiative, Blue Cross will continue to identify select high-cost drugs and will stop covering them when there are more cost-effective alternatives available for our commercial members.

FluMist^® not covered for 2016-17 flu season

Effective Oct. 1, 2016, Blue Cross Blue Shield of Michigan is not covering the FluMist nasal spray vaccine for the 2016-17 flu season. The corresponding procedure codes are *90660 and *90672.

This decision is based on a recommendation from the Centers for Disease Control and Prevention. Data has shown that the nasal spray is less effective than flu shots in protecting against the flu.

We encourage our members to get an annual flu vaccination.

Michigan BAC and MPSERS members to participate in Medical Drug Prior Authorization Program

Beginning Jan. 1, 2017, members of the Michigan Bricklayers and Allied Crafts Health Care Fund, or Michigan BAC, and the Michigan Public School Employees Retirement System, or MPSERS, will participate in the Medical Drug Prior Authorization Program.

This program does not apply to Medicare, Medicare Advantage or Federal Employee Program^® members.

The chart below lists the medications that are part of the Medical Drug Prior Authorization Program.

Drug names

Process for obtaining certain specialty drugs changes for URMBT non-Medicare members

Effective Jan. 1, 2017, non-Medicare members who are part of the UAW Retiree Medical Benefits Trust will be required to obtain certain specialty medications through Accredo, an Express Scripts specialty pharmacy, under their prescription drug benefit for the drugs to be covered. This change affects URMBT Ford, URMBT GM and URMBT Chrysler PPO and Traditional Care Network non-Medicare members.

Previously, regardless of where they were obtained, certain specialty medications may have been covered under these members’ medical plan. As of Jan. 1, 2017, these specialty medications, when obtained in the outpatient setting, will only be covered under the member’s prescription drug benefit through Accredo. If members don’t order from Accredo, they’ll be responsible for the cost.

For dates of service on or after Jan. 1, 2017, there will be a coverage review for an initial specialty medication claim submitted under the medical plan. However, subsequent submissions under the medical plan will be rejected, with instructions to the provider to submit the medication under the patient’s prescription benefit plan through Accredo. The places of service may include the home, doctor’s office or outpatient settings.

Provider reimbursement for drug administration and supplies associated with the drug administration will continue through the patient’s medical benefit.

To obtain the list of specialty medications included in this change or to submit a prescription for specialty medications on behalf of URMBT members, contact Accredo at 1-800-987-4904 or fax new prescriptions to Accredo at 1-800-391-9707.

Dose limits for Medicare members’ opioid prescriptions to take effect Jan. 1

The Centers for Medicare & Medicaid Services continues to combat the epidemic of prescription opioid abuse in the U.S. As a result, Blue Cross Blue Shield of Michigan and Blue Care Network will be required to establish a dose limitation for opioid drugs prescribed to our Medicare members. This change takes effect Jan. 1, 2017.

Safety limits for prescribed opioids
All Medicare prescription drug claims that include opioids and exceed a daily morphine equivalent dose of 250 mg will require a prior authorization before they may be dispensed at a pharmacy.

Blue Cross and BCN will calculate the daily morphine equivalent dose for each given Medicare member. We may deny an opioid prescription claim if the member’s cumulative morphine equivalent dose exceeds 250 mg across all of their claims. This daily cumulative morphine equivalent dose will be calculated using a Medicare member’s history of opioid prescription claims within our system.

Any opioid prescription claim or claims exceeding the 250 mg limit will require a prior authorization and clinical review by Blue Cross or BCN before the claims are covered at a pharmacy.

Known exceptions
CMS allows Medicare patients in certain situations to be excluded from this policy. Here are identified situations that are known exceptions from the daily morphine equivalent dose calculation:

• Hospice care
• Diagnoses or drug utilization history indicative of cancer
• Reasonable overlapping dispensing rates for prescription refills or new prescription orders for continuing fills
• Opioid usage previously determined by Blue Cross or BCN to be medically necessary through prior coverage determinations, prior authorization, pharmacy case management or appeals processes.

Prior authorization
Doctors who write prescriptions that exceed the safety limit must submit their prescriptions for a prior authorization. The prior authorization can be submitted by the doctor or his or her delegate. Please note:

• Documentation of medical necessity and acknowledgement of the significant clinical circumstance must be submitted to Blue Cross or BCN for a clinical review.

• The prescriber must demonstrate that the warranted amount of the opioid medication is needed to adequately manage the patient’s pain while being safe and appropriate.

For prior authorization, call our Clinical Help Desk at 1-800-437-3803 from 8 a.m. to 6 p.m. Monday through Friday.

Preauthorization for Medicare Advantage PPO outpatient PT and OT coming in January

As communicated in the September and October issues of The Record, Blue Cross Blue Shield of Michigan, in partnership with eviCore healthcare, is expanding its physical therapy use management program to include a preauthorization component.

Effective Jan. 1, 2017, outpatient physical and occupational therapy services for Blue Cross Medicare Plus Blue^SM members who reside in Michigan will require preauthorization. Preauthorization will be based on category assignments that are determined by 12 months of independent PT and outpatient PT claims data (both MAPPO and commercial PPO data). For details on category assignments, see the September Record.

eviCore will mail letters to providers of PT and OT services, identifying their category assignments, by mid-November. If you don’t receive a letter, contact eviCore Customer Service at 1-877-917- BLUE (2583).

Training opportunities
Blue Cross will host two seminars on the program expansion at the Lyon Meadows Conference Center on Nov. 7, 2016. A webinar of the seminars will be made available.

In addition, interactive webinars will be held throughout November and early December. The webinars will provide more detailed information about preauthorization requirements in relation to your category assignment. See the October Record for registration information.

Preauthorization
Beginning Dec. 19, 2016, you can request prior authorization online and locate the clinical worksheets and CPT code list for outpatient physical and occupational therapy services by logging in to web-DENIS.

• Click on Prior authorization.
• Enter the NPI and contract number.
• Select the service for which you are requesting prior authorization.
• Click “OK” to be redirected to the eviCore healthcare web portal and proceed with authorization.

Requests for preauthorization can also be submitted by phone at 1-877-917- BLUE (2583) or by fax at 855-774-1319, but the fastest way to obtain authorizations is online. If a prior authorization isn’t obtained for these services, claims will be denied and the provider will be responsible for the costs.

For more information
The eviCore implementation website** provides additional information, including fax forms, national guidelines, Frequently Asked Questions, Quick Reference Guide and webinar details.

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