Use our new benefit request forms for non-Medicare case management

Starting Jan. 1, 2017, when a Blue Cross Blue Shield of Michigan member with a non-Medicare Advantage commercial plan requests skilled nursing or long-term acute care hospital services that aren’t a standard benefit, our case managers will send new forms to treating providers.

The revised forms, shown at right, replace the Proposed Physician Treatment Plan/General Information Request, or PPTP/GI form. The new forms — based on InterQual^® Criteria — will help us review requests faster. You’ll no longer need to provide multiple pages of extensive clinical details, just complete the form in its entirety. However, if our case manager needs additional clinical data, we may request it from you.

When a hospital case manager requests Blue Cross case management, our assigned case manager will send you the new form to submit for review.

Note: The process isn't changing, only the forms.

Remember to encrypt protected health information

The Health Insurance Portability and Accountability Act of 1996 requires that electronically transmitted protected health information be encrypted in most circumstances.

It’s important to follow your organization’s policies regarding encryption whenever you send PHI to Blue Cross Blue Shield of Michigan. Your company’s encryption policies may apply to emails as well as data stored on a CD or USB drive.

Taking the extra time to encrypt shows a commitment to protecting the privacy of your patients. It also prevents unnecessary costs associated with disclosure of unencrypted PHI.

J0570 replaces J3490, J3590 when billing for Probuphine^® (buprenorphine)

The Centers for Medicare & Medicaid Services has established a permanent procedure code for specialty medical drug Probuphine^® (buprenorphine), effective Jan. 1, 2017.

All services from Aug. 1, 2016, through Dec. 31, 2016, will continue to be reported with code J3490 or J3590. All services performed on and after Jan. 1, 2017, must be reported with J0570.

The National Drug Code is 58284-0100-14.

Prior authorization is still required for Probuphine (buprenorphine) when reported with the new procedure code J0570, unless the group has opted out of the Specialty Pharmacy Prior Authorization Program.

J1942 replaces J3490 when billing for Aristada^®

The Centers for Medicare & Medicaid Services has established a permanent procedure code for Aristada^®, effective Jan. 1, 2017.

All services from Oct. 5, 2015, through Dec. 31, 2016, will continue to be reported with code J3490. All services performed on and after Jan. 1, 2017, must be reported with J1942.

Aristada continues to be covered for the U.S. Food and Drug Administration-approved indications as establisted on Oct. 5, 2015.

Pharmacy doesn’t require preauthorization of this drug.

J2182 replaces J3490, J3590 when billing for Nucala^® (mepolizumab)

The Centers for Medicare & Medicaid Services has established a permanent procedure code for Nucala^® (mepolizumab), effective Jan. 1, 2017.

All services from Dec. 1, 2015, through Dec. 31, 2016, will continue to be reported with codes J3490 and J3590. All services performed on and after Jan. 1, 2017, must be reported with J2182.

Specialty pharmacy prior authorization is required for all groups unless they have opted out of the Prior Authorization program.

J2786 replaces J3490, J3590 when billing for Cinqair^® (reslizumab)

The Centers for Medicare & Medicaid Services has established a permanent procedure code for specialty medical drug Cinqair^® (reslizumab), effective Jan. 1, 2017.

All services from June 1, 2016, through Dec. 31, 2016, will continue to be reported with codes J3490 and J3590. All services performed on and after Jan. 1, 2017, must be reported with J2786.

Specialty pharmacy prior authorization is required for all groups unless they have opted out of the Prior Authorization program.

J2840 replaces J3490, J3590 when billing Kanuma™

The Centers for Medicare & Medicaid Services has established a permanent procedure code for specialty medical drug Kanuma™, effective Jan. 1, 2017.

All services from May 1, 2016, through Dec. 31, 2016, will continue to be reported with codes J3490 or J3590. All services performed on and after Jan. 1, 2017, must be reported with J2840.

Specialty pharmacy prior authorization is required for all groups unless they have opted out of the Prior Authorization program.

J7175 replaces J7199 when billing for Coagadex^®

The Centers for Medicare & Medicaid Services has established a permanent procedure code for Coagadex^®, effective Jan. 1, 2017.

All services from Oct. 20, 2015, through Dec. 31, 2016, will continue to be reported with code J7199. All services performed on and after Jan. 1, 2017, must be reported with J7175.

Coagadex continues to be covered for the FDA-approved indications as establisted on Oct. 20, 2015.

Pharmacy doesn’t require preauthorization of this drug.

J7179 replaces J7199 when billing for Vonvendi

The Centers for Medicare & Medicaid Services has established a permanent procedure code for Vonvendi, effective Jan. 1, 2017.

All services from Dec. 8, 2015, through Dec. 31, 2016, will continue to be reported with code J7199. All services performed on and after Jan. 1, 2017, must be reported with J7179.

Vonvendi continues to be covered for the FDA-approved indications as establisted on Dec. 8, 2015.

Pharmacy doesn’t require preauthorization of this drug.

J7202 replaces J7199 when billing for Idelvion^® factor IX recombinant

The Centers for Medicare & Medicaid Services has established a permanent procedure code for Idelvion^® factor IX recombinant (albumin fusion protein), effective Jan. 1, 2017.

All services from March 16, 2016, through Dec. 31, 2016, will continue to be reported with code J7199. All services performed on and after Jan. 1, 2017, must be reported with J7202.

Idelvion factor IX recombinant (albumin fusion protein) continues to be covered for the FDA-approved indication as establisted on March 16, 2016.

Pharmacy doesn’t require preauthorization of this drug.

J7207 replaces J7199 when billing for Adynovate^® (antihemophilic factor recombinant) PEGylated

The Centers for Medicare & Medicaid Services has established a permanent procedure code for Adynovate^® (antihemophilic factor recombinant) PEGylated, effective Jan. 1, 2017.

All services from Nov. 13, 2015, through Dec. 31, 2016, will continue to be reported with code J7199. All services performed on and after Jan. 1, 2017, must be reported with J7207.

Adynovate (antihemophilic factor recombinant) PEGylated continues to be covered for the FDA-approved indications as establisted on Nov. 13, 2015.

Pharmacy doesn’t require preauthorization of this drug.

J7209 replaces J7199 when billing for Nuwiq^® (simoctocog alfa), antihemophilic factor (recombinant)

The Centers for Medicare & Medicaid Services has established a permanent procedure code for Nuwiq^®, effective Jan. 1, 2017.

All services from Sept. 15, 2015, through Dec. 31, 2016, will continue to be reported with code J7199. All services performed on and after Jan. 1, 2017, must be reported with J7209.

Nuwiq (simoctocog alfa), antihemophilic factor (recombinant) continues to be covered for the FDA-approved indications as establisted on Sept. 15, 2015.

Pharmacy doesn’t require preauthorization of this drug.

J7320 replaces Q9980 when billing for Hyaluronan or derivative, GenVisc 850

The Centers for Medicare & Medicaid Services has established a permanent procedure code for Hyaluronan or derivative, GenVisc 850, effective Jan. 1, 2017.

All services from Jan. 1, 2016, through Dec. 31, 2016, will continue to be reported with code Q9980. All services performed on and after Jan. 1, 2017, must be reported with J7320.

Hyaluronan or derivative, GenVisc 850, continues to be covered as establisted on Jan. 1, 2016.

Pharmacy doesn’t require preauthorization of this drug.

J7322 replaces J3490 when billing for Hymovis^®

The Centers for Medicare & Medicaid Services has established a permanent procedure code for Hymovis^® (hyaluronate, mod., non-crosslink), effective Jan. 1, 2017.

All services from Sept. 9, 2015, through Dec. 31, 2016, will continue to be reported with code J3490. All services performed on and after Jan. 1, 2017, must be reported with J7322.

Hymovis continues to be covered for the indications as establisted on Sept. 9, 2015.

Pharmacy doesn’t require preauthorization of this drug.

J7342 replaces J3490 when billing Otiprio^® (ciprofloxacin)

The Centers for Medicare & Medicaid Services has established a permanent procedure code for Otiprio^® (ciprofloxacin), effective Jan. 1, 2017.

All services from Dec. 10, 2015, through Dec. 31, 2016, will continue to be reported with code J3490. All services performed on and after Jan. 1, 2017, must be reported with J7342.

Otiprio continues to be covered for the FDA-approved indications as establisted on Dec. 10, 2015, for the treatment of pediatric patients with bilateral otitis media with effusion undergoing tympanostomy tube placement.

Pharmacy doesn’t require preauthorization of this drug.

J8670 replaces Q9981 when billing Varubi™ (rolapitant)

The Centers for Medicare & Medicaid Services (CMS) has established a permanent procedure code for Varubi™ (rolapitant), effective Jan. 1, 2017.

All services from July 1, 2016, through Dec. 31, 2016, will continue to be reported with code Q9981. All services performed on and after Jan. 1, 2017, must be reported with J8670.

Varubi™ (rolapitant) oral continues to be covered for the approved indications as establisted on July 1, 2016, for the oral antiemetic agent used to prevent delayed chemotherapy-induced nausea and vomiting in patients receiving chemotherapy.

Pharmacy doesn’t require preauthorization of this drug.

BlueCard^® connection: How do I report deluxe vision services for members enrolled outside of Michigan?

When billing deluxe vision services, such as V2025, V2520 or V2745, for Blue Cross members enrolled in an out-of-state plan, please use a claim form separate from one with standard, non-deluxe services to ensure the claims are processed accurately.

You can find more information on reporting vision care services in the “Vision Care Services” chapter of our online optometrist provider manual, located in web-DENIS.

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.

More clarification: Requirements for sleep testing

In a recent publication of the medical policy for sleep testing, we omitted some essential requirements. To clarify, the requirements are as follows:

• In order to perform and get reimbursed for in-center or out-of-center sleep testing, a doctor must be board-certified in sleep medicine by the American Board of Medical Specialties or the American Board of Sleep Medicine.
• Any M.D. or D.O. may prescribe a sleep test as long as it’s performed and interpreted by a doctor who is board-certified in sleep medicine.
• Follow our prior authorization program for in-lab sleep testing. To obtain an authorization you must be board-certified.

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.

Blue Cross extends continuity of care for members whose practitioners leave PPO network

Providers ending their participation in a Blue Cross Blue Shield of Michigan plan or network or who have been terminated from a Blue Cross plan or network with or without cause (for a non-quality or non-fraud related reason) have the option to continue treating members subject to the conditions stated below. At Blue Cross, this process is referred to as Continuity of Care. This includes primary care providers and specialists affiliated with the TRUST, EPO or BPP networks and ancillary providers that participate in the Blue Cross Traditional network.

Note: The option to continue care doesn’t apply to practitioners whose participation in a Blue Cross plan or network ends because of fraud or failure to meet quality standards.

Practitioners who want to continue a member’s care after they leave the TRUST, EPO and BPP networks are required by state law to provide members with a written notice within 15 days of the date they leave the provider network. This notice may be posted in the practitioner’s office or sent to members in a card or letter informing them of the practitioner’s intent to leave the network.

If a member wants to continue care after his or her practitioner leaves the network and enters into a written continuity of care arrangement, the following limitations apply:

Coverage limitations

Patients in an “active course of treatment” until the treatment is complete or for 90 days from the termination date, whichever is shorter. Active course of treatment is described as:

• An ongoing course of treatment for a life-threatening condition
• An ongoing course of treatment for serious acute condition
• The second or third trimester of pregnancy, through the postpartum period (if member is in the second or third trimester at the time of contract termination)
• An ongoing course of treatment for a health condition for which a treating physician or health care provider attests that discontinuing care by that physician or health care provider would worsen the condition or interfere with anticipated outcomes
• Terminal illness (care directly related to a diagnosed illness may continue for the remainder of the member’s life, if the member was diagnosed with the terminal illness prior to the date of contract termination)

Payment conditions

• As long as the approved continuity of care period is in effect, the practitioner is required to accept Blue Cross’ payment as payment in full, less any in-network copays or deductibles that the member may be required to pay.

• The above rules apply only to members who were suggested under the practitioner’s care before his or her termination from the network. Continuation beyond the designated times will result in out-of-pocket expenses for the member in the form of out-of-network copays and deductibles.

• Continuity of care isn’t automatic and must be initiated by the practitioner. When billing TRUST/BPP members after the termination is effective, the practitioner will need to include for each claim submission:
• A CMS-1500 paper claim form
• A copy of the continuity of care arrangement letter, signed by both the patient or subscriber and the provider
• Supporting medical records

• Practitioners should submit all the forms and correspondence listed above to:
  Attn: Continuity of Care Senior Analyst
  Blue Cross Blue Shield of Michigan
  600 E. Lafayette Blvd., MC 607A
  Detroit, MI 48226-9942

For EPO practitioners

EPO claims for continuity of care don’t follow the claims submission guidelines listed above. If you have any questions regarding the process, refer to your provider manual.

Reminder: Update your Provider Authorization form when changes occur

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

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

Keep these items in mind when changes occur. You should review your provider authorization information if you’ve:

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

You must update your provider authorization information if you will be sending claims using a different submitter ID or route your 835s to a different unique receiver/trading partner ID.

To make changes to your EDI setup:

• Go to bcbsm.com
• Click on Providers at the top of the page.
• Click on Quick Links, located on the right side of the page.
• Click on Electronic Connectivity (EDI) and then Update your Provider Authorization Form under EDI Agreements.

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

Reminders about 2017 Blue Cross qualification forms

You’re probably seeing patients who ask you to complete and return their 2017 Blue Cross Blue Shield of Michigan qualification forms.

Here are some reminders about completing the forms:

• No changes were made to the qualification forms for 2017.
• Perform the cotinine test only if the qualification form indicates it’s required, as it’s not a standard covered benefit.
• Make sure all fields on the form are completed in their entirety before submitting for accurate processing.
• If you’re a Michigan health care provider, submit Blue Cross qualification forms electronically to improve processing time. Out-of-state physicians, or those who can’t submit the form electronically, can fax completed forms to 1-866-392-6496.
• Continue using the Healthy Blue Living^SM qualification form for Blue Care Network members.

2017 criteria for medically necessary behavioral health treatment posted on web-DENIS

Several medical necessity criteria for behavioral health treatment have been updated, effective Jan.1, 2017. You can now access these documents on web-DENIS.

For 2017, updates have been made to the following:

• The New Directions Behavioral Health Medical Necessity Criteria. This document identifies the criteria for medically necessary psychiatric and substance abuse treatment.
• The medical necessity criteria for repetitive transcranial magnetic stimulation, also known as rTMS
• The BCBSM/New Directions Applied Behavior Analysis Medical Necessity Criteria

You can print or copy any of the above documents directly from web-DENIS. Follow these steps:

1. Log in to web-DENIS.
2. In the left navigation, click on BCBSM Provider Publications and Resources.
3. Click on Newsletters & Resources.
4. Under Other Resources, click on Clinical Criteria & Resources.
5. Scroll down to theBehavioral Health Clinical Criteria section of the page and click on the document you wish to copy or print.

If you have any questions, call Behavioral Health Services in the Ancillary Program Management department at 313-448-7745.

Reminder: Update your Provider Authorization form when changes occur

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

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

Keep these items in mind when changes occur. You should review your provider authorization information if you’ve:

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

You must update your provider authorization information if you will be sending claims using a different submitter ID or route your 835s to a different unique receiver/trading partner ID.

To make changes to your EDI setup:

• Go to bcbsm.com
• Click on Providers at the top of the page.
• Click on Quick Links, located on the right side of the page.
• Click on Electronic Connectivity (EDI) and then Update your Provider Authorization Form under EDI Agreements.

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

2017 criteria for medically necessary behavioral health treatment posted on web-DENIS

Several medical necessity criteria for behavioral health treatment have been updated, effective Jan.1, 2017. You can now access these documents on web-DENIS.

For 2017, updates have been made to the following:

• The New Directions Behavioral Health Medical Necessity Criteria. This document identifies the criteria for medically necessary psychiatric and substance abuse treatment.
• The medical necessity criteria for repetitive transcranial magnetic stimulation, also known as rTMS
• The BCBSM/New Directions Applied Behavior Analysis Medical Necessity Criteria

You can print or copy any of the above documents directly from web-DENIS. Follow these steps:

1. Log in to web-DENIS.
2. In the left navigation, click on BCBSM Provider Publications and Resources.
3. Click on Newsletters & Resources.
4. Under Other Resources, click on Clinical Criteria & Resources.
5. Scroll down to theBehavioral Health Clinical Criteria section of the page and click on the document you wish to copy or print.

If you have any questions, call Behavioral Health Services in the Ancillary Program Management department at 313-448-7745.

Utilization Review to conduct audit survey

The Utilization Review department performs post-payment audits of facility providers. These audits are usually conducted on-site at the provider’s location, on the internet or as a desk audit. When the audit is complete, we send a short audit survey so you can give us your opinion of the review process.

When our audit is done, the hospital contact person will receive an email, from the lead auditor, with a link to access the survey. We’ll also provide directions for completing the survey. Make sure you complete your responses for the type of audit conducted at your facility. Please complete the survey within two weeks from the date of the original survey.

Your feedback is important to us and will help us improve our service to you.

If you have any problems accessing the link, contact your lead auditor.

Check out our updated orthotic devices policy

We have updated our orthotic devices policy, effective Nov. 1, 2016.

To see the updated policy, check out the billing chart.

HEDIS^® reviews begin in February

Each year, from February through May, Blue Cross Blue Shield of Michigan conducts Healthcare Effectiveness Data and Information Set medical record reviews. This year, Inovalon™ will conduct these HEDIS** reviews for Blue Cross PPO and Medicare Plus BlueSM PPO members who received services in Michigan during 2016.

For the HEDIS reviews, Inovalon looks for details that may not have been captured in claims data, such as blood pressure readings, HbA1c lab results, colorectal screenings and body mass index. This information helps us improve our member quality initiatives.

Inovalon will contact you to schedule an appointment for a HEDIS review or request that you fax the necessary records. HEDIS also needs proof of service documentation for data collected from a medical record. Blue Cross will reimburse you $5 for each chart Inovalon receives.

These reviews are in addition to the out-of-state medical-record review process performed by Verscend^® for the Blue Cross and Blue Shield Association.

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

CMS requires opioid dosing safety edit

Starting Jan. 1, 2017, the Centers for Medicare & Medicaid Services is requiring health care plans to do a point-of-sale safety edit on opioid drugs (see the full list of products below).

What you need to know

• At the point of sale, an opioid claim will stop if it causes a member's cumulative, daily, morphine-equivalent dose to exceed 250 mg.
• When a member's cumulative-daily dose exceeds the 250 mg morphine-equivalent dose, a Blue Cross Blue Shield of Michigan clinical review is required.
• This could affect any opioid-prescribing doctor within a member's care model.
• The doctor who orders the opioid prescription that exceeds the 250 mg threshold will be subject to the clinical review.
• The edit can be resolved when the threshold-exceeding prescribing doctor or his or her delegate submits a prior-authorization request.

About the clinical review
You must submit medical-necessity documentation and acknowledge the significant clinical circumstance. The doctor must demonstrate the need for the prescribed amount of opioid medication. And the doctor must show that the medication will adequately manage the patient's pain and is safe and appropriate.

Helpful link
Use the Michigan Automated Prescription System to help you track a member's controlled substance prescription use. Find it at www.michigan.gov/mimapsinfo**.

List of opioid products

• Butorphanol
• Hydromorphone
• Opium
• Buprenorphine
• Levorphanol
• Oxycodone
• Codeine
• Meperidine
• Oxymorphone
• Dihydrocodeine
• Methadone
• Pentazocine
• Fentanyl
• Fentanyl citrate
• Morphine
• Tapentadol
• Hydrocodone
• Nalbuphine
• Tramadol

**Blue Cross Blue Shield of Michigan does not control this website or endorse its general content.