We’re moving from prenotification system to e-referral

As part of Blue Cross Blue Shield of Michigan’s utilization management efforts, we’re moving from the prenotification system to e-referral, starting July 31, 2017.

If you’ve been using the prenotification system for services requiring authorization (also called prior authorization or preauthorization), you’ll be switching to e-referral. Blue Care Network has been using e-referral for the past several years.

If you’re not an e-referral user already, you can sign up on the Sign Up or Change a User page on the ereferrals.bcbsm.com website. The page contains information providers need to sign up for access to the e-referral system.

We’ll provide more information on this change in future issues of The Record.

How to prepare for InterQual books’ format change to electronic only

Starting April 2017, McKesson Health Solutions’ InterQual^® Criteria books will only be available electronically. Blue Cross Blue Shield of Michigan will begin using the new electronic criteria in early August 2017.

New and updated InterQual Criteria will only be available electronically. You won’t be mailed an InterQual book in 2017 or beyond. Instead, every user will have access to the criteria through the InterQual^® View application.

Access to InterQual View

Facilities will need to register for access to the McKesson Download Central website and the McKesson Health Solutions’ Customer Hub to facilitate download, installation and use of InterQual View. Facilities with a direct license to McKesson may already have done this.

About Download Central

Download Central, which is personalized for your organization, displays your available software updates and accompanying product documentation. Use Download Central to download InterQual View and your annual software and criteria releases. You’ll need to access Download Central to download a yearly software and criteria release.

You can register for Download Central using the Registration Information link on the Download Central home page at mckesson.subscribenet.com.

In early April, you’ll receive a letter with your account ID, which you’ll need to register. You can also get your account ID by:

• Looking on the My Company’s information page on Customer Hub at mhscustomerhub.mckesson.com
• Emailing Product Support at CESupport@mckesson.com
• Calling 1-800-274-8374

When your registration is complete, you’ll receive a welcome email with instructions on setting up your password and accessing Download Central. If you complete the Download Central registration process and don’t receive a welcome email within 48 hours, email DigitalServices@McKesson.com.

About Customer Hub

Customer Hub is McKesson’s online support website. It provides customers the product support information they need, as quickly as possible, 24 hours a day, seven days a week. It provides customers with access to McKesson’s knowledge base to help quickly resolve product issues. It also has a document library that includes FAQs, release notes, clinical revision documents and links to other key resources.

To register for Customer Hub, send an email to MHSCustomerHub@McKesson.com and include your:

• Facility's full name
• City and state
• First and last name
• Job title
• Facility email address (personal email addresses aren’t accepted)
• Phone number

 McKesson will complete your registration and provide instructions on how to access the Customer Hub.

Support

For more information on how to use Download Central and install InterQual View, click here.

If you have questions, contact McKesson Health Solutions' Product Support by email at cesupport@mckesson.com or call 1-800-274-8374. If you have any Blue Cross-specific questions, contact your provider consultant.

Introducing Blue Cross and BCN hip and knee replacement bundled payment arrangement

Health care reform is driving significant change in health care, with cost becoming paramount to consumers. In addition to a reasonable price, consumers want access to quality, local health care providers and services.

In response, Blue Cross Blue Shield of Michigan and Blue Care Network released a Request for Application for a two-year hip and knee bundled payment arrangement to begin in January 2018. The arrangement will entail a single price for all services related to hip or knee replacement — from surgery through recovery. You and providers across the state are eligible to submit a response to the RFA, expressing interest in the program.

The goal of this arrangement is to:

• Reduce variability in cost and quality among hip and knee replacement procedures across the state.
• Improve care coordination and patient outcomes.
• Encourage the shift toward outpatient hip and knee replacement, when clinically appropriate.

The bundled payment arrangement will be one of many benefit options available to Blue Cross and BCN commercial members seeking high value care for their hip and knee replacement procedures. It doesn’t constitute an exclusive or narrow network.

There are quality standards providers must meet to participate in this arrangement. Providers who don’t meet the criteria will remain eligible to receive payment for these services according to their traditional fee-for-service contracts with Blue Cross and BCN.

If you’re interested in participating, you must submit your completed RFA document and a signed copy of the program addendum to Blue Cross and BCN by 5 p.m. Tuesday, April 18, 2017.

For more information about the program or a paper copy of the RFA and contract, please send an email request to HipKneeRFA@bcbsm.com.

Prescriptions issued by departicipated practitioners won’t be covered

Blue Cross Blue Shield of Michigan has established a “departicipation” process, which allows the company to terminate a provider from its provider networks if specific criteria are met. Effective immediately, if it’s in accordance with the member’s benefits, Blue Cross will no longer cover any prescriptions written by departicipated practitioners.

CPT codes added

The Centers for Medicare & Medicaid Services has added 11 new codes as part of its regular quarterly CPT updates. The codes are listed below.

Blue Cross, BCN will no longer cover Glumetza^®, starting April 1

To provide the best value for our members, Blue Cross Blue Shield of Michigan and Blue Care Network commercial plans will no longer cover brand-name and generic versions of Glumetza^®, effective April 1, 2017. Blue Cross members currently using these medications will be covered through April 30.

Glumetza is used to treat diabetes.

Blue Cross and BCN will provide coverage for generic Glucophage^®, generic Glucophage^® XR and generic Fortamet^®. Here’s a look at the price comparison based on the average cost for a 30-day supply:

**Approximate cost for a 30-day supply based on daily dose of 2,000mg/day and the average wholesale price. 
^Approximate cost for a 30-day supply based on daily dose of 1,500mg/day and the average wholesale price.
^^Approximate cost for a 30-day supply based on daily dose of 2,550mg/day and the average wholesale price.

If you prescribe Glumetza, discuss the covered alternatives with your patients.

BlueCard^® connection: Why did my BlueCard coordination of benefits claim finalize differently than I expected?

Similar to secondary and tertiary COB claims that you report for Michigan-enrolled members, your reimbursement amount for BlueCard COB claims could be affected by:

• The other carrier’s allowed amount
• A group contracted COB reimbursement policy
• The total charges
• Member cost sharing liability, as determined by the member’s home plan

To ensure that your BlueCard COB claim is processed correctly:

• Report the actual paid amount for the primary or secondary payer.
• Exclude any contractual allowances in the prior paid amount.
• Carefully review the payment information from all payers.

If you disagree with how one of your claims finalized, contact Provider Inquiry for assistance. A representative will work with you to confirm the claim processed as reported and may contact the appropriate plan on your behalf.

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.

PARS to provide additional information in June

Beginning June 30, 2017, the Provider Automated Response System, or PARS, will offer the option to obtain claims information. You’ll be able to get:

• Claims status, payment and rejection details
• Check information

Benefits and eligibility will still be provided through PARS.

We’ll provide an update in a future Record article.

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 changing practitioner fees July 1

Blue Cross Blue Shield of Michigan will change practitioner fees, effective with dates of service on or after July 1, 2017. This change applies to services provided to our Traditional, TRUST, Blue Preferred Plus^SM and Blue Cross^® Metro Detroit EPO members, regardless of customer group.

Blue Cross will use the 2017 Medicare resource-based relative value scale for most relative value unit-priced procedures for dates of service on and after July 1. Most fees are currently priced using the 2016 values.

At the same time, the conversion factor used to calculate anesthesia base units for anesthesia procedures will increase to $58.65 throughout Michigan. Also effective July 1, the percentage weight for the QK or QY modifier will be adjusted from 56 percent to 55 percent, and the QX modifier will be adjusted from 44 percent to 45 percent.

Each year, Blue Cross adjusts its fee schedule to add the equivalent of 1.5 percent to support an increase in Value-Based Reimbursement. This is a continuation of the approach we have taken in the past, as we transition from a pure fee-for-service payment model to one where the fees reflect the delivery of the service and the overall value of services delivered to the patient.

Fee schedules effective July 1 will be available on web-DENIS on April 1. To find fee schedule information on web-DENIS:

• Click the Provider Publications and Resources page.
• Click on Entire Fee Schedules and Fee Changes.

Only claims submitted with dates of service on or after July 1 will be reimbursed at the new rates.

Note: Physician Group Incentive Program allocation of professional fees remain the same this year.

For more information, contact your provider consultant.

RC Claim Assist now available to providers

RC Claim Assist, created by RJ Health Systems, is a free resource now available to Blue Cross Blue Shield of Michigan and Blue Care Network contracted providers who bill for drugs covered under the medical benefit. RC Claim Assist should only be used for claims submitted for Blue Cross and BCN commercial members.

Benefits of RC Claim Assist

• It provides a comprehensive overview of HCPCS and CPT drug codes, product names and national drug codes.
• It offers complete drug information on package-size billable units and reference pricing.

Things to know

• The tool should be used as a general reference only in conjunction with other resources, such as applicable fee schedules.
• The tool provides real-time data, reflecting information that’s valid as of the day and time you use the tool.
• The tool doesn’t include benefit, payment or medical policy.

How do I access RC Claim Assist?
Go to the RC Claim Assist log-in page. **

You’ll register to use RC Claim Assist by completing the following steps:

1. Enter your national provider identifier and click Submit.
2. Enter your first and last name.
3. You’ll then be prompted to create a unique password.

You can find more information, including an instructional video, on the RC Claim Assist website** under the About tab.

Questions?

• If you have questions about the data you see on RC Claim Assist, send an email to info@rjhealthsystems.com.
• If you have questions about billing or claims, contact Provider Inquiry.
• If you have questions about a claim that are contractual or complex in nature, contact your provider consultant.

**Blue Cross Blue Shield of Michigan and Blue Care Network do not control this website or endorse its general content.

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 setup process for the electronic data interchange. All EDI trading partners must complete a TPA 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 the information on your Provider Authorization form 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 835 files

You must update your Provider Authorization form if you’ll send claims using a different submitter ID or route your 835 files to a different unique receiver or trading partner ID.

To make changes to your EDI setup, visit bcbsm.com/providers and follow these steps:

• Scroll down, and click on Quick Links on the right side of the page.
• Click on Electronic Connectivity (EDI).
• Scroll down to the EDI agreements section, and click on Update your Provider Authorization Form.

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

We’re updating our process for making group changes

Soon, we’re removing the Group Change Form from bcbsm.com/providers. Authorized individuals will need to make any necessary group changes by using the Provider Enrollment and Change Self-Service online application.

If you aren’t currently registered for online enrollment and change processing, here’s how you can register:

1. Go to bcbsm.com/providers.
2. Hover your mouse over Join Our Network, and click on Enrollment and Changes.
3. Click on self-service FAQ.
4. Click on How do I sign up?

If you don’t have access to Provider Secured Services, you’ll need to register. You’ll find instructions under the How do I sign up? link found in Step 4 above. This only applies to professional group providers and professional group providers’ billing services. And it doesn’t matter what Blue Cross Blue Shield of Michigan or Blue Care Network coverage your patients may have.

Note: All authorized individuals in your office need to request their own individual user ID for Provider Secured Services.

Once you receive Provider Enrollment and Change Self-Service access, you can sign in to the application to submit group changes electronically.

For more information, contact Provider Enrollment and Data Management at 1-800-822-2761.

With updates to WebPass, behavioral health vendor aims to help providers

New Directions, which manages behavioral health services for our PPO members, recently launched a new version of WebPass.

Most preauthorization requests and care management referrals are sent to New Directions through WebPass, a secure internet portal. Using provider feedback, New Directions made updates to WebPass to improve the process for submitting concurrent care requests.

Enhancements to WebPass include an information carry-over feature. This new feature will copy information submitted on the Initial Request form and on the previously submitted Continued Stay Review forms and use it to pre-populate all subsequent Continued Stay Review forms. No more cutting and pasting from one review to the next.

You’ll be able to review the information carried over to decide if it should be left unchanged or edited based on the member’s current condition. Your edits and the original submission information will be clearly displayed, so you can be assured that no changes are made without your approval.

To make this feature work, New Directions is updating the existing Concurrent Request form to match the Initial Request form.

Want more information? A web-based training will be available to explain the new information carry-over feature. Or contact us at providerrelations@ndbh.com.

Need to sign up for WebPass?
Send an email to prwebpass@ndbh.com with a list of all staff members who need access to WebPass. Indicate the staff members’ first and last names, email addresses and the tax ID of the organization. Also indicate at least one administrator for the organization.

You may also list multiple points of contact. The administrator will be responsible for notifying New Directions of any new staff who require access to WebPass, as well as any who no longer need it.

Questions? Suggestions? Email prwebpass@ndbh.com.

Provider forums coming to a town near you

Blue Cross Blue Shield of Michigan and Blue Care Network provider forums are coming to you. We’ve scheduled a series of provider forums across the state focusing on topics of interest to providers. A forum scheduled for hospitals is noted at the end of the list.

The forums will cover topics such as:

• 2017 coding and documentation updates for ICD-10 CM, CPT and HCPCS (morning)
• HEDIS^® updates (morning)
• Patient experience (morning)
• Blue Cross Complete update (afternoon)
• Review of Blue Cross and BCN authorizations (afternoon)
• Products at a glance (afternoon)
• Who to contact at Blue Cross and BCN (afternoon)
• Blue Card update (afternoon)
• Provider enrollment updates (afternoon)

Schedule of events:

• Registration begins at 7:30 a.m. The morning session starts at 8 a.m. and includes a continental breakfast. The afternoon session begins at noon and includes lunch.
• You can register for the full day, or you can choose to attend just the morning or afternoon session.

We look forward to seeing you.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Two medications to be removed from the Medical Drug Prior Authorization Program

Beginning July 1, 2017, Delatestryl^® (testosterone enanthate) and DepoDelatestryl^®-Testosterone (testosterone cypionate) will be removed from the required Medical Drug Prior Authorization Program List.

Below are all the medications that are part of the Medical Drug Prior Authorization Program.

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

Blue Cross Blue Shield of Michigan reserves the right to change the prior authorization list at any time.

Specific self-administered drugs will no longer be part of members’ medical benefit coverage

As of July 1, 2017, specific self-administered drugs will no longer be covered under members’ medical benefits. See the list of drugs and associated HCPCS codes below:

Specialty drug to be added to Medical Drug Prior Authorization Program July 1

Beginning July 1, 2017, one additional specialty drug will require prior authorization by Blue Cross Blue Shield of Michigan before it will be covered under the member's medical benefits.

Prior authorization is just a clinical review approval, not a guarantee of payment. Providers will need to verify the necessary coverage for this medical benefit. Our office will accept the medical drug prior authorization request forms with supporting documentation for the newly added drug as early as June 15, 2017.

Starting July 1, 2017, the following drug will need prior authorization:

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

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

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

Below are all the medications that are part of the Medical Drug Prior Authorization Program.

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

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

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 setup process for the electronic data interchange. All EDI trading partners must complete a TPA 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 the information on your Provider Authorization form 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 835 files

You must update your Provider Authorization form if you’ll send claims using a different submitter ID or route your 835 files to a different unique receiver or trading partner ID.

To make changes to your EDI setup, visit bcbsm.com/providers and follow these steps:

• Scroll down, and click on Quick Links on the right side of the page.
• Click on Electronic Connectivity (EDI).
• Scroll down to the EDI agreements section, and click on Update your Provider Authorization Form.

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

With updates to WebPass, behavioral health vendor aims to help providers

New Directions, which manages behavioral health services for our PPO members, recently launched a new version of WebPass.

Most preauthorization requests and care management referrals are sent to New Directions through WebPass, a secure internet portal. Using provider feedback, New Directions made updates to WebPass to improve the process for submitting concurrent care requests.

Enhancements to WebPass include an information carry-over feature. This new feature will copy information submitted on the Initial Request form and on the previously submitted Continued Stay Review forms and use it to pre-populate all subsequent Continued Stay Review forms. No more cutting and pasting from one review to the next.

You’ll be able to review the information carried over to decide if it should be left unchanged or edited based on the member’s current condition. Your edits and the original submission information will be clearly displayed, so you can be assured that no changes are made without your approval.

To make this feature work, New Directions is updating the existing Concurrent Request form to match the Initial Request form.

Want more information? A web-based training will be available to explain the new information carry-over feature. Or contact us at providerrelations@ndbh.com.

Need to sign up for WebPass?
Send an email to prwebpass@ndbh.com with a list of all staff members who need access to WebPass. Indicate the staff members’ first and last names, email addresses and the tax ID of the organization. Also indicate at least one administrator for the organization.

You may also list multiple points of contact. The administrator will be responsible for notifying New Directions of any new staff who require access to WebPass, as well as any who no longer need it.

Questions? Suggestions? Email prwebpass@ndbh.com.

Provider forums coming to a town near you

Blue Cross Blue Shield of Michigan and Blue Care Network provider forums are coming to you. We’ve scheduled a series of provider forums across the state focusing on topics of interest to providers. A forum scheduled for hospitals is noted at the end of the list.

The forums will cover topics such as:

• 2017 coding and documentation updates for ICD-10 CM, CPT and HCPCS (morning)
• HEDIS^® updates (morning)
• Patient experience (morning)
• Blue Cross Complete update (afternoon)
• Review of Blue Cross and BCN authorizations (afternoon)
• Products at a glance (afternoon)
• Who to contact at Blue Cross and BCN (afternoon)
• Blue Card update (afternoon)
• Provider enrollment updates (afternoon)

Schedule of events:

• Registration begins at 7:30 a.m. The morning session starts at 8 a.m. and includes a continental breakfast. The afternoon session begins at noon and includes lunch.
• You can register for the full day, or you can choose to attend just the morning or afternoon session.

We look forward to seeing you.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

We’re making some changes in how we process high-cost claims

We’re implementing several enhancements to our current process for handling high-cost claims to better meet the needs of our provider partners and customers.

Enhancements include expediting prospective payments and expanding pre-payment high-dollar reviews.

Health care providers have told us they’re dissatisfied with the timeliness of the prospective payment process for high-cost claims and the disruption caused by post-pay audits. They’re also seeking pre-pay solutions as a way to improve payment accuracy, avoid overpayment recoveries and control unnecessary costs.

To help us address these challenges, we’ve established a strategic relationship with Equian, an industry leader in pre-pay solutions. Starting May 1, 2017, Equian will begin reviewing certain types of high-cost inpatient claims to detect and resolve errors before payment. Equian’s advanced analytics and service delivery model helps ensure their reviews are completed within five days, using only an itemized bill for input.

We’ve already made several enhancements to our process. For example, the process of identifying outliers for review will occur weekly versus monthly starting in mid-April 2017. And we’ve streamlined internal processes and approval workflows. We expect these changes will accelerate prospective payments by at least four weeks.

The result we hope to achieve by these changes is that all claims will be paid right the first time. This will reduce administrative costs and the need for multiple adjustments, speed up claims payments and help us build trust with our provider partners about the integrity of our payment process.

We’re collaborating extensively with health care providers to make sure these changes are implemented in a way that meets their needs and the needs of our members. As part of that effort, we hosted a webinar with key facilities Feb. 22.

If you have any questions, contact your provider consultant.

Skilled nursing facilities don’t need PT or OT preauthorizations for Medicare Plus Blue^SM PPO members

Blue Cross Blue Shield of Michigan doesn’t require preauthorization for outpatient physical therapy or occupational therapy services provided to Medicare Plus Blue^SM PPO members in skilled nursing facilities.

Recently, there was some confusion that skilled nursing facilities needed to obtain preauthorizations for Medicare Plus Blue PPO members who receive outpatient PT or OT services.

We’re reviewing the possibility of including these facilities at a later date. If we do include skilled nursing facilities, we’ll communicate that change in The Record and on web-DENIS. We apologize for any confusion.

Sign up for our 2017 Michigan hospital networking sessions

Blue Cross Blue Shield of Michigan will host a series of networking sessions to give hospitals the information they need to do business with us. The sessions include information about hospital billing, medical policy, Medicare Advantage, Blue Care Network, BlueCard^®, Blue Cross^® Complete and Medicaid.

The sessions are from 10 a.m. to 2 p.m., with sign-in at 9:30 a.m. at our Lyon Meadows Conference Center. We’ll provide $7 lunch vouchers for use in the conference center’s cafeteria. Below are the session dates:

To register, send an email to SEFacilityEducationRegistration@bcbsm.com. When registering, be sure to suggest topics for discussion at future meetings.

Reminder: Register today for annual hospital forum in Frankenmuth

Blue Cross Blue Shield of Michigan invites you to attend the annual hospital morning forum, sponsored by the Benefit Administration Committee. This year’s forum is Wednesday, May 3, 2017.

The event will include information on web-DENIS, BlueCard^®, AIM and Medicare Advantage. If you have any other agenda topic suggestions, please include them in your registration, and we’ll attempt to address them at the forum.

The forum starts with an information fair during registration, followed by classroom-style presentations. A lunch featuring Frankenmuth’s famous chicken will be served after the presentations. Immediately following lunch, from 1 to 2 p.m., there will be optional training on AIM.

To register, click here.

RSVP by clicking on the link above by Friday, April 28. Your response is also an RSVP for lunch.

Two medications to be removed from the Medical Drug Prior Authorization Program

Beginning July 1, 2017, Delatestryl^® (testosterone enanthate) and DepoDelatestryl^®-Testosterone (testosterone cypionate) will be removed from the required Medical Drug Prior Authorization Program List.

Below are all the medications that are part of the Medical Drug Prior Authorization Program.

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

Blue Cross Blue Shield of Michigan reserves the right to change the prior authorization list at any time.

Specific self-administered drugs will no longer be part of members’ medical benefit coverage

As of July 1, 2017, specific self-administered drugs will no longer be covered under members’ medical benefits. See the list of drugs and associated HCPCS codes below:

Specialty drug to be added to Medical Drug Prior Authorization Program July 1

Beginning July 1, 2017, one additional specialty drug will require prior authorization by Blue Cross Blue Shield of Michigan before it will be covered under the member's medical benefits.

Prior authorization is just a clinical review approval, not a guarantee of payment. Providers will need to verify the necessary coverage for this medical benefit. Our office will accept the medical drug prior authorization request forms with supporting documentation for the newly added drug as early as June 15, 2017.

Starting July 1, 2017, the following drug will need prior authorization:

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

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

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

Below are all the medications that are part of the Medical Drug Prior Authorization Program.

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

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

Clarification: MESSA excluded from the quantity, frequency limitations for orthopedic footwear and therapeutic shoes

The March Record article titled “Orthopedic footwear, therapeutic shoes will have quantity, frequency limitations, starting April 2017” should have stated that MESSA is excluded from the quantity and frequency limitations for the procedure codes below.

New prior authorization requirements begin this summer

This summer, Blue Cross Blue Shield of Michigan Medicare Advantage will start a new prior authorization program. Services that will require prior authorization include:

• Select specialty medications covered under the Medicare Part B medical benefit. The selected medications are not self-administered and must be administered (via injection or infusion) by a doctor or health care professional. This program will begin July 5, 2017.
• Select surgical procedures. This program will begin July 31, 2017.

Doctors must obtain prior authorization and verify patient benefits to be eligible for payment for administering these services. If a prior authorization isn’t obtained before services are rendered, the claim will be rejected. At that time, a doctor may still submit a request and obtain authorization within 120 days of the date of service, even though the patient has already received the services. However, the patient must meet all of the requirements and have the necessary coverage for the claim to be payable.

Authorization isn’t a guarantee of payment. Benefits and eligibility must be determined at the time services are rendered.

Blue Cross is creating this utilization management program to respond to concerns from many of our major group customers about potential safety issues and appropriate utilization of these services. A few of the services included in the program are listed at the end of the article. A complete code listing subject to the new requirement will be available on the Blue Cross provider site before the program launches.

On an ongoing basis, we’ll evaluate the program and may add or remove new drugs or procedures from the prior authorization list. When this happens, we’ll notify you.

Providers will submit authorization requests for these services electronically. Submitting these requests electronically is the preferred method because it saves time and allows you to view the status of the request at any time.

Part B drug requests should be submitted starting July 5, 2017, through NovoLogix^®, a secure online tool. NovoLogix allows providers to obtain real-time status checks on prior authorizations and to obtain immediate approvals for certain medications when patients meet the criteria.

Surgical procedure requests should be submitted through e-referral beginning July 31, 2017. Providers should be accustomed to using this system for their Blue Care Network members.

Look for more information regarding NovoLogix training and other program details in future issues of The Record and web-DENIS.

Below is a sampling of specialty drugs that require Medicare Part B prior authorization.

The following is a sampling of surgical procedures that require prior authorization:

• Arthroplasty (hip, knee, shoulder)
• Correction of hammertoe
• Nasal/sinus endoscopy
• Endovascular intervention, peripheral artery
• Radiofrequency ablation and TACE, Liver
• Vagus nerve stimulation
• Intrathecal catheter/pump placement
• Spinal cord stimulator insertion

Ciox Health is retrieving medical records for Medicare risk adjustment services

Blue Cross Blue Shield of Michigan and Blue Care Network are using Ciox Health to perform medical record retrieval for risk adjustment services for Medicare Advantage members, which started in March 2017.

Inovalon is continuing to serve as the vendor of Blue Cross for in-state Healthcare Effectiveness Data and Information Set, or HEDIS,** medical record retrievals for Blue Cross PPO and Medicare Advantage PPO members from March through May each year.

Verscend is still the medical record retrieval vendor for in-state commercial risk adjustment business and continues to partner with other Blue plans for out-of-state risk adjustment and HEDIS chart retrieval services.

Blue Cross and BCN request medical records every year to meet federal quality standards for data submission, coding accuracy and patient care.

Ciox Health is contractually bound to preserve the confidentiality of members’ protected health information obtained from medical records, in accordance with the Health Insurance Portability and Accountability Act of 1996.

You won’t need to submit patient-authorized information releases to comply with medical records requests when both the provider and health care plan have a relationship with the patient, and the information relates to this relationship [45 CFR 164.506(c)(4)]. For more information about privacy rules, go to hhs.gov/ocr/privacy.***

If you have any questions, contact Blue Cross provider outreach consultant Corinne Vignali at 313-225-7782.

Ciox Health, Inovalon and Verscend are independent companies that contract with Blue Cross Blue Shield of Michigan and Blue Care Network to provide medical record retrieval services.

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

***Blue Cross Blue Shield of Michigan doesn’t own or control the content of this website.

Medicare Advantage Diagnosis Closure Incentive program continues in 2017

Blue Cross Blue Shield of Michigan and Blue Care Network are continuing the Medicare Advantage Diagnosis Closure Incentive program this year, effective for dates of service on or after Jan. 1, 2017.

The program applies to Medicare Advantage patients, including those with Blue Cross Medicare Plus Blue^SM PPO, Medicare Plus Blue^SM Group PPO, BCN Advantage^SM HMO-POS and BCN Advantage^SM HMO coverage. It rewards participating primary care doctors for having annual, face-to-face visits with Blue Cross and BCN Medicare Advantage patients to evaluate, document and code diagnoses according to standards set by the Centers for Medicare & Medicaid Services.

Doctors will receive a financial incentive for closing diagnosis gaps identified by Blue Cross and BCN. A “gap” is a suspected or previous condition that hasn’t been documented and coded in the current year.

Diagnosis Evaluation Panel

The Diagnosis Evaluation Panel on Medicare Advantage Health e-BlueSM or BCN Health e-Blue^SM, found in the Provider Secured Services area of bcbsm.com, lists patients who are suspected of having a condition, based on one of the following, but whose diagnoses haven’t been submitted to Blue Cross or BCN in the current year:

• Pharmacy claims
• Medical claims
• Other supplemental data sources
• Prior-year diagnoses

Information on Health e-Blue is refreshed monthly so doctors can track their progress in closing identified diagnosis gaps.

Gap closure incentive
Blue Cross and BCN will pay doctors $100 for each Medicare Advantage member with one or more gaps identified between Jan. 1 and Sept. 30, 2017, and for whom all gaps are closed during a face-to-face visit by Dec. 31, 2017.

An identified gap can be closed after a face-to-face visit with the patient in 2017. During this visit, the doctor should manage, evaluate, assess or treat the condition, and the diagnosis should be documented in the patient’s medical record following CMS guidelines. The gap can then be closed through one of the following methods:

• Confirm the diagnosis code
• By submitting a claim with the diagnosis code
• Through Health e-Blue
• By submitting a patient’s medical record
• Notify Blue Cross or BCN that the patient doesn’t have the suspected condition through Health e-Blue

After a complete review, the doctor may document that the patient no longer has the condition previously identified.
More information about this incentive program will be posted on Health e-Blue for Medicare Advantage primary care doctors in the first quarter 2017.

If you don’t have access to Health e-Blue, you need to request it on the application for Provider Secured Services and complete the section for Health e-Blue. For more information, click here.

If you already have access to Provider Secured Services and Health e-Blue and just need to update users, fill out the Authorization to Add or Remove Health e-Blue Access (PDF) and fax it to the number on the form.

web-DENIS member care alerts

When checking patient eligibility and benefits on web-DENIS, check your member care alerts. The alerts have been updated to include 2017 patient gaps in care.

These alerts are color-coded to help you identify patients’ needs quickly, and they display a printable list of diagnosis gaps and treatment opportunities for patients.

2016 incentive payment

If you participated in the 2016 Diagnosis Closure Incentive program, your incentive payment will be mailed to you by the end of the third quarter in 2017.

Training available

Blue Cross and BCN can provide training to doctors and their office staff on proper documentation and coding guidelines, and the importance of closing gaps for Medicare Advantage patients.

Follow these steps to access online training resources:

• Log in to web-DENIS.
• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters & Resources.
• Click on Patient Care Reporting, and in the Training Resources section, look for:
• Online training for risk adjustment, documentation and coding
• E-learning module: Best Practices for Medical Record Documentation
• Documentation and ICD-10 Coding Tips for Professionals

The 30-minute, e-learning module includes a 10-question assessment. If you score 80 percent or better, you’ll receive one continuing education credit from the American Academy of Professional Coders.

These presentations are also available in BCN Provider Publications and Resources under Patient Care Reporting for Risk Adjustment. Contact your BCN provider consultant for assistance.

Guidelines for treating patients with rheumatoid arthritis

Disease-modifying anti-rheumatic drug therapy for rheumatoid arthritis is a HEDIS^®** measure used to determine Medicare star ratings. It assesses RA patients ages18 and older who filled at least one ambulatory DMARD prescription in the measurement year.

Why DMARD therapy?
Aggressive early treatment of RA is essential to helping prevent long-term damage and disability, and several major studies have documented treatment benefits. For instance, DMARD therapy increases quality of life more effectively than other treatment strategies.

According to the American College of Rheumatology, patients with a confirmed RA diagnosis should be treated with a DMARD regardless of the severity or how long they have had RA, unless contraindicated.

Although patients with RA may be stabilized with an anti-inflammatory or steroidal medication, such as prednisone, DMARD therapy is the only treatment that helps prevent further erosion and damage to joints. Anti-inflammatory or steroidal medication doesn’t.

Despite these benefits, managing providers should still see all of their patients undergoing DMARD therapy treatment in follow-up visits at least four times a year to monitor the disease, therapy effectiveness and any adverse events with the treatment.

**HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Ensuring accurate diagnosis and coding
Be sure claims submitted are consistent with appropriate diagnosis coding guidelines, below. Confirm a diagnosis of RA, versus osteoarthritis or joint pain, before entering it on claims. Members’ RA claims are sometimes coded inaccurately when they also have joint pain or other signs and symptoms that must be addressed. RA claims shouldn’t be submitted unless the diagnosis has been confirmed.

Please note these ICD-10 coding guidelines:

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

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

• Affecting three or more joints
• Presence of swelling in joints, especially multiple joints
• Erosion showing on X-ray of joints
• Metacarpophalangeal and proximal interphalangeal joint involvement
• Morning stiffness lasting more than 45 minutes
• Positive test results for cyclic citrullinated peptide or rheumatology factor
• Rheumatoid nodules
• Symmetrical joint pain
• Elevated erythrocyte sedimentation rate, or ESR, with joint pain, swelling, fevers, rash or weakness
• Weakness, such as a new onset in difficulty rising from a chair, along with an elevated ESR and creatinine kinase
• New blue or white color changes in the fingers and toes, particularly with ulcers

DMARD formulary enhancements
Remember — we’ve also enhanced the formulary for DMARD therapy, including removing prior authorization requirements for Humira^® and Enbrel^®, and lowering member cost share for three other DMARD drugs. Refer to this previous Record article for more information.

^Available to Medicare Plus Blue^SM members for the plan’s lowest copays.

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

CDR Associates to handle credit recovery efforts for Medicare Advantage claims

Beginning April 3, 2017, CDR Associates will expand its credit recovery efforts to include Blue Cross Blue Shield of Michigan Medicare Advantage claims.

Medicare Plus Blue^SM PPO claims data will be available through the Credit Balance Analysis System, known as CBAS, a web-based tool for providers to submit credit balance recoveries. CBAS links hospitals and Blue Cross for reporting, tracking and resolution of credit balance overpayments on NASCO and IKA.

CDR Associates will conduct claim audits onsite at hospital locations currently partnering with CDR. Claim recoveries will be handled via claim offset in IKA and won’t be via check refund.

Since 1996, Blue Cross has worked with CDR Associates to help manage its commercial credit balance recovery efforts.

Note: Providers may continue to submit a Request for offset of a Medicare Advantage overpayment form directly to Blue Cross Medicare Advantage, using the existing process. This involves identifying the reason for the overpayment of a medical claim paid through IKA. The claim is then adjusted in IKA, resulting in an offset of future claim payments.