Annual notice: What you need to know about our programs

At Blue Cross Blue Shield of Michigan and Blue Care Network, we continually implement, monitor, measure and evaluate strategies to improve the quality of care delivered to our members. Here’s a recap of some recent achievements:

• We successfully maintained accreditation with a Commendable rating from the National Committee for Quality Assurance for both our PPO and HMO.
• Blue Care Network received an Excellent rating from NCQA for our Medicare product.
• We launched a member mobile application, providing members with quick and easy access to Blue Cross account information.
• As part of our pharmacy programs, we developed a Medication Adherence Toolkit to assist physician organizations with their adherence efforts. And we distributed an Antibiotic Overuse Toolkit to promote appropriate antibiotic use.
• Electronic medical record use increased from 2015 to 2016 — advancing the speed of information exchange and improving patient data accuracy.
• Sixty-eight Michigan hospitals have signed a value-based contract.
• A total of 1,638 practices have been designated as patient-centered medical homes.

We annually update information about the following:

• Members rights and responsibilities
• Clinical practice guidelines
• Criteria used for level of care utilization management decisions
• Comprehensive care management
• Medical policies
• Pharmacy management
• Statement about incentives
• Translation services
• Utilization management staff availability
• Behavioral health care

Note: If information is accessed differently for certain patient populations, instructions are provided for each. Otherwise, information is the same across product lines and patient populations.

Member rights and responsibilities
Blue Cross Blue Shield of Michigan and Blue Care Network members have the right to:

• Receive clear and understandable written information about Blue Cross and BCN, its services, practitioners and providers, and their member rights and responsibilities.
• Receive easy-to-understand information about their care.
• Receive medically necessary care as outlined in the New Member Handbook and Summary of Benefits and Coverage.
• Receive considerate and courteous care with respect to their privacy and human dignity.
• Candidly discuss medically necessary treatment options for their health conditions, regardless of cost or benefit coverage.
• Participate in decision-making regarding their health care.
• Expect confidentiality regarding their care and know that Blue Cross Blue Shield of Michigan adheres to strict internal and external guidelines concerning their personal health information. This includes the use, access and disclosure of that information or any other information that is of a confidential nature.
• Refuse treatment to the extent permitted by law and be informed of the consequences of their actions.
• Voice concerns or complaints about their health care by contacting the Customer Service department or submitting a formal, written grievance through the Blue Cross and BCN appeals process.
• Review medical records at your office by scheduling an appointment during regular business hours.
• Make recommendations regarding the member rights and responsibilities policies of Blue Cross and BCN.
• Request the following information from Blue Cross and BCN:

• The current provider network in their region
• The professional credentials of the health care practitioners who are participating with Blue Cross and BCN, including participating practitioners who are board-certified in the specialty of pain medicine and the evaluation and treatment of pain
• The names of participating hospitals where individual participating physicians have privileges for treatment
• How to contact the appropriate Michigan agency to obtain information about complaints or disciplinary actions against a health care practitioner
• Any prior authorization requirement and limitation, restriction or exclusion by service, benefit or type of drug
• Information about the financial relationships between Blue Cross and BCN and a participating practitioner

Blue Cross and BCN members have the responsibility to:

• Read all Blue Cross and BCN materials provided for members, and call our Customer Service department with any questions.
• Coordinate all nonemergency care through their primary care doctors.
• Use the Blue Cross and BCN provider network unless otherwise approved by Blue Cross and their primary care physicians.
• Comply with the plans and instructions for care that they agreed to with their providers.
• Provide, to the extent possible, complete and accurate information that Blue Cross and BCN and its providers need to provide care.
• Make and keep appointments for nonemergency medical care. They must call their doctor’s offices if they need to cancel an appointment.
• Participate in the medical decisions regarding their health.
• Be considerate and courteous to practitioners, providers, their staff and other patients.
• Notify Blue Cross and BCN of address changes and additions or deletions of dependents covered by their contracts.
• Protect their identification cards against misuse and contact Customer Service immediately if their cards are lost or stolen.
• Report all other health care coverage or insurance programs that cover their health and their family’s health.
• Participate in understanding their health problems and the development of mutually agreed upon treatment.

Behavioral health care

For more information

• Information about our programs and additional resources are available at bcbsm.com/importantinfo.
• To request a printed copy of any of the information contained in this article, contact Vicki Boyle, director of Quality and Population Health, at 313-448-6145.
• If you have any questions about the information in this article, contact your provider consultant.

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

AMA adds 2 new CPT codes

The American Medical Association has added two new codes as part of its CPT updates. The codes, which will not be covered by Blue Cross Blue Shield of Michigan, are listed below.

3 CPT codes now payable

The following codes were initially not payable by Blue Cross Blue Shield of Michigan but are now payable. The new payable status is retroactive to the effective date of Jan. 1, 2017.

BlueCard^® connection: Why are claims for my patient rejecting as ‘membership not found’?

There are times when a patient’s contract number changes during an enrollment year. When this happens, a new identification card is issued to the patient. If you’re billing the patient’s claim based on information in your internal system from a previous visit, this could happen. Oftentimes, the patient isn’t aware of the change.

To ensure that your BlueCard claim is processed with the correct patient information:

• Ask the patient to present his or her insurance card.
• Verify the patient’s benefits and eligibility.
• Update your internal system to reflect your patient’s most recent contract information.

If you disagree with how one of your claims was processed, you may contact Provider Inquiry for assistance. A representative will work with you to validate the correct patient information by contacting the appropriate out-of-state plan on your behalf.

For more information on the BlueCard program, including links and articles on online tools, see 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.

We’ll update ClaimsXten™ for third quarter of 2017

Blue Cross Blue Shield of Michigan will be updating ClaimsXten for the third quarter of 2017.

We regularly update ClaimsXten to help ensure we’re using the most current CPT codes, and following Centers for Medicare & Medicaid Services guidelines and specialty society guidelines. When making our quarterly updates, we also reference information from industry seminars and publications, as well as Blue Cross payment policy revisions.

We reserve the right to make changes or corrections when required or when new information becomes available. In some instances, we may apply changes to ClaimsXten retroactively.

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.

Cost of external peer reviews to increase

The cost of external peer reviews for facilities (including hospitals) and doctor’s offices is increasing, effective Aug. 1, 2017. Peer reviews are typically requested by health care providers when they dispute an audit finding.

Here’s a look at the current and new fees:

Facility standard clinical review
Current: $350 per review
New (effective Aug. 1): $360 per review

Facility coding review
Current: $312 per review
New (effective Aug. 1): $318 per review

Professional standard clinical review
Current: $125 per hour
New (effective Aug. 1): $145 per hour

Professional standard coding review
Current: $100 per hour
New (effective Aug. 1): $115 per hour

According to Blue Cross Blue Shield of Michigan participation agreements with health care providers, if the peer review agency upholds Blue Cross’ decision regarding a claim, the facility or practitioner’s office will pay the cost of the appeal review.

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. All other forums are targeted to professional providers.

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.

Here’s how to use modifiers GC and QK for anesthesia services

We’d like to provide some direction on how to use modifiers GC and QK when reporting professional anesthesia services.

First, here are the definitions of these modifiers:

GC — The service was performed in part by a resident under the direction of a teaching physician.

QK — Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals.

Here are some additional directions on how these modifiers should be applied:

• When there’s a one-on-one situation with a resident and a teaching anesthesiologist (in a teaching setting), the anesthesiologist would apply only modifier GC.
• When an anesthesiologist uses modifier QK for two to four medically directed concurrent procedures, he or she should apply the QK modifier.

Don’t report both the GC and QK modifiers together on one claim.

We require documentation of infusion therapy drug administration times

Recent audits have shown that some providers aren’t documenting the times infusion therapy drugs were administered when billing drug administration codes.

The CPT manual states: “When reporting codes for which infusion time is a factor, use the actual time over which the infusion is administered.” The start and stop time for each drug infused must be documented in the administration record.

Here is some additional direction:

• After each 60 minutes of infusion time, an additional hour shouldn’t be billed until the infusion for that drug continued for an additional 31 minutes or more.
• A minimum continuous duration time of 31 minutes for the administration code billing for hydration is required.
• Hydration may not be reported concurrently with any other service.
• Intravenous push is defined as an infusion of 15 minutes or less.

Be sure to record the administration times of infusion therapy drugs to avoid a potential recovery of payments for infusion drug therapy.

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.

Medical Drug Prior Authorization Program to add Ocrevus™

Beginning June 1, 2017, Ocrevus (ocrelizumab) will be added to the required Medical Drug Prior Authorization Program list. Keep in mind that the prior authorization requirement doesn’t apply to Federal Employee Program^® members.

The following list shows all medications currently in the Medical Drug Prior Authorization Program.

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

URMBT launches pilot care management program for its members

Effective April 2017, the UAW Retiree Medical Benefits Trust has established a pilot care management program called Personal Health Management. The program is administered by Conifer Health Solutions^®, a company with decades of experience supporting employee populations to improve their quality of life.

Because this pilot program may include Trust members who receive care from you, we want to make sure you’re aware of it. Conifer Health is offering to provide personal care management services to Blue Cross Blue Shield of Michigan’s Trust members who are:

• Age 26 and older
• Residents of Michigan, Ohio or Indiana
• Facing illness- or medical-related issues

Members are strongly encouraged to participate in this volunteer program, which is free and confidential. Personal health nurses will assist members with coordinating their health care services, providing health education and facilitating implementation of their physicians’ treatment plans. This program can be coordinated with any care management services members currently receive from their health care providers.

Our pilot program with Conifer Health isn’t replacing existing Blue Cross Care Management programs. Members who are currently participating in a Blue Cross program will continue their engagement with that program.

Note: Conifer Health isn’t providing support to members receiving an organ transplant. In addition, Blue Cross Care Management will continue to manage all requests for alternate levels of care or extra contractual benefits.

If you have questions or need more information, contact Conifer Health at 1-888-209-2862.

Reminder: How to file replacement and void claims electronically

As you read in the March 2017 issue of The Record, professional providers will be required to submit claims electronically, starting June 30, 2017. To assist them with billing replacement and void claims electronically, we’ve put together a summary of the process. The following applies to Blue Cross Blue Shield of Michigan and Blue Care Network professional claims.

Background
Many of the paper claims we continue to receive fall into one of the following two categories:

• Replacement claim
• Corrects information (charges, diagnosis or procedure codes, quantities, etc.) reported in a previously submitted claim
• Void or cancel claim
• Cancels claims billed in error
• Voids claims with patient or provider demographic errors
• Tells us you don’t want the original submission to be processed

Process to follow
Send your electronic 837 transaction replacement or void claims with the following information:
In Loop 2300, CLM05-3, use frequency code 7 for a replacement claim.

• Report all the changes you want to include on the replacement claim.
• The replacement claim replaces the previously reported claim in its entirety.

In Loop 2300, CLM05-3, use frequency code value 8 to void or cancel a claim.

• You must submit a void claim if your original submission incorrectly reported:
• A patient’s name or contract number
• The National Provider Identifier or taxonomy code
• The date of service
• The previously reported claim will be voided in its entirety, so don’t make any changes to the claim.
• It must be coded exactly like the claim you want to void.

Whether you submit a frequency code value of 7 or 8, you must report the ICN (internal control number) of the original claim in Loop 2300, REF segment, along with qualifier F8. Note: If you’re requesting an adjustment against a previously adjusted claim, report the ICN of the last adjusted claim.

• For BCN: Report the 12-character ICN.
• For Blue Cross Blue Shield of Michigan: Report the 14-digit or 17-digit ICN.

Reminder: Be sure to send chart notes with prior authorization requests

As reported in the August Record, many claims are rejected because a claim submission contains incomplete documentation. Once the missing information is submitted, the claim is often approved, avoiding a member appeal.

One common example of incomplete or incorrect documentation is neglecting to include chart notes with prior authorization requests for a drug that is part of our prior authorization program. Chart notes help confirm the need for the drug, which supports the coverage requirements.

As always, verifying member benefits and eligibility, reporting your claims accurately, obtaining required prior authorizations and including chart notes with prior authorization requests will reduce the number claim rejections and resulting member appeals.

Cost of external peer reviews to increase

The cost of external peer reviews for facilities (including hospitals) and doctor’s offices is increasing, effective Aug. 1, 2017. Peer reviews are typically requested by health care providers when they dispute an audit finding.

Here’s a look at the current and new fees:

Facility standard clinical review
Current: $350 per review
New (effective Aug. 1): $360 per review

Facility coding review
Current: $312 per review
New (effective Aug. 1): $318 per review

Professional standard clinical review
Current: $125 per hour
New (effective Aug. 1): $145 per hour

Professional standard coding review
Current: $100 per hour
New (effective Aug. 1): $115 per hour

According to Blue Cross Blue Shield of Michigan participation agreements with health care providers, if the peer review agency upholds Blue Cross’ decision regarding a claim, the facility or practitioner’s office will pay the cost of the appeal review.

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. All other forums are targeted to professional providers.

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.

Follow these guidelines for providing durable medical equipment in ambulatory surgical facility

We’d like to clarify the guidelines for durable medical equipment, prosthetic, orthotic and medical supplies provided on consignment in an ambulatory surgical facility location. The criteria and billing guidelines for DME and medical supplies haven’t changed.

DME/P&O providers should submit claims using the place of service code for an office (11) or home (12). If the DME/P&O item provided in an ambulatory surgical facility isn’t for home use, the DME/P&O supplier shouldn’t submit a claim. This item is considered inclusive of the ambulatory surgical facility charges.

Items required aftersurgery in ambulatory surgical facility

If a patient had surgery in an ambulatory surgical facility and afterward requires DME/P&O items for home use, then a prescription/certificate of medical necessity is required by the ordering physician. The patient can take the certificate of medical necessity to the DME provider of his or her choice to obtain the necessary items or supplies.

Items from an ambulatory surgical facility’s “consignment closet”

After a surgical procedure, the member also may obtain equipment or supplies from the ambulatory surgical facility’s consignment closet. However, before dispensing the item, the facility must verify the patient’s DME and medical supply benefit. For a consignment item, the participating DME provider must submit the professional claim for the item the patient is taking for home use. The prescription/certificate of medical necessity is required and must be kept on file. DME providers don’t bill for services used in an ambulatory surgical facility.

Note: For consignment items, the ambulatory surgical facility is responsible for:

• Ensuring the DME/P&O supplier is a participating Blue Cross Blue Shield of Michigan provider
• Verifying that the patient’s benefits cover these items before providing them

If these procedures aren’t adhered to, the ambulatory surgical facility may be held liable for the incurred cost.

How DME providers should submit claims

DME providers should submit claims using a professional claim form and only report the place of service codes of home or office. The office place of service codes should only be billed when the item is purchased in a retail store. A prescription/certificate of medical necessity must be kept on file. A DME provider should never submit a claim for equipment or supplies used in an ambulatory surgical facility location. Ambulatory surgical facility providers shouldn’t submit a separate claim for DME/P&O items. Items provided in an ambulatory surgical facility location for home use must be billed by participating DME providers.

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.

Reminder: Be sure to send chart notes with prior authorization requests

As reported in the August Record, many claims are rejected because a claim submission contains incomplete documentation. Once the missing information is submitted, the claim is often approved, avoiding a member appeal.

One common example of incomplete or incorrect documentation is neglecting to include chart notes with prior authorization requests for a drug that is part of our prior authorization program. Chart notes help confirm the need for the drug, which supports the coverage requirements.

As always, verifying member benefits and eligibility, reporting your claims accurately, obtaining required prior authorizations and including chart notes with prior authorization requests will reduce the number claim rejections and resulting member appeals.

Follow these guidelines for providing durable medical equipment in ambulatory surgical facility

We’d like to clarify the guidelines for durable medical equipment, prosthetic, orthotic and medical supplies provided on consignment in an ambulatory surgical facility location. The criteria and billing guidelines for DME and medical supplies haven’t changed.

DME/P&O providers should submit claims using the place of service code for an office (11) or home (12). If the DME/P&O item provided in an ambulatory surgical facility isn’t for home use, the DME/P&O supplier shouldn’t submit a claim. This item is considered inclusive of the ambulatory surgical facility charges.

Items required aftersurgery in ambulatory surgical facility

If a patient had surgery in an ambulatory surgical facility and afterward requires DME/P&O items for home use, then a prescription/certificate of medical necessity is required by the ordering physician. The patient can take the certificate of medical necessity to the DME provider of his or her choice to obtain the necessary items or supplies.

Items from an ambulatory surgical facility’s “consignment closet”

After a surgical procedure, the member also may obtain equipment or supplies from the ambulatory surgical facility’s consignment closet. However, before dispensing the item, the facility must verify the patient’s DME and medical supply benefit. For a consignment item, the participating DME provider must submit the professional claim for the item the patient is taking for home use. The prescription/certificate of medical necessity is required and must be kept on file. DME providers don’t bill for services used in an ambulatory surgical facility.

Note: For consignment items, the ambulatory surgical facility is responsible for:

• Ensuring the DME/P&O supplier is a participating Blue Cross Blue Shield of Michigan provider
• Verifying that the patient’s benefits cover these items before providing them

If these procedures aren’t adhered to, the ambulatory surgical facility may be held liable for the incurred cost.

How DME providers should submit claims

DME providers should submit claims using a professional claim form and only report the place of service codes of home or office. The office place of service codes should only be billed when the item is purchased in a retail store. A prescription/certificate of medical necessity must be kept on file. A DME provider should never submit a claim for equipment or supplies used in an ambulatory surgical facility location. Ambulatory surgical facility providers shouldn’t submit a separate claim for DME/P&O items. Items provided in an ambulatory surgical facility location for home use must be billed by participating DME providers.

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.

Reminder: DME claims filing rules

According to Blue Cross and Blue Shield Association rules, durable medical equipment suppliers should file claims with the Blue plan in the state where the equipment or supplies were shipped (including mail-order supplies) or purchased (if purchased at a retail store).

Refer to the following guidelines when filing DME claims. Note: These guidelines apply to all members, including those with Medicare Advantage.

Medical Drug Prior Authorization Program to add Ocrevus™

Beginning June 1, 2017, Ocrevus (ocrelizumab) will be added to the required Medical Drug Prior Authorization Program list. Keep in mind that the prior authorization requirement doesn’t apply to Federal Employee Program^® members.

The following list shows all medications currently in the Medical Drug Prior Authorization Program.

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

URMBT launches pilot care management program for its members

Effective April 2017, the UAW Retiree Medical Benefits Trust has established a pilot care management program called Personal Health Management. The program is administered by Conifer Health Solutions^®, a company with decades of experience supporting employee populations to improve their quality of life.

Because this pilot program may include Trust members who receive care from you, we want to make sure you’re aware of it. Conifer Health is offering to provide personal care management services to Blue Cross Blue Shield of Michigan’s Trust members who are:

• Age 26 and older
• Residents of Michigan, Ohio or Indiana
• Facing illness- or medical-related issues

Members are strongly encouraged to participate in this volunteer program, which is free and confidential. Personal health nurses will assist members with coordinating their health care services, providing health education and facilitating implementation of their physicians’ treatment plans. This program can be coordinated with any care management services members currently receive from their health care providers.

Our pilot program with Conifer Health isn’t replacing existing Blue Cross Care Management programs. Members who are currently participating in a Blue Cross program will continue their engagement with that program.

Note: Conifer Health isn’t providing support to members receiving an organ transplant. In addition, Blue Cross Care Management will continue to manage all requests for alternate levels of care or extra contractual benefits.

If you have questions or need more information, contact Conifer Health at 1-888-209-2862.