Working to improve the provider experience: A top priority

Health care is changing rapidly as anyone who works in the industry knows well. To help keep up with the ever-changing marketplace, government regulations and increased scrutiny around health care spending, insurers such as Blue Cross Blue Shield of Michigan are creating new plans, working with vendors on cost-saving programs and structuring networks that focus on high-quality care for our members.

This often causes changes to the way that we interact with our health care providers — changes that can increase administrative work and add new patient care requirements. We’ve heard your concerns loud and clear, and understand that these changes can cause confusion, extra work and overall disruption as you try to care for your patients.

We want to let you know that addressing your concerns is a top business priority for us. In upcoming articles and provider forums, we promise to:

• Provide more information about the rationale behind our quality and incentive programs and how they affect our provider relationships.
• Continue to bring you information about things like medical record reviews and new product designs, but also provide you with the context around them and be very clear about what we’re asking of our provider community.
• Streamline our processes, communicating clearly about the projects and networks that we’re developing, and providing an overview of the environment in which we’re making these changes.

We hope that doing these things will reduce confusion and needless work, allowing you to keep your focus where it belongs — on your patients. We can’t change the fact that the health care industry is becoming more complex, but we pledge to do our part to communicate clearly and reduce confusion wherever possible.

We’re changing the name of Blue Cross^® Personal Choice PPO to Blue Cross^® Physician Choice PPO

An innovative PPO product we introduced last year is getting a new name. Blue Cross Personal Choice PPO will be called Blue Cross Physician Choice PPO.

The product isn’t changing — just the name. The new name better reflects the member’s ability to select health care providers, choosing between the wide options of a traditional PPO plan and the ability to save money through coordinated care.

Members in Physician Choice PPO can lower their out-of-pocket costs when they select a primary care doctor affiliated with a Level 1 Organized System of Care and use other health care providers associated with that OSC. An OSC is a community of doctors and hospitals within the Blue Cross PPO network that helps coordinate care for Blue Cross members. They do this by connecting members to providers, specialists and acute care hospitals in their communities, resulting in integrated, cost-effective care.

More information about Physician Choice PPO is available on ereferrals.bcbsm.com. We’ll be changing the plan name on all of our materials over the next few months.

Interested in joining PGIP? Here’s your chance

Here’s how participating network physicians, physician organizations and organized systems of care can get involved in the program that’s transforming health care in Michigan.

Blue Cross Blue Shield of Michigan encourages participating network physicians, organized systems of care and physician organizations to join the Physician Group Incentive Program. See information at right.

Network primary and specialty care physicians

• Can only join PGIP as part of a PGIP physician organization and must be affiliated with a PGIP physician organization to be a member of an OSC.
• Should contact a PGIP-participating PO directly to discuss specific membership criteria. Here’s a current list of the more than 40 PGIP physician organizations. (Each physician organization has its own criteria for membership. A physician can only be a member of one PO for the purposes of PGIP.)

Requirements
To participate in PGIP, a network physician must:

• Participate in the Blue Cross PPO, TRUST or Traditional lines of business.
• Be in good standing with the network.
• Be a medical doctor, doctor of osteopathy, doctor of chiropractic or doctor of podiatric medicine. Fully licensed psychologists are also eligible to participate in the program.

If you’re a physician with questions about participating in PGIP, contact your provider consultant. Not sure who that is? Check out the Contact Us section of bcbsm.com/providers.

POs and OSCs

• Blue Cross will accept applications from new POs and OSCs through Aug. 31, 2017.

Requirements

• If you represent a PO or an OSC and would like to complete an application to join PGIP, send an email to valuepartnerships@bcbsm.com.
• Be sure to specify whether you want to apply as a PO or an OSC.

For more information
Want more details? Check out the following webpages.

• Physicians: Information can be found on the following webpage: How to participate in PGIP
• Physician organizations: Information can be found on the following webpage: Join PGIP
• Organized systems of care: Information can be found on the following webpage: Models of Care

To learn more about PGIP, check out our bcbsm.com and valuepartnerships.com websites.

Provider Inquiry phone lines transitioning to PARS

Effective July 14, 2017, we’ll be transitioning most of our Provider Inquiry 800 numbers to our Provider Automated Response System, known as PARS. Note: This represents a date change from what you may have read previously.

The transition to PARS will offer you one-stop shopping for all of your inquiry needs. Following are the 800 numbers that will point to PARS:

1-800-245-9092
1-800-272-0172
1-800-255-1878
1-800-228-4599
1-800-437-3804
1-800-643-2583
1-800-482-0898
1-800-482-3146
1-800-482-5141
1-800-531-2583
1-800-255-1690**
1-800-688-3290**
1-866-872-5837
1-866-309-1719***

**BCN number
***Medicare Advantage number

Going forward, you’ll have one set of phone numbers that will offer you automated information you can access 24 hours per day, seven days per week. You can also use the same phone number when you need to speak to a Provider Inquiry representative during regular Provider Inquiry business hours.

PARS numbers
Beginning July 14, 2017, you can use the current PARS benefit phone numbers for benefits, eligibility and claims information, as follows.

Professional providers (non-Medicare Advantage):........................1-800-344-8525
Facility providers (non-Medicare Advantage):...................................1-800-249-5103
All vision and hearing service providers:...........................................1-800-482-4047
PARS professional and facility providers (Medicare Advantage): 1-866-309-1719

Claim information added to PARS
As we announced in the June Record, we’ve added claims status and inquiry information to PARS. Beginning July 14, 2017, you can use the PARS numbers for:

• Benefits and eligibility information
• Claims status and inquiry
• Any Provider Inquiry request

Most of our Provider Inquiry phone lines will be retired later this year. One of the exceptions is our Medicare Advantage number (1-866-309-1719), which will remain.

If you call Provider Inquiry directly, beginning July 14, 2017, you’ll automatically be transferred to the correct PARS line. The benefits of this change for providers include fewer phone numbers to juggle and more information available 24 hours per day.

If you experience any technical issues, send an email to the Provider IVR and Benefit Store mailbox at pibs@bcbsm.com. Be sure to include your name, phone number, time and date of your call and the PARS number you dialed.

View The Record on your mobile device

Due to advances in technology, more and more readers are reading newsletters like The Record on their mobile devices.

That’s why our email communications team took the initiative to create a more mobile-responsive Record newsletter, starting with this issue. We hope you find the changes useful.

Try viewing The Record on your mobile device and let us know what you think at provcomm@bcbsm.com. We also welcome other feedback on the newsletter.

Reminder: Changes to prior authorization processes coming soon

As you read in the April and June 2017 Record, there are three major changes coming to our prior authorization processes:

• Beginning July 5, 2017, we’ll require prior authorization for our Medicare Advantage PPO patients for select specialty medications administered in the provider’s office and covered under the Medicare medical benefit.
• Beginning July 31, 2017, prior authorization for Medicare Advantage patients will be required for select surgical procedures. Procedures will include the following:
• Arthroplasty (hip, knee, shoulder)
• Correction of hammertoe
• Nasal/sinus endoscopy
• Endovascular intervention, peripheral artery
• Radiofrequency ablation and transarterial embolization
• Vagus nerve stimulation
• Intrathecal catheter/pump placement
• Spinal cord stimulator insertion
• Gastric stimulation
• Beginning July 31, 2017, we’re moving from the prenotification system to e-referral. If you’ve been using the prenote system for services requiring prior authorization, you’ll be switching to e-referral.
  
  Note: 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.

The table in the June edition of The Record outlines all the prior authorization programs for MA PPO and commercial members, including the changes that are coming in July 2017.

Authorization for inpatients
The table below outlines authorization requirements for inpatient cases:

How can I get trained on e-referral?
We have an array of e-referral training opportunities and resources:

• e-referral webinars scheduled for July 27 or Aug. 31
• You can sign up by completing and faxing the webinar registration form to 1-866-652-8983 or email it as an attachment to ProviderInvitations@bcbsm.com. Instructions will be emailed to you a day or two before the webinar.
• e-referral online self-paced learning modules, which can be found on the e-referral website by clicking here.
• Training tools, such as the e-referral user guide and quick guide, which you can access from the e-referral website by clicking here.
• Your provider consultant. As always, you may reach out to your provider consultant to schedule a one-on-one meeting or a group training session.

More information on process changes
For information on the MA PPO prior authorization requirements for select specialty medications, see the article in this issue.

For more details on the upcoming changes, see the previous Record articles:

• New prior authorization requirements begin this summer
• We’re moving from prenotification system to e-referral
• We’re making some changes to our preauthorization processes

HCPCS update: New codes added, deleted

The Centers for Medicare & Medicaid Services has added several new codes and deleted one as part of its quarterly HCPCS updates. The codes, effective dates and Blue Cross Blue Shield of Michigan’s coverage decisions are below.

Outpatient Prospective Payment System

Medical/Surgical Supplies

Medicine Supplementary Drugs Other Than Chemotherapy/Contraception/Devices and Supplies

Medicine Supplementary/Injections

Pathology and Laboratory/Professional Services/Transfusion Medicine/Miscellaneous Blood Products

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 all applicable state and federal laws and regulations.

Here’s what you need to know when billing for STELARA^® (ustekinumab)

Effective July 1, 2017, procedure code Q9989 replaces J3490 and J3590 when billing for specialty medical drug STELARA (ustekinumab) for intravenous administration.

The Centers for Medicare & Medicaid Services has established a permanent procedure code for specialty medical drug STELARA^® (ustekinumab) for intravenous administration, effective July 1, 2017.

All services from Nov. 1, 2016, through June 30, 2017, should be reported with code J3490 and J3590. All services performed on and after July 1, 2017, must be reported with Q9989.

Prior authorization is still required for the specialty medical drug STELARA (ustekinumab) for intravenous administration when reported with the new procedure code Q9989, unless the group has opted out of the commercial Specialty Pharmacy Prior Authorization Program.

The NDC number for STELARA is 57894-0054-27.

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 all applicable state and federal laws and regulations.

BlueCard^® connection: Why are some of my BlueCard replacement claims denied?

All BlueCard claims must meet Blue Cross Blue Shield of Michigan claim reporting requirements. If you attempt to replace a claim that wasn’t valid or accurate, the Blue Cross denial message will advise you to send us a corrected original, not a replacement.

If you’re unsure why your original BlueCard claim was denied or if you disagree with the denial, contact our Provider Inquiry department for assistance before rebilling the BlueCard claim as a “frequency code 7” replacement claim. Rebilling the replacement claim may not change the outcome but rather delay resolving your claim. Instead, our Provider Inquiry representative can assist you by reviewing the claim and denial, and then contacting the plan, if appropriate.

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.

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 all applicable state and federal laws and regulations.

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 offering new value-based reimbursement for hematologists and oncologists in 2018

Value Partnerships continues to identify new ways to reward physicians for improving the overall value of health care for our members.

Background
Since 2009, Blue Cross Blue Shield of Michigan has been providing value-based reimbursement opportunities for physicians participating in the Physician Group Incentive Program. During the past several years, we’ve introduced more value-based reimbursement opportunities for more physician specialty types. And during the next one to two years, PGIP-participating specialists should continue to see additional value-based reimbursement opportunities tied to specialty-specific clinical measures.

VBR for hematologists, oncologists
We’re currently developing a new value-based reimbursement program for hematologists and oncologists who participate in PGIP’s Michigan Oncology Quality Consortium.

The Michigan Oncology Quality Consortium is a statewide collaborative quality initiative that focuses on improving the quality of care for cancer patients. MOQC collects clinical data through the American Society of Clinical Oncology’s Quality Oncology Practice Initiative. It uses the results to improve outcomes and patient care. Practices across the state participate in MOQC by:

• Submitting Quality Oncology Practice Initiative data to the MOQC Coordinating Center (housed at the University of Michigan)
• Attending regional and biannual meetings focused on sharing data and improvement
• Participating in quality initiatives

Blue Cross, MOQC Coordinating Center leadership and participating physicians collaborated to develop a set of quality and performance measures tied to value-based reimbursement for MOQC participants. The MOQC-participating practices will be evaluated for value-based reimbursement on the following Quality Oncology Practice Initiative measures:

• Pain addressed appropriately by second office visit and during most recent office visits (target 78 percent) and during end of life (target 80 percent)
• Tobacco cessation counseling administered or patient referred in past year (target 45 percent)
• Hospice enrollment, palliative care referral or services, or documented discussion (target 70 percent)

Performance measurement
Performance will be measured at the regional level. This means that all MOQC participating practices in each designated MOQC region will work together to improve performance across the region.

The regions have been defined by the MOQC Coordinating Center and based primarily on geography and other shared characteristics, and are composed of eight to 15 practices per region. All MOQC-participating oncology practices are aware of their associated regions.

Starting March 1, 2018, oncology practices within a region have the potential to receive 103 percent of the standard fee schedule if their region meets or exceeds target performance on each of the above three measures. If the practice is already receiving 105 percent or 110 percent of the standard fee schedule for performance on population-level measures of cost and quality, the MOQC value-based reimbursement represents an additional 3 percent.

The value-based reimbursement fee schedule for hematologists and oncologists is applied only to commercial PPO claims on all relative value unit based codes. The tables below illustrate how the MOQC value-based reimbursement will be applied and the measurement and reimbursement period.

** This measurement period may change for subsequent periods.

To receive MOQC value-based reimbursement, practices must:

1. Participate in PGIP.
2. Fully participate in the collaborative. MOQC collaborative participants must meet Collaborative Quality Initiative participation and performance requirements, which include contribution of data to the QOPI registry.

For more information

• For more details on value-based reimbursement criteria, see these 2016 Record articles:
• Here's what you need to know about participating in Value Partnerships quality programs
• We’re making some changes to the Value-Based Reimbursement Fee Schedule, effective July 1, 2016
• To learn more about MOQC, go to moqc.org.***
• To learn more about the American Society of Clinical Oncology’s Quality Oncology Practice Initiative, go to instituteforquality.org.***
• If you have questions about the information in this article, send an email to Marc Cohen, manager, Value Partnerships, at CQIprograms@bcbsm.com.

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

Colorectal cancer screening measure updated

Due to the importance of screening Medicare patients for colorectal cancer, we want to make sure you’re aware of updates to the Healthcare Effectiveness Data and Information Set measure for colorectal cancer screening, as well as screening coverage.

According to Dr. Tom Frieden, director of the Centers for Disease Control and Prevention, “There are more than 20 million adults in this country who haven’t had any recommended screening for colorectal cancer and who may therefore get cancer and die from a preventable tragedy.”

The HEDIS^® Colorectal Cancer Screening measure examines the percentage of adults, ages 50 to 75, who get the appropriate screening for colorectal cancer. It excludes patients with a history of colorectal cancer or a total colectomy, as well as those in hospice.

The following preventive screenings meet HEDIS specifications. They’re also fully covered without cost sharing when provided by an in-network health care provider.

• New: FIT DNA (e.g., multi-target stool DNA, Cologuard^®) test every three years for patients who show no signs or symptoms of colorectal disease and are at average risk for developing it.
• Screening fecal occult blood test every year
  

  Note: Performing FIT (FOBT or iFOBT) in an office setting or on a sample collected during digital rectal exam doesn’t meet HEDIS and the American Cancer Society’s requirements as a screening.

• Screening flexible sigmoidoscopy every five years
• Screening colonoscopy every 10 years:
• Patients at high risk for colorectal cancer are covered once every 24 months.
• Patients who aren’t high risk are covered once every 120 months or 48 months after a previous flexible sigmoidoscopy for patients who aren’t at high risk.
• HEDIS specifications count a colonoscopy for 10 years.
• A screening colonoscopy turns into a diagnostic colonoscopy with cost sharing if a patient has an abnormality such as a polyp.

While CT colonography meets HEDIS screening requirements, Medicare doesn’t reimburse for it as of April 1, 2017.

Go to Medicare.gov for more information.

Once you screen your patient for colorectal cancer, you must either:

• Submit a claim for one of the appropriate screenings, or
• Provide documentation in the medical record of one of the following:
• Put the date and name of the test performed in the medical history section of the chart
• Indicate the type of screening performed, date and result.

Helpful tips
Here are helpful tips for improving HEDIS scores:

• Begin colorectal screening at age 50. For high-risk patients, begin screenings sooner.
• Encourage stool tests in patients who are resistant to receiving a colonoscopy.
• Document test results in chart.
• Develop a callback system to ensure patients complete testing because only completed tests count.

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

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 all applicable state and federal laws and regulations.

Support charity by participating in physician survey

Blue Cross Blue Shield of Michigan wants to learn more about your experience as a health care provider and how we can be a better partner to you. That’s why we’re working alongside Gongos Research, an independent company, to conduct a study of physicians.

If randomly selected, you’ll receive an invitation to provide your opinions about health care industry topics, including your experiences with Blue Cross. We value your opinion and encourage you to participate if you receive an invitation. To show our appreciation, Blue Cross will donate $15,000 to a charity serving Michigan on behalf of survey respondents. Survey respondents will choose the charity.

You may receive a letter or email from us this July or August with a link to the online survey.

If you have questions about this Blue Cross Provider Survey study or Gongos Research, call 248-239-2300 and mention the “BCBSM Physician Survey.” To learn more about Gongos Research, go to gongos.com.**

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

Reminder: Update your Provider Authorization Form when changes occur

Blue Cross Blue Shield of Michigan is dedicated to safeguarding its members’ protected health information. To help us achieve this goal, we require that all electronic data interchange trading partners complete a Trading Partner Agreement and Provider Authorization Form before they exchange PHI with Blue Cross.

Terms of the TPA require you to notify Blue Cross of any changes in your trading partner information. Updating your Provider Authorization Form ensures that information is routed to the appropriate destination.

Please review your provider authorization information and update your form as needed 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 changed clearinghouses; these are often called service bureaus
• Changed software vendors
• Decided you no longer want to receive 835 remittance files
• Selected a new recipient for your 835 remittance files

You must also update your form if you plan to send claims using a different submitter ID or route your 835 remittance files to a different unique receiver or Trading Partner ID.

To make changes to your EDI setup:

• Visit bcbsm.com/providers.
• Click on Quick Links.
• Click on Electronic Connectivity (EDI), and then click on How to use EDI to exchange information with us electronically.
• Click on Update your Provider Authorization Form under “EDI Agreements.”

If you have questions about your EDI enrollment, Trading Partner Agreement or Provider Authorization Form, call our help desk at 1-800-542-0945.

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 all applicable state and federal laws and regulations.

Medicare Plus Blue^SM PPO updating claim editing processes

Starting in October 2017, Blue Cross Blue Shield of Michigan’s Medicare Plus Blue^SM PPO will enhance our claim editing processes to:

• Continue to promote correct coding.
• Continue to integrate applicable, appropriate local and national coverage determination guidelines in a way that will simplify our claims payment system.

These improvements will make our claims payment system easier for you and your billing staff to navigate. Medicare Plus Blue PPO will communicate unique clinical editing reason codes on the 835 response files or provider vouchers.

As a Medicare Advantage organization, Medicare Plus Blue PPO’s medical and payment policies comply with:

• National coverage determinations
• General coverage guidelines included in original Medicare manuals and instructions
• Written coverage decisions of the local Medicare administrative contractor

Reminder: When billing Medicare Plus Blue PPO, the guidelines and regulations established by these sources should be followed:

• Centers for Medicare & Medicaid Services’ medical policies
• American Medical Association CPT coding guidelines
• National bundling edits, including the Correct Coding Initiative
• Modifier usage
• Global surgery period
• Add-on code usage

As part of your contract with us, providers affiliated with Medicare Plus Blue PPO network agree to supply services to Blue Cross members and bill in accordance with these guidelines and requirements.

If you have questions about this update to Blue Cross’ Medicare claim editing process, contact our Provider Inquiry unit at 1-866-309-1719.

Medicare Plus Blue^SM PPO skilled nursing facility, home health care second-pass claim audits starting

HMS (formerly Health Data Insights) and SCIO Health Analytics^®, two Blue Cross and Blue Shield of Michigan vendors, will start a onetime second-pass audit for skilled nursing facility and home health care provider paid claims. This is the second time the vendor is choosing cases from a specific data period since the first audit was limited to a certain number of claims.

The audits will:

• Begin with April 2017 data and look back two years.
• Use a look-back date that’s based on the date the claim was paid.
• Require providers to submit medical charts.

The medical chart request letters will be staggered, going out over a three-month period.

For 2015 paid claims, the vendors will focus on CMS compliance requirements. The focus on 2016 paid claims will be on both compliance and medical necessity.

Audit finding letters will include information on how to request an appeal, if necessary. 

About HMS and SCIO
Through its vendors, HMS and SCIO, Blue Cross conducts retrospective provider audits to:

• Detect, prevent and correct fraud, waste and abuse.
• Facilitate accurate claim payment.
• Check that the most appropriate, cost-effective services and supplies were provided.
• Make sure that medical records and documentation verify the setting or level of service that was provided to the patient.

Got questions?
Call your Blue Cross provider consultant.

During an audit, if you need to speak to a vendor representative:

• Skilled nursing facilities can call HMS at 1-866-875-1749, Monday through Friday, 11 a.m. to 8 p.m. Eastern time.
• Home health care providers can call SCIO at 1-866-628-3488.

2 new drugs added to the Medical Drug Prior Authorization Program

Beginning Sept.1, 2017, Brineura™ (cerliponase alfa) and Radicava™ (edaravone) will be added to the commercial 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.

Reminder: New MA PPO prior authorization requirements for select specialty medications

What’s new?
Select specialty medications covered under the Medicare Part B medical benefit will require prior authorization, starting July 5, 2017. These are medications that aren’t self-administered, but must be administered via injection or infusion by a doctor or health care professional in the office setting.

The purpose of these new requirements is to help ensure that health care providers use the most effective therapies available, in keeping with the Centers of Medicare & Medicaid Services coverage guidelines for medical necessity, safety and efficacy.

Providers must obtain prior authorization and verify patient benefits to be eligible for payment for administering these medications. If a prior authorization isn’t obtained before services are rendered, the claim will be rejected. Also, providers may not bill members for services that required, but didn’t receive, preapproval.

Keep in mind that authorization isn’t a guarantee of payment. CMS benefit coverage rules and benefit exclusions or limitations will apply.

Which specialty medications will require prior authorization?
Below is a sampling of specialty drugs that will require Medicare Part B prior authorization:

We’ll evaluate the program on an ongoing basis, and may add or remove new drugs or procedures from the prior authorization list. When this happens, we’ll notify you via The Record or web-DENIS.

Beginning July 5, you can find a list of medications that will require a prior authorization on the Medicare Advantage PPO medical drug policies and forms page. Or from Provider Secured Services, click on Medicare Advantage PPO Medical Benefit – Medication Prior Authorization.

How do I initiate a prior authorization request?
Prior authorization requests can be submitted through the NovoLogix^® online tool. NovoLogix allows providers to obtain real-time status checks on prior authorizations and immediate approvals for certain medications when patients meet specific criteria. Use of the NovoLogix tool will save time and lessen your administrative burden by eliminating the manual process of submitting a form.

Submit prior authorization requests by following these steps:

• Log in to Provider Secured Services
• Click on Medicare Advantage PPO Medical Benefit – Medication Prior Authorization.
• Follow the instructions.

If you can’t access Provider Secured Services or aren’t registered to use NovoLogix, call 1-877-258-3932 Monday through Friday from 8 a.m. to 8 p.m. Eastern time.

If you have any questions about this process, call the Pharmacy Clinical Help Desk at 1-800-437-3803.

How do I request access to NovoLogix?

• If you already use Provider Secured Services, fill out Addendum P and fax the form to us at 1-800-495-0812.
• If your office or facility has never used Provider Secured Services, learn how at bcbsm.com/providers. When completing the application, be sure to check “Medical Drug PA” in Section 6.
• If you can’t access Provider Secured Services, call 1-877-258-3932 Monday through Friday from 8 a.m. to 8 p.m. Eastern time.

Want more information

• You can find a drug list, NovoLogix user guide, NovoLogix tutorial video and FAQ document from Provider Secured Services. Click on Medicare Advantage PPO Medical Benefit – Medication Prior Authorization.

• You can also find our medical policies and request forms in the Provider Toolkit for Medicare Advantage PPO. Click on Medicare Advantage PPO medical drug policies and forms.

Dart Container of Michigan’s employee groups to join Medical Drug Prior Authorization Program

Beginning Sept. 1, 2017, Dart Container of Michigan’s active and retired employee groups will participate in the Medical Drug Prior Authorization Program.

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

Licensed professional counselors and clinical licensed master social workers may bill for code *96102

Licensed professional counselors and clinical licensed master social workers are now eligible to bill Blue Cross Blue Shield of Michigan for procedure code *96102, a code that relates to psychological testing. Direct reimbursement is 80 percent of the physician fee schedule. This change was effective March 1, 2017.

Reminder: Update your Provider Authorization Form when changes occur

Blue Cross Blue Shield of Michigan is dedicated to safeguarding its members’ protected health information. To help us achieve this goal, we require that all electronic data interchange trading partners complete a Trading Partner Agreement and Provider Authorization Form before they exchange PHI with Blue Cross.

Terms of the TPA require you to notify Blue Cross of any changes in your trading partner information. Updating your Provider Authorization Form ensures that information is routed to the appropriate destination.

Please review your provider authorization information and update your form as needed 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 changed clearinghouses; these are often called service bureaus
• Changed software vendors
• Decided you no longer want to receive 835 remittance files
• Selected a new recipient for your 835 remittance files

You must also update your form if you plan to send claims using a different submitter ID or route your 835 remittance files to a different unique receiver or Trading Partner ID.

To make changes to your EDI setup:

• Visit bcbsm.com/providers.
• Click on Quick Links.
• Click on Electronic Connectivity (EDI), and then click on How to use EDI to exchange information with us electronically.
• Click on Update your Provider Authorization Form under “EDI Agreements.”

If you have questions about your EDI enrollment, Trading Partner Agreement or Provider Authorization Form, call our help desk at 1-800-542-0945.

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 all applicable state and federal laws and regulations.

Medicare Plus Blue^SM PPO updating claim editing processes

Starting in October 2017, Blue Cross Blue Shield of Michigan’s Medicare Plus Blue^SM PPO will enhance our claim editing processes to:

• Continue to promote correct coding.
• Continue to integrate applicable, appropriate local and national coverage determination guidelines in a way that will simplify our claims payment system.

These improvements will make our claims payment system easier for you and your billing staff to navigate. Medicare Plus Blue PPO will communicate unique clinical editing reason codes on the 835 response files or provider vouchers.

As a Medicare Advantage organization, Medicare Plus Blue PPO’s medical and payment policies comply with:

• National coverage determinations
• General coverage guidelines included in original Medicare manuals and instructions
• Written coverage decisions of the local Medicare administrative contractor

Reminder: When billing Medicare Plus Blue PPO, the guidelines and regulations established by these sources should be followed:

• Centers for Medicare & Medicaid Services’ medical policies
• American Medical Association CPT coding guidelines
• National bundling edits, including the Correct Coding Initiative
• Modifier usage
• Global surgery period
• Add-on code usage

As part of your contract with us, providers affiliated with Medicare Plus Blue PPO network agree to supply services to Blue Cross members and bill in accordance with these guidelines and requirements.

If you have questions about this update to Blue Cross’ Medicare claim editing process, contact our Provider Inquiry unit at 1-866-309-1719.

Medicare Plus Blue^SM PPO skilled nursing facility, home health care second-pass claim audits starting

HMS (formerly Health Data Insights) and SCIO Health Analytics^®, two Blue Cross and Blue Shield of Michigan vendors, will start a onetime second-pass audit for skilled nursing facility and home health care provider paid claims. This is the second time the vendor is choosing cases from a specific data period since the first audit was limited to a certain number of claims.

The audits will:

• Begin with April 2017 data and look back two years.
• Use a look-back date that’s based on the date the claim was paid.
• Require providers to submit medical charts.

The medical chart request letters will be staggered, going out over a three-month period.

For 2015 paid claims, the vendors will focus on CMS compliance requirements. The focus on 2016 paid claims will be on both compliance and medical necessity.

Audit finding letters will include information on how to request an appeal, if necessary. 

About HMS and SCIO
Through its vendors, HMS and SCIO, Blue Cross conducts retrospective provider audits to:

• Detect, prevent and correct fraud, waste and abuse.
• Facilitate accurate claim payment.
• Check that the most appropriate, cost-effective services and supplies were provided.
• Make sure that medical records and documentation verify the setting or level of service that was provided to the patient.

Got questions?
Call your Blue Cross provider consultant.

During an audit, if you need to speak to a vendor representative:

• Skilled nursing facilities can call HMS at 1-866-875-1749, Monday through Friday, 11 a.m. to 8 p.m. Eastern time.
• Home health care providers can call SCIO at 1-866-628-3488.

2 new drugs added to the Medical Drug Prior Authorization Program

Beginning Sept.1, 2017, Brineura™ (cerliponase alfa) and Radicava™ (edaravone) will be added to the commercial 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.

Reminder: New MA PPO prior authorization requirements for select specialty medications

What’s new?
Select specialty medications covered under the Medicare Part B medical benefit will require prior authorization, starting July 5, 2017. These are medications that aren’t self-administered, but must be administered via injection or infusion by a doctor or health care professional in the office setting.

The purpose of these new requirements is to help ensure that health care providers use the most effective therapies available, in keeping with the Centers of Medicare & Medicaid Services coverage guidelines for medical necessity, safety and efficacy.

Providers must obtain prior authorization and verify patient benefits to be eligible for payment for administering these medications. If a prior authorization isn’t obtained before services are rendered, the claim will be rejected. Also, providers may not bill members for services that required, but didn’t receive, preapproval.

Keep in mind that authorization isn’t a guarantee of payment. CMS benefit coverage rules and benefit exclusions or limitations will apply.

Which specialty medications will require prior authorization?
Below is a sampling of specialty drugs that will require Medicare Part B prior authorization:

We’ll evaluate the program on an ongoing basis, and may add or remove new drugs or procedures from the prior authorization list. When this happens, we’ll notify you via The Record or web-DENIS.

Beginning July 5, you can find a list of medications that will require a prior authorization on the Medicare Advantage PPO medical drug policies and forms page. Or from Provider Secured Services, click on Medicare Advantage PPO Medical Benefit – Medication Prior Authorization.

How do I initiate a prior authorization request?
Prior authorization requests can be submitted through the NovoLogix^® online tool. NovoLogix allows providers to obtain real-time status checks on prior authorizations and immediate approvals for certain medications when patients meet specific criteria. Use of the NovoLogix tool will save time and lessen your administrative burden by eliminating the manual process of submitting a form.

Submit prior authorization requests by following these steps:

• Log in to Provider Secured Services
• Click on Medicare Advantage PPO Medical Benefit – Medication Prior Authorization.
• Follow the instructions.

If you can’t access Provider Secured Services or aren’t registered to use NovoLogix, call 1-877-258-3932 Monday through Friday from 8 a.m. to 8 p.m. Eastern time.

If you have any questions about this process, call the Pharmacy Clinical Help Desk at 1-800-437-3803.

How do I request access to NovoLogix?

• If you already use Provider Secured Services, fill out Addendum P and fax the form to us at 1-800-495-0812.
• If your office or facility has never used Provider Secured Services, learn how at bcbsm.com/providers. When completing the application, be sure to check “Medical Drug PA” in Section 6.
• If you can’t access Provider Secured Services, call 1-877-258-3932 Monday through Friday from 8 a.m. to 8 p.m. Eastern time.

Want more information

• You can find a drug list, NovoLogix user guide, NovoLogix tutorial video and FAQ document from Provider Secured Services. Click on Medicare Advantage PPO Medical Benefit – Medication Prior Authorization.

• You can also find our medical policies and request forms in the Provider Toolkit for Medicare Advantage PPO. Click on Medicare Advantage PPO medical drug policies and forms.