Blue Cross to implement 2017 InterQual^® criteria Oct. 2

Blue Cross Blue Shield of Michigan will implement InterQual^® acute care, rehabilitation, long-term acute care, skilled nursing and home health criteria on Oct. 2, 2017. On this date, newly modified InterQual criteria will take effect and all previously published modifications (local rules) will be replaced with the new criteria.

The Blue Cross modifications of the InterQual criteria (local rules) can be accessed online by following these steps:

• Log in to web-DENIS.
• Click on BCBSM Provider Publications and Resources in the left column.
• Click on Newsletters & Resources.
• Click on Clinical Criteria & Resources.

Note: The 2017 InterQual criteria are only available electronically. Services requiring prenotification or precertification must be submitted via e-referral. For details on registering for e-referral, see the April Record article.

Preauthorization program for commercial Blue Cross PPO plans coming in January

Beginning Jan. 1, 2018, our fully insured and IBU commercial Blue Cross Blue Shield of Michigan PPO plans will require preauthorizations for the following services:

• Interventional pain management
• Radiation therapy (oncology) services
• Inpatient and outpatient lumbar spinal fusion surgery

These programs will be administered by eviCore healthcare, a national specialty benefits management company that focuses on quality, cost and use of health care services.

MESSA is currently excluded. Auto groups and the UAW Retiree Medical Benefits Trust are also excluded. Blue Care Network HMO isn’t affected by this change.

Similar eviCore preauthorization programs were rolled out for Michigan Medicare Plus Blue^SM PPO members in 2016.

For more information

Look for more detailed information in the November issue of The Record about the commercial PPO preauthorization program, including:

• Opportunities for training (encouraged for resources involved in the preauthorization and billing processes)
• Details about the preauthorization process
• How to identify members who require preauthorization

Once the eviCore implementation site is live, it will include information on forms, guidelines, FAQs and other pertinent details.

Pharmacy network change for Blue Cross and BCN Medicare Part D plans

Effective Jan. 1, 2018, Blue Cross Blue Shield of Michigan and Blue Care Network Medicare Part D plans will move to an Express Scripts managed pharmacy network, Medicare Preferred Value Network. These Medicare Part D plans will adopt standard and preferred pharmacy contracts for 30- and 90-day prescriptions.

How this affects our members
Currently, our members pay a lower cost share only when they obtain 90-day prescriptions. This change will allow them to pay a lower cost share for both 30- and 90-day prescriptions when they go to a preferred pharmacy. It will also support the improvement of our members’ medication adherence.

Members can locate preferred pharmacies near them by logging in to our website, bcbsm.com/pharmaciesmedicare, or by calling the Customer Service number on the back of their Blue Cross member ID card.

10 tips to improve your BlueCard^® experience

Over the past two years, we’ve been answering your questions about BlueCard in our “BlueCard^® Connection” feature in The Record. To help streamline your BlueCard experience, we’ve compiled key information from that feature into a series of 10 tips. We hope you find them helpful.

1. Check your patient’s eligibility, benefits and authorization requirements every visit by calling 1-800-676-2583. The member’s three-letter alpha prefix routes you to the member’s home plan. Taking the time to make the call at the time of service can save you time down the road and ensure prompt payment when the claim is filed.
2. Reference the BlueCard chapter available in every online provider manual frequently. The chapter includes detailed information on the BlueCard program, links to online tools and links to all of the BlueCard-related Record articles.  Using the BlueCard chapter of the manual as your point of reference may avoid a call to Provider Inquiry or help you prepare for the call when you need assistance.
3. Complete the medical record contact information available in the Provider Enrollment section of web-DENIS. Providing us with your billing office fax number allows us to fax any medical record requests we receive from out-of-area Blue plans directly to your office. Use the Medical Record Request form you receive as the cover sheet to return the medical records to Blue Cross Blue Shield of Michigan. The form will request the information needed to determine benefits on your claim. Note: Return only what’s requested. Sending information not requested can delay or deny the claim. If the information the plan is requesting isn’t available, return the Medical Record Request form, indicating the information isn’t available, and notify the member.
4. Report a valid, accurate and timely claim. Our standard reporting requirements apply to BlueCard claims.
5. View an out-of-area Blue plan’s medical policy to determine the plan’s medical criteria for a specific service. Links to the Medical Policy & Pre-Cert/Pre-Auth Router are available on web-DENIS — in the BlueCard chapter of every online provider manual — and on bcbsm.com.
6. Consider requesting a prior approval from the member’s home plan for ongoing treatment plans, such as IV therapy; physical, occupational or speech therapy; radiation oncology or chemotherapy. Check out the plan’s medical policy online and be prepared to provide the plan with the dates of service and expected treatment plan when calling for the prior approval. If approved, claims for these services will process without being denied for lack of medical records.
7. If you a receive a claim denial and the reason for the denial isn’t clear to you — or if you’ve resubmitted a claim and you receive the same denial — contact Provider Inquiry for assistance before rebilling the claim.
8. Contact Provider Inquiry to initiate a claim reconsideration if your BlueCard claim has denied for any reason other than that the member’s benefit doesn’t cover the service reported. Our Provider Inquiry representatives will review the claim with you and work with the plan, if necessary, on your behalf. Claims that deny because the service isn’t a covered benefit of the member’s contract should be addressed by the member and their plan.
9. View the web-DENIS broadcast messages at least weekly. Messages marked with a yellow “new” flag are those that were added within the last week. System issues or updates affecting BlueCard claims will be posted via web-DENIS broadcast messages.
10. Contact your provider consultant if you think updates to the BlueCard chapter of the online provider manuals are needed or if you’d like to request a Record article on a particular topic.

Blue Cross continues to work to improve your BlueCard experience through claims processing initiatives and efforts to educate our claims processing staff and Provider Inquiry representatives about BlueCard. We want to ensure that your claims are processed in a timely manner and that the information you receive about BlueCard is accurate. As always, if you have any questions or concerns about BlueCard, contact your provider consultant.

Blue Cross won’t cover services rendered and prescriptions issued by sanctioned providers

Blue Cross Blue Shield of Michigan will no longer cover services rendered or prescriptions written by sanctioned providers. A sanctioned provider is a provider who has been terminated from Blue Cross’ provider networks through either:

• The departicipation process; or
• A recommendation by Blue Cross’ Audit and Investigation Committee

A sanctioned provider also refers to any provider who appears on any exclusion list issued by the Office of the Inspector General, the Government Services Agency, the Centers for Medicare & Medicaid Services or state licensing boards.

This policy is effective immediately, if in accordance with the member’s benefits. It replaces Blue Cross’ previously published Prescription Block Policy.

Blue Cross will, as reasonably possible, give its affected members 30 days’ notice that services rendered and prescriptions issued by a sanctioned provider will no longer be covered.

Coding corner: Seizures vs. epilepsy

Epilepsy is a brain disorder often associated with seizures. According to the Centers for Disease Control and Prevention, epilepsy affects more than 2 million adults in the U.S.

When a person has two or more seizures, he or she is considered to have a seizure disorder. A seizure is triggered by a change in normal brain activity and is the main sign of epilepsy. Seizures can also be caused by other medical problems. Symptoms can vary according to the cause and part of the brain that’s affected.

There can be multiple causes that trigger seizures and epilepsy, including:

• Developmental problems, such as cerebral palsy
• Head injuries
• Poisoning

If known, physician documentation must specify the reason for the seizure, such as epilepsy with known seizure disorder, traumatic brain injury, cerebrovascular accident, brain tumor, substance use disorder, electrolyte imbalance, genetic disorder or other.

If the cause is unknown or documentation is lacking, only the symptoms can be coded, which can result in failure to correctly capture the patient’s condition.

Supporting documentation related to treatment, such as anti-seizure medications, EEG or imaging studies, and specific blood tests, helps accurately capture and report the diagnosis.

To accurately assign a code, the specific description of the epilepsy or recurrent seizure condition is necessary. The code for epilepsy shouldn’t be assigned unless the physician specifically states epilepsy as the condition in the diagnostic statement.

The types of seizures are grand mal, myoclonic, atonic, tonic, clonic and absence (petit mal). Accurate documentation of the seizure type is important in assigning the correct ICD-10-CM codes. The ICD-10-CM coding system has more codes to accommodate higher specificity in capturing diagnoses. Some examples are given in the chart below.

Epilepsy and recurrent seizures require a fifth digit when coding in ICD-10-CM to indicate whether the patient’s condition is intractable. If a patient has intractable epilepsy, his or her condition may be difficult to control using anticonvulsant medications, such as phenytoin or phenobarbital.

As with many other conditions, physician documentation is crucial to accurately code a diagnosis of seizure or epilepsy.

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.

Reminder: Blue Cross doesn’t reimburse claims for experimental, investigational or medically unnecessary services

We’d like to remind you that Blue Cross Blue Shield of Michigan’s payment policy excludes reimbursement for experimental, investigational or medically unnecessary procedures, treatments, drugs or devices. This payment policy applies to all claims reported for Blue Cross Blue Shield of Michigan commercial contracts, including the BlueCard^® program.

Health care providers may not bill members for such services unless, prior to the services, all of these requirements are met:

1. You provide the member with a cost estimate of the service.
2. You have the member confirm in writing that he or she assumes financial responsibility for the service.
3. The member understands that Blue Cross won’t reimburse the provider for the service.

BlueCard claims for services that Blue Cross Blue Shield of Michigan reimburses, based on our payment policy, but that are denied by the member’s out-of-state home plan as experimental, investigational or medically unnecessary, according to the member’s contracted benefits, may be the member’s financial responsibility.

CPT Category II and Z codes aid data collection and lessen administrative work for offices

Doctors may want to consider using CPT Category II and Z codes as they ease an office’s administrative burden. They also decrease – not eliminate – the need for medical record reviews to determine if certain standards are met.

What are CPT Category II and Z codes?
CPT Category II codes are tracking codes, while Z codes are for body mass index diagnosis. Certain CPT Category II codes and Z codes facilitate data collection for Healthcare Effectiveness Data and Information Set, or HEDIS^®, measures. Used together, these codes can give you credit for quality care without the need for medical record review and can help close gaps in HEDIS measures.

Here’s a closer look:

• CPT Category II codes describe components that are usually included in the evaluation and management process such as A1c or blood pressure test results. Like CPT Category I codes, they are billed in the procedure code field.

• CPT Category II codes are adopted and reviewed by the Performance Measure Advisory Group. PMAG is made up of experts in performance measurement from organizations such as the American Medical Association, the National Committee for Quality Assurance, the Centers for Medicare & Medicaid Services and others.

• Z codes can facilitate data collection, for instance, if a doctor submits a claim with the appropriate ICD-10 diagnosis code to indicate a patient’s BMI. This will alleviate the need to review the member’s medical record for BMI documentation.

Closing HEDIS gaps with CPT Category II codes
Keep these tips in mind when billing CPT Category II codes:

• Manage and document all acute and chronic patient conditions appropriately.
• Ensure that services provided and diagnoses are documented in the medical record.
• Submit accurate and timely claims for every office visit.
• Report all services completed on a claim.

Here’s a list and description of CPT Category II codes that meet HEDIS measures.

Reviewing BMI results with Z codes
ICD-10 BMI results should be included in your office visit claims, typically with the patient’s annual wellness visit or physical. Make sure you document your patient’s height, weight and BMI in the patient’s medical record and that your medical billing coders include the ICD-10 BMI code.

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

HCPCS update: New modifier added

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

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.

Here’s what you need to know about Blue Cross inpatient authorization requirements

Inpatient admission authorization requests for Blue Cross Blue Shield of Michigan commercial PPO and Blue Cross Medicare Plus Blue^SM PPO must be submitted through e-referral, effective July 31, 2017. The only exceptions are newborn and gender reassignment authorization requests, which must be faxed.

The application of clinical criteria is required in some cases to receive authorization for Blue Cross inpatient stays. For more information, see the Blue Cross Authorization Requirements & Criteria page on the e-referral site.

Members with Medicare Plus Blue or URMBT coverage
Concurrent review will occur for all inpatient admissions for members with Blue Cross Medicare Plus Blue PPO coverage and those with Blue Cross commercial PPO coverage through the UAW Retiree Medical Benefits Trust. Following is additional information for submitting inpatient requests for these members:

• Facilities and providers should request an appropriate number of days when submitting their authorization request, based on the member’s diagnosis and clinical presentation.
• Requests for additional days must be submitted through e-referral and must include clinical updates.
• If the member is discharged before the last covered day, a discharge date should be entered in e-referral. The discharge date and the total number of days the member was inpatient can be added to e-referral as a note. For instructions on how to do this, see the e-referral User Guide. Go to the Submit an Inpatient Authorization section, and review the Create New (communication) instructions.

Requirements for Blue Cross commercial and Medicare Plus Blue
Following are details about submitting authorizations for various types of services for members with Blue Cross commercial and Medicare Plus Blue:

**Length-of-stay request should be appropriate for treatment type.
***Behavioral health and substance abuse requests that require an acute inpatient admission must be submitted with a medical diagnosis.
****Gender reassignment requests must be submitted with a medical diagnosis.

Note: The Federal Employee Program^® requires all gender reassignment surgeries obtain prior approval for the surgical procedure and precertification for the inpatient admission.

We’re changing how behavioral health facilities handle certain requests for Medicare Plus Blue^SM members

Starting Oct. 16, 2017, the way Blue Cross Blue Shield of Michigan Medicare Plus Blue^SM PPO behavioral health facilities submit initial authorization requests, concurrent reviews and discharge summaries will change for inpatient, partial hospitalization and intensive outpatient services. The changes will affect both substance use and mental health disorders.

Here’s a summary of the changes:

The Behavioral Health e-referral User Guide will be updated before Oct. 16, 2017, to include instructions for submitting requests for inpatient, partial hospitalization and intensive outpatient services for Blue Cross Medicare Plus Blue PPO members.

You can refer to the updated user guide for instructions on how to attach the Behavioral Health Discharge Summary form to the case in the e-referral system. The User Guide will also show you how to complete the questionnaire for a concurrent review.
You can access the user guide at ereferrals.bcbsm.com. Click on Blue Cross and then on Behavioral Health.

Sign up to use e-referral system
Facilities contracted with Blue Cross Medicare Plus Blue PPO that have not signed up for access to the e-referral system should apply immediately. Each utilization review user at each facility will need his or her own individual access.

To get access to e-referral, you must register to use the Blue Cross Provider Secured Services portal. Go to ereferrals.bcbsm.com and click on Sign Up or Change a User. Follow the instructions under the heading “To sign up as a new e-referral user.”

These instructions apply whether your facility is new to Provider Secured Services or you’re already signed up for Provider Secured Services and just need access to the e-referral system.

It’s crucial that you sign up as soon as possible because granting access takes some time and you’ll need access before Oct. 16.

Note: The information in this article applies only to services for Blue Cross Medicare Plus Blue PPO members. For Blue Cross PPO (commercial) members, the instructions are different. Most, but not all, Blue Cross PPO members have their behavioral health coverage managed by New Directions. For those members, you can use the New Directions WebPass tool online at webpass.ndbh.com to request initial and continuing stay authorizations for inpatient admissions and check the status of these requests. You can also call 1-800-762-2382.

Medicare Plus Blue^SM PPO updating claim editing processes

Recently, we told you about how, starting in October, 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 appropriate local and national coverage determination guidelines in a way that will simplify our claims payment system and make it easier for you to navigate.

Medicare Plus Blue PPO will include 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 the 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.

Blue Cross updates policy for medical specialty drug infusions

Beginning Jan. 1, 2018, Blue Cross Blue Shield of Michigan will require prior authorization to cover infusions of select specialty drugs administered in the hospital outpatient department. Members must instead receive their infusions in a professional office setting, a professional infusion center or in the member’s home.

All drugs included in this program already require prior authorization for payment. Approved authorizations will be payable at professional settings and through home infusion with no further action required. An updated review for medical necessity will be required for members to receive infusions in a hospital outpatient facility.

Updated medical necessity review
If a member must receive his or her infusion in a hospital outpatient facility, please follow the normal steps for a prior authorization request and include the:

• Authorization number previously approved
• Rationale that clearly describes the reason that the infusion must be administered in a facility setting
• Supporting chart notes

Specialty drugs subject to this requirement include:

Verscend Technologies to retrieve medical records for Blue Cross, BCN commercial risk adjustment services

Blue Cross Blue Shield of Michigan and Blue Care Network will use Verscend Technologies, an independent company, to perform medical record retrieval for risk adjustment services for commercial members, beginning in October 2017.

Verscend will remain the medical record retrieval vendor for in-state commercial risk adjustment business and continue to work with other Blue plans for out-of-state risk adjustment and retrieval services for Healthcare Effectiveness Data and Information Set charts.

Blue Cross and BCN request medical records every year to meet the Centers for Medicare & Medicaid Services’ standards for data submission and coding accuracy, and CMS’ and Health and Human Services’ regulations and quality standards for patient care.

Verscend Technologies 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 questions, contact Blue Cross and BCN provider outreach consultants Sue Brinich at 586-839-8614, Tom Rybarczyk at 313-378-8259 or Corinne Vignali at 313-969-0417.

**Blue Cross Blue Shield of Michigan doesn’t 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 our members’ protected health information. These safeguards include completion of a Trading Partner Agreement and Provider Authorization form as part of the electronic data interchange setup process.

All EDI trading partners must complete a TPA and Provider Authorization form before they can share protected health information with Blue Cross.

Terms of the TPA require you to notify us of any changes in your trading partner information. If you switch service bureaus or 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.

You should review your provider authorization information if you’ve:

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

You must update your provider authorization information if you send claims using a different submitter ID or route your 835s to a different unique receiver/Trading Partner ID.

To make changes to your EDI setup, go to bcbsm.com and click on the following:

• Providers
• Quick Links
• Electronic Connectivity EDI
• How to use EDI to exchange information with us electronically
• Update your Provider Authorization Form, which is found under EDI agreements

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

Here are some FEP checklists for criteria that’s required for review of medical necessity

The Blue Cross Blue Shield of Michigan Federal Employee Program^® team has put together some criteria checklists. These are lists of medical documentation for criteria that’s required for review of medical necessity.

To view and use the checklists, click on the links below:

• Abdominoplasty
• Bariatric**
• BRCA***
• Gender reassignment surgery****
• Mammoplasty
• Procedure code *83516
• Sleep study
• FEP criteria for specific services requiring medical review

**Prior approval required for outpatient morbid obesity
***Prior approval required for preventative testing
****Prior approval required

Precertification, signed consent for case management must be obtained before residential treatment center admission for FEP members

Precertification and signed consent for case management must be obtained before Federal Employee Program^® members are admitted to residential treatment centers for psychiatric or substance use treatment. RTC benefits are denied for inpatient care provided or billed by a residential treatment center without precertification and signed consent for case management. Requests for retrospective reviews aren’t allowed.

For questions about the FEP residential treatment center benefit, call FEP Customer Service at 1-800-482-3600. For questions or requests for precertification and case management, call New Directions Behavioral Health at 1-800-342-5891.

Medicare Plus Blue^SM PPO updating claim editing processes

Recently, we told you about how, starting in October, 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 appropriate local and national coverage determination guidelines in a way that will simplify our claims payment system and make it easier for you to navigate.

Medicare Plus Blue PPO will include 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 the 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.

Blue Cross updates policy for medical specialty drug infusions

Beginning Jan. 1, 2018, Blue Cross Blue Shield of Michigan will require prior authorization to cover infusions of select specialty drugs administered in the hospital outpatient department. Members must instead receive their infusions in a professional office setting, a professional infusion center or in the member’s home.

All drugs included in this program already require prior authorization for payment. Approved authorizations will be payable at professional settings and through home infusion with no further action required. An updated review for medical necessity will be required for members to receive infusions in a hospital outpatient facility.

Updated medical necessity review
If a member must receive his or her infusion in a hospital outpatient facility, please follow the normal steps for a prior authorization request and include the:

• Authorization number previously approved
• Rationale that clearly describes the reason that the infusion must be administered in a facility setting
• Supporting chart notes

Specialty drugs subject to this requirement include:

Verscend Technologies to retrieve medical records for Blue Cross, BCN commercial risk adjustment services

Blue Cross Blue Shield of Michigan and Blue Care Network will use Verscend Technologies, an independent company, to perform medical record retrieval for risk adjustment services for commercial members, beginning in October 2017.

Verscend will remain the medical record retrieval vendor for in-state commercial risk adjustment business and continue to work with other Blue plans for out-of-state risk adjustment and retrieval services for Healthcare Effectiveness Data and Information Set charts.

Blue Cross and BCN request medical records every year to meet the Centers for Medicare & Medicaid Services’ standards for data submission and coding accuracy, and CMS’ and Health and Human Services’ regulations and quality standards for patient care.

Verscend Technologies 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 questions, contact Blue Cross and BCN provider outreach consultants Sue Brinich at 586-839-8614, Tom Rybarczyk at 313-378-8259 or Corinne Vignali at 313-969-0417.

**Blue Cross Blue Shield of Michigan doesn’t 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 our members’ protected health information. These safeguards include completion of a Trading Partner Agreement and Provider Authorization form as part of the electronic data interchange setup process.

All EDI trading partners must complete a TPA and Provider Authorization form before they can share protected health information with Blue Cross.

Terms of the TPA require you to notify us of any changes in your trading partner information. If you switch service bureaus or 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.

You should review your provider authorization information if you’ve:

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

You must update your provider authorization information if you send claims using a different submitter ID or route your 835s to a different unique receiver/Trading Partner ID.

To make changes to your EDI setup, go to bcbsm.com and click on the following:

• Providers
• Quick Links
• Electronic Connectivity EDI
• How to use EDI to exchange information with us electronically
• Update your Provider Authorization Form, which is found under EDI agreements

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

Here are some FEP checklists for criteria that’s required for review of medical necessity

The Blue Cross Blue Shield of Michigan Federal Employee Program^® team has put together some criteria checklists. These are lists of medical documentation for criteria that’s required for review of medical necessity.

To view and use the checklists, click on the links below:

• Abdominoplasty
• Bariatric**
• BRCA***
• Gender reassignment surgery****
• Mammoplasty
• Procedure code *83516
• Sleep study
• FEP criteria for specific services requiring medical review

**Prior approval required for outpatient morbid obesity
***Prior approval required for preventative testing
****Prior approval required

Medication therapy management: A tool to help patients reach their treatment goals

Blue Cross Blue Shield of Michigan’s Medication Therapy Management program for 2017 can help address the human and financial toll that medication non-adherence, improper medication use and adverse drug reactions can have on patients.

Medication therapy management is a pharmacist-provided service that can help patients get the most out of their medications. Pharmacists conduct a medication review with eligible members, either in person or over the phone, and discuss all aspects of medication usage with the member.

The Centers for Medicare & Medicaid Services has made medication therapy management a free benefit that’s provided by all Medicare Part D prescription drug plans to eligible members.

Eligibility

Medicare members who are eligible for Blue Cross Blue Shield of Michigan’s Medication Therapy Management program for 2017 must meet all of the following criteria:

• Have at least three of the following chronic medical conditions:
• Diabetes
• Heart failure
• Chronic obstructive pulmonary disease
• Hyperchlolesterolemia
• Hypertension
• Take at least eight Part D medications
• Be reasonably expected to incur at least $3,919 worth of drug expenses in one calendar year

These members will be sent a welcome packet in the mail inviting them to participate. After finishing a medication review with a member, the pharmacist will send the member a summary of what was discussed, any issues that were addressed and a current medication list. In addition, the member’s Part D claims will be monitored throughout the year to check for any new issues or major changes in therapy.

Benefits

Here are some of the benefits of medication therapy management:

• Improves medication adherence
• Identifies drug interactions with other drugs, foods, vitamins and herbal supplements
• Suggests possible therapeutic options to help reduce the financial burden of medication use
• Reconciles medications across multiple prescribers

Close coordination between prescribers and the medication therapy management team will help you get the most from the program. It’s an important tool for helping patients reach their treatment goals, but you may need to encourage eligible patients to take advantage of the services.

Let your eligible patients know that the program:

• Is free and part of their prescription drug benefit
• May be done over the phone at their convenience
• Can help them better manage their medications and, possibly, decrease costs
• Can identify potential adverse reactions between drugs, foods, vitamins and herbal supplements

For more information on this topic, send an email to Kim Moon, a manager with Pharmacy Services, at kmoon@bcbsm.com.

We no longer require patient signatures for home drug deliveries

Effective Jan. 1, 2018, for Blue Cross Blue Shield of Michigan and Blue Care Network participating Michigan retail and mail order pharmacies, patient signatures will no longer be required on home deliveries of prescription drugs. This change doesn’t apply to in-store pickup of prescriptions. Signatures from the member or the member’s representative will still be required at the time of dispensing for in-store pickup of medication.

However, in lieu of delivery signatures, documentation must include:

• Courier electronic tracking that must correlate with the delivery slip and indicates what’s included in the delivery

Also, delivery records need to be available as requested and for audit purposes. In the event of an audit, providers must provide the auditor with:

• A copy of accreditation, if applicable
• Policies regarding packaging, storage and shipment of drug to ensure drug stability
• Policies of patient education to ensure the safe delivery of drug and drug stability

Note: Patient signatures with a date on the delivery slip will continue to be accepted.

In the event shipment is stolen or drug stability is compromised, Blue Cross Blue Shield of Michigan and BCN can’t be billed for replacement of the drug.