Blue Cross task force takes on growing opioid crisis

Overdose deaths in Michigan tripled in the last five years with more than 1,000 people treated in emergency departments daily for not using prescription opioids as directed. It’s alarming, though not surprising, that opioid abuse and deaths in the U. S. have reached the level of a natural disaster.

In August, the White House Commission on Combating Drug Addiction and the Opioid Crisis urged the president to declare the opioid crisis a national emergency. Soon after, Blue Cross Blue Shield of Michigan established a task force to advance efforts that were already underway to fight opioid addiction and misuse.

“Opioid abuse is a public health crisis that is growing at a terrifying pace,” said Todd Anderson, Blue Cross’ director of Public Policy. “As Michigan’s largest health insurer with a strong social mission, Blue Cross has a responsibility to address it.”

Anderson and Dr. Duane DiFranco, senior medical director for Blue Cross, are leading the task force. It includes representatives from across the company to ensure a comprehensive, coordinated approach. Its objectives are to:

• Examine opportunities with providers and members
• Enhance access to high quality treatment
• Fight fraud and abuse
• Improve state and federal laws
• Provide support for innovative community coalitions that are addressing the crisis
• Champion a communications effort to educate the public, the media and our members

“Our goal is to establish a plan that helps prevent opioid abuse and enables providers to better identify patients with opioid use disorders — and to more effectively treat them,” DiFranco said.

Following are some facts about the opioid epidemic from the Blue Cross Blue Shield Association and other key sources. For more details about these statistics, click on links below the graphic.

Sources:

To read more about the information in the graphic, click on the following links:

650,000 prescriptions**
Overdose deaths in Michigan**
BCBSA report**
70% of youth**
One in 4 teens**
McKinsey report**

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

Here’s more information about new preauthorization program for commercial PPO

As we communicated in the October Record article titled “Preauthorization program for commercial Blue Cross PPO plans coming in January,” some of our commercial PPO members will require preauthorization for the services listed below, beginning Jan. 1, 2018. The requirement is for our members with individual health plans and some of our members with coverage through their employers.

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

The prior authorization program for these members will be administered by eviCore healthcare, a national specialty benefits management company that focuses on quality, cost and use of health care services.

To view a list of codes, visit the eviCore site.

How to determine if a prior authorization is required for your patient
If you schedule a patient for a procedure that is from one of the three programs then you:

• Log in to Provider Secured Services and go to web-DENIS.
• Under Subscriber Info on the left-side of the page, click Eligibility/Coverage.
• Select Prior Authorization.
• Once you verify that prior authorization is required, contact eviCore for a prior authorization request through one of the following:
• eviCore’s online portal through web-DENIS
• By phone at 1-877-917-2583, from 7 a.m. to 8 p.m. Monday through Friday

You’ll need to provide eviCore with the following information for the prior authorization request:

• Member ID, name and date of birth
• Rendering facility name and address
• Referring or ordering physician name, NPI, state and ZIP code
• Patient treatment plan, clinical presentation
• Completed physician worksheet
• Supporting information such as imaging studies, prior tests and related office notes

Authorizations submitted online are typically processed within three calendar days. In most cases, authorizations are processed on the same day. For expedited authorizations, call 1-877-917-2583.

You can request prior authorization through eviCore beginning Dec. 18 for services on or after Jan. 1, 2018.

What happens next

Approved requests are faxed to the ordering provider, mailed to the member or printed on demand at eviCore website. Authorizations are good for 45 calendar days from the date of determination for interventional pain management and lumbar spinal fusion. For radiation therapy (oncology), the number of days the authorization is valid varies based on the procedure.

Denied requests are communicated, along with determination and rationale, via fax to the ordering provider and mailed to the member. Appeals and peer-to-peer conversation requests can be sent to eviCore. This information will be available at the eviCore website in December.

Liability
If a member sees an in-state participating provider and services are rendered before prior authorization is obtained, the provider is held liable. If a member sees an in-state non-participating provider or an out-of-state provider and prior authorization is not obtained before services are rendered, the member is held liable.

Training
To help you make a smooth transition, we’re offering online training on the prior authorization process through eviCore.

Training sessions will cover:

• Overview of eviCore healthcare
• Overview of eviCore’s clinical approach
• Review of prior authorization process and specifics of the program
• Review of web portal
• Overview of eviCore’s provider resources

Online training dates

Each session is 60 minutes. The training will be recorded and then available on web-DENIS.

How to register for a training

• Select a date and time for the program you’re interested in.
• Go to evicore.webex.com.
• Click on the Training Center tab at the top of the page.
• Click the Upcoming tab and find the date and time of the conference you wish to attend.
• Click Register and enter the registration information.

Note: The sessions are named “Blue Cross and Blue Shield of Michigan Radiation Therapy Provider Orientation” and “Blue Cross and Blue Shield of Michigan Interventional Pain & Lumbar Spine Fusion Provider Orientation.”

After you have successfully registered for the conference, you’ll receive an email containing the toll-free phone number and meeting number, conference password and a link to the web portion of the conference. Please keep the registration email so you’ll have the information for your session.

Training sessions will be stored at the eviCore site and can be accessed for future reference.

How to contact eviCore

Email ClientServices@eviCore.com or call 1-877-917-2583, from 7 a.m. to 8 p.m. Monday through Friday, for issues that require immediate attention such as:

• Provider verification
• Authorization questions
• Letter issues
• Member eligibility issues
• eviCore healthcare standard processes and procedures
• Data questions or issues

Note: 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.

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.

Blue Cross to provide behavioral health services for some UAW Retiree Medical Benefits Trust members

As of Jan. 1, 2018, Blue Cross Blue Shield of Michigan will provide behavioral health (mental health and substance abuse) administrative services for non-Medicare UAW Retiree Medical Benefit Trust members. These services include preauthorization and case management. This was previously performed by a different vendor.

The behavioral health benefits for these members are not changing.

Phone numbers for approvals and customer service are on the back of the members’ ID cards. Be sure to check web-DENIS for patient eligibility and benefits.

Enhanced search categories within Find a Doctor support patient satisfaction

For patients — especially those with a high-deductible health care plan or a health savings account — their cost share for services and procedures can be a real concern. Studies show that when patients can anticipate costs, they tend to be more satisfied.

With patient satisfaction in mind, we’ve made it easier for your patients to find in-network care and plan for their share of the costs with the recently enhanced Find a Doctor category search.

How do they use it?
After logging in to their member account with the Blue Cross mobile app or bcbsm.com and launching Find a Doctor, your patients can immediately use the new Select a category drop-down menu to select one of five types of provider searches.

More targeted results
The various search categories give your patients more targeted results. They can quickly find:

• Doctors by name
• Doctors by specialty
• Places by name
• Places by type
• Costs for procedures

All searches return results that are based on your patients’ Blue Cross Blue Shield of Michigan or Blue Care Network coverage. Only in-network providers appear in the list.

And, when you order imaging, a diagnostic test or procedure for your patients, the Costs for procedures search category can help them search for what’s needed and see an estimate of the total cost involved, by provider.

Building better relationships
Gain trust and build stronger relationships with your Blue Cross and BCN patients by helping them make more informed decisions about their health care. Point them to Find a Doctor for focused, relevant, in-network provider search results. Help patients with high-deductible health care plans anticipate their share of the costs for diagnostic and specialty care with the Costs for procedures search category.

Some generic statin drugs to be covered at zero cost share for select members

Effective Dec. 1, 2017, Blue Cross Blue Shield of Michigan and Blue Care Network will cover low- to moderate-dose generic statin drugs at zero cost share when they’re prescribed for members between the ages of 40 and 75.

We’re doing this because the U.S. Preventive Services Task Force recommends that adults without a history of cardiovascular disease use a low- to-moderate-dose statin to prevent CVD events and mortality when they meet the following criteria:

• They’re between the ages of 40 and 75.
• They have one or more CVD risk factors, such as dyslipidemia, diabetes, hypertension or smoking.
• Their calculated 10-year risk of a CVD event is 10 percent or greater.

This change applies to Blue Cross and BCN commercial (non-Medicare) members and doesn’t apply to grandfathered, retiree or religious-accommodated groups.

The low- to moderate-dose generic statin drugs we’ll cover at zero cost share, when members meet plan requirements and have a prescription, include:

• Atorvastatin (brand name Lipitor^®) — Less than or equal to 20 mg
• Fluvastatin (brand name Lescol^®/XL) — Less than or equal to 80 mg
• Lovastatin (brand name Mevacor^®) — Less than or equal to 40 mg
• Pravastatin (brand name Pravachol^®) — Less than or equal to 80 mg
• Rosuvastatin (brand name Crestor^®) — Less than or equal to 10 mg
• Simvastatin (brand name Zocor^®) — Less than or equal to 40 mg

Members outside of the 40-to-75 age range will continue to receive generic statins at their applicable cost share.

Note: Quantity limits apply. Refer to the Quantity Limit Program document here. If a patient’s use of these drugs exceeds our quantity limits, you may request approval to deviate from the dosing guidelines.

HHS awards $144 million in grants to fight opioid addiction

On Sept. 15, the U.S. Department of Health and Human Services announced $144.1 million in grants to prevent and treat opioid addiction. These grants will be administered by the Substance Abuse and Mental Health Services Administration, an agency within HHS.

According to HHS, the grants will:

• Help expand treatment and recovery services to pregnant and postpartum women who are struggling with substance abuse
• Train our first responders to effectively use overdose reversing drugs
• Improve access to medication-assisted treatment
• Increase long term recovery services

SAMHSA’s National Survey on Drug Use and Health estimates 11.8 million people misused opioids in the past year — from pain relievers to heroin.

“Opioid use disorders continue to plague our nation,” said Elinore McCance-Katz, M.D., assistant secretary for Mental Health and Substance Use. “These funds will support and expand prevention, treatment and recovery services in America’s communities.”

The grants will be distributed over the next three to five years to 58 recipients, including states, cities, health care providers and community organizations.

For information, read the news release** on the HHS website.

**Blue Cross doesn’t own or control this website or endorse its general content

HCPCS, CPT updates and early release codes

Third-quarter HCPCS code updates
Outpatient prospective payment system

Third-quarter CPT code updates
Pathology and laboratory — proprietary laboratory analysis

2018 early release HCPCS code updates
Medicine supplementary — oral drugs, injection

Injection

2018 early release CPT code updates
Category III and medicine codes — Surgery, radiology, medicine, pathology and laboratory, vaccines/toxoids

Coding corner: Medical record documentation for COPD and associated respiratory conditions

According to the Centers for Disease Control and Prevention, approximately 15.7 million Americans have been diagnosed with chronic obstructive pulmonary disease. The prevalence of COPD, coupled with the increased specificity required by ICD-10-CM, makes documenting the disease and any respiratory conditions currently associated with it imperative to ensure the appropriate diagnosis code is applied.

The two common forms of COPD are emphysema and chronic bronchitis. However, many patients diagnosed with COPD have both emphysema and chronic bronchitis.

Important tips to remember

• Always document and code to the highest level of specificity and report diagnosis codes at their highest number of characters available. For example, if the provider documents “acute bronchitis” or “chronic bronchitis” (both unspecified), then report ICD-10-CM codes J20.9 and J42, respectively. However, if the provider doesn’t indicate whether the bronchitis is acute or chronic, the appropriate ICD-10-CM code would be J40 (bronchitis not specified as acute or chronic). It’s important to indicate, through coding, whether the condition is acute, chronic or in acute exacerbation.
• Since COPD-related conditions can be coded in a variety of ways, the final code selection must take into account the specific details of the patient’s condition as documented by the health care provider.
• ICD-10-CM code J44.9 (chronic obstructive pulmonary disease, unspecified) should only be used if the information in the medical record is insufficient to assign a more specific code.
• When COPD with an acute exacerbation is documented without acute bronchitis, then report ICD-10-CM code J44.1 (chronic obstructive pulmonary disease with acute exacerbation).
• Code J44.0 (chronic obstructive pulmonary disease with acute bronchitis) is assigned when the medical record supports acute bronchitis and COPD. (An additional code is used to identify the infection.)

It’s important to review the ICD-10-CM Chapter Specific Coding Guidelines (Chapter 10: Diseases of Respiratory System J00-J99) and any instructional notes under the various COPD subcategories and codes in the tabular list of the ICD-10-CM manual to select the correct code. In addition to the codes listed above, you may need to use additional codes to identify current or previous tobacco usage and dependence or other environmental exposure.

Note: ICD-10-CM coding for all conditions should follow the ICD-10-CM Official Guidelines for Coding and Reporting.

ICD-10-CM diagnosis codes and ICD-10-CM Official Guidelines for Coding and Reporting are subject to change. It’s the responsibility of the provider to ensure that current ICD-10-CM diagnosis codes and the current ICD-10-CM Official Coding Guidelines for Coding and Reporting are reviewed prior to the submission of claims.

Keep in mind that 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.

UAW Retiree Medical Benefits Trust coverage changing for Medicare members in 2018

Effective Jan. 1, 2018, the UAW Retiree Medical Benefits Trust (“the Trust”) will transition coverage for its Medicare primary members in Michigan from the Blue Cross Blue Shield Traditional Care Network plan to the Medicare Plus Blue^SM Group PPO. This means that on Jan. 1, 2018, many of your patients who receive coverage through the Trust will be enrolling in a Blue Cross Blue Shield of Michigan Medicare Advantage PPO plan.

There are several advantages to enrolling in a MA PPO plan:

• No monthly contributions to the Trust required
• Free fitness club membership in the Silver Sneakers fitness program
• Lower deductibles than the TCN plan
• No referrals required to visit the doctor, specialist or hospital of your choice

You’ll likely continue to see these same retirees, who will be Blue Cross Blue Shield Medicare Advantage members beginning Jan. 1, 2018. If you’re part of the Blue Cross MA PPO network, these members will be able to find your practice or facility in our online provider directory.

While most of our health care providers are familiar with our MA PPO plan, there are some differences in benefits and care management. Click here for more information about the plan.

As always, it’s important to ask your patients about recent changes in insurance carriers and benefits — and also request a copy of their ID card when they come for services. You can also check member benefits and eligibility on web-DENIS.

While referrals are not required for the MA PPO plan, members may need authorization prior to receiving certain hospital services. You’ll want to review the authorization guidelines and criteria on the e-referral site.

UAW Retiree Medical Trust promoting home health care services for members

Blue Cross Blue Shield of Michigan has moved forward with a number of initiatives to encourage an increase in home health care services for UAW Retiree Medical Trust commercial members. The primary purpose of this initiative is, ultimately, to decrease the likelihood of members being readmitted to hospitals.

We’re asking that facilities and providers assist us in referring our members to home health care for complex conditions or following a hospital stay. URMBT members can receive home care services without meeting “homebound” criteria. This differs from the Medicare guideline that requires homebound status.

Although each member has unique needs, there are a number of well-documented reasons why home care services could reduce hospital readmissions:

1. Home care assists in ensuring that the member or caregiver understands and complies with the member’s discharge plan.
2. Home care performs thorough, hands-on medication reconciliation.
3. Home care can identify and address potential barriers that may exist in the home setting.
4. Home care is “the bridge” between the facility discharge and the primary care physician follow-up.
5. Home care provides added support to the member or caregiver.
6. Home care provides insight into the home environment and can thoroughly assess the biopsychosocial situation.

If you have questions or need more information please contact Michele Ohneck, director of Medical Management URMBT, at 313-448-8465.

In-home assessments benefit providers, members

Blue Cross Blue Shield of Michigan and our participating health care providers share a mission: to provide our members with the right care at the right time and place. One way we do this is through in-home assessments.

We use the services of several in-home assessment vendors to meet the needs of our members with Medicare Advantage, individual and small group plans who may have difficulty getting to their doctor’s office. During these assessments, a doctor, nurse or physician assistant comes to the member’s home to discuss their medical history and conduct a brief exam. Members are encouraged to invite a caregiver, family member or friend to join them for the assessment.

In-home assessments don’t replace the care a doctor provides or an annual wellness visit. However, they provide members with another opportunity to discuss any symptoms, current medical conditions or health questions they may have.

Here are some other ways that an in-home assessment benefits members:

• It’s free. It’s part of their member benefits, and doesn’t affect their health care coverage, premiums or out-of-pocket costs.
• It’s easy. The visit typically lasts an hour. A licensed medical professional will check basic vital signs, ask some routine health-related questions and answer any questions the member may have.
• It’s helpful. The assessment provides valuable one-on-one time with a health care professional, and also helps members prepare for their annual doctor visit.
• It brings peace of mind. Assessment results are shared with the member and their doctor to support the care they already receive.

Members selected for an in-home assessment may meet one or more of the following criteria:

• They’re not participating in any health and wellness program offered by their health plan.
• They haven’t seen their doctor recently.
• They haven’t taken steps to address any chronic conditions they have.

Behavioral health documentation guidelines now available

When documenting behavioral health services provided to our members, contracted behavioral health providers must follow the guidelines we recently published. The guidelines apply to services for Blue Cross Blue Shield of Michigan PPO (commercial), Blue Cross Medicare Plus Blue^SM, Blue Care Network HMO^SM (commercial) and BCN Advantage^SM members. They were developed for all products to make it easier for providers to locate and follow them.

Where to locate guidelines

You’ll find the guidelines at ereferrals.bcbsm.com. Click on either Blue Cross or BCN, as appropriate. Then click on Behavioral Health.

The guidelines are published in two documents:

• Behavioral health medical record documentation requirements for applied behavior analysis services
• Behavioral health medical record documentation requirements and privacy regulations — for services other than ABA

You can also access the guidelines by visiting bcbsm.com/providers and logging in to Provider Secured Services. Then follow these steps:

• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters and Resources.
• Click on Clinical Criteria & Resources.
• Scroll down to the Behavioral Health Information header.
• Click on the links under the Behavioral Health Medical Record Documentation Requirements subhead.

The guidelines contain the requirements for documenting specific treatments. For applied behavioral analysis, or ABA, this includes line therapy, supervision, parental training or socialization groups, and re-evaluation. For non-ABA treatment, this includes the initial evaluation and subsequent individual, group and family therapy.

Why the guidelines were developed

Over the past few years, Blue Cross and BCN have added new types of providers who have enhanced our networks’ capabilities for care. Some providers have never worked with insurance carriers and haven’t previously had to document their services clearly and specifically enough to match the services billed.

In addition, we’ve had complaints from members that the services billed did not match the services they thought they were receiving. We’ve also been subject to additional reporting requirements from federal and local government agencies and from our accrediting organizations. These require more detailed documentation of services provided.

With these issues in mind, we developed documentation guidelines to align with those published by the Centers for Medicare & Medicaid Services, with local and federal regulatory agencies, with accrediting agencies and with good documentation practices. We feel this will help providers document their care in ways that meet both medical and legal requirements.

Additional information

In each guidelines document, you’ll see requirements for both medical and nonmedical treatment providers. Medical providers (physicians, nurse practitioners and physician assistants) must follow the CMS documentation guidelines in the Medical Learning Network guide ICN 006764 (August 2016).

For nonmedical providers, we’ve outlined detailed documentation requirements for the most common types of interventions that would be used.

When you document these interventions, there’s no need to document anything that did not occur. On the other hand, you should document any interventions you provided in addition to those we listed. That way, you’ll have a way to remember these interventions and these notes will complete the member’s record.

Also, standard care involves using screening tools to document the progress of your patient. Documenting the use of those tools can be helpful in measuring the progress of your patient or in identifying measurably poor progress and the subsequent need to review the treatment interventions provided.

Many electronic medical records already have most of these or all of these items within their database, although it may take some time to learn where they are to make the process go more quickly.

We encourage you to familiarize yourself with the new documentation requirements and start to use them immediately. Over the next few weeks, provider manuals will be updated with hyperlinks to the guideline documents.

Remember: The general rule of thumb is “If it isn’t documented, it didn’t occur.”

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.

Final reminder: Submit 2017 service dates for Medicare Advantage Diagnosis Closure Incentive program

The 2017 Medicare Advantage Diagnosis Closure Incentive program is effective for dates of service Jan. 1, 2017, or later. As part of the program, health care providers should complete patient diagnoses, supported by any necessary documentation in their medical records and following M.E.A.T. (manage, evaluate, assess or treat) guidelines.

This is a final reminder that you’re required to address 2017 diagnosis gaps with a face-to-face visit with your patients by Dec. 31, 2017. You then have until Jan. 31, 2018, to submit results of your 2017 patient visits on Health e-Blue. (See side panel at right for information on accessing Health e-Blue.)

You’ll find diagnosis gaps for your patients on Health e-Blue’s Diagnosis Evaluation panel. Health care providers can use the monthly reports on Health e-Blue to document that diagnosis gaps have been closed.

Keep in mind that if a prior service year date is entered for a 2017 diagnosis gap, the diagnosis gap will open with the next refresh and the gap closure won’t count toward your 2018 incentive payment.

Physicians who close 100 percent of all identified gaps for each attributed patient will receive $100 per patient. Your incentive payment will be mailed to you by the end of the third quarter in 2018.

See the July Record for details.

Have questions about dates of service, diagnosis gap submissions or the Diagnosis Closure Incentive program? Contact our provider consultants on the HEDIS^® and risk adjustment provider outreach team:

• Sue Brinich at 586-839-8614
• Tom Rybarczyk at 313-378-8259
• Corinne Vignali at 313-969-0417

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

Use proper coding to improve HEDIS^® scores for appropriate antibiotic treatment

Antibiotic resistance is a known and growing problem, and misuse of antibiotics is the main culprit. More than 90 percent of the time, the cause of acute bronchitis is viral, yet many patients are prescribed antibiotics. Although antibiotics are inappropriate for viral infections, there are times when patients may have a compromising comorbid condition or a competing bacterial diagnosis. In situations like these, an antibiotic is appropriate and necessary.

Blue Cross Blue Shield of Michigan recently contacted a subset of Blue Cross health care providers who prescribed an antibiotic for acute bronchitis or upper respiratory infection. The outreach revealed that patients commonly had a comorbid condition to justify the antibiotic, but diagnosis codes were simply not documented.

When an antibiotic is prescribed, be sure to include the diagnosis code for the bacterial infection or comorbidity. It’s important that you include this information and the correct exclusion codes, when necessary, because HEDIS^® antibiotic measurement data is captured through diagnosis codes and prescription claims. See the table below for an overview of HEDIS antibiotic measures and exclusions.

For additional information about these measures and other key HEDIS measures, see our "Clinical quality corner tip sheets" on web-DENIS.

Want to know how you’re performing on antibiotics and other HEDIS^® measures? Access Health e-Blue and check out the quality summary report. See screen shot below for a look at the type of information you’ll find in the report.

If you have questions about this article, contact RxQualityPrograms@bcbsm.com.

When comparable alternatives exist, Blue Cross and BCN don’t cover select high-cost prescription drugs

To address the high cost of drugs and provide the best value for our members, Blue Cross Blue Shield of Michigan and Blue Care Network commercial plans don’t cover select high-cost, FDA-approved drugs because there are more cost-effective therapeutic alternatives.

Vanatol LQ, used to treat headaches, is one of these high-cost drugs that will no longer be covered, starting Nov. 1, 2017. The table below compares the average cost of one dose of Vanatol LQ to that of its associated therapeutic alternatives.

As part of this ongoing initiative, we’ll continue to identify select high-cost drugs and stop covering them when there are more cost-effective alternatives available.

Are you billing correctly for these drugs?

We often receive bills for the following drugs with incorrect quantities under the prescription drug benefit. To ensure that your claims are accurate and processed in timely manner, refer to the tables below. Drugs are listed by their name and strength.

Medications often associated with incorrect days' supply

Restasis^®

Spiriva^® 18 MCG CP-HandiHaler^®

Victoza^®

If you have questions about drug claims, contact our claims processor Express Scripts at 1-800-922-1557.

For any questions about the information in this article, contact our Pharmacy Services Clinical Help Desk at 1-800-437-3803.

Commercial Medical Drug Prior Authorization Program adds a specialty drug

Starting Dec. 1, 2017, one additional specialty drug, as follows, will require prior authorization by Blue Cross Blue Shield of Michigan before it will be covered under a member’s medical benefits.

Keep in mind that prior authorization is a clinical review approval only, not a guarantee of payment.

You can find prior authorization forms for all physician-administered medications on web-DENIS. When logged in, follow these steps:

• Click on BCBSM Provider Publications and Resources.
• Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
• Click on Go to the Forms page.
• Click on Physician administered medications.

We won’t consider requests for coverage until we receive one of the following:

• Physician-signed medication request form by fax or mail
• Request uploaded to NovoLogix

Our standard processing time to review requests is 15 days. We’ll review urgent requests within 72 hours.

Here are all the medications that are currently part of the Commercial Medical Drug Prior Authorization Program list:

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

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

Blue Cross to expand preauthorization requirements for PT, OT services for Medicare Plus Blue^SM members

In partnership with eviCore healthcare, Blue Cross Blue Shield of Michigan will expand its use management preauthorization program for outpatient physical and occupational rehabilitation for members with Medicare Plus Blue to include outpatient skilled nursing facilities and doctors with the following degrees: M.D., D.O., D.P.M. and D.D.S.

Starting Jan. 1, 2018, all skilled nursing facilities and doctors with the above-mentioned degrees will be required to obtain preauthorization for all outpatient PT and OT rehabilitation services for members with Medicare Plus Blue, our Medicare Advantage PPO plan.

The program applies to Michigan members being treated by Michigan health care providers. Speech therapy is not included in this program.

We’re offering online orientation sessions to explain the preauthorization requirements.

Register in advance
Anyone who wants to attend one of the online orientation sessions must register in advance. Each online orientation session is free and will last about one hour.

Online orientation sessions

How to register
Follow these steps to register for and participate in a session.

1. Once you’ve chosen a date and time, go to evicore.webex.com.
2. Click on the Training Center tab at the top of the page.
3. Find the date and time of the conference you to attend by clicking the Upcoming tab. All of the online orientation sessions will be named “BCBSM/eviCore Provider Session – Therapies Prior Authorization.”
4. Click on Register.
5. Enter the registration information.

After you’ve registered for the conference, you’ll receive a registration email containing:

• The toll-free phone number and pass code you’ll need for the audio portion of the conference
• A link to the online portion of the conference
• The conference password

Keep the registration email so you’ll have the link to the conference and the call-in number for the session in which you will be participating.

If you’re unable to participate in a session at any of the times listed, you can obtain a copy of the presentation by contacting clientservices@evicore.com.

Federal Employee Program’s Pregnancy Care Incentive Program offers support, rewards

The Blue Cross and Blue Shield Federal Employee Program^® offers the Pregnancy Care Incentive Program to pregnant members. The program is designed to encourage pregnant mothers to receive prenatal care timely throughout their pregnancy. The program also helps pregnant women make healthier choices to keep themselves and their babies healthy.

The FEP Pregnancy Care Incentive Program offers support and rewards during each stage of pregnancy. Eligible members can earn rewards toward a health account to be used for most qualified expenses.

For more information, direct members to www.fepblue.org/maternity or to Customer Service at 1-800-482-3600.

Have questions about our e-referral tool? Check out our training tools

Recently, we’ve received some questions from health care providers seeking assistance with the e-referral tool used to submit referrals and authorizations. Here’s a list of the many training opportunities available on the e-referral site that we hope will help.

On the Training Tools page, you’ll find the:

• e-referral User Guide (PDF), a step-by-step guide on accessing the system, submitting and more
• e-referral Quick Guide (PDF), a simple how-to guide on getting started
• Behavioral Health User Guide (PDF), a step-by-step guide for behavioral health providers
• Blue Cross^® Physician Choice PPO User Guide (PDF), specifically for Physician Choice PPO authorizations
• FAQs for using the e-referral system (PDF), a useful guide for Blue Cross providers
• Online self-paced learning modules
• Physician Choice PPO online training presentation

If you still have questions after reviewing these resources, reach out to your provider consultant.

Blue Cross aligns with CMS for payable diagnostic codes for genetic testing for Lynch syndrome

Blue Cross Blue Shield of Michigan has aligned its policy for payable diagnostic codes for genetic testing for Lynch syndrome with the Centers for Medicare & Medicaid Services. We’re adding all diagnostic codes payable by CMS. See the list of affected codes here.

UAW Retiree Medical Trust promoting home health care services for members

Blue Cross Blue Shield of Michigan has moved forward with a number of initiatives to encourage an increase in home health care services for UAW Retiree Medical Trust commercial members. The primary purpose of this initiative is, ultimately, to decrease the likelihood of members being readmitted to hospitals.

We’re asking that facilities and providers assist us in referring our members to home health care for complex conditions or following a hospital stay. URMBT members can receive home care services without meeting “homebound” criteria. This differs from the Medicare guideline that requires homebound status.

Although each member has unique needs, there are a number of well-documented reasons why home care services could reduce hospital readmissions:

1. Home care assists in ensuring that the member or caregiver understands and complies with the member’s discharge plan.
2. Home care performs thorough, hands-on medication reconciliation.
3. Home care can identify and address potential barriers that may exist in the home setting.
4. Home care is “the bridge” between the facility discharge and the primary care physician follow-up.
5. Home care provides added support to the member or caregiver.
6. Home care provides insight into the home environment and can thoroughly assess the biopsychosocial situation.

If you have questions or need more information please contact Michele Ohneck, director of Medical Management URMBT, at 313-448-8465.

In-home assessments benefit providers, members

Blue Cross Blue Shield of Michigan and our participating health care providers share a mission: to provide our members with the right care at the right time and place. One way we do this is through in-home assessments.

We use the services of several in-home assessment vendors to meet the needs of our members with Medicare Advantage, individual and small group plans who may have difficulty getting to their doctor’s office. During these assessments, a doctor, nurse or physician assistant comes to the member’s home to discuss their medical history and conduct a brief exam. Members are encouraged to invite a caregiver, family member or friend to join them for the assessment.

In-home assessments don’t replace the care a doctor provides or an annual wellness visit. However, they provide members with another opportunity to discuss any symptoms, current medical conditions or health questions they may have.

Here are some other ways that an in-home assessment benefits members:

• It’s free. It’s part of their member benefits, and doesn’t affect their health care coverage, premiums or out-of-pocket costs.
• It’s easy. The visit typically lasts an hour. A licensed medical professional will check basic vital signs, ask some routine health-related questions and answer any questions the member may have.
• It’s helpful. The assessment provides valuable one-on-one time with a health care professional, and also helps members prepare for their annual doctor visit.
• It brings peace of mind. Assessment results are shared with the member and their doctor to support the care they already receive.

Members selected for an in-home assessment may meet one or more of the following criteria:

• They’re not participating in any health and wellness program offered by their health plan.
• They haven’t seen their doctor recently.
• They haven’t taken steps to address any chronic conditions they have.

Behavioral health documentation guidelines now available

When documenting behavioral health services provided to our members, contracted behavioral health providers must follow the guidelines we recently published. The guidelines apply to services for Blue Cross Blue Shield of Michigan PPO (commercial), Blue Cross Medicare Plus Blue^SM, Blue Care Network HMO^SM (commercial) and BCN Advantage^SM members. They were developed for all products to make it easier for providers to locate and follow them.

Where to locate guidelines

You’ll find the guidelines at ereferrals.bcbsm.com. Click on either Blue Cross or BCN, as appropriate. Then click on Behavioral Health.

The guidelines are published in two documents:

• Behavioral health medical record documentation requirements for applied behavior analysis services
• Behavioral health medical record documentation requirements and privacy regulations — for services other than ABA

You can also access the guidelines by visiting bcbsm.com/providers and logging in to Provider Secured Services. Then follow these steps:

• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters and Resources.
• Click on Clinical Criteria & Resources.
• Scroll down to the Behavioral Health Information header.
• Click on the links under the Behavioral Health Medical Record Documentation Requirements subhead.

The guidelines contain the requirements for documenting specific treatments. For applied behavioral analysis, or ABA, this includes line therapy, supervision, parental training or socialization groups, and re-evaluation. For non-ABA treatment, this includes the initial evaluation and subsequent individual, group and family therapy.

Why the guidelines were developed

Over the past few years, Blue Cross and BCN have added new types of providers who have enhanced our networks’ capabilities for care. Some providers have never worked with insurance carriers and haven’t previously had to document their services clearly and specifically enough to match the services billed.

In addition, we’ve had complaints from members that the services billed did not match the services they thought they were receiving. We’ve also been subject to additional reporting requirements from federal and local government agencies and from our accrediting organizations. These require more detailed documentation of services provided.

With these issues in mind, we developed documentation guidelines to align with those published by the Centers for Medicare & Medicaid Services, with local and federal regulatory agencies, with accrediting agencies and with good documentation practices. We feel this will help providers document their care in ways that meet both medical and legal requirements.

Additional information

In each guidelines document, you’ll see requirements for both medical and nonmedical treatment providers. Medical providers (physicians, nurse practitioners and physician assistants) must follow the CMS documentation guidelines in the Medical Learning Network guide ICN 006764 (August 2016).

For nonmedical providers, we’ve outlined detailed documentation requirements for the most common types of interventions that would be used.

When you document these interventions, there’s no need to document anything that did not occur. On the other hand, you should document any interventions you provided in addition to those we listed. That way, you’ll have a way to remember these interventions and these notes will complete the member’s record.

Also, standard care involves using screening tools to document the progress of your patient. Documenting the use of those tools can be helpful in measuring the progress of your patient or in identifying measurably poor progress and the subsequent need to review the treatment interventions provided.

Many electronic medical records already have most of these or all of these items within their database, although it may take some time to learn where they are to make the process go more quickly.

We encourage you to familiarize yourself with the new documentation requirements and start to use them immediately. Over the next few weeks, provider manuals will be updated with hyperlinks to the guideline documents.

Remember: The general rule of thumb is “If it isn’t documented, it didn’t occur.”

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.

Blue Cross to expand preauthorization requirements for PT, OT services for Medicare Plus Blue^SM members

In partnership with eviCore healthcare, Blue Cross Blue Shield of Michigan will expand its use management preauthorization program for outpatient physical and occupational rehabilitation for members with Medicare Plus Blue to include outpatient skilled nursing facilities and doctors with the following degrees: M.D., D.O., D.P.M. and D.D.S.

Starting Jan. 1, 2018, all skilled nursing facilities and doctors with the above-mentioned degrees will be required to obtain preauthorization for all outpatient PT and OT rehabilitation services for members with Medicare Plus Blue, our Medicare Advantage PPO plan.

The program applies to Michigan members being treated by Michigan health care providers. Speech therapy is not included in this program.

We’re offering online orientation sessions to explain the preauthorization requirements.

Register in advance
Anyone who wants to attend one of the online orientation sessions must register in advance. Each online orientation session is free and will last about one hour.

Online orientation sessions

How to register
Follow these steps to register for and participate in a session.

1. Once you’ve chosen a date and time, go to evicore.webex.com.
2. Click on the Training Center tab at the top of the page.
3. Find the date and time of the conference you to attend by clicking the Upcoming tab. All of the online orientation sessions will be named “BCBSM/eviCore Provider Session – Therapies Prior Authorization.”
4. Click on Register.
5. Enter the registration information.

After you’ve registered for the conference, you’ll receive a registration email containing:

• The toll-free phone number and pass code you’ll need for the audio portion of the conference
• A link to the online portion of the conference
• The conference password

Keep the registration email so you’ll have the link to the conference and the call-in number for the session in which you will be participating.

If you’re unable to participate in a session at any of the times listed, you can obtain a copy of the presentation by contacting clientservices@evicore.com.

Blue Cross aligns with CMS for payable diagnostic codes for genetic testing for Lynch syndrome

Blue Cross Blue Shield of Michigan has aligned its policy for payable diagnostic codes for genetic testing for Lynch syndrome with the Centers for Medicare & Medicaid Services. We’re adding all diagnostic codes payable by CMS. See the list of affected codes here.

How do I report a BlueCard^® inpatient acute care readmission claim?

The same reporting requirement for Blue Cross Blue Shield of Michigan readmission claims applies to BlueCard. If a patient is admitted within 14 days of a previous discharge, the hospital should determine if the two admissions meet our readmission criteria to be billed as a combined claim.

If the admissions should be combined and reported on a single claim, you’ll need to report leave of absence days for the time the patient was out of the hospital. The combined inpatient claim with leave of absence days should be reported as follows:

• Report Value Code 80 for the covered days — the days the patient was in the hospital.
• Report Value Code 81 for the noncovered days — the days the patient wasn’t in the hospital.
• The units reported for revenue code 0180 should equal the number of days the patient wasn’t in the hospital.
• There shouldn’t be any charge reported for revenue code 0180; therefore, report 0.00 for the covered amount.
• There should never be any monetary amount in the noncovered charge for Revenue Code 0180.

 Note: The reporting requirements for readmission claims can be found in the “Claims” chapter of the Inpatient Hospital manual.

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

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.

Clarification: Inpatient authorization requirements

In an October Record article titled “Here’s what you need to know about Blue Cross inpatient authorization requirements,” some words were omitted in the first paragraph that would have made the article’s meaning clearer. The first paragraph should have read as follows:

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

We’ve revised the online version of the article and you can access it by clicking here.

When comparable alternatives exist, Blue Cross and BCN don’t cover select high-cost prescription drugs

To address the high cost of drugs and provide the best value for our members, Blue Cross Blue Shield of Michigan and Blue Care Network commercial plans don’t cover select high-cost, FDA-approved drugs because there are more cost-effective therapeutic alternatives.

Vanatol LQ, used to treat headaches, is one of these high-cost drugs that will no longer be covered, starting Nov. 1, 2017. The table below compares the average cost of one dose of Vanatol LQ to that of its associated therapeutic alternatives.

As part of this ongoing initiative, we’ll continue to identify select high-cost drugs and stop covering them when there are more cost-effective alternatives available.

Are you billing correctly for these drugs?

We often receive bills for the following drugs with incorrect quantities under the prescription drug benefit. To ensure that your claims are accurate and processed in timely manner, refer to the tables below. Drugs are listed by their name and strength.

Medications often associated with incorrect days' supply

Restasis^®

Spiriva^® 18 MCG CP-HandiHaler^®

Victoza^®

If you have questions about drug claims, contact our claims processor Express Scripts at 1-800-922-1557.

For any questions about the information in this article, contact our Pharmacy Services Clinical Help Desk at 1-800-437-3803.

Commercial Medical Drug Prior Authorization Program adds a specialty drug

Starting Dec. 1, 2017, one additional specialty drug, as follows, will require prior authorization by Blue Cross Blue Shield of Michigan before it will be covered under a member’s medical benefits.

Keep in mind that prior authorization is a clinical review approval only, not a guarantee of payment.

You can find prior authorization forms for all physician-administered medications on web-DENIS. When logged in, follow these steps:

• Click on BCBSM Provider Publications and Resources.
• Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
• Click on Go to the Forms page.
• Click on Physician administered medications.

We won’t consider requests for coverage until we receive one of the following:

• Physician-signed medication request form by fax or mail
• Request uploaded to NovoLogix

Our standard processing time to review requests is 15 days. We’ll review urgent requests within 72 hours.

Here are all the medications that are currently part of the Commercial Medical Drug Prior Authorization Program list:

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

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