Certain hospital outpatient infusions no longer covered without additional authorization

Blue Cross Blue Shield of Michigan will require additional prior authorization in order for members to receive infusions of certain medical specialty drugs in a hospital outpatient facility, starting Jan. 1, 2018.

These are the same 30 drugs that already require prior authorization for payment. You’ll find the list of drugs in the October Record article “Blue Cross updates policy for medical specialty drug infusions.” We’ll notify providers as additional drugs are added to this requirement in 2018.

Professional setting

Infusions administered in the following professional settings will only require prior authorization for the drug, not the location:

• Provider’s office
• Ambulatory infusion center
• Home infusion therapy

Hospital outpatient facility

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

• The authorization number, if previously approved
• Rationale that clearly describes the reason the infusion must be administered in a hospital setting
• Supporting chart notes

Blue Cross will send members with current medication authorizations on file updated authorization letters that include the approved sites of care. Blue Cross will include the approved sites of care in all authorization letters for new requests.

Claims submitted without receiving prior approval of the medical drug or the hospital outpatient location will be rejected. The member will be liable for the charges.

Web-DENIS authorization information

The Authorization History section within web-DENIS Facility Claims will stop displaying current authorization information Nov. 28, 2017. Historical authorization information, for periods before Nov. 28, 2017, will be available through the end of 2017.

For ordering providers:
There is no change to view authorizations. The ordering provider can look up the authorization on e-referral and inform the rendering provider if the service is authorized.

For the rendering provider:
Rendering providers won’t be able to use e-referral to look up authorizations for services managed by our Blue Cross medical drug vendor, NovoLogix^®. We’re working to develop an online method to display this information in 2018.

Until then, here are the alternative methods to confirm authorization before administering a medical drug:

• Request confirmation from the ordering provider – The ordering provider can look up the authorization on e-referral and inform the rendering provider if the service is authorized.
• Ask the patient to bring in the letter of authorization received from Blue Cross – The member can share a copy of the letter he or she receives.
• Call Blue Cross Provider Inquiry – During business hours, you can call a Provider Inquiry representative either through the Provider Automated Response System phone numbers or directly at the following numbers:

◦ Physicians and professional providers	1-800-344-8525
◦ Hospitals or facilities	1-800-249-5103
◦ For Federal Employee Program® members	1-800-840-4505

• Contact your provider consultant – If you’re not sure who your provider consultant is, you’ll find contact information on the Contact Us pages of our website.