The way you look up authorizations is changing

Do you currently use web-DENIS to determine the status of authorization requests? If so, you’ll need to follow a different process going forward. Exactly how you’ll do it will depend on whether you’re the provider ordering the service or the provider rendering the service — and whether the service is managed by Blue Cross Blue Shield of Michigan or by one of our vendors.

Use e-referral to look up authorizations if:

• You’re the provider ordering the service — Effective Nov. 28, 2017, authorizations for services managed by Blue Cross vendors are now available on the e-referral system. Authorizations for services managed directly by Blue Cross have been available on e-referral since July 31, 2017. As a result, you can now find authorizations for Blue Cross PPO and Blue Cross Medicare Plus Blue^SM PPO, in addition to Blue Care Network and BCN Advantage^SM patients, on e-referral, regardless of whether the service is managed by Blue Cross, BCN or a vendor.
• You’re the provider rendering the service and the service is managed by Blue Cross (not a Blue Cross vendor) — If the service is managed by Blue Cross directly, you can find the authorization information on the e-referral system.

Use an alternate method of looking up authorizations if you’re the provider rendering the service and the service is managed by a Blue Cross vendor.

Effective Nov. 28, 2017, authorizations for services managed by Blue Cross vendors are moving to the e-referral system. However, rendering providers won’t be able to use e-referral to look up authorizations for services managed by a Blue Cross vendor as the rendering provider information isn’t available. We’re working to develop an online method of finding this information, which we expect to announce in 2018. Until then, you’ll need to use an alternate method to confirm authorization before rendering a Blue Cross vendor-authorized service.

Alternate methods of looking up an authorization

Here are the alternatives rendering providers can use to find an authorization for a service managed by a Blue Cross vendor:

• 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 his or her letter of authorization — The member can share a copy of the letter he or she receives with details on the authorization determination.
• Call Blue Cross Provider Inquiry — During business hours, you can speak to a Provider Inquiry representative to find an authorization by calling the appropriate Provider Automated Response System phone numbers and following the prompts below.**
• PARS will ask if you’re calling for claims, or eligibility and benefits.
• If you’re calling before the service has been rendered, and you need to know if authorization is required, you should choose Eligibility and Benefits.
• If you’re calling about authorization after the service has been rendered, and you have already billed a claim, you should choose Claims.
• Eligibility and benefits:
• PARS will ask for your Provider ID (NPI or Blue Cross pin/code).
• PARS will ask for your provider type/provider specialty.
• PARS will ask for the member information.
• ✔ Member contract number, date of birth, first name
• PARS will provide eligibility and general information.
• At this point, you can request a hardcopy of the benefits, or you can say “eligibility and benefits” to continue; cost share will then be provided.
• You must listen to at least one benefit before asking to speak to a representative. You can select the benefit you want to hear after you have heard the cost share information for the policy.
• After the benefit information is given, listen to the menu options and select “representative” when prompted.
• Claims:
• PARS will ask if you’re calling on behalf of a Michigan member.
• PARS will ask if the services were rendered in Michigan.
• PARS will ask for your Provider ID (NPI or Blue Cross pin/code).
• PARS will ask for the member information.
• ✔ Member contract number, date of birth, first name
• PARS will ask if you’re checking the status of your claim. You should answer “no” to this question.
• PARS will ask if you’ve received a voucher for the claim you billed. You should answer “voucher” to this question.
• PARS will ask the reason for your call. Select “follow up on a previous inquiry.”
• PARS will ask if you’re calling on the status of your claim, checking benefits and eligibility or if you would like to speak to a representative. Say “representative.”

Here are the PARS phone numbers for the different types of providers:

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

Blue Cross vendor-authorized services include:

• AIM Specialty Health — Radiology management and sleep studies
• NovoLogix^® — Drugs covered under the medical benefit
• Beacon Health — Behavioral health
• New Directions — Behavioral health
• eviCore healthcare — Cardiac rehabilitation, radiation therapy and physical therapy

Note: eviCore is currently Blue Cross’ vendor for Medicare Advantage members and will become the vendor for commercial members beginning Jan. 1, 2018, for interventional pain management, radiation therapy (oncology) services, and inpatient and outpatient lumbar spinal fusion surgery.

Web-DENIS authorization information

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

For more information

More information about e-referral is available in our July 2017 Record article. Training materials are available on the e-referral Training page.

**These instructions are only for navigating PARS when checking on authorizations.

ClaimsXten™ upgrade brings enhancements to Clear Claim Connection

Blue Cross Blue Shield of Michigan will launch a technical upgrade for ClaimsXten in the first quarter of 2018. The upgrade will bring a new look to Clear Claim Connection, along with enhanced performance capabilities.

Clear Claim Connection, also known as C3, is a web-based disclosure solution for Michigan professional and certain facility providers. It allows access to our payment policy, editing rules and associated rationale.

We’ll share more information about the ClaimsXten™ Clear Claim Connection redesign in future issues of The Record.

Reminder: Online training for prior authorization program begins in December

Beginning Jan. 1, 2018, some Blue Cross Blue Shield of Michigan commercial PPO members will require preauthorizations for the services listed below. 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.

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.

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.

For more information about the preauthorization process, see the November Record article “Here’s more information about determination, training for new preauthorization program for commercial PPO.”

We’re making a change in how some groups handle preauthorizations for proton beam therapy

Effective Jan. 1, 2018, eviCore healthcare will handle proton beam therapy preauthorizations for some of our commercial PPO members.

To obtain preauthorization for a patient you’re scheduling for proton beam therapy, follow these steps:

• Log in to Provider Secured Services and go to web-DENIS.
• Under Subscriber Info on the left side of the page, click on Eligibility/Coverage.
• Select Prior Authorization.
• Enter the provider NPI and contract number for the member. Programs requiring prior authorization for that member will appear.
• Select the appropriate program for your member.
• Sign on to select the vendor. (Web-DENIS will direct health care providers to the appropriate vendor for their member, which will be either eviCore or AIM, depending on their contract.)

Note: Federal Employee Program^® members and State of Michigan and UAW Retiree Medical Benefits Trust groups are excluded from this program. MESSA is also excluded and will continue with AIM.

These are the proton beam therapy codes that will require preauthorization:

• *77520
• *77522
• *77523
• *77525

For more information about how to determine preauthorization, see the November Record article titled “Here’s more information about determination, training for new preauthorization program for commercial PPO.”

We’re updating our MA PPO clinical editing appeals process

Blue Cross Blue Shield of Michigan Medicare Advantage PPO is updating its appeal process for clinical edits. Beginning Dec. 1, 2017, the following changes will take effect:

• There will be one level of appeal for clinical edit denials. These are claim denials in which the event code is either 870 or 852 (as noted on the paper voucher).
• Appeals must be submitted with a Clinical Editing Appeal form. All required fields must be completed or the appeal will be returned. The form can be found on the Blue Cross Provider site by clicking here.
• Submit the appeals form one of the following ways:
• Fax it to 1-866-526-7179
• Mail it to Clinical Editing Appeals
  Mail Code G820
  Blue Cross Blue Shield of Michigan – MA PPO
  611 Cascade West Parkway, SE
  Grand Rapids, MI 49546-2143
• Appeals must be submitted within 180 days of the original clinical editing denial.
• Documentation supporting the appeal must be submitted with the appeal. What is required may vary depending on the service being appealed. For example, office services that have been denied may require office notes, services denied as duplicates will require records for both the denied and paid service to show more than one was performed, and surgical denials may require operative reports. It’s important to look at the reason for denial and submit documentation appropriate to the procedure code that was denied and the denial reason.

This process is based on the Blue Care Network clinical editing appeals process. So, while the explanation codes and the fax number may be different, if you’ve had to submit an appeal to BCN in the past for a clinical edit, you’ve followed the process that will be in place for MA PPO. We believe it will allow us better tracking and timely resolution of your appeals.

If you have questions about the changes in the appeal process, call MA PPO Provider Inquiry at 1-866-309-1719 or contact your provider representative.

Battling the opioid epidemic

As part of Blue Cross Blue Shield of Michigan’s efforts to tackle the opioid epidemic, we’ve ramped up our efforts to communicate about the topic in our various health care provider-focused communications. Check out the column by Dr. Duane J. DiFranco in Hospital and Physician Update, and the following items below:

What clinical practices can do to minimize drug diversion

Making sure that opioids don’t end up in the wrong hands plays a key role in fighting opioid misuse and abuse. And physicians have a unique opportunity to prevent and report drug diversion.

The Centers for Medicare & Medicaid Services is offering assistance with a booklet that can help doctors prevent and report the diversion of prescription drugs.

The booklet, A Prescriber’s Role in Preventing the Diversion of Prescription Drugs, offers the following advice:

• Exercise caution with patients who use or request combination or “layered” drugs for enhanced effects (for example: antipsychotics with opioids or benzodiazepines).
• Document thoroughly when prescribing narcotics or choosing not to prescribe.
• Protect access to prescription pads.
• Keep a Drug Enforcement Administration or license number confidential unless disclosure is required by state law.
• Write prescriptions clearly to minimize the potential for forgery.
• Move to electronic prescribing so that paper prescriptions aren’t required.
• Adhere to strict refill policies and educate the office staff about them.
• Ask patients to bring in any unused portion of narcotics if they’re not using them.
• Use state prescription drug monitoring programs, where available, to monitor patient prescribing before refilling or adding new medications.
• Refer patients with extensive pain management or prescription controlled medication needs to specialized practices.
• Communicate with pharmacists or other health care providers, as well as pharmacy benefit managers, and collaborate with them when you observe suspicious behaviors.
• Collaborate with pharmacy benefit managers and managed care plans to determine the medical necessity of prescriptions for controlled substances.

Prescribing opioids for chronic pain

The Centers for Disease Control and Prevention has published several resources that can provide guidance to doctors when prescribing opioids. These include:

• Guideline for Prescribing Opioids for Chronic Pain — A guideline designed to help improve communication between providers and patients about the risks and benefits of opioid therapy, and to reduce opioid abuse and misuse.
• Applying CDC’s Guideline for Prescribing Opioids — A training video about the guideline.
• Tapering Opioids for Chronic Pain — A pocket guide to help doctors determine whether a patient’s prescription for opioids should be reduced to a lower dosage or discontinued.

Reminder: Include key information in opioid requests

When it’s necessary to prescribe opioids, it’s important to submit all opioid requests with the following information:

• Recent chart notes
• Diagnosis
• Documentation of trial and failure of alternatives
• Treatment plan

This will help prevent delays in processing these claims. For more information, see the article in the September Record.

Make sure prescriptions are signed by a qualified prescriber

During recent pharmacy audits, we saw a rising number of nonqualified individuals signing prescriptions or signing on behalf of the prescriber. We’d like to clarify who may sign prescriptions for claims billed to the Blue Cross Blue Shield of Michigan and Blue Care Network prescription drug program.

The prescriber should make sure prescriptions are signed by a licensed doctor of medicine or osteopathic medicine and surgery (referred to as the “delegating doctor”). Prescriptions can also be signed by a licensed physician assistant, dentist, doctor of podiatric medicine and surgery, optometrist certified under MCL 333.17435 to administer and prescribe therapeutic pharmaceutical agents, or veterinarian (referred to as the “other prescriber”).

The following chart shows the licensed individuals with independent and delegated prescribing authority for controlled and non-controlled substances:

¹The delegating prescriber’s name and DEA number must be on the prescription along with the APRN’s name and DEA number.
²Independent prescribing authority if there is a collaborative practice agreement in place with the physician.

If the pharmacist who receives a prescription doesn’t recognize the name or credentials of the signatory on a prescription, the pharmacist may call the prescriber’s office or facility to verify the authorization for the prescription.

Only the individuals noted above should sign a prescription. A medical assistant or other office assistant who doesn’t meet these qualifications should not sign prescriptions.

In addition, we don’t accept stamped signatures, and all written prescriptions must be signed and dated.

Here are some highlights of changes to 2018 products, health care options

We’ve received some questions from health care providers about Blue Cross Blue Shield of Michigan’s 2018 product lineup and wanted to provide some highlights and resources for additional information.

Here are a few highlights of changes to 2018 group products and other health care options:

Blue Cross^® Physician Choice PPO
Personal Choice PPO has changed its name to Physician Choice PPO. The product continues to offer a competitive price point for employers with more choices for access and cost sharing for employees. On Oct. 1, we expanded the product to the entire Lower Peninsula.

Physician Choice PPO leverages Blue Cross’ innovative Organized Systems of Care program. OSCs are communities of doctors and hospitals within the Blue Cross PPO network that help provide customized, coordinated care that’s right for each patient. Features include:

• Multiple deductible plan options
• Access to multiple OSCs throughout Michigan’s with more than 4,000 primary care doctors, 11,000 specialists and 100 hospitals
• Access to the entire Blue Cross PPO network as well as out-of-network doctors and hospitals
• Levels of cost share for members based on the choices they make — costs are lowest with a primary care doctor in a Level 1 OSC
• Prescription drug coverage

Smart choices for medical care
When it’s not a true emergency, medical care at a local hospital emergency room can be time-consuming and expensive. That’s why Blue Cross and Blue Care Network offer other health care options that are smart, convenient and low-cost in comparison with emergency room treatment, including:

• Primary care doctor
• 24-Hour Nurse Line
• Blue Cross Online Visits^SM
• Retail health clinics
• Urgent care centers

 Hearing program
For Blue Cross and BCN employer groups with more than 100 full-time equivalent employees, we’ve created three new riders that will offer:

• A hearing exam only
• Frequency at 24 months for a hearing exam plus hearing aid coverage with a dollar maximum allowance of $3,000 for a monaural hearing aid or $6,000 for a binaural hearing aid
• Frequency at 36 months for a hearing exam plus hearing aid coverage with a dollar maximum allowance of $3,000 for monaural hearing aid or $6,000 for binaural hearing aid

 Medical specialty drug coverage
In 2018, the Blue Cross’ medical specialty drug program will expand its prior authorization process to require additional approval to pay for infusion services for select drugs in a hospital outpatient setting. Preferred locations, which are already a Blue Cross benefit, are billed as professional settings, rather than facility settings, and include home infusion, doctors’ offices and infusion centers.

For more information
As always, be sure to check eligibility and benefits for your patients on web-DENIS. For more information on our group products, click here.

For information on our individual products for 2018, see this article, also in this issue.

We’re offering 28 products for the individual marketplace in 2018

Blue Cross Blue Shield of Michigan and Blue Care Network are offering a total of 28 products for the individual marketplace in 2018, including:

• Nine PPO products and 19 HMO products
• 15 products in 63 rural counties
• 22 products in two West Michigan counties
• 28 products in three Southeast Michigan counties
• 22 products in 15 urban counties

We’ve modified some plans and made deductible and out-of-pocket changes to most plans. We’re closing 13 plans, effective Dec. 31, 2017: the EPO network, PPO Multi-State Plans, Personal Plus HMO plan, Select Gold HMO plan and Partnered HMO network.

Some of the key product changes for 2018 include:

• HMO plans will have limited BlueCard coverage. For out-of-state care, these plans cover only urgent and emergency care.
• PPO plans will have out-of-network cost sharing for out-of-state scheduled services in-network cost sharing for out-of-state urgent and emergency care.
• Specialty prescription coinsurance moves from 20 to 25 percent to 40 to 45 percent for preferred and non-preferred plans.
• The Premier PPO Bronze Extra plan (the Centers for Medicare & Medicaid Services standard plan) will be modified to include lower copays for primary care office visits, specialty office visits, urgent care visits and generic prescription drugs — all covered before the deductible.
• The Gold Metal tier is limited to the Preferred HMO Network and the Premier PPO Network.
• Silver Extra is modified to conform with the 2018 version of the CMS Silver Standard Plan.
• The Bronze (basic) Health Savings Account has been modified as follows:
• Closed the HSA option for these plans.
• Opened a Bronze (basic) plan that isn’t HSA-eligible in the Select and Metro Detroit HMO networks. The plan covers primary care physician visits, laboratory services and urgent care before deductible.
• An HSA option will only be available with Bronze Saver plans on the HMO network.
• The PPO network HSA options are the Bronze and Silver Saver plans.
• All preferred plans will now be available statewide.
• All IBU PPO and HMO plans will offer behavior health online visits with each plan’s primary care visit copay.

With the Silver Extra plan (the CMS standard plan), the prescription drug deductible applies only to specialty prescription drugs. Generics, preferred brand and non-preferred brands are covered with a copayment and no deductible.

As always, check member eligibility and benefits at every visit before providing
services. You can do this through web-DENIS or by calling our Provider Automated Response System.

Note: Member ID cards will be reissued for individual products in 2018. Check prefixes carefully when checking benefits and eligibility.

Blue Cross will administer physical therapy benefits for Ford UAW Trust Medicare retirees

Beginning Jan. 1, 2018, Blue Cross Blue Shield of Michigan will administer physical therapy benefits for Ford UAW Retiree Medical Benefits Trust members who have Medicare as their primary insurance. This transition doesn’t change the members’ benefits.

TheraMatrix™ will continue to administer physical therapy benefits for Ford members who don’t have Medicare.

Be sure to check web-DENIS for patient eligibility and benefits.

Coding corner: Proper coding for major depressive disorder

Major depressive disorder, also known as clinical depression, is a common but serious mood disorder. It affects how one feels, thinks and behaves. A person having trouble doing activities nearly every day for at least two weeks may be suffering from this disorder. Signs and symptoms of MDD, including details of the most recent episode, should always be documented in the patient’s medical record to substantiate the diagnosis.

Example of symptoms of an MDD episode

• Depressed or irritable mood
• Decreased interest or pleasure
• Change in activity
• Fatigue or loss of energy
• Diminished concentration, memory or ability to make decisions
• Guilt or sense of worthlessness
• Significant change in weight or appetite
• Change in sleep patterns
• Restlessness, inability to sit still
• Aches or pains, headaches, cramps or digestive problems without a clear physical cause and don’t subside with treatment
• Thoughts of death, self-harm or suicide

Major depressive disorder is assigned to ICD-10-CM categories F32 Major depressive disorder, single episode and F33 Major depressive disorder, recurrent. Categories F32 and F33 include fourth characters, and sometimes fifth characters, to capture information about the severity of the major depressive disorder. The severity can be defined as:

• Mild: The patient experiences at least five of the symptoms needed for a diagnosis of MDD, which also pose a mild overall functional impairment.
• Moderate: The patient experiences at least seven to eight symptoms, or the symptoms pose a moderate overall functional impairment.
• Severe without psychotic features: The patient experiences most or all of the symptoms, or the symptoms he or she experiences pose a severe functional impairment, but the patient presents without any psychotic features.
• Severe with psychotic features: The patient experiences most or all of the symptoms, or the symptoms he or she experiences pose a severe functional impairment and the patient presents with psychotic features.
• In full remission: The patient previously had two or more episodes but has been free from symptoms for at least two months.
• In partial remission: Some symptoms may still be present but the full criteria are no longer met, or there are no longer any significant symptoms of an episode, but the patient hasn’t been in remission for two months or longer.

If information isn’t present in the medical record that identifies the severity of the disorder, the ICD-10-CM classification includes “unspecified” diagnosis codes. Unspecified codes are used when the information in the medical record is insufficient to assign a more specific code.

Caution should be taken to only code the medical condition that is stated in the medical record, even when documentation of the clinical requirements for a different level of severity is noted in the medical record. For example, if “depression” is documented in the patient’s medical record but the medical record also states, “Exhibits sadness and is withdrawing from friends,” only the depression can be coded. The diagnosis is what is coded. Additional clinical documentation would be considered supporting documentation for the depression. Providers should clearly state the level of severity of the depression and correlate this with supporting documentation, such as current prescribed medications, a PHQ-9 or another standardized assessment.

Listed below are all the subcategory choices for MDD.

ICD-10 code choices

• F32.0 Major depressive disorder, single episode, mild
• F32.1 Major depressive disorder, single episode, moderate
• F32.2 Major depressive disorder, single episode, severe without psychotic features
• F32.3 Major depressive disorder, single episode, severe with psychotic features
• F32.4 Major depressive disorder, single episode, in partial remission
• F32.5 Major depressive disorder, single episode, in full remission
• F32.9 Major depressive disorder, single episode, unspecified
• F33.0 Major depressive disorder, recurrent, mild
• F33.1 Major depressive disorder, recurrent, moderate
• F33.2 Major depressive disorder, recurrent, severe without psychotic features
• F33.3 Major depressive disorder, recurrent, severe with psychotic features
• F33.4 Major depressive disorder, recurrent, in remission
• F33.9 Major depressive disorder, recurrent, unspecified

Note: Medical record documentation that simply states “depression” and has no further supporting documentation will index to subcategory F32.9, Major depressive disorder, single episode, unspecified per the ICD-10-CM Alphabetic Index.

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. Also, 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.

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.

We have new value-based reimbursement opportunities for specialists participating in CQIs

As part of our continuing efforts to transform reimbursement from the traditional fee-for-service to fee-for-value, we have five new Collaborative Quality Initiatives value-based reimbursement opportunities that reward specialists for improving quality of care through performance in our CQIs, effective March 1, 2018.

Value Partnerships initially launched the CQI VBR in 2017 with the Michigan Urology Surgery Improvement Collaborative, which is also continuing in 2018, to reward MUSIC physicians for reducing infection rates and unnecessary biopsies in prostate cancer patients across Michigan.

As a result of this successful endeavor, and to strengthen our fee-for-value approach, we’re launching CQI VBR for the following CQIs for the 2018 VBR reimbursement period:

• Anesthesiology Surgery Performance Improve & Reporting Exchange Collaborative, also known as ASPIRE
• Blue Cross Blue Shield of Michigan Cardiovascular Consortium, also known as BMC2
• Michigan Anticoagulation Quality Improvement Initiative, also known as MAQI2
• Michigan Surgical Quality Collaborative, also known as MSQC
• Michigan Oncology Quality Consortium, also known as MOQC

The coordinating centers that run the operations for the CQIs listed above developed measures and a scoring method, in collaboration with consortium clinical leadership, which were approved by Blue Cross for use for the 2018 VBR period. Each CQI uses a unique scoring method that best fits its collaborative. Performance is measured and scored at one or more of the following levels:

• Affiliated hospital – Physician performance is grouped by the collective average of the physicians at their primary hospital (affiliation determined by the coordinating center and consortium members).
• Affiliated physician organization – Physician performance is grouped by the collective average at the PO.
• Collaborative-wide – Physician performance is based on the collective average of all physicians.
• Regional – Physician performance is assessed at a regional level.
• Physician practice – physician performance is based on the collective average at the physician practice.

The measures for each CQI are listed in the table below and reflect clinically relevant data that is abstracted into each CQI’s registry. Physicians who meet the performance expectations of their affiliated CQI will receive 103 percent CQI VBR, which is in addition to any specialist VBR opportunity available through the Physician Group Incentive Program. The CQI VBR reimbursement period will follow the same reimbursement period as other specialist VBR. The CQI VBR also follows the same guidelines as the specialist VBR.

• The physician must be enrolled in Blue Cross’ PGIP program through one of the affiliated PGIP physician organizations for at least one year.

Unique to CQI VBR are the following guidelines:

• The physician must be contributing data for at least two years in the respective CQI’s clinical data registry (with at least one year worth of baseline data) to be considered eligible (specific to CQI VBR).
• The physician isn’t nominated by the PO for CQI VBR. Instead, the CQI coordinating center notifies Blue Cross of which physicians meet the performance targets based on the scoring entity mentioned above (i.e., affiliated hospital, affiliated PO). The PO is responsible for notifying physicians who receive VBR, similar to the specialist VBR.

In some cases, physicians may be participating in more than one CQI. For those instances, physicians are limited to receiving 103 percent VBR for CQI performance. For example, if a physician participates in both the BMC2 and MSQC CQIs and the physician’s performance is such that he or she would be eligible for CQI VBR for both, the physician will receive 103 percent VBR.

** There are targets set for each of the measures developed by their respective CQI coordinating center with approval from Blue Cross.

Medicare Plus Blue^SM PPO updating claim editing processes

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

• Promote correct coding
• Integrate applicable, appropriate local and national coverage determination guidelines in a way that will simplify our claims payment system.

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

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

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

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

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

As part of your contract with us, health care 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.

Complete your fourth-quarter attestation through CAQH ProView

As communicated through web-DENIS in October, Blue Cross Blue Shield of Michigan and Blue Care Network have transitioned the quarterly attestation process from the PRIME-Hub website to CAQH ProView. Health care providers and practice managers should use CAQH to review and confirm their demographic data instead of going to the Atlas PRIME-Hub website or submitting their electronic Big Group Audit or physician organization attestation roster to their assigned provider data analytics analyst.

If you haven’t already, visit the CAQH provider portal and create an account sometime this quarter. Also, be sure to log in, validate any existing information within your account and submit changes as needed through the Provider Self-Service tool.

For resources to help you use CAQH most efficiently, click here. If you have questions or need support with completing your attestations, contact CAQH at 1-888-599-1771 or reach out to your provider consultant.

Report national drug code number on Medicare Advantage PPO drug claims for accurate processing

National drug code information is used during the claims process to ensure the most accurate and up-to-date pricing for medical drugs, based on the date of service. This applies to any claim submitted on the professional 1500 (HCFA) claim form and ANSI 837P where a medical drug was provided.

This process has been utilized for several years for commercial PPO and Blue Care Network plans.

Although it isn’t required to include the NDC and NDC units on a claim, we recommend you include them to expedite accurate claims processing. Note: Healthcare Common Procedure Coding System and Current Procedural Terminology^® codes and quantities are required on all drug claims, as required by Health Insurance Portability and Accountability Act of 1996.

NDC formatting

Many NDCs are displayed on drug packaging in a 10-digit format. Proper billing of an NDC requires an 11-digit number in a 5-4-2 format. Converting NDCs requires a strategically placed zero, depending on the 10-digit format. The following table shows common 10-digit NDC formats indicated on packaging and the appropriate conversion to an 11-digit format. The correctly formatted additional “0” is in red in the following examples.

Note: Hyphens indicated below are used only to illustrate the various formatting examples for NDCs. Don’t use hyphens when entering the NDC in your claim.

Finding the NDC and unit of measure

An asterisk may appear as a placeholder for any leading zeroes in the NDC found on the medication’s packaging. The container label also displays the appropriate unit of measure for that drug. The unit of measure is by weight (grams: GR), volume (milliliter: ML) or count (unit: UN). Each dispensed dose should be converted into one of these, following the manufacturer's unit of measure. International units (F2) must be converted to standard measurements (GR, ML and UN).

• For drugs that come in a vial in powder form that need to be reconstituted before administration, bill each vial (UN).
• For drugs that come in a vial in liquid form, bill in milliliters (ML).
• For topical forms of medicine (e.g., cream, ointment, bulk powder in a jar), bill in grams (GR).

Submitting the NDC on claims
Here are some tips and general guidelines for proper submission of valid NDCs and related information on professional claims:

• The NDC should be submitted along with the applicable HCPCS or CPT code.
• The NDC should follow the “5digit4digit2digit” format (11 numeric characters with no spaces or special characters).
• To submit electronic claims (ANSI 837P), report the following information:

• To submit paper claims, enter the NDC information in field 24 of the CMS-1500 claim form. In the shaded portion of field 24A-24G, enter the qualifier “N4” left-justified, immediately followed by the national drug code. Next, enter the appropriate qualifier for the correct dispensing unit (GR, UN or ML), followed by the quantity and the price per unit, as indicated in the example below.

Here are two claims billing examples:

• The format for billing should be:
  N4 + NDC code + 3 spaces + unit of measure + quantity
  Example: N450242005306   ML50

• The format for billing should be:
  N4 + NDC code + 3 spaces + unit of measure + quantity
  Example: N468817013450   UN3

Online health care services to include behavioral health

We’re enhancing our online health care services — Blue Cross Online Visits^SM — to include behavioral health care, effective Jan. 1, 2018. This provides our members with an alternative to in-person therapy or psychiatric appointments.

Blue Cross Online Visits will increase access to behavioral health care — especially important in rural counties where there’s limited access to behavioral health practitioners. It’s also useful for patients who aren’t comfortable with counseling in a face-to-face setting.

How it works

Formerly called 24/7 online health care, Blue Cross Online Visits is powered by American Well^® and will include appointments with therapists and psychiatrists. Behavioral health visits are video-only appointments scheduled for 45 minutes.

Members can access online visits in one of the following ways:

• Website: bcbsmonlinevisits.com
• App: BCBSM Online Visits, which replaces the Amwell^® app

Health care providers in our networks can continue to conduct telemedicine visits after receiving an authorization. Doctors who already provide or wish to provide their own telemedicine services should review the Blue Cross Blue Shield of Michigan telemedicine policy and the Blue Care Network eVisits and telemedicine policies. Members will have the same cost share as their current outpatient behavioral health benefit.

With online visits, members talk with a doctor or therapist through a secure web-based video application that’s compliant with the Health Insurance Portability and Accountability Act of 1996. Visits are confidential and follow federal mental health parity rules.

Online visits don’t include treatment for substance abuse disorders or urgent and emergency behavioral health issues.

Who’s eligible for behavioral health care?

• Therapy is available for adults and children 10 and older.
• Psychiatry visits are for adults age 18 and older.

What plans or groups don’t have access to Blue Cross Online Visits?

• Medicaid, Medicare Advantage (group and individual) and MiChild
• Medicare/Medigap (non-exact fill)
• Federal Employee Program^®
• FlexLink groups
• Specialty products, such as dental, vision and hearing

Questions from patients?
If patients ask you if they have access to Blue Cross Online Visits, suggest that they call the number on the back of their member ID card or log in to the Blue Cross member portal.

Reminder: We need you to update information for practitioners, locations that don’t accept appointments

Blue Cross Blue Shield of Michigan and Blue Care Network members rely on our online provider directory to make appointments with our physicians. Therefore, we’re requesting that you update the information for your non-appointing practitioners (i.e., providers who don’t see patients for appointments) and locations.

Information about providers who don’t see patients for appointments, as well as locations that aren’t used for patient appointments, should be suppressed so that it isn’t displayed on the online directory. Emergency room physicians and administrative addresses are examples of information that shouldn’t be displayed in the directory.

To ensure that these providers and locations are suppressed, go to the Enrollment and Changes page on bcbsm.com. For information on using the Provider Enrollment and Change Self-Service online application, click here.

If you have questions or need support with updating your data, call Provider Enrollment at 1-800-822-2761 or contact your provider consultant.

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.

Announcing 2018 coverage changes to MPSERS members’ hearing, vision services

Effective Jan. 1, 2018, the hearing and vision benefits for Michigan Public School Employees’ Retirement System members will no longer be administered by Blue Cross Blue Shield of Michigan. Details about these changes are listed below.

MPSERS hearing services
Starting Jan. 1, 2018, Blue Cross will provide routine hearing care benefits and hearing aids for MPSERS members exclusively through TruHearing, an independent company that provides hearing services. TruHearing doesn’t provide Blue Cross-branded products or services. But our arrangement allows them to work with us to administer the MPSERS hearing care and hearing aids benefit.

We’ve let all MPSERS members know about this benefit change through our various member communications. Our members won’t receive a new ID card from TruHearing. An ID card isn’t necessary, because TruHearing will coordinate services directly between the member and provider.

Benefit highlights
MPSERS members can have:

• An audiometric hearing exam once every 36 months with a $45 copay
• Three provider visits
• Up to two TruHearing Flyte 770 hearing aids ($499 copayment per aid) or Flyte 990 hearing aids ($799 copay per aid) every 36 months
• A 45-day trial with the purchase of each Flyte hearing aid
• A three-year manufacturer warranty
• 48 batteries per aid

Tips for providers

• Routine hearing services and hearing aids are only covered for MPSERS members when they call TruHearing at 1-855-205-6305 and follow the directions provided.
• Give MPSERS members the opportunity for a trial with Flyte to give the members the best opportunity to use the benefit.
• Ask members who decide to waive their hearing benefit (whether it’s their preference or a medical necessity) to complete a TruHearing Select Non-covered Services form.
• Providers will need to submit these forms directly to TruHearing.
• Members who waive their benefits can then use the TruHearing Choice discount program, which includes 100-plus hearing aid models from five manufacturers at prices ranging from $695 to $2,250.
• Collect member hearing exam copayments through the TruHearing provider portal, Echo.
• TruHearing will remit the allowable amount for the exam to providers approximately 10 days after the exam copay has been collected in Echo.
• Collect full TruHearing Flyte hearing aid copayments through Echo.
• TruHearing will remit the professional fee to providers after the member’s 45-day trial period.
• Providers can get more details about Flyte hearing aids at TruHearing.com/flyte,** which offers providers Flyte spec sheets, a fitting guide, a reference guide and other information about the Flyte product line. There are also training courses available to providers on Audiology online (audiologyonline.com**).
• In December 2017, the Flyte website will be updated with the new Flyte 770/990 information.
• For more information about training or tools needed to ensure successful Flyte fittings or partnering with TruHearing, providers should contact TruHearing Provider Outreach at 1-855-286-0550 or Provider.outreach@truhearing.com.
• Financing is available for MPSERS members through AllWell Financing, if interested.

MPSERS vision services
Starting Jan. 1, 2018, Medicare Advantage and commercial retirees with MPSERS coverage will transition from Blue Cross’ Blue Vision^SM plan to EyeMed Vision Care.

In December 2017, EyeMed will mail members a separate welcome kit detailing their 2018 vision benefits. The kit will also include the member’s new EyeMed vision ID card. Retirees who share a vision policy with a dependent or spouse will receive two identical ID cards with the retiree’s name on it.

Providers should continue to contact Blue Vision at 1-800-877-7195 if they have any questions about dates of service between Jan. 1, 2014, and Dec. 31, 2017. If providers have questions about dates of service beginning Jan. 1, 2018, they should contact EyeMed at 1-888-581-3648.

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

Reminder: 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 BlueSM 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.

Avoid use of imaging studies for low back pain in first six weeks unless an exclusion applies

In a three-month period, more than one-fourth of U.S. adults experience at least one day of back pain. Recommended treatment guidelines indicate that you shouldn’t do imaging for low back pain within the first six weeks unless an exclusion applies.

Imaging studies done less than six weeks after the onset of low back pain rarely improve outcomes, and they increase medical costs and radiation exposure. Less than 1 percent of imaging identifies a specific cause of low back pain within the first six weeks of the onset of pain.

Exclusions may include, but aren’t limited to, conditions such as history of cancer, recent trauma within the last three months, history of HIV or history of organ transplant.

Managing acute low back pain in the first six months may include:

• Instructing the patient to stay active as tolerated by pain
• Avoiding bed rest
• Doing back exercises
• Injury prevention
• Using of over-the-counter pain relievers

If ordering an imaging study prior to six weeks of the onset of back pain when an exclusion applies, be sure to code the exclusion in addition to the diagnoses of low back pain.

Encourage your patients to be screened for cervical cancer

Screening offers the best chance to find cervical cancer and treat it successfully, which is why you should encourage your patients to be screened for cervical cancer. Screening can also prevent most cervical cancers by finding and prompting treatment for abnormal cervical cell changes or pre-cancers before they have a chance to turn into a cervical cancer.

When detected early, cervical cancer is highly treatable. There’s a five-year survival rate of 91 percent compared to 16 percent if it has spread. Early detection is attributed to the effectiveness of the Pap test.

When should your patients be screened?
The American Cancer Society recommends the following guidelines for cervical cancer screening:

• All women should begin cervical cancer screening at age 21. Women aged 21 to 29 should have a Pap test every three years
• Women aged 30 to 65 should be screened with a Pap test combined with a human papillomavirus, known as HPV, test every five years

For more information on cervical cancer screening, visit the American Cancer Society website at cancer.org.**

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

Medicare Plus Blue^SM PPO updating claim editing processes

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

• Promote correct coding
• Integrate applicable, appropriate local and national coverage determination guidelines in a way that will simplify our claims payment system.

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

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

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

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

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

As part of your contract with us, health care 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.

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.

Announcing 2018 coverage changes to MPSERS members’ hearing, vision services

Effective Jan. 1, 2018, the hearing and vision benefits for Michigan Public School Employees’ Retirement System members will no longer be administered by Blue Cross Blue Shield of Michigan. Details about these changes are listed below.

MPSERS hearing services
Starting Jan. 1, 2018, Blue Cross will provide routine hearing care benefits and hearing aids for MPSERS members exclusively through TruHearing, an independent company that provides hearing services. TruHearing doesn’t provide Blue Cross-branded products or services. But our arrangement allows them to work with us to administer the MPSERS hearing care and hearing aids benefit.

We’ve let all MPSERS members know about this benefit change through our various member communications. Our members won’t receive a new ID card from TruHearing. An ID card isn’t necessary, because TruHearing will coordinate services directly between the member and provider.

Benefit highlights
MPSERS members can have:

• An audiometric hearing exam once every 36 months with a $45 copay
• Three provider visits
• Up to two TruHearing Flyte 770 hearing aids ($499 copayment per aid) or Flyte 990 hearing aids ($799 copay per aid) every 36 months
• A 45-day trial with the purchase of each Flyte hearing aid
• A three-year manufacturer warranty
• 48 batteries per aid

Tips for providers

• Routine hearing services and hearing aids are only covered for MPSERS members when they call TruHearing at 1-855-205-6305 and follow the directions provided.
• Give MPSERS members the opportunity for a trial with Flyte to give the members the best opportunity to use the benefit.
• Ask members who decide to waive their hearing benefit (whether it’s their preference or a medical necessity) to complete a TruHearing Select Non-covered Services form.
• Providers will need to submit these forms directly to TruHearing.
• Members who waive their benefits can then use the TruHearing Choice discount program, which includes 100-plus hearing aid models from five manufacturers at prices ranging from $695 to $2,250.
• Collect member hearing exam copayments through the TruHearing provider portal, Echo.
• TruHearing will remit the allowable amount for the exam to providers approximately 10 days after the exam copay has been collected in Echo.
• Collect full TruHearing Flyte hearing aid copayments through Echo.
• TruHearing will remit the professional fee to providers after the member’s 45-day trial period.
• Providers can get more details about Flyte hearing aids at TruHearing.com/flyte,** which offers providers Flyte spec sheets, a fitting guide, a reference guide and other information about the Flyte product line. There are also training courses available to providers on Audiology online (audiologyonline.com**).
• In December 2017, the Flyte website will be updated with the new Flyte 770/990 information.
• For more information about training or tools needed to ensure successful Flyte fittings or partnering with TruHearing, providers should contact TruHearing Provider Outreach at 1-855-286-0550 or Provider.outreach@truhearing.com.
• Financing is available for MPSERS members through AllWell Financing, if interested.

MPSERS vision services
Starting Jan. 1, 2018, Medicare Advantage and commercial retirees with MPSERS coverage will transition from Blue Cross’ Blue Vision^SM plan to EyeMed Vision Care.

In December 2017, EyeMed will mail members a separate welcome kit detailing their 2018 vision benefits. The kit will also include the member’s new EyeMed vision ID card. Retirees who share a vision policy with a dependent or spouse will receive two identical ID cards with the retiree’s name on it.

Providers should continue to contact Blue Vision at 1-800-877-7195 if they have any questions about dates of service between Jan. 1, 2014, and Dec. 31, 2017. If providers have questions about dates of service beginning Jan. 1, 2018, they should contact EyeMed at 1-888-581-3648.

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

Reminder: Don’t resubmit claims involved in audits

Blue Cross Blue Shield of Michigan requests that you not resubmit inpatient or outpatient facility claims that are already part of an audit. Why? It’s time consuming to rebill charges. And it can create more problems once the audit process is complete and we send the claims for adjustment.

Once you receive a patient listing with an audit notice letter:

• Don’t adjust the related claims any further.
• Let your billing and finance departments know which claims we’re auditing.
• Ask your finance team to hold billing any more audit-related claims unless you’re notified by us to do so.

Audited claims could include cases for:

• Readmissions
• Transfers
• Diagnosis-related groups
• Catastrophic-cost outliers
• Emergency room
• High-dollar claims
• Hospital physical therapy, occupational therapy and speech-language pathology
• Ambulatory surgery facilities
• Freestanding outpatient physical therapy facilities
• End-stage renal disease
• Skilled nursing facilities
• Home health care
• Hospice
• Focus

Note: Catastrophic-cost outliers can only have charges rebilled up to 30 days before the audit. To learn more, see “Reminder: Here’s what you need to know about catastrophic case audits” in the November 2015 Record.

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

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

Here’s a summary of the changes:

The Behavioral Health e-referral User Guide was updated 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 show you how to completethe 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 Medicare Plus Blue PPO that haven’t signed up for access to the e-referral system should apply immediately. Each utilization review user at each facility will need 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 time.

Note: The information in this article applies only to services for 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. Those members can use the online WebPass tool at webpass.ndbh.com ** to request initial and continuing stay authorizations for inpatient admissions, and check the status of these requests. They can also call 1-800-762-2382.

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

Reminder: Review, confirm your demographic data

Blue Cross Blue Shield of Michigan and Blue Care Network members rely on our online provider directory for accurate, up-to-date provider information. Therefore, we’re requesting that you review and confirm your demographic data with us throughout the year. The Provider Enrollment and Data Management team will also mail your demographic information to you twice a year and request that you update or confirm it.

If there are any changes or updates to your data, send them to the Provider Enrollment and Data Management team via:

• Mail: Provider Enrollment — Attestation
  20500 Civic Center Drive
  Southfield, MI 48076-4115
  H201 — Provider Data Quality
• Fax: 1-844-216-4941
• Email: providerdataintegrity@bcbsm.com

If you have questions or need support with updating your data, visit bcbsm.com, call Provider Enrollment at 1-800-822-2761 or contact your provider consultant.

High-cost insulins with comparable alternatives among Blue Cross and BCN’s Custom Select drug list exclusions

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 exclude drugs from the Custom Select drug list when there is a more cost-effective alternative available.

Insulin exclusions

Blue Cross and BCN commercial plans won’t cover all formulations of the following insulin products for the Custom Select drug list, effective Jan. 1, 2018:

• Apidra^®, Apidra^® Solostar^®
• Humalog^® (except Junior KwikPen), Humalog^® Mix
• Humulin^® (except U-500), Humulin^® Kwikpen^®

Members who use these insulin products can continue to fill prescriptions for them through March 1, 2018. This will give them the opportunity to talk to their providers about treatment options.

Insulin products of the same type are interchangeable and work the same way to lower A1c. The following table shows what is and isn’t covered and the cost implications:

Other exclusions
In addition to the high-cost insulin, we’ve listed other drugs below that we’re removing from our Custom Select drug list, effective Jan. 1, 2018 (along with some covered alternatives):

**Indicates that there is no generic version of the alternative drug currently available

We’ll continue to identify certain high-cost drugs and will stop covering them when there are more cost-effective alternatives available for our commercial members.

The Custom Select drug list is found on bcbsm.com, on our pharmacy services page.

We’re changing the way we process DME HCPCS codes, effective March 1, 2018

Effective March 1, 2018, Blue Cross Blue Shield of Michigan is changing how we process durable medical equipment HCPCS codes. We’re adding four categories to explain how we’ll pay for DME:

• Capped rental
• Purchase only
• Rent forever
• Short-term rental

We’re also expanding the capped rental and reasonable useful lifetime time frame.

The DME capped rental period is expanding from 10 monthly payments to 13 monthly payments. After 13 monthly payments, the equipment will be considered purchased.

The reasonable useful lifetime for purchased DME is expanding from every three years to five years. This aligns with Centers for Medicare & Medicaid Services policy.

These changes will result in updates to the rental fees, specifically for the capped rental HCPCS codes. These changes will be incorporated into the newly published DME/P&O Fee Schedule, effective March 1, 2018.

You can access the fee schedule via web-DENIS.

• Log in to web-DENIS.
• Click on BCBSM Provider Publications and Resources.
• Click on Entire Fee Schedules and Fee Changes.

In a web-DENIS alert and in the January Record, we’ll be publishing a list of the DME HCPCS codes in each of the four categories.