Training available for new medical and radiation oncology programs for URMBT members

Beginning Jan. 1, 2019, Blue Cross Blue Shield of Michigan will start two utilization management programs for oncology services given to UAW Retiree Medical Benefits Trust (URMBT) non-Medicare members. Blue Cross is partnering with AIM Specialty Health^® for these programs, and we announced them in an October Record article.

In the coming months, there will be a series of webinars for providers and office staff to learn more about the programs and how to use the AIM ProviderPortal^SM. We encourage you and your practice to participate even if you’re already familiar with AIM and the ProviderPortal through other health care plans or specialty programs.

There will be separate webinars for medical oncology and radiation oncology, and they will also be targeted toward clinical and non-clinical staff. The schedule is listed below.

Email providerinvitations@bcbsm.com to participate in one of these sessions and to obtain dial-in and webinar details.

Medical oncology
For non-clinical provider staff

For doctors and clinicians

Radiation oncology
For non-clinical provider staff

For doctors and clinicians

For more information about these programs, go to the AIM ProviderPortal** or call AIM at 1-800-728-8008. You can also visit bcbsm.com.

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

Reminder: Update your practice information, complete your attestation

It’s time for your quarterly review of your practice’s demographic information to make sure everything is up to date.

Individual practitioners:

• Review all your practice locations.
• Verify that CAQH ProView lists each location’s information correctly.
• Don’t forget to check your address suite numbers and phone numbers, too.

Practice groups:

• Verify that all practice locations are current, including suite numbers and phone numbers using the Provider Enrollment and Change Self-Service tool in Provider Secured Services.
• Suppress locations and providers that don’t see patients for appointments. For example, emergency room physicians or administrative addresses shouldn’t display for members in our online directory.

More information and resources

• CAQH ProView** — This site is helpful to both providers and practice managers.
• Provider Secured Services — This site provides steps to sign up for Provider Secured Services and get access to Provider Enrollment and Change Self-Service.
• You can also call Provider Enrollment at 1-800-822-2761 to sign up for Provider Secured Services.

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

Tell us how you answer the phone with our new feature in Provider Self-Service

How your office greets members by telephone is important — it helps them know they’ve reached the correct provider. As a result, the Centers for Medicare & Medicaid Services is now confirming how providers name their offices by phone through its annual data directory audit for health care plans.

To continue improving our member experience and stay compliant with CMS, we’ve added a new feature to the Provider Enrollment and Change Self-Service tool in Provider Secured Services. You can now add your office’s telephone greeting when adding or modifying your practice locations. We’ll display your office telephone greeting as your practice name in our online directory.

Why not update it now?
Log in to Provider Secured Services to access Provider Enrollment and Change Self-Service to refresh your practice location now and keep your online directory listing up to date.

If you have any questions, reach out to Provider Enrollment at 1-800-822-2761.

Remember to refer Blue Cross members to network providers

Providers affiliated with Blue Cross Blue Shield of Michigan and Blue Care Network have a contractual obligation to use network providers when referring our members for services. This includes referring members for toxicology and drug-of-abuse testing services, and applies to both Blue Cross and BCN commercial and Medicare Advantage members enrolled in the following plans:

• Blue Cross PPO
• Blue Cross Medicare Plus Blue^SM PPO
• BCN HMO^SM
• BCN Advantage^SM

A significant number of contracted providers refer members to out-of-network laboratories. This puts members at risk of having to pay higher costs. Since the tests are available at network labs, these additional costs are unnecessary. Follow the dictates of your provider agreement and the directions in our provider manuals, which instruct you to refer these members to network labs.

Our goal is to:

• Give your patients convenient access to high-quality, cost-efficient toxicology testing services that meet their clinical needs.
• Help our members avoid higher copayments and other out-of-pocket costs that may result from using out-of-network labs.

You can confirm which labs are in-network or out-of-network as follows:

Blue Cross PPO

• For salaried employees covered through Ford, General Motors and the Michigan Public School Employees' Retirement System, call Quest Diagnostics™ at 1-866-697-8378.
• For all other Blue Cross PPO members, use the Blue Cross online provider directory.

Blue Cross Medicare Plus Blue PPO
Call either of the following resources:

• Joint Venture Hospital Laboratories — 1-800-445-4979
• Quest Diagnostics — 1-866-697-8378
  

BCN HMO and BCN Advantage

• Call Joint Venture Hospital Laboratories at 1-800-445-4979.

Contacting PARS
If you need more help locating a network lab or want to discuss specific lab testing needs, call one of the following Provider Automated Response System numbers during business hours:

Blue Cross PPO, BCN HMO or BCN Advantage

• Professional providers — 1-800-344-8525
• Facility providers — 1-800-249-5103

Blue Cross Medicare Care Blue PPO

• 1-866-309-1719

After confirming member benefits using the automated system, you can speak to someone in Provider Inquiry to get help finding an in-network lab.

PCMH providers will receive board certification exceptions

Blue Cross Blue Shield of Michigan and Blue Care Network will continue to conduct annual board certification status reviews of family medicine, internal medicine and pediatric practitioners in our managed care networks.

However, effective Jan. 1, 2019, if board certification status has lapsed for a designated patient-centered medical home physician, Blue Cross will grant an exception and allow the practitioner to remain in our managed care networks. This exception doesn’t apply to new practitioner enrollments. We’ll continue to require that all practitioners have board certification upon initial enrollment for affiliation with us.

If board certification status has lapsed and the practitioner doesn’t have PCMH designation, he or she must complete his or her applicable specialty’s Maintenance of Certification requirements within a two-year time frame to remain in our managed care networks.

Continuity of Care in place for URMBT members in the medical or radiation oncology programs

Beginning Jan. 1, 2019, Blue Cross Blue Shield of Michigan will begin two new utilization management programs for oncology services delivered to UAW Retiree Medical Benefits Trust members. The programs require prior authorization for some outpatient medical and radiation oncology treatments through AIM Specialty Health^®. We announced this in an October Record article.

Trust members who are in a current course of medical oncology or radiation oncology treatment (as described in the October article) as of Jan. 1, 2019, won’t need a prior authorization for six months. We’re doing this to ensure that these members don’t have an interruption in their care.

If treatment continues beyond six months or if a patient’s treatment path changes, a prior authorization will be required.

We’ll send additional communications directly to providers who are treating these members 30 days before the end of the six-month period to remind them that authorizations will be required.

For more information about these programs, go to the AIM ProviderPortal** or call AIM at 1-800-728-8008. You can also go to bcbsm.com.

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

New program for UAW Retiree Medical Benefits Trust members provides options for some diagnostic services

Beginning Jan. 1, 2019, Blue Cross Blue Shield of Michigan will offer a program for UAW Retiree Medical Benefits Trust members that allows them to choose from a list of health care providers for high-tech diagnostic imaging services.

The program, called Specialty Care Shopper, is offered in partnership with AIM Specialty Health^®. With this program, members of the Trust who require diagnostic imaging services (e.g., MRI and CT scans) have an opportunity to choose from different health care providers. It allows the members to look for high-quality services while helping them keep their out-of-pocket costs as low as possible.

How will it work?
When a member needs an MRI or CT scan, his or her health care provider will prescribe one and obtain authorization for the service from AIM. AIM then reaches out to the member and offers him or her the choice of cost-effective options in the area (based on AIM’s online imaging provider registration tool, called OptiNet^®).

If a member agrees to change his or her rendering provider, AIM will help do that.

How do I go register with AIM?
Go online to aimspecialtyhealth.com/goweb**. Then select BCBS Michigan from the dropdown menu. Fill out OptiNet tool information to be included as one of the rendering providers who will be suggested for Trust members.

The information requested includes:

• A facility’s specifications
• Technologist and physician qualifications
• Accreditation
• Equipment
• Technical registration

AIM uses this information to determine how closely providers adhere to industry-recognized standards (such as those established by the American College of Radiology and the Intersocietal Accreditation Commission).

If you don’t register with AIM on the OptiNet registration tool, then your facility name won’t be included in the online directory and Trust members won’t be able to select you as part of the Shopper program.

It’s important to note, however, that Trust members can still receive services from providers who aren’t registered with AIM’s OptiNet program. The program is designed to help members make educated decisions about their care.

What happens to my information once I enter it?
Once you complete your registration, your responses are evaluated and given a score for each modality you perform. Your facility’s score and allowed payment amount will be shared with ordering physicians during the provider selection component of the prior authorization review.

What if I don’t register?
Then your facility name won’t be included in the online directory and Trust members won’t be able to select you as part of the Shopper program.

Note: Members can still receive services from providers who aren’t registered with AIM’s OptiNet program. This program is only designed to help members make educated decisions about their care.

I’ve already registered with AIM’s OptiNet tool. Do I have to re-register?
No. You don’t need to re-enter your information. But be sure to look at your information online to make sure it’s accurate.

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

Coding corner: 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. Always document signs and symptoms of MDD in the patient’s medical record to support the diagnosis. Include details of the most recent episode.

Examples 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 that don’t subside with treatment
• Thoughts of death, self-harm or suicide

MDD is assigned to the following ICD-10-CM categories:

• F32 — Major depressive disorder, single episode
• F33 — Major depressive disorder, recurrent

Categories F32 and F33 include fourth characters, and sometimes fifth characters, to capture information about the severity of the MDD. The severity can be defined as:

• Mild: The patient experiences at least five of the symptoms needed for a diagnosis, 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 the symptoms, or the symptoms pose a severe functional impairment, but the patient presents without any psychotic features.
• Severe with psychotic features: The patient experiences most or all the symptoms, or the symptoms 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’s 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 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 Patient Health Questionnaire-9, or PHQ-9, or another standardized assessment.

ICD-10-CM code subcategory choices for MDD:

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.

2018 Updates ICD- 10-CM Official Guidelines for Coding and Reporting
(Updates are in bold)

Chapter 5: Mental, Behavioral and Neurodevelopmental Disorders (F01 – F99)

b. Mental and behavioral disorders due to psychoactive substance use

1) In Remission
Selection of codes for “in remission” for categories F10-F19, Mental and behavioral disorders due to psychoactive substance use (categories F10-F19 with -11, -.21) requires the provider’s clinical judgment. The appropriate codes for “in remission” are assigned only on the basis of provider documentation (as defined in the Official Guidelines for Coding and Reporting), unless otherwise instructed by the classification.

Mild substance use disorders in early or sustained remission are classified to the appropriate codes for substance abuse in remission, and moderate or severe substance use disorders in early or sustained remission are classified to the appropriate codes for substance dependence in remission.

3) Psychoactive Substance Use Disorders
As with all other diagnoses, codes for psychoactive substance use disorders (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses). Use these codes only when the psychoactive substance use is associated with a physical, mental or behavioral disorder, and such a relationship is documented by the provider.

Reminder: FEP made changes to care admissions request for skilled nursing facility

On April 30, 2018, all post-acute care admissions, including skilled nursing facilities, were routed to the Precertification Utilization Management team. Federal Employee Program^® members must sign a consent for case management to use their benefit for a skilled nursing facility. All clinical information along with the member’s signed consent for case management can be faxed to 1-866-411-2573 for precertification review.

Note: If an FEP member has Medicare Part B, and also has Medicare Part B services on the claim, then that claim must be submitted to Medicare for processing before FEP can process the claim.  

If you have benefit questions, contact FEP Customer Service at 1-800-482-3600. If you have facility precertification questions, contact precertification at 1-800-572-3413. If you have questions about case management services, call 1-800-325-6278.

Reminder: FEP programs help members manage a chronic condition

The Blue Cross Blue Shield Federal Employee Program^® offers initiatives to encourage members with a reported diagnosis of diabetes or hypertension to make healthier choices to reduce the progression of complications related to diabetes or heart disease.

To manage high blood pressure

The Hypertension Management Program provides contract holders and their spouses who are 18 and older with a free blood pressure monitor through CVS Caremark^®. Members are automatically enrolled in the program following three qualifications.

• They complete the FEP Blue Health Assessment.
• Members report a diagnosis of high blood pressure.
• At least one medical claim has been processed during the past 12 months with a diagnosis of hypertension.

To manage diabetes

The Diabetes Management Incentive Program is designed to encourage members to achieve and maintain control of their blood sugar and help manage or slow the progression of complications related to diabetes. Through this program, eligible members can earn a maximum of $100 toward a health account to be used for most qualified medical expenses.

The Diabetes Meter Program allows members with diabetes to receive, at no cost, one glucometer kit each calendar year. Members will still need to obtain a prescription for test strips and lancets for the new meter from their doctor.

FEP members

Members with hypertension or diabetes are encouraged to participate in these programs. They are voluntary, free and confidential. The self-monitoring tools provided by these programs support members’ efforts to manage their chronic conditions.

For more information about these and other health care programs offered by the Blue Cross Blue Shield Federal Employee Program, members should contact FEP Customer Service at 1-800-482-3600 or visit fepblue.org.

Scoring hypopnea in adults: Which standard is acceptable?

There’s been some confusion among health care providers about what criteria Blue Cross Blue Shield of Michigan will accept for diagnostic purposes when scoring hypopnea in adults.

There are two standards used in scoring hypopnea. The American Academy of Sleep Medicine** recommends a 3 percent or greater oxygen desaturation from the pre-event baseline or the event associated with an arousal, while the Centers for Medicare & Medicaid Services requires a 4 percent or greater oxygen desaturation.

Keep in mind that Blue Cross will accept either standard when scoring hypopnea.

To read more about Blue Cross’ sleep apnea policy, see the policy titled Continuing Coverage of CPAP Machines and Supplies for the Treatment of Obstructive Sleep Apnea. To access our medical policies, follow these steps:

• From the web-DENIS homepage, click on BCBSM Provider Publications and Resources.
• To search for a policy by procedure code, click on Benefit policy for a code.
• If you don’t have the code, click on Medical Policy and Precert/Pre-Auth Router.

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

Procedure code D0190 not a covered dental or medical benefit

As a reminder, procedure code D0190 isn’t a covered dental or medical benefit. This dental code indicates screening (including state or federally mandated screening) used to determine an individual's need to be seen by a dentist for diagnosis.

Professional providers who provide screening for this purpose shouldn’t bill procedure code D0190. This service is considered an integral part of a routine evaluation and management service and isn’t separately reimbursable.

Commercial Medical Drug Prior Authorization Program adding Onpattro

Beginning Dec. 1, 2018, Onpattro™ will be added to the Blue Cross Blue Shield of Michigan commercial Medical Drug Prior Authorization Program.

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

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

Our office accepts medical drug prior authorization requests by one of the following methods:

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

1. Click on BCBSM Provider Publications and Resources.
2. Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
3. Click on Under Other Resources, then select Forms.
4. Click on Physician administered medications.

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

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.

Training available for new medical and radiation oncology programs for URMBT members

Beginning Jan. 1, 2019, Blue Cross Blue Shield of Michigan will start two utilization management programs for oncology services given to UAW Retiree Medical Benefits Trust (URMBT) non-Medicare members. Blue Cross is partnering with AIM Specialty Health^® for these programs, and we announced them in an October Record article.

In the coming months, there will be a series of webinars for providers and office staff to learn more about the programs and how to use the AIM ProviderPortal^SM. We encourage you and your practice to participate even if you’re already familiar with AIM and the ProviderPortal through other health care plans or specialty programs.

There will be separate webinars for medical oncology and radiation oncology, and they will also be targeted toward clinical and non-clinical staff. The schedule is listed below.

Email providerinvitations@bcbsm.com to participate in one of these sessions and to obtain dial-in and webinar details.

Medical oncology
For non-clinical provider staff

For doctors and clinicians

Radiation oncology
For non-clinical provider staff

For doctors and clinicians

For more information about these programs, go to the AIM ProviderPortal** or call AIM at 1-800-728-8008. You can also visit bcbsm.com.

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

Remember to refer Blue Cross members to network providers

Providers affiliated with Blue Cross Blue Shield of Michigan and Blue Care Network have a contractual obligation to use network providers when referring our members for services. This includes referring members for toxicology and drug-of-abuse testing services, and applies to both Blue Cross and BCN commercial and Medicare Advantage members enrolled in the following plans:

• Blue Cross PPO
• Blue Cross Medicare Plus Blue^SM PPO
• BCN HMO^SM
• BCN Advantage^SM

A significant number of contracted providers refer members to out-of-network laboratories. This puts members at risk of having to pay higher costs. Since the tests are available at network labs, these additional costs are unnecessary. Follow the dictates of your provider agreement and the directions in our provider manuals, which instruct you to refer these members to network labs.

Our goal is to:

• Give your patients convenient access to high-quality, cost-efficient toxicology testing services that meet their clinical needs.
• Help our members avoid higher copayments and other out-of-pocket costs that may result from using out-of-network labs.

You can confirm which labs are in-network or out-of-network as follows:

Blue Cross PPO

• For salaried employees covered through Ford, General Motors and the Michigan Public School Employees' Retirement System, call Quest Diagnostics™ at 1-866-697-8378.
• For all other Blue Cross PPO members, use the Blue Cross online provider directory.

Blue Cross Medicare Plus Blue PPO
Call either of the following resources:

• Joint Venture Hospital Laboratories — 1-800-445-4979
• Quest Diagnostics — 1-866-697-8378
  

BCN HMO and BCN Advantage

• Call Joint Venture Hospital Laboratories at 1-800-445-4979.

Contacting PARS
If you need more help locating a network lab or want to discuss specific lab testing needs, call one of the following Provider Automated Response System numbers during business hours:

Blue Cross PPO, BCN HMO or BCN Advantage

• Professional providers — 1-800-344-8525
• Facility providers — 1-800-249-5103

Blue Cross Medicare Care Blue PPO

• 1-866-309-1719

After confirming member benefits using the automated system, you can speak to someone in Provider Inquiry to get help finding an in-network lab.

Continuity of Care in place for URMBT members in the medical or radiation oncology programs

Beginning Jan. 1, 2019, Blue Cross Blue Shield of Michigan will begin two new utilization management programs for oncology services delivered to UAW Retiree Medical Benefits Trust members. The programs require prior authorization for some outpatient medical and radiation oncology treatments through AIM Specialty Health^®. We announced this in an October Record article.

Trust members who are in a current course of medical oncology or radiation oncology treatment (as described in the October article) as of Jan. 1, 2019, won’t need a prior authorization for six months. We’re doing this to ensure that these members don’t have an interruption in their care.

If treatment continues beyond six months or if a patient’s treatment path changes, a prior authorization will be required.

We’ll send additional communications directly to providers who are treating these members 30 days before the end of the six-month period to remind them that authorizations will be required.

For more information about these programs, go to the AIM ProviderPortal** or call AIM at 1-800-728-8008. You can also go to bcbsm.com.

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

Reminder: FEP made changes to care admissions request for skilled nursing facility

On April 30, 2018, all post-acute care admissions, including skilled nursing facilities, were routed to the Precertification Utilization Management team. Federal Employee Program^® members must sign a consent for case management to use their benefit for a skilled nursing facility. All clinical information along with the member’s signed consent for case management can be faxed to 1-866-411-2573 for precertification review.

Note: If an FEP member has Medicare Part B, and also has Medicare Part B services on the claim, then that claim must be submitted to Medicare for processing before FEP can process the claim.  

If you have benefit questions, contact FEP Customer Service at 1-800-482-3600. If you have facility precertification questions, contact precertification at 1-800-572-3413. If you have questions about case management services, call 1-800-325-6278.

Scoring hypopnea in adults: Which standard is acceptable?

There’s been some confusion among health care providers about what criteria Blue Cross Blue Shield of Michigan will accept for diagnostic purposes when scoring hypopnea in adults.

There are two standards used in scoring hypopnea. The American Academy of Sleep Medicine** recommends a 3 percent or greater oxygen desaturation from the pre-event baseline or the event associated with an arousal, while the Centers for Medicare & Medicaid Services requires a 4 percent or greater oxygen desaturation.

Keep in mind that Blue Cross will accept either standard when scoring hypopnea.

To read more about Blue Cross’ sleep apnea policy, see the policy titled Continuing Coverage of CPAP Machines and Supplies for the Treatment of Obstructive Sleep Apnea. To access our medical policies, follow these steps:

• From the web-DENIS homepage, click on BCBSM Provider Publications and Resources.
• To search for a policy by procedure code, click on Benefit policy for a code.
• If you don’t have the code, click on Medical Policy and Precert/Pre-Auth Router.

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

Update or review your demographic information twice a year

Our Provider Enrollment and Data Management team mails your demographic data to you twice a year. When you receive them:

• Review and confirm the accuracy of your demographic information.
• Respond to each mailing to keep your demographic data up to date.

If you don’t respond with information updates or confirm that your current information is correct, it won’t appear in our online directory.

Help our members find and reach you
Blue Cross Blue Shield of Michigan and Blue Care Network members rely on the online provider directory for accurate, up-to-date provider information. If there are any changes or updates to your demographics, send them to us via:

• Mail
  Provider Enrollment — Attestation
  20500 Civic Center Drive
  Southfield, MI 48076-4115
  H200–PDA
• Fax
  1-844-216-4941
• Email
  providerdataintegrity@bcbsm.com

If you have questions or need support making updates, visit bcbsm.com or call Provider Enrollment at 1–800–822–2761.

AllianceRx Walgreens Prime specialty pharmacy program starts Jan. 1

AllianceRx Walgreens Prime has become the exclusive provider of specialty pharmacy services for some Blue Cross Blue Shield of Michigan and Blue Care Network commercial (non-Medicare) members. Blue Cross has notified the affected members about this change.

To ensure there’s no interruption in therapy, you’ll need to write a new prescription for your affected patients before Jan. 1, 2019, if:

• They have Blue Cross or BCN insurance coverage that requires them to get specialty medications from AllianceRx Walgreens Prime.

• They’re currently using a pharmacy other than a Walgreens retail location or AllianceRx Walgreens Prime (formerly Walgreens Specialty Pharmacy) for a specialty medication.

Take no action for patients with remaining refills for prescriptions currently filled at a Walgreens retail location or AllianceRx Walgreens Prime.

About AllianceRx Walgreens Prime
AllianceRx Walgreens Prime will help patients with complex health conditions get convenient access to medications you prescribe that:

• Need injections
• Need to be taken on a strict schedule
• Have special storage needs

AllianceRx Walgreens Prime will:

• Reduce the demands on your time.
• Help simplify the referral process.
• Handle insurance verification, prior authorization and financial assistance coordination.
• Provide a team of pharmacists, nurses and patient care coordinators to help ensure your patients get the specialty pharmacy care they deserve.

In addition, patient care coordinators will regularly contact your patients to offer helpful information. They’ll also provide guidance that encourages medication compliance, and they’ll:

• Help your patients better understand their complex health conditions.
• Work with Blue Cross to coordinate and verify pharmacy benefits, as necessary.
• Assist your patients when they need new or existing prescriptions filled, and schedule refills.
• Encourage your patients to take their medications exactly as prescribed.
• Help your patients manage medication side effects.
• Evaluate responses to prescribed medication therapies.
• Call prescribers when necessary.
• Offer access to pharmacists by telephone 24/7.
• Deliver specialty medications to the most clinically appropriate sites that meet your patients’ needs (such as your office, a clinic, treatment center or a patient’s home or workplace).

For more information, visit alliancerxwp.com/hcp.**

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

Commercial Medical Drug Prior Authorization Program adding Onpattro

Beginning Dec. 1, 2018, Onpattro™ will be added to the Blue Cross Blue Shield of Michigan commercial Medical Drug Prior Authorization Program.

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

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

Our office accepts medical drug prior authorization requests by one of the following methods:

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

1. Click on BCBSM Provider Publications and Resources.
2. Click on Commercial Pharmacy Prior Authorization and Step Therapy forms.
3. Click on Under Other Resources, then select Forms.
4. Click on Physician administered medications.

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

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.

We’ve made enhancements to PARS

We’re expanding our self-service offerings to help meet your business needs. This includes a change to the Provider Automated Response System, known as PARS.

Effective Nov. 1, 2018, providers will have the ability to receive benefits and eligibility information for infusion therapy when selecting the following practices:

• General practice
• DME
• Pediatrics
• Other services

Simply say “infusion” to receive benefits and eligibility information. After hearing the benefits, you’ll have the opportunity to speak to a live servicing agent.

Using PARS is:

• Quick — Inquiry is answered within a few minutes.
• Convenient — It’s available 24 hours a day, seven days a week.
• Personalized — Caller controls the information he or she wants to hear or skip.
• Accurate — Receipt of a fax or email provides documentation of the information received on a given day.

PARS provides information for:

• Blue Cross Blue Shield of Michigan and Blue Care Network commercial
• Medicare Advantage
• Federal Employee Program^®
• Professional, facility, vision and hearing

When calling with questions about the determination of a claim, our Customer Service representatives will encourage you to use PARS to retrieve your information. They’ll help you navigate through the system and find what you’re looking for.

Reminder: How to bill when Blue Cross is secondary payer

When billing Blue Cross Blue Shield of Michigan as a secondary payer, providers are required to accept our allowed amount for covered services. This policy is part of our professional participation agreement with providers.

If you have questions, contact Provider Inquiry.

We’ve added a Documentation Guidelines section to Benefit Explainer

To make it easier for you to find information about medical criteria, payment policies and procedure code updates, we’ve added a Documentation Guidelines tab to Benefit Explainer.

To find the Documentation Guidelines tab in Benefit Explainer:

• Log in to Provider Secured Services.
• Select web-DENIS.
• Click on BCBSM Provider Publications and Resources.
• Click on Benefit Policy for a Code.
• Select Medical/Payment Policy or the BPR tab.
• Click on Topic to select and enter desired search criteria.
• Select Finish, then click on Search.
• Medical Payment Policy Report or BPR Report displays.
• Click on Additional Information.
• Select Documentation Guidelines to view the information.

The information found under the Documentation Guidelines tab will still be available in The Record billing chart and web-DENIS alerts.

Here’s what the new tab looks like through the Medical/Payment Policy Report tab:

Here’s what the new tab looks like through the BPR tab:

HCPCS and CPT update: New codes added

The Centers for Medicare & Medicaid Services has added several new HCPCS and CPT codes. The codes, effective dates and Blue Cross Blue Shield of Michigan’s coverage decisions are below.

HCPCS codes

Outpatient Prospective Payment System — Injection

Medicine/professional — Evaluation and management

Medicine Supplementary — Injections

Medicine/professional — Miscellaneous/data gathering codes

CPT codes
Pathology and Laboratory — Proprietary laboratory analysis codes

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

Battling the opioid epidemic: A roundup of news and information

Michigan opioid overdose deaths hit new record
The Detroit Free Press** reported Oct. 4 that overdose deaths from opioids reached a record high in Michigan last year, according to a new report released by the Michigan Department of Health and Human Services. The report says that 1,941 of the last year's 2,729 overdose deaths were opioid-related, an increase of 9 percent over 2016. This represents a slowing of the year-over-year increase in opioid-related deaths. Between 2015 and 2016, opioid overdose deaths jumped 35 percent.

Senate passes bills to address opioid epidemic
The Senate passed a sweeping package of bills Sept. 17 aimed at addressing the nation’s deadly opioid epidemic, The Washington Post** reported. Last year, President Trump and Congress had vowed a federal government response to a crisis that affects millions of Americans and is responsible for the deaths of close to 50,000 last year. The package of 70 Senate bills costs $8.4 billion and creates, expands and renews programs across multiple agencies.

Opioids before joint replacement tied to worse recovery
Prolonged use of opioid painkillers before total knee or hip replacement may greatly increase a patient’s risk of repeat surgery and hospitalization, according to a new study in the Journal of Bone & Joint Surgery, HealthDay^® News** reported. Hospital readmission rates in the knee replacement group were 1.4 percent higher among those who used painkillers for more than 60 days and 2.2 percent higher within the hip replacement group.

CDC releases study on opioid use disorder in labor and delivery
The Centers for Disease Control and Prevention recently released the first multi-state analysis of trends** in opioid use disorder in labor and delivery. The analysis indicated that the number of pregnant women with OUD at labor and delivery more than quadrupled from 1999 through 2014, with significant increases in every one of the 28 states with available data. For more information, see the CDC’s graphic,** which highlights strategies to address opioid use disorder and improve maternal and infant health.

Blue plans working together to improve addiction treatment
Blue Cross Blue Shield of Michigan is working with doctors and other experts nationwide to make sure our members have access to the most effective addiction treatment centers to get the care they need. A new Blue Cross Blue Shield Association program, which will include a new designation for effective treatment programs, builds upon the existing Blue Distinction^® programs that identify the high-quality doctors and hospitals. For more information, see the MI Blues Perspectives blog.

Study: Nearly 30 percent of opioid prescriptions lack clear clinical explanation
A study published in the Annals of Internal Medicine found that 28.5 percent of opioid prescriptions written in the U.S. between 2006 and 2015 lacked a documented clinical reason, USA Today** reported. The findings, based on analysis of data from the National Ambulatory Medical Care Survey, showed 66 percent of opioid prescriptions were for noncancer pain while 5 percent were intended to treat cancer-related pain.

GDAHC recognizes Michigan OPEN for health care leadership
The Greater Detroit Area Health Council recognized Michigan Opioid Prescribing and Engagement Network with the Eagle Award for Visionary Leadership. The award recognizes the contributions of an organization in Southeast Michigan that has made steady progress in advancing health care quality, access or cost. Michigan OPEN, along with other leaders in health care, will be honored Nov. 8 at the 2018 Salute to Healthcare celebration. For information about Michigan OPEN initiatives, visit Michigan-open.org.**

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

MESSA is launching new product, effective Jan. 1

The Michigan Education Special Services Association is launching a new product called Essentials by MESSA, effective Jan. 1, 2019. This product is an addition to existing MESSA plans.

Essentials by MESSA offers premiums and deductibles that are lower than some other MESSA products, made possible by reducing and eliminating some benefits that members have said aren’t crucial to their health care needs. As always, providers should refer to web-DENIS for benefits before rendering services.

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.