Virtual program focuses on improving member well-being, resilience

Blue Cross Blue Shield of Michigan has launched the innovative Blue Cross^® Virtual Well-Being program to help your patients learn how to improve their overall well-being and increase resilience.

Virtual Well-Being features live weekly webinars and downloadable content for members, with topics that focus on helping them on their personal journey toward well-being. Webinar topics will include resilience, emotional health, financial wellness, mindfulness, gratitude, meditation, physical health and more. Webinars are also available for our group customers to help them develop, deliver and enhance their worksite well-being programs.

Members can register for Virtual Well-Being webinars at bluecrossvirtualwellbeing.com. They can also watch past webinars on this website at any time, and download content they can share with their family and friends. Virtual Well-Being is available for all Blue Cross and Blue Care Network members.

“The health of our members is a top priority at Blue Cross, so we’re excited about offering this innovative program that will focus on how they can improve their overall well-being,” said Cindy Bjorkquist, director of well-being programs at Blue Cross.

Well-being focuses on a person’s holistic health, and it’s a measure of a person’s perception of how his or her life is going. Research has shown that people with a greater sense of well-being are more resilient, happier, more engaged and productive, make healthier choices and have reduced stress.

“Being mindful and practicing a greater state of well-being will help our members face day-to-day challenges both at home and at work. But many people aren’t sure how to start down a path of improving their well-being,” Bjorkquist said. “That’s where Virtual Well-Being’s benefit comes in. The virtual coordinator guides members through engaging topics on how to improve well-being, which will include mindfulness training and changing their brains’ ‘default setting’ to increase happiness, gratitude and creativity, as well as other positive benefits.”

In addition to Virtual Well-Being, Blue Cross offers its members online resources to help them improve their health and well-being on the Blue Cross^® Health & Wellness website, powered by WebMD^®. This includes an interactive health assessment, Digital Health Assistant programs, a personal health record, health trackers, videos, healthy recipes and more.

WebMD Health Services is an independent company supporting Blue Cross Blue Shield of Michigan and Blue Care Network by providing health and wellness services.

Blue Cross and BCN offer several diabetes prevention and management programs for members

In the face of sobering statistics about diabetes from the Centers for Disease Control and Prevention, Blue Cross Blue Shield of Michigan and Blue Care Network are working to help members who currently have diabetes or are at risk of getting it.

Consider the following statistics:

• More than 30 million people have diabetes. That’s 1 in 10 individuals — and 1 of 4 don’t know they have it.
• Eighty-four million people are prediabetic. That’s 1 in 3 people — and 9 out of 10 aren’t aware that they are.
• Diabetes is the seventh leading cause of death in the U.S.
• Medical costs for people with diabetes are more than twice the cost for those without it.

Here’s a summary of programs available in 2019. Two are focused on diabetes prevention, while the others are for patients who currently have diabetes.

Diabetes prevention

We’ve joined forces with two independent companies, Solera and Omada, to offer diabetes prevention programs.

• Solera manages the Medicare Diabetes Prevention Program for BCN Advantage^SM and Medicare Plus Blue^SM members who are prediabetic. It’s a structured intervention program with the goal of preventing progression to Type 2 diabetes in individuals with prediabetes. The program, which launched in April 2018, includes education and support, and is proven to help participants lose weight, adopt healthy habits and reduce their risk of Type 2 diabetes.
  
  For details, see the article on Page 7 of the January-February 2018 issue of BCN Provider News.

• Omada offers a diabetes prevention program for our HMO and PPO commercial populations. Self-funded groups must opt in to offer it to their employees.
  
  The program, which began Jan. 1, 2019, uses coaches from Omada, along with digital health tools, such as wireless digital scales and online resources, to help members lose weight. It’s a technology-driven, intensive behavioral counseling program focused on reducing the risk of obesity-related chronic disease. As part of the program, participants make incremental changes to their nutrition, physical activity, sleep and stress management patterns.

Diabetes management

The following programs include education and insulin or glucose monitoring.

• The Fit4D program provides education and coaching services to select members who meet certain criteria. They must:
  
  • Be fully insured Medicare Plus Blue members, BCN Advantage^SM members, commercial fully insured members or UAW Retiree Medical Benefits Trust members
  • Have a diagnosis of Type 1 or 2 diabetes
  • Be 18 or older
  • Have an A1c of 8.0 or above
  The program supports members with diabetes as they self-manage their conditions and follow treatment and care plan recommendations. It includes phone communication, optional text messages and email. It also includes optional online group webinars. There’s no cost for the member.
  
  See the article on Page 15 of the November-December 2018 issue of BCN Provider News for details.

• Livongo, an independent company that focuses on helping people with chronic conditions, is working with Blue Cross and BCN to offer a program for members with diabetes that features blood glucose monitoring and coaching. It’s for commercial HMO and PPO members who have Type 1 or Type 2 diabetes, and whose employer group is self-funded and has opted in to the program. It includes:
  
  
  • High-tech remote monitoring that transmits data in real time
  • Meter and strips (Test strips only work with Livongo’s device.)
  • Certified diabetes educators on call 24/7 for acute events
  • Access to education and free diabetic supplies (lancets and test strips)
  • Personalized coaching, blood glucose level trend management
  • Phone calls from a coach, triggered by out-of-range glucose readings

  In addition, members can get their own clinical data in a user-friendly format to share with their primary care physician and family members. Neither Blue Cross nor Livongo shares information with physicians directly. It’s the member’s responsibility to discuss his or her glucose readings with the primary care doctor. However, Livongo encourages members to share information with their providers and sends them automated reminders to do so.

• Hygieia, an insulin guidance service, offers a program that’s free for commercial HMO and PPO members who have Type 2 diabetes and live in Southeast Michigan. It includes individual meetings to help patients make better use of their insulin, which includes get the right dose between doctor visits.
  
  Participants receive a hand-held device and d-Nav^® software, which provide insulin dose recommendations when the member is due to take an insulin dose. It adjusts the recommended dosage as necessary so the patient’s blood sugar remains under control.
  
  
  • Members receive the d-Nav device, blood glucose test strips, control solution and lancets at no extra cost.
  • To initiate the d-Nav service, members must visit a Hygieia clinic. Clinics are only located in Southeast Michigan at this time.
  This program requires participants to follow up in person and by phone as appropriate. Hygieia reaches out to the member’s primary care physician to communicate expected outcomes. Hygieia also informs the member’s physician of any significant changes and gives them access to a secure physician portal to follow the progress of their patients.

Battling the opioid epidemic: A roundup of recent news and information

We’re expanding our CLIMB opioid treatment model to Blue Cross fully insured commercial PPO members
As reported in the January – February issue of Hospital and Physician Update, the CLIMB opioid treatment model that was piloted last year for Blue Care Network and BCN Advantage^SM members is being rolled out to Blue Cross Blue Shield of Michigan fully insured commercial PPO members this year. Providers can now refer these members to the program for addiction treatment at two facilities: Pine Rest Christian Mental Health Services near Grand Rapids and Henry Ford Maplegrove Center in Bloomfield Hills.

For more details, see the column by Dr. William Beecroft that ran in the January – February issue of Hospital and Physician Update.

Blue Cross and community partners taking another step to address growing opioid epidemic
Blue Cross Blue Cross Blue Shield of Michigan is contributing to the Michigan Opioid Partnership, which will distribute a combined $2.6 million in grants to focus efforts on beginning medication assisted treatment in hospitals and emergency rooms, and improving transitions to outpatient care. Providing medication assisted treatment during hospital stays and emergency room visits has been shown to reduce the number of opioid-related deaths in the communities where it’s used.

This partnership is a component of Blue Cross’ intense multipronged strategy to combat the opioid epidemic. Other initiatives include a broad awareness campaign, an online toolkit for employers and a cap on the number of pills that can be prescribed to first-time users.

For more information on the steps Blue Cross has taken to address the opioid epidemic over the past year, see the column from Dr. Duane DiFranco that ran in the January – February issue of Hospital and Physician Update.

Fentanyl edges out heroin as deadliest drug in U.S.
As reported in USA Today** on Dec. 12, 2018, fentanyl is now the deadliest drug in America, federal health officials announced. This is the first time the synthetic opioid has been the nation’s deadliest drug. There were more than 18,000 overdose deaths in 2016, the most recent year for which statistics are available.

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

HCPCS replacement codes established

The HCPCS procedure codes listed below are effective Jan. 1, 2019:

J0185 replaces J3490 and C9463 when billing for Cinvanti^®
The Centers for Medicare & Medicaid Services has established a permanent procedure code for Cinvanti.

All services through Dec. 31, 2018, will continue to be reported with J3490 or C9463.
All services performed on and after Jan. 1, 2019, must be reported with J0185.

J0517 replaces J3490, J3590 and C9466 when billing for Fasenra^®
CMS has established a permanent procedure code for Fasenra.

All services through Dec. 31, 2018, will continue to be reported with J3490, J3590 or C9466. All services performed on and after Jan. 1, 2019, must be reported with J0517.

Prior authorization is still required for Fasenra (benralizumab) when reported with the new procedure code J0517 for all groups unless they are opted out of the prior authorization program.

J0567 replaces J3490 and J3590 when billing for Brineura^®
CMS has established a permanent procedure code for Brineura.

All services through Dec. 31, 2018, will continue to be reported with J3490 or J3590. All services performed on and after Jan. 1, 2019, must be reported with J0567.

Prior authorization is still required for Brineura (cerliponase alfa) when reported with the new procedure code J0567 for all groups unless they are opted out of the prior authorization program.

All groups have the option to opt out of the prior authorization program. If prior authorization isn’t a requirement for a group, a manual review is required for procedure code J0567 for those groups.

J0584 replaces J3490 and J3590 when billing for Crysvita^®
CMS has established a permanent procedure code for Crysvita.

All services through Dec. 31, 2018, will continue to be reported with J3490 or J3590. All services performed on and after Jan. 1, 2019, must be reported with J0584.

Prior authorization is still required for Crysvita (burosumab-twza) when reported with the new procedure code J0584 for all groups unless they are opted out of the prior authorization program.

All groups have the option to opt out of the prior authorization program. If prior authorization isn’t a requirement for a group, a manual review is required for procedure code J0584 for those groups.

J1095 replaces J3490 when billing for Dexycu^®
CMS has established a permanent procedure code for Dexycu.

All services through Dec. 31, 2018, will continue to be reported with J3490. All services performed on and after Jan. 1, 2019, must be reported with J1095.

J1301 replaces J3490 and J3590 when billing Radicava^®
CMS has established a permanent procedure code for Radicava.

All services through Dec. 31, 2018, will continue to be reported with J3490 or J3590. All services performed on and after Jan. 1, 2019, must be reported with J1301.

Prior authorization is still required for Radicava (edaravone) when reported with the new procedure code J1301 for all groups unless they are opted out of the prior authorization program.

All groups have the option to opt out of the prior authorization program. If prior authorization isn’t a requirement for a group, a manual review is required for procedure code J1301 for those groups.

J1454 replaces J3490 when billing for Akynzeo^®
CMS has established a permanent procedure code for Akynzeo.

All services through Dec. 31, 2018, will continue to be reported with J3490. All services performed on and after Jan. 1, 2019, must be reported with J1454.

J1746 replaces J3490 and J3590 when billing for Trogarzo^®
CMS has established a permanent procedure code for Trogarzo.

All services through Dec. 31, 2018, will continue to be reported with J3490 or J3590. All services performed on and after Jan. 1, 2019, must be reported with J1746.

Prior authorization is still required for Trogarzo (ibalizumab-ulyk) when reported with the new procedure code J1746 for all groups unless they are opted out of the prior authorization program.

J2186 replaces J3490 when billing for Vabomere^®
CMS has established a permanent procedure code for Vabomere.

All services through Dec. 31, 2018, will continue to be reported with J3490. All services performed on and after Jan. 1, 2019 must be reported with J2186.

J2797 replaces J3490 when billing for VARUBI IV^®
CMS has established a permanent procedure code for VARUBI IV.

All services through Dec. 31, 2018, will continue to be reported with J3490. All services performed on and after Jan. 1, 2019, must be reported with J2797.

J3245 replaces J3490 and J3590 when billing for Ilumya^®
CMS has established a permanent procedure code for Ilumya.

All services through Dec. 31, 2018, will continue to be reported with J3490 or J3590. All services performed on and after Jan. 1, 2019, must be reported with J3245.

Prior authorization is still required for Ilumya (tildrakizumab-asmn) when reported with the new procedure code J3245 for all groups unless they are opted out of the prior authorization program.

J3304 replaces Q9993 when billing for Zilretta^®
CMS has established a permanent procedure code for Zilretta.

All services through Dec. 31, 2018, will continue to be reported with Q9993. All services performed on and after Jan. 1, 2019, must be reported with J3304.

Prior authorization is still required for Zilretta (triamcinolone acetonide preservative-free, extended-release microsphere formulation) when reported with the new procedure code J3304 for all groups unless they are opted out of the prior authorization program.

J3397 replaces J3490 and J3590 when billing for Mepsevii^®
CMS has established a permanent procedure code for Mepsevii.

All services through Dec. 31, 2018, will continue to be reported with J3490 or J3590. All services performed on and after Jan. 1, 2019, must be reported with J3397.

Prior authorization is still required for Mepsevii (vestronidase alfa-vjbk) when reported with the new procedure code J3397 for all groups unless they are opted out of the prior authorization program.

All groups have the option to opt out of the prior authorization program. If prior authorization isn’t a requirement for a group, a manual review is required for procedure code J3397 for those groups.

J3398 replaces J3490, J3590 and C9032 when billing for Luxturna^®
CMS has established a permanent procedure code for Luxturna.

All services through Dec. 31, 2018, will continue to be reported with J3490, J3590 or C9032. All services performed on and after Jan. 1, 2019, must be reported with J3398.

Prior authorization is still required for Luxturna (voretigene neparvovec-rzyl) when reported with the new procedure code J3398 for all groups unless they are opted out of the prior authorization program.

All groups have the option to opt out of the prior authorization program. If prior authorization isn’t a requirement for a group, a manual review is required for procedure code J3398 for those groups.

J7170 replaces Q9995 when billing for Hemlibra^®
CMS has established a permanent procedure code for Hemlibra.

All services through Dec. 31, 2018, will continue to be reported with Q9995. All services performed on and after Jan. 1, 2019, must be reported with J7170.

J7203 replaces J7199 when billing for Rebinyn^®
CMS has established a permanent procedure code for Rebinyn (coagulation Factor IX [recombinant], GlycoPEGylated).

All services through Dec. 31, 2018, will continue to be reported with J7199. All services performed on and after Jan. 1, 2019, must be reported with J7203.

J9057 replaces J9999 and C9030 when billing for Aliqopa^®
CMS has established a permanent procedure code for Aliqopa.

All services through Dec. 31, 2018, will continue to be reported with J9999 or C9030. All services performed on and after Jan. 1, 2019, must be reported with J9057.

J9173 replaces J9999 when billing for Imfinzi^®
CMS has established a permanent procedure code for Imfinzi.

All services through Dec. 31, 2018, will continue to be reported with J9999. All services performed on and after Jan. 1, 2019, must be reported with J9173.

J9229 replaces J9999 and C9028 when billing for Besponsa^®
CMS has established a permanent procedure code for Besponsa.

All services through Dec. 31, 2018, will continue to be reported with J9999 or C9028. All services performed on and after Jan. 1, 2019, must be reported with J9229.

J9311 replaces J3590 and C9467 when billing for Rituxan Hycela^®
CMS has established a permanent procedure code for Rituxan Hycela.

All services through Dec. 31, 2018, will continue to be reported with J3590 or C9467. All services performed on and after Jan. 1, 2019, must be reported with J9311.

For more information about HCPCS codes, see the article titled “2019 HCPCS Update: Coverage decisions on 2019 procedure codes now available.”

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.

Clarification: Sphenopalatine ganglion block for headache, CPT codes *64505 and *64999

In the November billing chart, we included the Sphenopalatine Ganglion Block for Headache Policy (CPT codes *64505 and *64999) in the experimental procedures section. We want to clarify that the codes may have different coverage positions, such as established or experimental, in other medical policies.

The policy stated in the chart read:

Sphenopalatine ganglion blocks are considered experimental for all indications, including but not limited to the treatment of migraines and non-migraine headaches. This policy is effective Nov. 1, 2018.

It should have included the following:

Individual policy criteria determine the coverage status of the procedure codes mentioned in this policy. Tests listed in this policy may have different coverage positions (such as established or experimental/investigational) in other medical policies.

HEDIS medical record reviews begin in February

Each year from February through May, Blue Cross Blue Shield of Michigan conducts Healthcare Effectiveness Data and Information Set, or HEDIS^®,** medical record reviews. This year, Blue Cross HEDIS clinical consultants will conduct HEDIS reviews for Blue Cross commercial PPO and Medicare Plus Blue^SM PPO members for the 2018 measurement year.

For the HEDIS reviews, Blue Cross looks for details that may not have been captured in claims data, such as blood pressure readings, HbA1c lab results, colorectal screenings and body mass index. This information helps us improve health care quality for our members.

Blue Cross HEDIS clinical consultants will contact you to schedule an appointment for a HEDIS review or request that you fax the necessary records. The HEDIS review also requires proof of service documentation for data collected from a medical record.

These reviews are in addition to the out-of-state medical record reviews that Inovalon conducts for the Blue Cross and Blue Shield Association.

To give you a look ahead at all 2019 chart reviews, see the table below.

To read more about medical record reviews, see article, “Here’s what you need to know about medical record reviews,” also in this issue.

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

Here’s what you need to know about medical record reviews

There are many reasons a health care provider may receive a request for a medical records review — including ensuring that a member is receiving quality care (see article on HEDIS medical record reviews in this issue), following up on a member appeal and investigating possible fraud or abuse. Whatever the reason, our research has shown that submitting medical records is one of the major “pain points” for providers. With that thought in mind, we’d like to provide some guidelines that we hope will ease the process for providers:

General guidelines

• Take the time to carefully read the request you receive and understand exactly what’s being requested. If you’re unsure, call the number provided. Otherwise, you risk sending the wrong information, delaying the process.
• When submitting a medical record for review, include the patient’s date of birth on the record or a demographic sheet containing the patient’s address, contract number, date of birth and other key information.
• If including handwritten notes, make sure the documentation is legible.
• If you’ve submitted a medical record for review and haven’t heard back, don’t assume something is wrong and send additional, unsolicited information. You can call the number on the request to obtain a status update.

Closing gaps in care
One of the main reasons Blue Cross Blue Shield of Michigan may request a medical record review is to ensure that providers are closing gaps in care as part of an effort to boost HEDIS^® scores.** HEDIS initiatives address issues such as ensuring that members receive necessary preventive health screenings and effectively managing a member’s chronic condition. To reduce the need for medical record reviews related to closing gaps in care, be sure to:

• Submit claims with CPT Category II codes to help us determine if specific HEDIS measures are met without needing to request and review medical records, as explained in a July 2018 Record article.
• Use appropriate ICD-10 codes if you need to indicate that a member is excluded from a specific measure.

BlueCard^® claims
When submitting medical record requests regarding BlueCard claims, keep the following in mind:

• The home plan may have different medical criteria than Blue Cross Blue Shield of Michigan. It’s important to use the Medical Policy and Pre-Cert/Pre-Auth Router, available from the BCBSM Provider Publications and Resources page of web-DENIS, to determine the policy and authorization needs of out-of-state Blue Cross plans.
• When a home plan needs to conduct a medical record review, a medical records request is sent. Don’t submit medical records unless you’ve received a medical record request letter.
• If your claim has been rejected citing a need for medical records and you have not received a medical request letter, contact Provider Inquiry for assistance.
• Unsolicited medical records submitted to Blue Cross Blue Shield of Michigan aren’t forwarded to the member’s home plan.
• Only send the items requested in the medical record request.
• If you’re unsure of what’s needed, contact Provider Inquiry for assistance.
• If you’re unable to provide what’s being requested, respond to the request and indicate the reason you’re unable to provide the requested information.
• The member may need to help obtain the information.
• Allow 30 days for review of medical records.

For more information

• Review your online provider manual for medical record documentation guidelines.
• If you have a question about a specific situation that isn’t addressed in this article, contact Provider Inquiry.
• Check out our Clinical Quality Corner tip sheets on web-DENIS for additional details on proper coding and documentation for specific HEDIS measures. You can access them from the BCBSM Newsletters and Resources page of web-DENIS.

Note: We’re currently updating our tip sheets for 2019 and will share them with you as soon as available.

**HEDIS^®, which stands for Healthcare Effectiveness Data and Information Set, is a registered trademark of the National Committee for Quality Assurance, or NCQA.

Prior authorization changes coming to AIM authorization program for MAPPO members

Beginning May 1, 2019, the PPO radiology management program, administered by AIM Specialty Health, will be adding a cardiology and in-lab sleep study prior authorization program for Medicare Plus Blue^SM PPO members. This includes UAW Retiree Medical Benefits Trust members with Medicare Plus Blue coverage.

The additional cardiac procedures for Medicare Plus Blue members will include:

Percutaneous coronary intervention

• *92920
• *92924
• *92928
• *92933
• *92937
• *92943

 Diagnostic coronary catheterization

*93454 through *93461

In addition, Blue Cross Blue Shield of Michigan will require prior authorization for in-lab sleep testing by in-state providers for Medicare Plus Blue. Preapproval must be obtained for the following procedure codes:

• *95805
• *95807
• *95808
• *95810
• *95811

The in-lab sleep study program is the same as the program currently in place for commercial PPO members.

All authorized sleep study services should be performed at a laboratory or center accredited by the American Academy of Sleep Medicine or the Joint Commission. Also, all TRUST providers performing sleep study services for both Medicare Plus Blue and Blue Cross PPO commercial members must be certified in sleep medicine by a board recognized by Blue Cross.

URMBT commercial PPO members are excluded from the prior authorization requirement by AIM Specialty Health for expanded cardiology services described above.

Lastly, there are new prior authorization procedure codes for the AIM high-tech radiology program (breast MRI). These new codes, which are required for both Blue Cross commercial PPO and Medicare Plus Blue PPO members, are as follows:

• *77046 through *77049

All cardiology, in-lab sleep study and high-tech radiology procedure codes will require prior authorization for both office settings and hospital outpatient locations. A list of these codes will be available on e-referral in May 2019. You may also refer to Blue Cross’ online provider manuals.

You can request authorization through AIM’s provider portal at aimspecialtyhealth.com or by contacting AIM at 1-800-728-8008.

Northwood to cover DME/P&O utilization management and claims for Medicare Plus Blue PPO starting in May

Northwood Inc., an independent company that manages the durable medical equipment, prosthetics, orthotics and medical supply provider network for Medicare Plus Blue^SM PPO members, will also handle authorizations, utilization management and claims processing, starting in May.

Beginning with dates of service on or after May 1, 2019, Northwood-contracted providers will be required to obtain authorizations and submit their claims to Northwood. Continue to submit out-of-network claims for Medicare Plus Blue PPO members directly to Blue Cross. For out-of-network claims, use the Medicare fee schedule, which may involve a higher level of cost-sharing for members.

All Medicare Plus Blue plans include DME/P&O and medical supplies, along with some inhalation medications used with nebulizers that are covered under original Medicare.

In the next few months, Northwood will send provider education communication materials to its contracted providers with details on the transition and information about handling authorizations, utilization management and claims for Medicare Plus Blue members.

If you have any questions, contact Northwood Provider Relations at provideraffairs@northwoodinc.com or 1-800-447-9599.

We’re encouraging physician organizations to recruit more psychiatrists, psychologists and chiropractors

Did you know?

• Approximately 15 percent of adults receive mental health services every year.
• Approximately 14 percent of Blue Cross Blue Shield of Michigan members seek care from a chiropractor — a higher percentage than those who seek care from a cardiologist or dermatologist.

Although Blue Cross members frequently use chiropractic and mental health services, the number of participating chiropractors, psychiatrists and fully licensed psychologists in our Physician Group Incentive Program physician organizations lags behind the number of providers in other specialties. That’s why we’re increasing the engagement reward for POs that recruit psychiatrists, fully licensed psychologists and chiropractors from $500 per new practitioner to $1,000 per new practitioner this year.

Background
This change is part of our ongoing commitment to better integrate behavioral health with general medical care and encourage collaboration among all provider types.

“Closer collaboration among physicians, chiropractors and behavioral health specialist within the setting of a PO or Organized System of Care can have a positive effect on both cost and quality performance,” said Emily Santer, health care manager with Value Partnerships. “Our OSC program, along with our Patient-Centered Medical Home and PCMH-Neighborhood programs, all promote good communication among practitioners who provide care to a shared population of patients. POs and OSCs are held accountable for the quality of care provided to their attributed members, along with the costs associated with the attributed membership.”

Behavioral health integration at MedNetOne
MedNetOne was one of the first Michigan physician organizations to actively seek behavioral health specialists as members.

“Integrating behavioral health with primary care for whole person care was the impetus behind our efforts to actively recruit behavioral health specialists as members of MedNetOne,” said Ewa Matuszewski, CEO of MedNetOne. “True coordination of care under the PCMH model — a model to which we are deeply committed — is only achieved when there is a strong behavioral health component in the PCMH ecosystem.”

Matuszewski points to Judson Center Family Health Clinic in Warren as a good example of collaboration between primary care physicians and behavioral health specialists. The clinic, staffed in part by MedNetOne care team members, specializes in helping individuals achieve optimal mental and physical health.

“Our behavioral health metrics and anecdotal evidence have verified the value of adopting this integrated approach and we strongly encourage other POs to do the same,” Matuszewski said.

Recognizing POs for recruitment efforts
The Value Partnerships team would like to offer kudos to the following physician organizations for their recruiting efforts from the fall of 2017 through the summer of 2018:

• Psychologists
• Henry Ford Medical Group
• Medical Network One
• Spectrum Health Medical Group
• United Physicians
• Psychiatrists
• University of Michigan Health System
• Henry Ford Medical Group
• Chiropractors
• CIPA
• Oakland Southfield Physicians

Helping your Federal Employee Program^® patients with their heart health

We realize that there are many factors that go into helping people get and stay healthy. For example, regular exercise is great, but if people sit down for long stretches at a time every day, that’s a problem. Research has shown that it’s important for people to be active throughout the day to help keep their heart healthy.

In addition, there are some key numbers that patients should know to maintain their health. They should be educated about their blood pressure, cholesterol and blood sugar levels and what needs to be done to manage them. The American Heart Association recommends that, starting at age 20, people should see their doctor on a regular basis and create a plan to check and track their numbers.

To help your Federal Employee Program^® patients develop these and other healthy habits, we’ve created a brochure that you can distribute to them.

FEP also provides other resources to help members. The chronic condition program and online health coaching tools help them better understand their conditions and medications as they work to achieve optimum health.

For more information, FEP members can go to fepblue.org or call the Customer Service number on the back of their member ID card.

Our RA Limited Choice program gets new name — CA Limited Choice

Blue Cross Blue Shield of Michigan and Blue Care Network are renaming their Religious Accommodation Limited Choice program. It will now be called the Contraceptive Accomodation Limited Choice, or CA Limited Choice, program. We originally offered the program to comply with the Affordable Care Act’s contraception exemption for religiously accommodated groups.

Members who enroll in the program on or after Feb. 1, 2019, will receive new ID cards. Members who are already enrolled may continue to use their RA Limited Choice ID cards.

Blue Cross and BCN members must use either their CA Limited Choice ID card or their RA Limited Choice ID card to obtain contraceptive services at no cost share from an in-network provider. Contraceptive coverage for office procedures and prescription drugs are included in the program. However, a member is only eligible for prescription drug coverage if the member’s group purchases prescription drugs through Blue Cross or BCN.

Coverage for some infertility treatment drugs will change, starting April 1

As part of our commitment to providing  our members with safe, high-quality, cost-effective prescription drugs, we’re making some changes to our drug coverage.

Starting April 1, 2019, Blue Cross Blue Shield of Michigan and Blue Care Network will make coverage changes for some infertility treatment drugs as follows:

Members with an approved prior authorization can continue to fill their prescriptions until the prior authorization end date but may have a higher copayment.

We notified affected members of these changes and encouraged them to discuss treatment options with their doctors.

Commercial Medical Drug Prior Authorization Program adds Hemlibra

Beginning March 1, 2019, Hemlibra^® will be added to the Medical Drug Prior Authorization Program for Blue Cross Blue Shield of Michigan commercial PPO members. This change applies to members starting therapy on or after March 1.

Click here to see a list of all medications that require medical drug prior authorization as of March 1, 2019. Keep in mind that prior authorization provides clinical review approval only; it’s not a guarantee of payment.

You can request medical drug prior authorization by using one of the following methods:

You can find prior authorization forms for 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. Under Other Resources,click on Forms.
4. Click on Physician administered medications.

Refer to the opt-out list for Blue Cross PPO groups that don’t require members to participate in the Commercial Medical Drug Prior Authorization Program. To access the list, follow these steps:

1. When logged in to web-DENIS, click on BCBSM Provider Publications and Resources. 
2. Click on Newsletters & Resources.
3. Click on Forms.
4. Click on Physician administered medications.
5. Click on BCBSM Medical Drug Prior Authorization Program list of groups that have opted out.

Note: The prior authorization requirement doesn’t apply to Blue Cross Medicare Plus Blue^SM PPO or Federal Employee Program^® members.

Blue Cross reserves the right to make changes to the medical drug prior authorization list at any time.

Laboratory procedure code *87798 will require supportive documentation, effective March 1, 2019

Procedure code *87798, a not-otherwise-classified procedure code, has been moving through our claims systems without receiving individual consideration, while other not-otherwise-classified codes have required medical records to be submitted. However, effective March 1, 2019, Blue Cross Blue Shield of Michigan will require identification of the organism being tested and/or supportive documentation when a claim for this code is submitted.

Clarification: Billing on behalf of a behavioral health provider

In an article in the March 2018 Record, we explained that modifiers AJ and HO are required on claims where the services are billed by a supervising behavioral health provider but rendered by one of the following provider types:

• Limited licensed professional counselor
• Limited licensed master social worker
• Temporary limited licensed psychologist
• Limited licensed marriage and family therapist

We want to let you know that these modifiers must be used when billing on behalf of any behavioral health provider, not just the ones listed above.

Modifiers AJ and HO are used to:

• Indicate that the billing provider did not render the service.
• Identify the rendering provider, which drives the appropriate reimbursement.
• Identify providers who don’t require supervision but choose not to bill us directly, including licensed master social workers – clinical, licensed professional counselors, limited licensed psychologists and licensed marriage and family therapists.

Refer to the chart below when billing on behalf of behavioral health providers: 

Services that are within the scope of licensure and billed using these modifiers will be reimbursed at the appropriate reimbursement of 80 percent of the traditional fee schedule. Services billed using these modifiers that are not within the scope of licensure will be rejected since they’re not payable to this provider type.

If you have any questions, contact Provider Inquiry.

Clarification: Telehealth visits and DME/P&O

In an October 2018 Record article, we reported that members can no longer receive prescriptions for durable medical equipment, prosthetics and orthotics items through telehealth visits. We should have added that this doesn’t apply to CPAP devices.

Keep in mind that Blue Cross Blue Shield of Michigan will continue to cover medically necessary DME items ordered by providers after face-to-face visits.

Clarification: Prior authorization scope change for PPO members

In a December Record article, Blue Cross Blue Shield of Michigan shared information about a program change, directing providers to obtain prior authorization for high-tech radiology, in-lab sleep management and echocardiogram services for PPO non-Medicare patients who live in Michigan.

We wanted to add clarifying information regarding UAW Retiree Medical Benefits Trust (URMBT) non-Medicare members. For these members, authorizations will be required for high-tech radiology, medical oncology and radiation oncology services whether they live in or out of state.

Here’s what you need to know about 2019 Michigan Skilled Nursing Facility Pay-for-Performance Program

In 2019, Blue Cross Blue Shield of Michigan freestanding and hospital-based skilled nursing providers can earn incentives for participating in a health information exchange through the Michigan Health Information Network notification service as part of the Michigan Skilled Nursing Facility Pay-for-Performance Program.

The goals of the program are to:

• Enhance the population-based model of health.
• Promote a team-based approach.
• Engage a strong commitment to the care continuum.
• Help ensure that a patient’s caregivers receive timely notification of an admission, discharge, transfer or emergency room visit.
• Improve coordination of care and outcomes.
• Reduce the likelihood of an unplanned readmission.

Program details and reward

Blue Cross will recognize SNFs that are successful in fully implementing the MiHIN admission, discharge and transfer process. We’ll also recognize facilities that implemented the process during previous program years and continue to meet program expectations.

Providers achieving the program expectations and deadlines will be eligible to receive an additional 3 percent reward for either six or 12 months following the incentive’s effective date.

SNFs that don’t meet the SNF P4P program requirements or choose not to participate will forfeit the incentive opportunity.

Important dates

Additional information
See the program guides in the SNF provider manual.

Prior authorization changes coming to AIM authorization program for MAPPO members

Beginning May 1, 2019, the PPO radiology management program, administered by AIM Specialty Health, will be adding a cardiology and in-lab sleep study prior authorization program for Medicare Plus Blue^SM PPO members. This includes UAW Retiree Medical Benefits Trust members with Medicare Plus Blue coverage.

The additional cardiac procedures for Medicare Plus Blue members will include:

Percutaneous coronary intervention

• *92920
• *92924
• *92928
• *92933
• *92937
• *92943

 Diagnostic coronary catheterization

*93454 through *93461

In addition, Blue Cross Blue Shield of Michigan will require prior authorization for in-lab sleep testing by in-state providers for Medicare Plus Blue. Preapproval must be obtained for the following procedure codes:

• *95805
• *95807
• *95808
• *95810
• *95811

The in-lab sleep study program is the same as the program currently in place for commercial PPO members.

All authorized sleep study services should be performed at a laboratory or center accredited by the American Academy of Sleep Medicine or the Joint Commission. Also, all TRUST providers performing sleep study services for both Medicare Plus Blue and Blue Cross PPO commercial members must be certified in sleep medicine by a board recognized by Blue Cross.

URMBT commercial PPO members are excluded from the prior authorization requirement by AIM Specialty Health for expanded cardiology services described above.

Lastly, there are new prior authorization procedure codes for the AIM high-tech radiology program (breast MRI). These new codes, which are required for both Blue Cross commercial PPO and Medicare Plus Blue PPO members, are as follows:

• *77046 through *77049

All cardiology, in-lab sleep study and high-tech radiology procedure codes will require prior authorization for both office settings and hospital outpatient locations. A list of these codes will be available on e-referral in May 2019. You may also refer to Blue Cross’ online provider manuals.

You can request authorization through AIM’s provider portal at aimspecialtyhealth.com or by contacting AIM at 1-800-728-8008.

Our RA Limited Choice program gets new name — CA Limited Choice

Blue Cross Blue Shield of Michigan and Blue Care Network are renaming their Religious Accommodation Limited Choice program. It will now be called the Contraceptive Accomodation Limited Choice, or CA Limited Choice, program. We originally offered the program to comply with the Affordable Care Act’s contraception exemption for religiously accommodated groups.

Members who enroll in the program on or after Feb. 1, 2019, will receive new ID cards. Members who are already enrolled may continue to use their RA Limited Choice ID cards.

Blue Cross and BCN members must use either their CA Limited Choice ID card or their RA Limited Choice ID card to obtain contraceptive services at no cost share from an in-network provider. Contraceptive coverage for office procedures and prescription drugs are included in the program. However, a member is only eligible for prescription drug coverage if the member’s group purchases prescription drugs through Blue Cross or BCN.

Laboratory procedure code *87798 will require supportive documentation, effective March 1, 2019

Procedure code *87798, a not-otherwise-classified procedure code, has been moving through our claims systems without receiving individual consideration, while other not-otherwise-classified codes have required medical records to be submitted. However, effective March 1, 2019, Blue Cross Blue Shield of Michigan will require identification of the organism being tested and/or supportive documentation when a claim for this code is submitted.

Clarification: Prior authorization scope change for PPO members

In a December Record article, Blue Cross Blue Shield of Michigan shared information about a program change, directing providers to obtain prior authorization for high-tech radiology, in-lab sleep management and echocardiogram services for PPO non-Medicare patients who live in Michigan.

We wanted to add clarifying information regarding UAW Retiree Medical Benefits Trust (URMBT) non-Medicare members. For these members, authorizations will be required for high-tech radiology, medical oncology and radiation oncology services whether they live in or out of state.

Coverage for some infertility treatment drugs will change, starting April 1

As part of our commitment to providing  our members with safe, high-quality, cost-effective prescription drugs, we’re making some changes to our drug coverage.

Starting April 1, 2019, Blue Cross Blue Shield of Michigan and Blue Care Network will make coverage changes for some infertility treatment drugs as follows:

Members with an approved prior authorization can continue to fill their prescriptions until the prior authorization end date but may have a higher copayment.

We notified affected members of these changes and encouraged them to discuss treatment options with their doctors.

Commercial Medical Drug Prior Authorization Program adds Hemlibra

Beginning March 1, 2019, Hemlibra^® will be added to the Medical Drug Prior Authorization Program for Blue Cross Blue Shield of Michigan commercial PPO members. This change applies to members starting therapy on or after March 1.

Click here to see a list of all medications that require medical drug prior authorization as of March 1, 2019. Keep in mind that prior authorization provides clinical review approval only; it’s not a guarantee of payment.

You can request medical drug prior authorization by using one of the following methods:

You can find prior authorization forms for 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. Under Other Resources,click on Forms.
4. Click on Physician administered medications.

Refer to the opt-out list for Blue Cross PPO groups that don’t require members to participate in the Commercial Medical Drug Prior Authorization Program. To access the list, follow these steps:

1. When logged in to web-DENIS, click on BCBSM Provider Publications and Resources. 
2. Click on Newsletters & Resources.
3. Click on Forms.
4. Click on Physician administered medications.
5. Click on BCBSM Medical Drug Prior Authorization Program list of groups that have opted out.

Note: The prior authorization requirement doesn’t apply to Blue Cross Medicare Plus Blue^SM PPO or Federal Employee Program^® members.

Blue Cross reserves the right to make changes to the medical drug prior authorization list at any time.

Northwood to cover DME/P&O utilization management and claims for Medicare Plus Blue PPO starting in May

Northwood Inc., an independent company that manages the durable medical equipment, prosthetics, orthotics and medical supply provider network for Medicare Plus Blue^SM PPO members, will also handle authorizations, utilization management and claims processing, starting in May.

Beginning with dates of service on or after May 1, 2019, Northwood-contracted providers will be required to obtain authorizations and submit their claims to Northwood. Continue to submit out-of-network claims for Medicare Plus Blue PPO members directly to Blue Cross. For out-of-network claims, use the Medicare fee schedule, which may involve a higher level of cost-sharing for members.

All Medicare Plus Blue plans include DME/P&O and medical supplies, along with some inhalation medications used with nebulizers that are covered under original Medicare.

In the next few months, Northwood will send provider education communication materials to its contracted providers with details on the transition and information about handling authorizations, utilization management and claims for Medicare Plus Blue members.

If you have any questions, contact Northwood Provider Relations at provideraffairs@northwoodinc.com or 1-800-447-9599.

Clarification: Telehealth visits and DME/P&O

In an October 2018 Record article, we reported that members can no longer receive prescriptions for durable medical equipment, prosthetics and orthotics items through telehealth visits. We should have added that this doesn’t apply to CPAP devices.

Keep in mind that Blue Cross Blue Shield of Michigan will continue to cover medically necessary DME items ordered by providers after face-to-face visits.