Inpatient lumbar spinal fusion procedures require two authorizations

Two authorizations are needed for inpatient spinal fusion procedures that require clinical review: one authorization for the procedure and one for the admission.

The medical necessity for the procedure is reviewed by eviCore. The facility must request an inpatient authorization through e-referral for the inpatient stay. Blue Cross Blue Shield of Michigan will then review appropriateness of the setting.

For an inpatient lumbar spinal fusion procedure, the facility needs to load an authorization with procedure code *99222 in e-referral. Don’t use the lumbar spinal fusion procedure codes or you’ll receive a block message.

If the inpatient authorization for a lumbar spinal fusion procedure requires an admission date change, email e-referralinquiries@bcbsm.com.

Don’t contact eviCore to convert an existing outpatient authorization to an inpatient authorization, as they will redirect you to Blue Cross.

Reminder: Indicating that services are related to auto accidents on claims

If you provide services to a patient who has been in an auto accident and the services are related to the accident, be sure to indicate that on the claim you submit to Blue Cross Blue Shield of Michigan.

For most claims of this type, the auto insurance company is the primary carrier, and we need to know that when processing these claims. Include the information below when submitting these claims.

For electronic claims:

Facility claims
Loop 2300 HI*BH* and report occurrence code 01 or 02 to indicate auto-related

Professional claims
Loop 2300 DTP*439* (accident date) Loop 2300 CLM11-1 with qualifier AA (auto accident)

For paper claims:

Facility claims
Submit with an occurrence code (either 01 or 02) to indicate that it was an auto accident.

Professional claims
Submit checking the auto-related indicator.

More information about submitting claims related to auto accidents is available in your provider manual on web-DENIS.

We invite you to join PGIP as a physician organization

Our Physician Group Incentive Program offers incentives to participating practitioners, physician organizations and organized systems of care for improving health care delivery. We’re pleased to announce that we’ll accept applications for PGIP from new POs from Aug. 1 through Aug. 31, 2019.

To request application materials, send an email to valuepartnerships@bcbsm.com.

A PGIP physician organization consists of physicians working together to:

• Transform systems of care to effectively manage patient populations.
• Build the infrastructure needed to optimize, measure and monitor quality of care.
• Promote collaborative relationships.
• Support the most cost-effective delivery of services to improve patient outcomes.

About PGIP

PGIP is an innovative provider program developed with input from doctors across Michigan to help improve the quality and efficiency of health care in the state. PGIP facilitates change through approximately 20 initiatives, including our nationally recognized Patient-Centered Medical Home program. PGIP rewards physician organizations and organized systems of care for improving health care delivery to their attributed patient population.

If you’re interested in participating in PGIP as an individual practitioner, click here.

For more information, visit valuepartnerships.com.

We’re using updated utilization management criteria for behavioral health

On Aug. 1, 2019, Medicare Plus Blue^SM PPO, Blue Cross Blue Shield of Michigan’s Medicare Advantage plan, and Blue Care Network’s commercial and Medicare Advantage plans (BCN HMO^SM and BCN Advantage^SM) will begin using the 2019 InterQual^® criteria for behavioral health utilization management determinations.

We previously communicated about this in a web-DENIS message and a news item at ereferrals.bcbsm.com.

In addition, certain types of determinations will be based on modifications to InterQual criteria or on local rules or medical policies, as shown in the table below:

Note: Determinations on Blue Cross PPO (commercial) behavioral health services are handled by New Directions, an independent company that provides behavioral health services for some Blue Cross members.

Links to the updated versions of the modified criteria (local rules) and medical policies are available, as applicable, on the Blue Cross Behavioral Health page and the BCN Behavioral Health page at ereferrals.bcbsm.com. For information on non-behavioral health InterQual criteria, see the article titled 2019 InterQual criteria to be implemented Aug. 1 for non-behavioral health determinations.

2019 InterQual^® criteria to be implemented Aug. 1 for non-behavioral health determinations

Blue Cross Blue Shield of Michigan and Blue Care Network will start using the 2019 InterQual criteria on Aug. 1, 2019, for all levels of care. We’ll use these criteria to make utilization management determinations for requests to authorize non-behavioral health services subject to review for the following members:

• Blue Cross PPO (commercial)
• Blue Cross Medicare Plus Blue^SM PPO
• BCN HMO^SM (commercial)
• BCN Advantage^SM

When clinical information is requested for a medical or surgical admission or for other services, we require submission of the specific components of the medical record that validate that the request meets the criteria.

Blue Cross and BCN also use local rules — modifications of InterQual criteria — in making utilization management determinations. The 2019 local rules will also go into effect on Aug. 1, 2019.

By the end of July, you’ll be able to access the updated versions of the modifications (local rules), as applicable, for:

• Blue Cross — on the Authorization Requirements & Criteria page in the Blue Cross section of our ereferrals.bcbsm.com website. You’ll see links to the criteria in both the Blue Cross PPO and the Medicare Plus Blue PPO sections of that page. You can also find the 2019 InterQual criteria by the end of July within BCBSM Provider Publications and Resources. Click Newsletters & Resources, click Clinical Criteria & Resources and scroll down to the section titled BCBSM modifications to InterQual criteria.
• BCN — on the Authorization Requirements & Criteria page in the BCN section of our ereferrals.bcbsm.com website. Look under the Referral and authorization information heading.

Refer to the table below for more specific information on which criteria are used in making determinations for various types of non-behavioral health authorization requests.

Note: The information in the table applies to lines of business and members whose authorizations are managed by Blue Cross or BCN directly and not by an independent company that provides services to Blue Cross Blue Shield of Michigan.

InterQual criteria for behavioral health
See the article titled We’re using updated utilization management criteria for behavioral health for information on the updated behavioral health criteria we’ll use starting Aug. 1, 2019.

Medicare Part B medical specialty drug prior authorization list changing

We’re making changes to the Medicare Plus Blue^SM PPO and BCN Advantage^SM Part B medical specialty prior authorization drug list, as follows:

• For dates of service on or after July 22, 2019, Darzalex^® (J9145) will require prior authorization.
• Effective immediately, Myozyme^® (J0220) is removed from the prior authorization list because it’s no longer available in the U.S.

Here’s some additional information you need to know about the change for Darzalex.

Medicare Plus Blue PPO
We require prior authorization for Darzalex when you bill electronically through an 837P transaction or on a professional CMS-1500 claim form, for the following sites of care:

• Physician office (place of service code 11)
• Outpatient facility (place of service code 19, 22 or 24

BCN Advantage
We require prior authorization for Darzalex when you bill it as a professional service or an outpatient facility service electronically through an 837P transaction or on a professional CMS-1500 claim form for:

• Physician office (place of service code 11)
• Outpatient facility (place of service code 19, 22 or 24)
• Home (place of service code 12)

We also require prior authorization when you bill electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x.

Reminder: You must get authorization before administering these medications.

Use the NovoLogix^® online web tool to quickly submit your requests. It offers real-time status checks and immediate approvals for certain medications.

• For Medicare Plus Blue, you can fax an Addendum P form to gain access to the NovoLogix online web tool.
• For BCN Advantage, if you have access to Provider Secured Services, you already have access to submit authorization requests through NovoLogix.

Blue Cross, BCN accepting claims for applied behavior analysis services with 2019 procedure codes

For dates of service on or after June 1, 2019, Blue Cross Blue Shield of Michigan and Blue Care Network are accepting claims for applied behavior analysis services billed with the following codes:

• *97151
• *97152
• *97153
• *97154
• *97155
• *97156
• *97157
• *97158
• *0362T
• *0373T

Claims billed with the following codes will still be honored:

• H0031
• H0032
• H2019
• H2014
• S5108
• S5111

This applies to Blue Cross’ PPO and BCN HMO^SM members. All services continue to require authorization.

Billing guidelines
We’re updating the ABA billing guidelines to reflect the 2019 codes. Look for the updated guidelines on the Autism pages within Provider Secured Services, which you can access by visiting bcbsm.com/providers and logging in to Provider Secured Services.

• To access the BCN Autism page:
  1. Click on BCN Provider Publications and Resources (on the right).
  2. Click on Autism (in the left navigation).
  3. Click on Applied Behavior Analysis Billing Guidelines and Procedure Codes under the Autism provider resource materials heading.
• To access the Blue Cross Autism page:
  1. Click on BCBSM Provider Publications and Resources (on the right).
  2. Click on Newsletters & Resources (on the left).
  3. Click on Clinical Criteria & Resources (in the left navigation).
  4. Scroll down and click on Autism (in the Resources section).
  5. Click on Applied Behavior Analysis Billing Guidelines and Procedure Codes under the Autism provider resource materials heading.

Reminder: naviHealth managing authorizations for MA members moving to post-acute care facilities

We notified you in a May Record article that naviHealth will be managing authorizations for Medicare Plus Blue^SM PPO and BCN Advantage^SM members who are moving into skilled nursing, long-term acute care and inpatient rehabilitation facilities. The transition to naviHealth became effective for authorization requests submitted for admission dates on or after June 1, 2019, for both in-state and out-of-state cases.

The transition from acute care facilities to post-acute care facilities will be supported by naviHealth, which will access the necessary resources to help ensure a safe discharge and prevent unplanned readmissions.

Here’s some additional information to keep in mind:

• Post-acute care facilities should always check to see if an authorization is in place when they’re handling an admission for a Medicare Advantage patient. If an authorization wasn’t submitted by the acute care facility, then the post-acute care facility should submit the authorization request.
• Retrospective authorizations can be submitted electronically up to 90 days post-discharge from an acute care facility. Beyond 90 days, authorizations must be phoned in or faxed.

For more details on how to submit authorization requests, see the May Record article.

Also, we recently updated our FAQ on post-acute care services. Click here to access it.

If you missed the training, you can view recorded webinars on navihealth.com/bcbsm.

Reminder: Update your Provider Authorization form when you have changes

Blue Cross Blue Shield of Michigan is dedicated to safeguarding the protected health information of our members. These safeguards include the completion of a Trading Partner Agreement and Provider Authorization form as part of the electronic data interchange setup process. All EDI trading partners must complete a TPA and Provider Authorization form before exchanging any PHI with Blue Cross.

Terms of the TPA require you to notify Blue Cross of any changes in your trading partner information. If you switch service bureaus (clearinghouses), software vendors, billing services or the recipient for your 835 files, you must update your Provider Authorization form. Updating the form ensures information is routed to the appropriate destination. No update is needed when your submitter and Trading Partner IDs don’t change.

You should review your provider authorization information if you’ve:

• Joined a new group practice
• Left a group practice and now bill using your own NPI
• Hired a new billing service
• Started submitting claims through a clearinghouse or you’ve changed clearinghouses
• Decided you no longer want to receive 835 remittance files
• Selected a new destination for your 835s

You must update your Provider Authorization form if you’ll be sending claims using a different submitter ID or routing your 835s to a different unique receiver or Trading Partner ID. To make changes to your EDI setup, visit bcbsm.com/providers and follow these steps:

1. Click on Quick Links.
2. Click on Electronic Connectivity (EDI).
3. Click on How to use EDI to exchange information with us electronically.
4. Click on Update your Provider Authorization Form under EDI Agreements.

If you have any questions about EDI enrollment, contact the EDI Help Desk at 1-800-542-0945. For assistance with TPA and Provider Authorization form, select the TPA option.

Reminder: Update your Provider Authorization form when you have changes

Blue Cross Blue Shield of Michigan is dedicated to safeguarding the protected health information of our members. These safeguards include the completion of a Trading Partner Agreement and Provider Authorization form as part of the electronic data interchange setup process. All EDI trading partners must complete a TPA and Provider Authorization form before exchanging any PHI with Blue Cross.

Terms of the TPA require you to notify Blue Cross of any changes in your trading partner information. If you switch service bureaus (clearinghouses), software vendors, billing services or the recipient for your 835 files, you must update your Provider Authorization form. Updating the form ensures information is routed to the appropriate destination. No update is needed when your submitter and Trading Partner IDs don’t change.

You should review your provider authorization information if you’ve:

• Joined a new group practice
• Left a group practice and now bill using your own NPI
• Hired a new billing service
• Started submitting claims through a clearinghouse or you’ve changed clearinghouses
• Decided you no longer want to receive 835 remittance files
• Selected a new destination for your 835s

You must update your Provider Authorization form if you’ll be sending claims using a different submitter ID or routing your 835s to a different unique receiver or Trading Partner ID. To make changes to your EDI setup, visit bcbsm.com/providers and follow these steps:

1. Click on Quick Links.
2. Click on Electronic Connectivity (EDI).
3. Click on How to use EDI to exchange information with us electronically.
4. Click on Update your Provider Authorization Form under EDI Agreements.

If you have any questions about EDI enrollment, contact the EDI Help Desk at 1-800-542-0945. For assistance with TPA and Provider Authorization form, select the TPA option.

Reminder: Expanding medical coverage for U-M employees who are transgender

As reported in the June Record, Blue Cross Blue Shield of Michigan and Blue Care Network will begin covering additional medical services for University of Michigan employees who are transgender, effective July 1, 2019.

The following additional gender-affirming services for members transitioning from male to female will be covered:

• Face and neck hair removal
• Facial feminization surgery
• Chondrolaryngoplasty (Adam’s apple reduction)

Currently, Blue Cross and BCN cover genital surgery, mastectomy in female-to-male transition, hormone therapy and counseling when medically necessary to treat gender dysphoria for U-M employees. Gender dysphoria involves a conflict between a person’s gender identity and their gender assigned at birth.

Coverage for the new services will require that members meet benefit criteria and medical necessity criteria. Blue Cross Comprehensive Major Medical members must use Blue Cross participating providers. Blue Cross and BCN members must use network providers. This benefit has up to a $30,000 lifetime limit. Michigan Medicine, formerly the University of Michigan Health System, is the only provider in our network that currently performs the facial feminization surgical services.

For complete details, see the June Record article.

Livanta LLC replaces KEPRO as BFCC-QIO for several Medicare regions

Starting June 8, 2019, Livanta LLC replaced KEPRO as Beneficiary and Family Centered Care-Quality Improvement Organization, serving Medicare regions 2, 3, 5, 7 and 9. Any outstanding Medicare cases under review by KEPRO were either completed by June 7, 2019, or transferred to Livanta for completion.

Livanta’s contact information is listed below. All related Medicare beneficiary notices should be updated to include the following address, phone number and fax number:

Livanta LLC
9090 Junction Drive, Suite 10
Annapolis Junction, MD 20701
Phone: 1-888-524-9900
Fax: 1-833-868-4059

Although Livanta will be servicing the regions listed above, some regions will continue to be serviced by KEPRO. KEPRO will retain beneficiary appeals and quality-of-care reviews on a regional basis for Medicare regions 1, 4, 6, 8 and 10. Contact information for the following Medicare regions are listed below.

Here’s additional information about Dart Container prior authorization

In the May 2019 Record, we let you know that Inetico began providing prior authorizations for Dart PPO enrollees. Here’s additional information about the process.

Dart Container requires prior authorization for all chemotherapy drugs and treatment. This includes those that don’t require approval by Blue Cross Blue Shield of Michigan.

You must obtain approval for any chemotherapy drugs or treatment from Inetico, a care coordination and care management provider working on behalf of Dart Container of Michigan LLC.

In addition, send the following requests to Inetico for approval:

• Any injection medication that exceeds $500 and doesn’t require prior authorization by Blue Cross
• Inpatient admission, outpatient surgery, MRI, MRA, CT, CTA, bone scans, epidural, PT, OT, speech, infusion, chemotherapy and radiation therapies, home health care, dialysis and durable medical equipment over $1,000

Inetico replaced the services of AIM Specialty Health and New Directions Behavioral Health for Dart PPO enrollees, group number 71750.

Services that require authorization by Inetico include:

Medical

• Inpatient precertification
• Preauthorization
• Disease management
• Care transition to home

Mental health

• Inpatient
• Residential
• Partial
• Intensive outpatient
• rTMS, or repetitive transcranial magnetic stimulation

Substance use disorder

• Acute detox
• Residential
• Partial outpatient
• Intensive outpatient

Specialty health programs (previously managed by AIM)

• High-tech imaging (MRI, CT, PET)
• Proton beam

Inetico will also manage prior authorizations for air ambulance services, except for those related to specified organ and bone marrow transplants.

If you require Inetico’s services, call 1-877-224-6700.

Blue Cross Blue Shield of Michigan handles prior authorizations for specified organ and bone marrow transplants and specialty drugs.

Specialty drugs are a designation of pharmaceuticals that are classified as high-cost, high complexity drugs that typically require special handling, distribution, administration or monitoring. Prior authorization is required for specialty drugs that are covered under a member’s medical benefit, not the pharmacy benefit.

For specialty drugs, call the Pharmacy Clinical Help Desk at 1-800-437-3803.

For transplants, call the Human Organ Transplant and Air Ambulance Program at 1-800-242-3504.

Blue Cross expanding medical benefit prior authorization program for commercial members starting Aug. 1

Beginning Aug. 1, 2019, the Magna International, Magna Mirrors and Michigan Electrical groups will be added to the Medical Drug Prior Authorization Program for Blue Cross Blue Shield of Michigan PPO commercial members. This change applies to members starting therapy on or after Aug. 1.

The authorization requirement only applies to groups that are currently participating in the commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To find a list of groups that don’t take part in the program, follow these steps:

1. Log in to Provider Secured Services.
2. Click on BCBSM Provider Publications and Resources.
3. Click on Newsletters & Resources.
4. Click on Forms.
5. Click on Physician administered medications.
6. Click on BCBSM Medical Drug Prior Authorization Program list of groups that have opted out.

BCN Advantage^SM, Blue Cross Medicare Plus Blue^SM PPO and Federal Employee Program^® members don’t take part in the Medical Drug Prior Authorization Program.

Keep in mind that a prior authorization approval isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members. Members are responsible for the full cost of medications not covered under their medical benefit coverage.

For a list of requirements for drugs covered under the medical benefit, click here.

FEP promotes healthy families with incentives for prenatal visit, well-child visits and annual checkups

The Blue Cross and Blue Shield Federal Employee Program^® is dedicated to supporting healthy pregnancies and newborn care.

The Pregnancy Care Incentive Program rewards Standard and Basic Option members who submit a doctor-signed medical record showing a prenatal visit in the first trimester. FEP Blue Focus members are rewarded for receiving a routine annual physical exam through the Routine Annual Physical Incentive Program.

Well-child visits after a child is born are encouraged. For FEP Blue Focus, Standard and Basic members, healthy newborn visits and screenings are covered with no out-of-pocket costs if the member sees a preferred provider.

If your patients would like more information, direct them to www.fepblue.org. They’ll find details for the Pregnancy Care Incentive Program and Routine Annual Physical Incentive Program under the Wellness Resources & Tools tab.

Members can also call Customer Service at 1-800-482-3600.

Inpatient lumbar spinal fusion procedures require two authorizations

Two authorizations are needed for inpatient spinal fusion procedures that require clinical review: one authorization for the procedure and one for the admission.

The medical necessity for the procedure is reviewed by eviCore. The facility must request an inpatient authorization through e-referral for the inpatient stay. Blue Cross Blue Shield of Michigan will then review appropriateness of the setting.

For an inpatient lumbar spinal fusion procedure, the facility needs to load an authorization with procedure code *99222 in e-referral. Don’t use the lumbar spinal fusion procedure codes or you’ll receive a block message.

If the inpatient authorization for a lumbar spinal fusion procedure requires an admission date change, email e-referralinquiries@bcbsm.com.

Don’t contact eviCore to convert an existing outpatient authorization to an inpatient authorization, as they will redirect you to Blue Cross.

Reminder: Indicating that services are related to auto accidents on claims

If you provide services to a patient who has been in an auto accident and the services are related to the accident, be sure to indicate that on the claim you submit to Blue Cross Blue Shield of Michigan.

For most claims of this type, the auto insurance company is the primary carrier, and we need to know that when processing these claims. Include the information below when submitting these claims.

For electronic claims:

Facility claims
Loop 2300 HI*BH* and report occurrence code 01 or 02 to indicate auto-related

Professional claims
Loop 2300 DTP*439* (accident date) Loop 2300 CLM11-1 with qualifier AA (auto accident)

For paper claims:

Facility claims
Submit with an occurrence code (either 01 or 02) to indicate that it was an auto accident.

Professional claims
Submit checking the auto-related indicator.

More information about submitting claims related to auto accidents is available in your provider manual on web-DENIS.

We’re using updated utilization management criteria for behavioral health

On Aug. 1, 2019, Medicare Plus Blue^SM PPO, Blue Cross Blue Shield of Michigan’s Medicare Advantage plan, and Blue Care Network’s commercial and Medicare Advantage plans (BCN HMO^SM and BCN Advantage^SM) will begin using the 2019 InterQual^® criteria for behavioral health utilization management determinations.

We previously communicated about this in a web-DENIS message and a news item at ereferrals.bcbsm.com.

In addition, certain types of determinations will be based on modifications to InterQual criteria or on local rules or medical policies, as shown in the table below:

Note: Determinations on Blue Cross PPO (commercial) behavioral health services are handled by New Directions, an independent company that provides behavioral health services for some Blue Cross members.

Links to the updated versions of the modified criteria (local rules) and medical policies are available, as applicable, on the Blue Cross Behavioral Health page and the BCN Behavioral Health page at ereferrals.bcbsm.com. For information on non-behavioral health InterQual criteria, see the article titled 2019 InterQual criteria to be implemented Aug. 1 for non-behavioral health determinations.

2019 InterQual^® criteria to be implemented Aug. 1 for non-behavioral health determinations

Blue Cross Blue Shield of Michigan and Blue Care Network will start using the 2019 InterQual criteria on Aug. 1, 2019, for all levels of care. We’ll use these criteria to make utilization management determinations for requests to authorize non-behavioral health services subject to review for the following members:

• Blue Cross PPO (commercial)
• Blue Cross Medicare Plus Blue^SM PPO
• BCN HMO^SM (commercial)
• BCN Advantage^SM

When clinical information is requested for a medical or surgical admission or for other services, we require submission of the specific components of the medical record that validate that the request meets the criteria.

Blue Cross and BCN also use local rules — modifications of InterQual criteria — in making utilization management determinations. The 2019 local rules will also go into effect on Aug. 1, 2019.

By the end of July, you’ll be able to access the updated versions of the modifications (local rules), as applicable, for:

• Blue Cross — on the Authorization Requirements & Criteria page in the Blue Cross section of our ereferrals.bcbsm.com website. You’ll see links to the criteria in both the Blue Cross PPO and the Medicare Plus Blue PPO sections of that page. You can also find the 2019 InterQual criteria by the end of July within BCBSM Provider Publications and Resources. Click Newsletters & Resources, click Clinical Criteria & Resources and scroll down to the section titled BCBSM modifications to InterQual criteria.
• BCN — on the Authorization Requirements & Criteria page in the BCN section of our ereferrals.bcbsm.com website. Look under the Referral and authorization information heading.

Refer to the table below for more specific information on which criteria are used in making determinations for various types of non-behavioral health authorization requests.

Note: The information in the table applies to lines of business and members whose authorizations are managed by Blue Cross or BCN directly and not by an independent company that provides services to Blue Cross Blue Shield of Michigan.

InterQual criteria for behavioral health
See the article titled We’re using updated utilization management criteria for behavioral health for information on the updated behavioral health criteria we’ll use starting Aug. 1, 2019.

Medicare Part B medical specialty drug prior authorization list changing

We’re making changes to the Medicare Plus Blue^SM PPO and BCN Advantage^SM Part B medical specialty prior authorization drug list, as follows:

• For dates of service on or after July 22, 2019, Darzalex^® (J9145) will require prior authorization.
• Effective immediately, Myozyme^® (J0220) is removed from the prior authorization list because it’s no longer available in the U.S.

Here’s some additional information you need to know about the change for Darzalex.

Medicare Plus Blue PPO
We require prior authorization for Darzalex when you bill electronically through an 837P transaction or on a professional CMS-1500 claim form, for the following sites of care:

• Physician office (place of service code 11)
• Outpatient facility (place of service code 19, 22 or 24

BCN Advantage
We require prior authorization for Darzalex when you bill it as a professional service or an outpatient facility service electronically through an 837P transaction or on a professional CMS-1500 claim form for:

• Physician office (place of service code 11)
• Outpatient facility (place of service code 19, 22 or 24)
• Home (place of service code 12)

We also require prior authorization when you bill electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x.

Reminder: You must get authorization before administering these medications.

Use the NovoLogix^® online web tool to quickly submit your requests. It offers real-time status checks and immediate approvals for certain medications.

• For Medicare Plus Blue, you can fax an Addendum P form to gain access to the NovoLogix online web tool.
• For BCN Advantage, if you have access to Provider Secured Services, you already have access to submit authorization requests through NovoLogix.

Reminder: naviHealth managing authorizations for MA members moving to post-acute care facilities

We notified you in a May Record article that naviHealth will be managing authorizations for Medicare Plus Blue^SM PPO and BCN Advantage^SM members who are moving into skilled nursing, long-term acute care and inpatient rehabilitation facilities. The transition to naviHealth became effective for authorization requests submitted for admission dates on or after June 1, 2019, for both in-state and out-of-state cases.

The transition from acute care facilities to post-acute care facilities will be supported by naviHealth, which will access the necessary resources to help ensure a safe discharge and prevent unplanned readmissions.

Here’s some additional information to keep in mind:

• Post-acute care facilities should always check to see if an authorization is in place when they’re handling an admission for a Medicare Advantage patient. If an authorization wasn’t submitted by the acute care facility, then the post-acute care facility should submit the authorization request.
• Retrospective authorizations can be submitted electronically up to 90 days post-discharge from an acute care facility. Beyond 90 days, authorizations must be phoned in or faxed.

For more details on how to submit authorization requests, see the May Record article.

Also, we recently updated our FAQ on post-acute care services. Click here to access it.

If you missed the training, you can view recorded webinars on navihealth.com/bcbsm.

Reminder: Update your Provider Authorization form when you have changes

Blue Cross Blue Shield of Michigan is dedicated to safeguarding the protected health information of our members. These safeguards include the completion of a Trading Partner Agreement and Provider Authorization form as part of the electronic data interchange setup process. All EDI trading partners must complete a TPA and Provider Authorization form before exchanging any PHI with Blue Cross.

Terms of the TPA require you to notify Blue Cross of any changes in your trading partner information. If you switch service bureaus (clearinghouses), software vendors, billing services or the recipient for your 835 files, you must update your Provider Authorization form. Updating the form ensures information is routed to the appropriate destination. No update is needed when your submitter and Trading Partner IDs don’t change.

You should review your provider authorization information if you’ve:

• Joined a new group practice
• Left a group practice and now bill using your own NPI
• Hired a new billing service
• Started submitting claims through a clearinghouse or you’ve changed clearinghouses
• Decided you no longer want to receive 835 remittance files
• Selected a new destination for your 835s

You must update your Provider Authorization form if you’ll be sending claims using a different submitter ID or routing your 835s to a different unique receiver or Trading Partner ID. To make changes to your EDI setup, visit bcbsm.com/providers and follow these steps:

1. Click on Quick Links.
2. Click on Electronic Connectivity (EDI).
3. Click on How to use EDI to exchange information with us electronically.
4. Click on Update your Provider Authorization Form under EDI Agreements.

If you have any questions about EDI enrollment, contact the EDI Help Desk at 1-800-542-0945. For assistance with TPA and Provider Authorization form, select the TPA option.

Reminder: Update your Provider Authorization form when you have changes

Blue Cross Blue Shield of Michigan is dedicated to safeguarding the protected health information of our members. These safeguards include the completion of a Trading Partner Agreement and Provider Authorization form as part of the electronic data interchange setup process. All EDI trading partners must complete a TPA and Provider Authorization form before exchanging any PHI with Blue Cross.

Terms of the TPA require you to notify Blue Cross of any changes in your trading partner information. If you switch service bureaus (clearinghouses), software vendors, billing services or the recipient for your 835 files, you must update your Provider Authorization form. Updating the form ensures information is routed to the appropriate destination. No update is needed when your submitter and Trading Partner IDs don’t change.

You should review your provider authorization information if you’ve:

• Joined a new group practice
• Left a group practice and now bill using your own NPI
• Hired a new billing service
• Started submitting claims through a clearinghouse or you’ve changed clearinghouses
• Decided you no longer want to receive 835 remittance files
• Selected a new destination for your 835s

You must update your Provider Authorization form if you’ll be sending claims using a different submitter ID or routing your 835s to a different unique receiver or Trading Partner ID. To make changes to your EDI setup, visit bcbsm.com/providers and follow these steps:

1. Click on Quick Links.
2. Click on Electronic Connectivity (EDI).
3. Click on How to use EDI to exchange information with us electronically.
4. Click on Update your Provider Authorization Form under EDI Agreements.

If you have any questions about EDI enrollment, contact the EDI Help Desk at 1-800-542-0945. For assistance with TPA and Provider Authorization form, select the TPA option.

Reminder: Expanding medical coverage for U-M employees who are transgender

As reported in the June Record, Blue Cross Blue Shield of Michigan and Blue Care Network will begin covering additional medical services for University of Michigan employees who are transgender, effective July 1, 2019.

The following additional gender-affirming services for members transitioning from male to female will be covered:

• Face and neck hair removal
• Facial feminization surgery
• Chondrolaryngoplasty (Adam’s apple reduction)

Currently, Blue Cross and BCN cover genital surgery, mastectomy in female-to-male transition, hormone therapy and counseling when medically necessary to treat gender dysphoria for U-M employees. Gender dysphoria involves a conflict between a person’s gender identity and their gender assigned at birth.

Coverage for the new services will require that members meet benefit criteria. Blue Cross Comprehensive Major Medical members must use Blue Cross participating providers. Blue Cross and BCN members must use network providers. This benefit has up to a $30,000 lifetime limit. Michigan Medicine, formerly the University of Michigan Health System, is the only provider in our network that currently performs the facial feminization surgical services.

For complete details, see the June Record article.

Livanta LLC replaces KEPRO as BFCC-QIO for several Medicare regions

Starting June 8, 2019, Livanta LLC replaced KEPRO as Beneficiary and Family Centered Care-Quality Improvement Organization, serving Medicare regions 2, 3, 5, 7 and 9. Any outstanding Medicare cases under review by KEPRO were either completed by June 7, 2019, or transferred to Livanta for completion.

Livanta’s contact information is listed below. All related Medicare beneficiary notices should be updated to include the following address, phone number and fax number:

Livanta LLC
9090 Junction Drive, Suite 10
Annapolis Junction, MD 20701
Phone: 1-888-524-9900
Fax: 1-833-868-4059

Although Livanta will be servicing the regions listed above, some regions will continue to be serviced by KEPRO. KEPRO will retain beneficiary appeals and quality-of-care reviews on a regional basis for Medicare regions 1, 4, 6, 8 and 10. Contact information for the following Medicare regions are listed below.

Here’s additional information about Dart Container prior authorization

In the May 2019 Record, we let you know that Inetico began providing prior authorizations for Dart PPO enrollees. Here’s additional information about the process.

Dart Container requires prior authorization for all chemotherapy drugs and treatment. This includes those that don’t require approval by Blue Cross Blue Shield of Michigan.

You must obtain approval for any chemotherapy drugs or treatment from Inetico, a care coordination and care management provider working on behalf of Dart Container of Michigan LLC.

In addition, send the following requests to Inetico for approval:

• Any injection medication that exceeds $500 and doesn’t require prior authorization by Blue Cross
• Inpatient admission, outpatient surgery, MRI, MRA, CT, CTA, bone scans, epidural, PT, OT, speech, infusion, chemotherapy and radiation therapies, home health care, dialysis and durable medical equipment over $1,000

Inetico replaced the services of AIM Specialty Health and New Directions Behavioral Health for Dart PPO enrollees, group number 71750. For more information, click here to see the article in the May 2019 Record.

Services that require authorization by Inetico include:

Medical

• Inpatient precertification
• Preauthorization
• Disease management
• Care transition to home

Mental health

• Inpatient
• Residential
• Partial
• Intensive outpatient
• rTMS, or repetitive transcranial magnetic stimulation

Substance use disorder

• Acute detox
• Residential
• Partial outpatient
• Intensive outpatient

Specialty health programs (previously managed by AIM)

• High-tech imaging (MRI, CT, PET)
• In-lab sleep studies
• Echo cardiology
• Proton beam

Inetico will also manage prior authorizations for air ambulance services, except for those related to specified organ and bone marrow transplants.

If you require Inetico’s services, call 1-877-224-6700.

Blue Cross Blue Shield of Michigan handles prior authorizations for specified organ and bone marrow transplants and specialty drugs.

Specialty drugs are a designation of pharmaceuticals that are classified as high-cost, high complexity drugs that typically require special handling, distribution, administration or monitoring. Prior authorization is required for specialty drugs that are covered under a member’s medical benefit, not the pharmacy benefit.

For specialty drugs, call the Pharmacy Clinical Help Desk at 1-800-437-3803.

For transplants, call the Human Organ Transplant and Air Ambulance Program at 1-800-242-3504.

Blue Cross expanding medical benefit prior authorization program for commercial members starting Aug. 1

Beginning Aug. 1, 2019, the Magna International, Magna Mirrors and Michigan Electrical groups will be added to the Medical Drug Prior Authorization Program for Blue Cross Blue Shield of Michigan PPO commercial members. This change applies to members starting therapy on or after Aug. 1.

The authorization requirement only applies to groups that are currently participating in the commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To find a list of groups that don’t take part in the program, follow these steps:

1. Log in to Provider Secured Services.
2. Click on BCBSM Provider Publications and Resources.
3. Click on Newsletters & Resources.
4. Click on Forms.
5. Click on Physician administered medications.
6. Click on BCBSM Medical Drug Prior Authorization Program list of groups that have opted out.

BCN Advantage^SM, Blue Cross Medicare Plus Blue^SM PPO and Federal Employee Program^® members don’t take part in the Medical Drug Prior Authorization Program.

Keep in mind that a prior authorization approval isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members. Members are responsible for the full cost of medications not covered under their medical benefit coverage.

For a list of requirements for drugs covered under the medical benefit, click here.

naviHealth now completing NOMNC and DENC forms and providing them to skilled nursing facilities

We’ve changed the processes for completing the Notice of Medicare Non-Coverage form, also known as the NOMNC, and the Detailed Explanation of Non-Coverage form, also known as the DENC. Both forms are required by the Centers for Medicare & Medicaid Services for Medicare Advantage members.

Here’s what’s changing:

• naviHealth will now complete the NOMNC form and provide it to the skilled nursing facility before each member’s termination of services. The skilled nursing facility will continue to be responsible for delivering the form to the member.
• When the member appeals the termination of services decision, naviHealth will complete the DENC form and provide it to the skilled nursing facility. The facility will continue to be responsible for delivering the form to the member. naviHealth will also obtain the medical records and the valid signed NOMNC form from the skilled nursing facility. And it will send these documents, along with the DENC, to the Quality Improvement Organization.

We expect that these changes will help you comply with these government regulations.

Additional information you need to know
It’s crucial for skilled nursing facilities to deliver the NOMNC and DENC forms in a timely manner. Failure of the facility to deliver the NOMNC form to the member may result in the provider being held financially liable for the continued services until two days after the member receives a valid notice or until the effective date of the valid notice, whichever is later, per CMS 100-04 Chapter 30 §260.3.6. Providers may not balance bill the member for these services.

Background information
Skilled nursing facilities must notify Medicare beneficiaries about their right to appeal a termination of services decision. The facilities must do so by complying with requirements for providing the NOMNC form. This includes adhering to the time frames for delivery.

A valid DENC form must be provided to the Quality Improvement Organization when the organization notifies the skilled nursing facility about an appeal of a termination of the services. The form must be issued to the member and returned, along with the requested supporting documentation, to the QIO. Also, it must be returned within the established time frame set forth by the QIO in the notification to the provider of the appeal.

Copies of the NOMNC and DENC forms, and instructions are available here.**

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

Comprehensive lists of requirements for medical specialty drugs and pharmacy benefit drugs available

We’ve developed comprehensive lists of requirements for medical specialty drugs and pharmacy benefit drugs for Blue Cross Blue Shield of Michigan PPO and Blue Care Network HMO^SM commercial members. These lists, which are typically updated monthly, include the most current information on utilization management requirements.

Medical benefit drugs

The medical specialty drug list identifies medical drugs targeted in the prior authorization and site-of-care programs, and includes the following information about them:

• Medical necessity criteria
• Quantity limits
• Step therapy requirements

The medical specialty drug list is available online in the following locations:

• On the Blue Cross Medical Benefit Drugs-Pharmacy page within the ereferrals.bcbsm.com website. Look under the For Blue Cross commercial members heading.
• On the BCN Medical Benefit Drugs-Pharmacy page on the ereferrals.bcbsm.com website
• Within Provider Secured Services:
  • Log in.
  • Click BCBSM Provider Publications and Resources (on the right).
  • Click Newsletters and Resources.
  • Click Forms.
  • Click Physician administered medications.
  • Click Requirements for drugs covered under the medical benefit – BCN HMO and Blue Cross PPO.
• In the medical policy, precertification and preauthorization router, enter quantity limit in the Keyword/Phrase field and click Search.

2 HCPCS replacement codes take effect July 1

The HCPCS procedure codes described below are effective July 1, 2019.

J7208 replaces J7199 when billing from JIVI^® (antihemophilic factor, recombinant [Pegylated-aucl]).

The Centers for Medicare & Medicaid Services has established a permanent procedure code for specialty medical drug JIVI (triamcinolone acetonide extended-release injectable suspension, for intra-articular use).

All services from Aug. 30, 2018, through June 30, 2019, can continue to be reported with J7199. All services performed on and after July 1, 2019, must be reported with J7208.

Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl, (jivi), 1 i.u. continues to be covered for FDA-approved indications, which is in the routine prophylactic treatment of hemophilia A in previously treated adults and adolescents age 12 or older.

Pharmacy doesn’t require preauthorization of this drug.

Q5114 replaces J9999 when billing Ogivri, trastuzumab-dkst, biosimilar.

CMS has an established a permanent procedure code for Ogivri.

All services from Dec. 1, 2017, through June 30, 2019, will continue to be reported with procedure code J9999. All services performed on and after July 1, 2019, must be reported with Q5114.

Ogivri continues to be covered for the approved FDA indications as established on Dec. 1, 2017.

Pharmacy doesn’t require preauthorization of this drug.

For more information about HCPCS codes, see the article titled HCPCS, CPT updates and early release codes.

HCPCS, CPT updates and early release codes

2019 second quarter HCPCS update
Injections

Inhalation solutions

2019 second quarter CPT* code updates — Pathology and laboratory
Proprietary laboratory analysis codes

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.

Medicare Part B medical specialty drug prior authorization list changing

We’re making changes to the Medicare Plus Blue^SM PPO and BCN Advantage^SM Part B medical specialty prior authorization drug list, as follows:

• For dates of service on or after July 22, 2019, Darzalex^® (J9145) will require prior authorization.
• Effective immediately, Myozyme^® (J0220) is removed from the prior authorization list because it’s no longer available in the U.S.

Here’s some additional information you need to know about the change for Darzalex.

Medicare Plus Blue PPO
We require prior authorization for Darzalex when you bill electronically through an 837P transaction or on a professional CMS-1500 claim form, for the following sites of care:

• Physician office (place of service code 11)
• Outpatient facility (place of service code 19, 22 or 24

BCN Advantage
We require prior authorization for Darzalex when you bill it as a professional service or an outpatient facility service electronically through an 837P transaction or on a professional CMS-1500 claim form for:

• Physician office (place of service code 11)
• Outpatient facility (place of service code 19, 22 or 24)
• Home (place of service code 12)

We also require prior authorization when you bill electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x.

Reminder: You must get authorization before administering these medications.

Use the NovoLogix^® online web tool to quickly submit your requests. It offers real-time status checks and immediate approvals for certain medications.

• For Medicare Plus Blue, you can fax an Addendum P form to gain access to the NovoLogix online web tool.
• For BCN Advantage, if you have access to Provider Secured Services, you already have access to submit authorization requests through NovoLogix.