New care management program to launch in 2020

Blue Cross Blue Shield of Michigan is preparing to launch an all-new integrated care management program next year.

The new program takes a holistic, member-centric approach to help ensure the greatest effect on our members’ overall health and the cost of care. It will be deployed across all lines of business, including Blue Cross PPO, Blue Care Network, group and individual customers, and Medicare Advantage members.

It’s not intended to replace the doctor-patient relationship in any way, but to support health care providers in their efforts to provide the best possible care for patients. Keep in mind that the Provider-Delivered Care Management program, which is part of Value Partnerships, will continue.

For more details, see the column by Drs. Aaron Friedkin and Duane DiFranco and Ann Baker in the May ‑ June 2019 issue of Hospital and Physician Update.

Gain insights about your patients from CAHPS research on improving the patient experience

The Centers for Medicare & Medicaid Services can help providers better understand their Medicare patients’ needs and expectations through information gleaned from the Consumer Assessment of Healthcare Providers and Systems, or CAHPS, survey.

CMS annually compiles survey findings as part of an effort to improve the patient experience and better understand health outcomes. Results from the CAHPS survey, developed by the Agency for Healthcare Research and Quality, contribute to the CMS star ratings system.

You can learn more about the CAHPS survey and how the survey can be used to improve the patient experience by clicking here. Also, be sure to check out the CAHPS survey tip sheet to find out why this annual survey is so important, how it’s conducted, what questions are asked and ways you can address care opportunities for patients.

SCIO Health Analytics auditing outpatient claims for commercial business

SCIO Health Analytics^®, an independent company that provides services for Blue Cross Blue Shield of Michigan, began auditing outpatient claims for our commercial business on May 1, 2019.

The audits will:

• Start with claims paid on or after Jan. 1, 2018.
• Confirm compliance with Blue Cross guidelines and policy.
• Validate proper billing of revenue, CPT and HCPCS codes, modifiers and units.
• Ensure services are documented.
• Detect, prevent and correct waste and abuse.
• Facilitate accurate claims payments.

You’ll need to provide the proper medical charts for review. After an audit, SCIO will send you its findings and instructions for appeal, if necessary.

If you need to speak to a SCIO representative during the audit, call 1-866-628-3488, ext. 7525.

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

Most Americans think drug companies should be held responsible for their role in opioid crisis
A new NPR poll found that 57% of Americans say pharmaceutical companies should be held responsible for making the opioid crisis worse. Additionally, it found that a third of Americans have been touched directly by the deadly opioid epidemic that kills more than 100 people every day. One in three have been personally affected in some way, either by knowing someone who has overdosed or by knowing someone with an opioid addiction, said Mallory Newall, lead Ipsos researcher on the survey. To read more, click here.**

Opioid company’s top executives found guilty of bribing doctors
A federal jury in Boston found John Kapoor, founder of Insys Therapeutics, and four other executives guilty of bribing doctors to boost sales of Subsys^®, a highly addictive fentanyl sublingual spray, npr.org** reported.

Forum addresses role employers can play in stemming opioid epidemic
The human costs of the opioid epidemic are substantial, and they trickle down to employers in the form of absenteeism and compromised performance on the job. One study found that opioid abuse costs U.S. employers $18 billion annually in lost productivity. Blue Cross Blue Shield of Michigan recently sponsored a Health Forum of West Michigan panel discussion about opioids. It looked at five key steps employers need to take to help employees struggling with substance use disorders. Read more in a MI Blues Perspectives blog.

Meijer launches drug take-back program
Meijer recently announced a Consumer Drug Take-Back Program at all its supercenters across the Midwest. At Meijer, you can simply dispose of your old prescriptions during pharmacy hours at secure kiosks. This includes opioids, controlled substances and over-the-counter medications. The Meijer Drug Take-Back Program allows our customers to remove the risk of an unforeseen accident occurring with expired or unused medications, while enabling them to properly dispose of prescription drugs and reducing the possibility of creating a public health hazard, said Jason Beauch, vice president of Meijer Pharmacy. Read more in a MI Blues Perspectives blog.

What if patients don’t want to be prescribed opioids?
With so many people becoming addicted to opioids over the past few years, it’s not surprising that many people don’t want to rely on opioids to relieve pain. Dr. Duane DiFranco, vice president, Medicare STARs and Clinical Performance, offers some nonopioid alternatives in a MI Blues Perspectives blog targeted to members.

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

HCPCS update: New codes added

The Centers for Medicare & Medicaid Services recently added several new codes as part of its quarterly Health Care Procedure Coding System updates. The codes, effective date and Blue Cross Blue Shield of Michigan’s coverage decisions are below.

Outpatient prospective payment system — Injections

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.

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.

Note: The Federal Employee Program^® follows its own criteria related to procedure codes J3490, J3590, J9271 and J9305.

Coding corner: Treating patients with seizure disorder

What is a seizure and how does it differ from epilepsy?

A seizure occurs from an episode of a sudden, uncontrolled electrical disturbance in the brain. It can cause abnormal movements and changes in awareness and behavior lasting anywhere from a few seconds to several minutes. Epilepsy is a condition characterized by recurrent seizures with no clear underlying cause. Status epilepticus describes a seizure that lasts longer than five minutes, or when seizures occur close together and the patient doesn't recover consciousness in between.

Depending on the type of seizure, signs and symptoms may include the following:

• A staring spell
• Uncontrollable jerking movements of the arms and legs
• Loss of consciousness or awareness
• Cognitive or emotional symptoms, such as fear, anxiety or déjà vu
• Temporary confusion following a seizure (postictal state)

Seizures can be caused by many underlying conditions:

• Congenital abnormalities
• Head injuries
• Poisoning
• Stroke
• Brain tumor

Documentation and coding tips

If known, provider documentation should specify the underlying cause of the seizure, such as:

• Low blood sugar
• Traumatic brain injury
• Alcohol or drug use, abuse, dependence or withdrawal

To assign a code properly, documentation of the seizure type is required. The following are a few common types of seizures:

• Tonic-clonic (grand mal)
• Myoclonic
• Atonic
• Tonic
• Clonic
• Absence (petit mal)

For greater specificity, providers should also document the status of the seizure:

• Intractable or not intractable
• Presence or absence of status epilepticus

Provider documentation must also include the treatment plan, if known, or plans to refer the patient to a neurologist or other specialist for treatment:

• Use of anti-convulsion medications such as carbamazepine, phenytoin, lamotrigine or levetiracetam
• Surgery
• Vagus nerve stimulation
• Responsive neurostimulation
• Deep brain stimulation

According to ICD-10-CM, a single seizure episode is classified to code R56.9, unspecified convulsions.

Epilepsy, or recurrent seizures, is classified to category G40. The ICD-10-CM coding system subcategorizes epilepsy even further:

• Generalized versus localized epilepsy
• Localized epilepsy with localized onset versus simple partial seizures

In addition, separate codes identify idiopathic versus symptomatic epilepsy with a fifth character to specify whether the seizures are intractable and a sixth character to identify the presence or absence of status epilepticus.

Some examples of seizure disorder codes appear in the chart below:

Sources:

• www.mayoclinic.org**
• 2019 ICD-10-CM Professional for Physicians

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

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.

We’re expanding medical coverage for U-M employees who are transgender

Blue Cross Blue Shield of Michigan and Blue Care Network will soon begin covering additional medical services for University of Michigan employees who are transgender.

The following additional gender-affirming services for members transitioning from male to female will be covered starting July 1, 2019:

• 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, causing significant distress.

Coverage for the new services will require that members meet medical necessity criteria, use network providers and have 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.

You can request authorizations for members who have a Blue Cross plan starting June 15, 2019. For members with a BCN plan, authorizations can be requested starting June 12.

The group number for Blue Cross members is 007005187, while the group number for BCN members is 00124316. The number will be on the front of their member ID card. As always, be sure to check web-DENIS for benefits and eligibility.

For more information
For more details, see the University of Michigan fact sheet on health plan coverage for gender-affirming services.

Transgender members may also use new coverage for fertility preservation if medical or surgical interventions related to their transition could result in infertility. For more details, see the University of Michigan fact sheet on coverage for services related to infertility.

You must use network laboratories for your Blue Cross and BCN patients

During our regular reviews of claims data, we’ve seen that a number of providers continue to send lab work for Blue Cross Blue Shield of Michigan and Blue Care Network patients to noncontracted laboratories. Also, we’ve found some patients are taking their scripts for lab work to noncontracted labs, not realizing this may result in higher costs.

When patients go out of network for lab services, it may cause unnecessary cost-sharing expenses and balance-billing by the labs — and we’re committed to helping control costs for our members. We encourage you let your patients know that going to a contracted lab helps ensure they avoid higher copayments and possible other out-of-pocket costs.

Network labs offer a full complement of routine tests, BRCA testing and other specialty testing. In addition, we use contracted labs to obtain lab data needed for regulatory reporting and clinical quality review.

According to your participation agreement, you must use network providers (including labs) when referring patients for non-emergency services. Make sure to verify a laboratory’s participation in the appropriate network before referring patients for lab samples.

Below is a list of labs used for our members:

Failure to meet program requirements for using participating laboratory services may lead to corrective action, including potential termination from the Blue Cross network.

Medicare Part B medical specialty drug prior authorization list changing

Starting in June 2019, we’re adding the following medications to the Medicare Plus Blue^SM PPO and BCN Advantage^SM Part B specialty prior-authorization drug list.

Medicare Plus Blue
For dates of service on or after June 3, 2019, the following medications will require prior authorization:

• J3590 Ultomiris™
• J9999 (C9044) Libtayo^®
• J3245 Ilumya™
• Q5109 Ixifi™
• J3590/J9999 Elzonris™
• J3397 Mepsevii™
• J3490 Tegsedi™
• J9173 Imfinzi^®
• J3304 Zilretta^®

We require prior authorization for these medications when you bill them 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
For dates of service on or after June 3, 2019, the following medications will require prior authorization:

• J3590 Ultomiris™
• J9999 (C9044) Libtayo^®
• J3245 Ilumya™
• Q5109 Ixifi™
• J3590/J9999 Elzonris™
• J3397 Mepsevii™
• J3490 Tegsedi™
• J9173 Imfinzi^®
• J3304 Zilretta^®

We require prior authorization for these medications when you bill them 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.

Important reminder
You must get authorization before administering these medications. Use the NovoLogix^® online tool to quickly submit your requests. It offers real-time status checks and immediate approvals for certain medications. Also note:

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

Cardiology procedures and in-lab sleep study assessments added to Medicare Plus Blue PPO radiology management program

On May 1, 2019, the radiology management program administered by AIM Specialty Health^® added authorization requirements for select cardiology procedures and for in-lab sleep study assessments for Medicare Plus Blue^SM PPO members.

The program includes UAW Retiree Medical Benefits Trust members with Medicare Plus Blue coverage.

Following are the CPT codes for the procedures that were added to the program.

Percutaneous coronary intervention:

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

Note: For these procedures, we require review for medical necessity and clinical appropriateness after the service has been completed. Due to the medical nature of this procedure, we don't require pre-service review for the codes listed above.

Diagnostic coronary catheterization:

• *93454
• *93455
• *93456
• *93457
• *93458
• *93459
• *93460
• *93461

Note: The diagnostic coronary catherization codes listed above require prior authorization.

In-lab sleep studies:

• *95805
• *95806
• *95807
• *95808
• *95810
• *95811

Note: The sleep study codes listed above require prior authorization.

Questions?

If you have questions, call 1-800-728-8008. You can also visit the AIM website.

Blue Cross makes changes to its drug testing policy on urine, oral fluids, hair

Approximately one-third of chronic pain patients don’t use opioids as prescribed or they abuse them, according to the American Society of Interventional Pain Physicians.

Sometimes this misuse can be categorized as substance use disorder. The medical community defines substance use disorder as the recurrent use of alcohol or drugs that causes clinically and functionally significant physical or mental impairment, disability, and failure to meet major responsibilities at work, school or home. Doctors diagnose substance use disorder when there is drug use combined with impaired control, social impairment and risky behavior.

One strategy for monitoring substance use disorder in patients is biologic specimen testing for the presence or absence of drugs. Currently, urine is the most commonly used biologic substance.

On May 1, 2019, Blue Cross Blue Shield of Michigan changed the reporting policy for definitive drug testing. A definitive drug test is one that’s medically necessary and clinically justified when the results of presumptive testing have been evaluated and support the need for follow-up definitive testing that will contribute to clinical decision making.

Procedure codes

• Procedure codes G0480 through G0483 and G0659 should now be used for billing definitive drug testing.
• Procedure codes *80320 through *80377 and *83992 are now considered informational and should continue to be billed in addition to the appropriate G-code for reporting purposes, effective Aug. 1, 2019.

Following are additional details related to the policy change:

Inclusions

• Presumptive urine drug testing
• For outpatient pain management, presumptive urine drug testing is used in:
• Baseline screening at the initiation of treatment
• Subsequent monitoring of treatment at an appropriate frequency, based on the risk level of the individual, including assessment of aberrant behavior
• For outpatient substance use disorder treatment, presumptive urine drug testing used in:
• Baseline screening at the initiation of treatment, one time per program entry
• Weekly screening during the first four weeks of treatment
• Subsequent targeted screening once every one to three months
• For an individual not participating in outpatient pain management or outpatient substance use disorder treatment:
• When a clinical evaluation suggests use of non-prescribed medications or illegal substances
• Definitive and confirmatory urine drug testing
• Definitive urine drug testing is used:
• When immunoassays for the relevant drug or drugs aren’t commercially available
• When definitive drug levels are required for clinical decision making

Exclusions:

• Urine drug testing as a third-party requirement (for example, for employment, licensing or a court order)
• Simultaneously testing for the same drug with both a blood and a urine specimen

Note: Oral fluid drug testing and hair drug testing are considered experimental.

Find out the next steps for CAQH Direct Assure 2.0

About 25% of our practitioners are currently participating in CAQH Direct Assure. We’ll continue rolling out Direct Assure in phases, with the goal of having all providers using Direct Assure by the end of December 2019.

The next step is to roll out Phase IV of Direct Assure at the end of June. Practitioners who will be included in this rollout are doctors who are likely to be audited by the Centers for Medicare & Medicaid Services:

• Primary care physicians
• Cardiologists
• Oncologists
• Ophthalmologists

What you need to do
To make a smooth transition to CAQH Direct Assure, continue to keep your CAQH record updated with your correct practice location information. You can familiarize yourself with the Direct Assure application by watching the Updating your practice locations in CAQH ProView video tutorial. This video will walk you through the screens and steps involved in providing your current location information to Blue Cross through CAQH.

While making updates to practice locations in CAQH, keep the following in mind:

• If, after logging in to CAQH, you see a pop-up message that says Help Patients Find You, that means that you’re now participating in Direct Assure.
• Once you’re active with Direct Assure, when you add, delete or update a group’s address in CAQH, that information will be sent to Blue Cross for processing.
• Don’t forget to add your Type 2 NPI information for each location.
• Selecting I see patients here one day per week or I see patients one day per month on the Practice Affiliation page will display the location in the directory. If a practitioner doesn’t offer appointments for patients at this location, he or she should select Other so the record doesn’t display in the directory.

If you have questions, you can reach out to CAQH directly at 1-888-599-1771 or contact Provider Enrollment at 1-800-822-2761.

We’re expanding CAQH ProView 3.0 to include delegated credentialing practitioners

Blue Cross Blue Shield of Michigan is expanding the use of the CAQH ProView 3.0 application. The application will include enrollment demographic and credentialing data for delegated credentialing practitioners.

The purpose of this initiative is to:

• Streamline the data exchange process between delegated practitioner groups and Blue Cross.
• Allow data to be exchanged consistently and more efficiently.
• Improve our provider data quality for our members to view in our directories.

Blue Cross will be accepting automated data feeds from CAQH ProView 3.0 into our provider data repository, Portico. This automated process will make it more efficient for us to maintain provider data and will reduce duplication of data submission for the delegated groups.

We expect to begin beta testing this electronic data exchange with the University of Michigan Medical Group and Genesys PHO for initial enrollment and changes during the latter part of 2019, with the exchange of recredentialing data to follow.

Note: We still require signature documents for contracting. Continue to send these documents to the Provider Enrollment and Data Management department.

Discharge information may update automatically in e-referral for inpatient care

Recent updates to the e-referral system have improved the efficiency of inpatient authorizations for Michigan facilities. Blue Cross Blue Shield of Michigan and Blue Care Network obtain discharge information through Michigan Health Information Network Shared Services. Through upgrades to the process, e-referral may automatically populate changes to discharge dates.

• If the discharge date results in a shorter length of stay than initially approved, e-referral will reduce the days on the approved case to match the facility’s date.
• If the discharge date results in a longer length of stay than initially approved, e-referral will add the requested days and approve or pend the case.

This change applies to all Blue Cross and BCN fully approved cases in the e-referral system, including commercial and Medicare Advantage.

After adding an extension or reducing the number of days, the provider should confirm that the information in e-referral has been updated.

• If the information is correct, no further action is needed.
• If the information is incorrect, providers should contact the appropriate Blue Cross or BCN areas to relay the changes needed.

The updates are expected to reduce the need for providers to manually enter discharge information on a case.

Here’s helpful information about clinical editing appeals for Blue Cross PPO and Medicare Plus Blue claims

When we receive clinical editing appeals for PPO and Medicare Plus Blue^SM PPO claims, we review the entire claim and all documentation provided. The goal of the review is to make sure that the documentation supports the services and procedures reported on the claim and that the claim follows correct coding and billing guidelines.

Occasionally, the documentation does not support the coding on the claim. When this happens, a recovery may occur on a code or service that wasn’t appealed. When this happens, you have a right to appeal the determination since it is a new edit or denial.

For more information, see your online provider manual.

Two Medicare star measures support statin therapy for patients with cardiovascular disease and diabetes

To underscore the importance of statin therapy, the Centers for Medicare & Medicaid Services includes two Medicare star measures aimed at its use for patients with cardiovascular disease and diabetes.

The Centers for Disease Control and Prevention estimates that adults with diabetes are 1.7 times more likely to die from cardiovascular disease than adults without it. Additionally, nearly two out of five people with diabetes who could benefit from statin therapy to lower their risk of heart attack, stroke and related deaths weren’t prescribed it, according to the Journal of the American College of Cardiology.

We encourage you to consider prescribing statins for your patients diagnosed with atherosclerotic cardiovascular disease and diabetes.

To learn more about the use of statin therapy, view these tip sheets:

• Statin Therapy for Patients with Cardiovascular Disease
• Statin Use in Persons with Diabetes

Medication reconciliation reimbursement increases to $35 for Medicare Advantage members

When medication reconciliation is conducted within 30 days of a hospital discharge and a claim is submitted for CPT II code *1111F, Blue Cross Blue Shield of Michigan will reimburse providers $35 for its Medicare Advantage products: Medicare Plus Blue^SM and BCN Advantage^SM. Blue Cross commercial continues to reimburse at $35.

Medication Reconciliation Post-Discharge is a HEDIS^® measure.**

To receive reimbursement, follow these steps when patients are discharged after a hospital stay:

• Schedule a medication reconciliation as soon as possible.
• Perform medication reconciliation by comparing the hospital discharge medications against the patient’s current list of medications.
• Physicians, physician assistants, pharmacists, registered nurses and nurse practitioners may conduct a medication reconciliation.
• One example of acceptable documentation in the outpatient medical record is Current and discharge medications were reconciled.
• Submit *1111F with the post-discharge office visit claim within 30 days of the discharge. The code description is Discharge medications reconciled with the current medication list in outpatient medical record.

About the HEDIS measure
Medication Reconciliation Post-Discharge assesses patients age 18 and older in the measurement year who were discharged from an acute or non-acute inpatient stay between Jan. 1 and Dec. 1 of the measurement year. It looks at patients whose medications were reconciled from the date of discharge through 30 days after discharge (31 days total).

Click here to review the Medication Reconciliation Post-Discharge tip sheet.

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

Managing acute low back pain in adults

Many adults will experience low back pain at some point in their life. More than 25% of adults say they’ve experienced back pain in the past three months, according to the National Institute of Neurological Disorders and Stroke. Most of the time, low back pain is easily treated or will resolve on its own.

Imaging for acute low back pain usually isn’t required within the first six weeks, unless certain red flags are present. These include:

• Infection
• Spinal fracture
• Leg weakness
• Loss of bladder control or bowel control
• Numbness or tingling
• Fever

A conservative approach is generally considered preferable if red flags aren’t present.

In 2018, the Michigan Quality Improvement Consortium published a guideline** for adults with low back pain or back-related leg symptoms for more than six weeks. The following are some of the focus areas recommended by the consortium when treating patients with low back pain:

• Performing a history and physical exam
• Encouraging patients to stay active within the limits permitted by pain
• Referring to non-invasive therapy if the patient experiences persistent disability at two weeks
• Prescribing medication on a time-contingent basis, not a pain-contingent basis.
• Offering reassurance

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

We’re expanding medical coverage for U-M employees who are transgender

Blue Cross Blue Shield of Michigan and Blue Care Network will soon begin covering additional medical services for University of Michigan employees who are transgender.

The following additional gender-affirming services for members transitioning from male to female will be covered starting July 1, 2019:

• 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, causing significant distress.

Coverage for the new services will require that members meet medical necessity criteria, use network providers and have 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.

You can request authorizations for members who have a Blue Cross plan starting June 15, 2019. For members with a BCN plan, authorizations can be requested starting June 12.

The group number for Blue Cross members is 007005187, while the group number for BCN members is 00124316. The number will be on the front of their member ID card. As always, be sure to check web-DENIS for benefits and eligibility.

For more information
For more details, see the University of Michigan fact sheet on health plan coverage for gender-affirming services.

Transgender members may also use new coverage for fertility preservation if medical or surgical interventions related to their transition could result in infertility. For more details, see the University of Michigan fact sheet on coverage for services related to infertility.

You must use network laboratories for your Blue Cross and BCN patients

During our regular reviews of claims data, we’ve seen that a number of providers continue to send lab work for Blue Cross Blue Shield of Michigan and Blue Care Network patients to noncontracted laboratories. Also, we’ve found some patients are taking their scripts for lab work to noncontracted labs, not realizing this may result in higher costs.

When patients go out of network for lab services, it may cause unnecessary cost-sharing expenses and balance-billing by the labs — and we’re committed to helping control costs for our members. We encourage you let your patients know that going to a contracted lab helps ensure they avoid higher copayments and possible other out-of-pocket costs.

Network labs offer a full complement of routine tests, BRCA testing and other specialty testing. In addition, we use contracted labs to obtain lab data needed for regulatory reporting and clinical quality review.

According to your participation agreement, you must use network providers (including labs) when referring patients for non-emergency services. Make sure to verify a laboratory’s participation in the appropriate network before referring patients for lab samples.

Below is a list of labs used for our members:

Failure to meet program requirements for using participating laboratory services may lead to corrective action, including potential termination from the Blue Cross network.

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

A few training sessions remain for health care providers to learn more about naviHealth’s clinical model and provider portal.

As you read in a May Record article, 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 is effective for authorization requests submitted for admission dates on or after June 1, 2019, for both in-state and out-of-state cases.

Following is the schedule for remaining webinar dates and times. Click here to register.

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.

To access an FAQ on post-acute care services, click here.

Here’s what you need to know about prior authorization requirements for acute detoxification

Members with Blue Cross Blue Shield of Michigan commercial PPO health plans require prior authorizations for uncomplicated acute detoxification through New Directions. To submit a prior authorization request to New Directions, call 1-800-762-2382 or visit New Directions WebPass.

This prior authorization requirement is for members with Blue Cross health plans that include behavioral health benefits. Groups with behavioral health benefits carved out are excluded.

Keep the following in mind:

• When members need detoxification, but a medical condition, such as acute pancreatitis, chest pains or dehydration, is the primary focus of care, authorization should be obtained from Blue Cross through the e-referral system.
• If a member has been admitted for acute detoxification and then develops acute medical complications, you must request authorization through e-referral — even if you’ve already received prior authorization for acute detoxification through New Directions.

Medicare Part B medical specialty drug prior authorization list changing

Starting in June 2019, we’re adding the following medications to the Medicare Plus Blue^SM PPO and BCN Advantage^SM Part B specialty prior-authorization drug list.

Medicare Plus Blue
For dates of service on or after June 3, 2019, the following medications will require prior authorization:

• J3590 Ultomiris™
• J9999 (C9044) Libtayo^®
• J3245 Ilumya™
• Q5109 Ixifi™
• J3590/J9999 Elzonris™
• J3397 Mepsevii™
• J3490 Tegsedi™
• J9173 Imfinzi^®
• J3304 Zilretta^®

We require prior authorization for these medications when you bill them 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
For dates of service on or after June 3, 2019, the following medications will require prior authorization:

• J3590 Ultomiris™
• J9999 (C9044) Libtayo^®
• J3245 Ilumya™
• Q5109 Ixifi™
• J3590/J9999 Elzonris™
• J3397 Mepsevii™
• J3490 Tegsedi™
• J9173 Imfinzi^®
• J3304 Zilretta^®

We require prior authorization for these medications when you bill them 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.

Important reminder
You must get authorization before administering these medications. Use the NovoLogix^® online tool to quickly submit your requests. It offers real-time status checks and immediate approvals for certain medications. Also note:

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

Cardiology procedures and in-lab sleep study assessments added to Medicare Plus Blue PPO radiology management program

On May 1, 2019, the radiology management program administered by AIM Specialty Health^® added authorization requirements for select cardiology procedures and for in-lab sleep study assessments for Medicare Plus Blue^SM PPO members.

The program includes UAW Retiree Medical Benefits Trust members with Medicare Plus Blue coverage.

Following are the CPT codes for the procedures that were added to the program.

Percutaneous coronary intervention:

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

Note: For these procedures, we require review for medical necessity and clinical appropriateness after the service has been completed. Due to the medical nature of this procedure, we don't require pre-service review for the codes listed above.

Diagnostic coronary catheterization:

• *93454
• *93455
• *93456
• *93457
• *93458
• *93459
• *93460
• *93461

Note: The diagnostic coronary catherization codes listed above require prior authorization.

In-lab sleep studies:

• *95805
• *95806
• *95807
• *95808
• *95810
• *95811

Note: The sleep study codes listed above require prior authorization.

Questions?

If you have questions, call 1-800-728-8008. You can also visit the AIM website.

Discharge information may update automatically in e-referral for inpatient care

Recent updates to the e-referral system have improved the efficiency of inpatient authorizations for Michigan facilities. Blue Cross Blue Shield of Michigan and Blue Care Network obtain discharge information through Michigan Health Information Network Shared Services. Through upgrades to the process, e-referral may automatically populate changes to discharge dates.

• If the discharge date results in a shorter length of stay than initially approved, e-referral will reduce the days on the approved case to match the facility’s date.
• If the discharge date results in a longer length of stay than initially approved, e-referral will add the requested days and approve or pend the case.

This change applies to all Blue Cross and BCN fully approved cases in the e-referral system, including commercial and Medicare Advantage.

After adding an extension or reducing the number of days, the provider should confirm that the information in e-referral has been updated.

• If the information is correct, no further action is needed.
• If the information is incorrect, providers should contact the appropriate Blue Cross or BCN areas to relay the changes needed.

The updates are expected to reduce the need for providers to manually enter discharge information on a case.

Here’s helpful information about clinical editing appeals for Blue Cross PPO and Medicare Plus Blue claims

When we receive clinical editing appeals for PPO and Medicare Plus Blue^SM PPO claims, we review the entire claim and all documentation provided. The goal of the review is to make sure that the documentation supports the services and procedures reported on the claim and that the claim follows correct coding and billing guidelines.

Occasionally, the documentation does not support the coding on the claim. When this happens, a recovery may occur on a code or service that wasn’t appealed. When this happens, you have a right to appeal the determination since it is a new edit or denial.

For more information, see your online provider manual.

Medicare Part B medical specialty drug prior authorization list changing

Starting in June 2019, we’re adding the following medications to the Medicare Plus Blue^SM PPO and BCN Advantage^SM Part B specialty prior-authorization drug list.

Medicare Plus Blue
For dates of service on or after June 3, 2019, the following medications will require prior authorization:

• J3590 Ultomiris™
• J9999 (C9044) Libtayo^®
• J3245 Ilumya™
• Q5109 Ixifi™
• J3590/J9999 Elzonris™
• J3397 Mepsevii™
• J3490 Tegsedi™
• J9173 Imfinzi^®
• J3304 Zilretta^®

We require prior authorization for these medications when you bill them 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
For dates of service on or after June 3, 2019, the following medications will require prior authorization:

• J3590 Ultomiris™
• J9999 (C9044) Libtayo^®
• J3245 Ilumya™
• Q5109 Ixifi™
• J3590/J9999 Elzonris™
• J3397 Mepsevii™
• J3490 Tegsedi™
• J9173 Imfinzi^®
• J3304 Zilretta^®

We require prior authorization for these medications when you bill them 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.

Important reminder
You must get authorization before administering these medications. Use the NovoLogix^® online tool to quickly submit your requests. It offers real-time status checks and immediate approvals for certain medications. Also note:

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

Stimulant drugs will have new quantity limits starting July 1, 2019

On July 1, 2019, Blue Cross Blue Shield of Michigan will implement new quantity limits for stimulant drugs, as shown in the table below. This change only affects our commercial (non-Medicare) members who have Blue Cross pharmacy benefits.

Our goal is to provide our members with safe, high-quality prescription drugs. In May, we sent letters to notify members who may be affected by these quantity limit changes. The letters encourage members to discuss treatment options with their physicians.

If necessary, you can request an override of the quantity limits for your patients. The request should include documentation stating that the amount you’re prescribing is medically necessary.

To get a form for a quantity limit override, log in as a provider at bcbsm.com/providers or call the Pharmacy Services Clinical Help Desk at 1-800-437-3803 and select Option 1.

Here are quantity limits for stimulant drugs, effective July 1, 2019: