Increase in value-based reimbursement for PCMH-designated practices announced

Effective Sept. 1, 2019, through Aug. 31, 2020, value-based reimbursement for the Patient-Centered Medical Home designation will increase from 110% to 115%.

The temporary change recognizes that PCMH value-based reimbursement has remained at the same level for 10 years, but the expectations have become more rigorous over time and continue to evolve.

As part of the continued evolution of the program, we encourage PCMH practices to collaborate with their physician organizations to:

• Adopt more advanced PCMH capabilities
• Use care managers or care teams and the health information exchange to improve care coordination

Value-based reimbursement for PCMH designation will return to 110%, effective Sept. 1, 2020. The additional 5% value-based reimbursement will be reallocated from PCMH to the Provider-Delivered Care Management program for primary care physicians.

We'll be communicating about these changes in future issues of The Record.

If you have any questions about these changes, contact your PGIP physician organization.

Corrective action plans can affect PGIP physicians’ value-based reimbursement eligibility

Primary care physicians and specialists participating in the Physician Group Incentive Program are eligible to receive value-based reimbursement as set forth in the Value-Based Reimbursement Fee Schedule. Value-based reimbursement is available to practitioners who meet the criteria for quality programs developed under PGIP.

However, practitioners may become ineligible for value-based reimbursement if Blue Cross Blue Shield of Michigan places them on a corrective action plan because they don’t meet utilization standards. They’ll remain ineligible until the designation cycle following the completion of the requirements of their corrective action plan.

The review process

Blue Cross’ PPO credentialing and network management teams review PPO/TRUST practitioner credentialing and profile information to help determine which applicants should be accepted for initial and continued affiliation in the network.

The network management team:

• Evaluates each practitioner’s business practice profile against established demographic and utilization criteria
• Compares the practitioner’s utilization to that of his or her peers who also practice in Michigan and have a similar specialty

Every practitioner in the PPO/TRUST network contractually agrees to provide PPO members with efficient, cost-effective care that meets prevailing utilization standards. Blue Cross monitors utilization patterns with the understanding that the unique aspects of a practitioner’s individual practice may affect his or her ability to perform within the averages established by the practitioner’s peers.

Individual practice profile data is reviewed twice a year (March and September). Blue Cross monitors PPO practice profiles to evaluate practice patterns and ensure PPO standards are met. The network management team typically evaluates TRUST practices based on the cost of care.

Working with Network Management

Practitioners who receive a formal communication from PPO Network Management regarding utilization have an opportunity to provide valid reasons for the variance in their practice profile. A practitioner may be placed on a corrective action plan, or CAP, after PPO Network Management has reviewed the practitioner’s rationale for the variance. Failure to respond to communications will result in being placed on a CAP.

Any practitioner placed on a CAP will lose any applicable value-based reimbursement 60 days after being placed on the CAP.

After successful completion of a CAP, practitioners will be eligible for value-based reimbursement evaluation during the next designation cycle.

Moving forward, in additional to letters being sent to the individual practitioner, a copy will be sent to the practitioner’s physician organization (if the practitioner is a PGIP participant).

For more information

For more information about the PPO Network Management corrective action process, see the November 2012 Record article titled TRUST PPO network information in review.

For more details on the value-based reimbursement criteria, see the February 2018 Record article titled Corrective action affects your value-based reimbursement eligibility.

Board-certified behavior analysts will need to be licensed by State of Michigan to be eligible for reimbursement

Starting Jan. 7, 2020, board-certified behavior analysts practicing in Michigan must have a current license from the State of Michigan to be eligible for reimbursement from Blue Cross Blue Shield of Michigan and Blue Care Network. Board-certified behavior analysts who aren’t licensed aren’t eligible for reimbursement for services provided on or after Jan. 7, 2020.

For information on the licensing process, refer to the Behavior Analysts webpage** of the Michigan Department of Licensing and Regulatory Affairs website.

**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.

Auditing will begin Sept. 1 for Medicare Plus Blue’s reimbursed diagnosis-related group claims

HMS^® will begin auditing Medicare Plus Blue^SM PPO’s reimbursed diagnosis-related group claims for clinical and coding validation, starting Sept. 1, 2019. HMS is an independent company working for Blue Cross Blue Shield of Michigan.

The audits will review medical records to ensure claims were billed in accordance with coding guidelines, and diagnoses were supported by documentation in the medical record.

Be ready to share medical charts for review. After an audit, HMS will send the findings and information on how you can ask for an appeal, if necessary.

The purpose of the clinical audit of the diagnosis-related group, or DRG, is to:

• Confirm compliance with national coding guidelines.
• Ensure documentation supports diagnoses and procedures reported.
• Detect, prevent and correct waste and abuse.
• Facilitate accurate claim payments.

HMS will be holding webinars for providers with information on the overall DRG clinical validation process and helpful tips. Schedules will be provided in a future web-DENIS message.

DRG clinical validation audits take a three-phase approach. See the scope of each phase and the data period for each phase in the chart below.

Questions?
During an audit, call 1-866-875-1749 to speak with an HMS representative.

Reminder: You’re invited to a Stars Premiere event near you

This year, Blue Cross Blue Shield of Michigan’s Quality and Provider Education team and the Customer Experience team are inviting you to a special production called the Stars Premiere.

Don’t miss this opportunity to join us to hear about and experience the latest ideas for providing exceptional patient experiences. The event will include information about Medicare Stars HEDIS^® measures,** the Health Outcomes Survey and much more.

The Stars Premiere will be held in theaters around the state. When you attend, you will engage in 90 minutes of conversation and practice activities and walk away with tips and tactics to implement in your office to improve patient experience and earn Continuing Education Unit credits from AAPC. We’ll also include important information about closing gaps in care.

What to expect

You’ll be able to choose from either the 8 a.m. or 11 a.m. session, depending on your area of interest. There will be morning refreshments and movie popcorn. Here’s the schedule of events:

• 8 a.m. session
• 8 to 9:30 a.m.: Patient experience and satisfaction session for physicians, office managers and other patient experience leaders
• 9:30 to 10:45 a.m.: HEDIS, HOS and Stars update session for physicians, office managers and other staff who work to close gaps in care

Note: Arrive at 7:45 a.m. for refreshments.

• 11 a.m. session
• 11 a.m. to noon: ICD-10 for coders, billers and others interested in coding

Note: Arrive at 10:45 a.m. for refreshments.

Locations and registration

The dates and locations are below. To register, click on the links. Note: Registration is required in order to attend this event.

• Tuesday, Sept. 17: Celebration! Cinema Lansing & IMAX, 200 E. Edgewood Blvd., Lansing
• 8 a.m. session
• 11 a.m. session

• Wednesday, Sept. 18: Celebration! Cinema Grand Rapids North & IMAX, 2121 Celebration Drive NE., Grand Rapids
• 8 a.m. session
• 11 a.m. session

• Thursday, Sept. 19: AMC Cherry Blossom 14, 3825 Marketplace Circle, Traverse City
• 8 a.m. session
• 11 a.m. session

• Tuesday, Sept. 24: AMC Forum 30, 44681 Mound Road, Sterling Heights
• 8 a.m. session
• 11 a.m. session

• Wednesday, Sept. 25: GQY Quality 10 GDX, 3250 Kabobel Drive, Saginaw
• 8 a.m. session
• 11 a.m. session

• Thursday, Sept. 26: GQT Quality 16, 3686 Jackson Road, Ann Arbor
• 8 a.m. session
• 11 a.m. session

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

Quarterly update: Requirements changed for some commercial medical benefit drugs

Blue Cross Blue Shield of Michigan and Blue Care Network encourage proper utilization of high-cost medications that are covered under the medical benefit. As part of this effort, we maintain a comprehensive list of requirements for both PPO and HMO commercial members.

During April, May and June of 2019, the following medical drugs had authorization requirements updates, site-of-care updates or both:

**Will become a unique code.

For a more detailed list of requirements, review the Blue Cross or BCN Drugs Covered Under the Medical Benefit pages at ereferrals.bcbsm.com.

Additional notes
The authorization requirements apply only to groups that are currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. Refer to the opt-out list for PPO groups that don’t require members to participate in the programs. Follow these steps to access the list:

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 on the right.
6. Click on BCBSM Medical Drug Prior Authorization Program list of groups that have opted out.

These changes don’t apply to Medicare Plus Blue^SM PPO, Federal Employee Program^® Service Benefit Plan or BCN Advantage^SM members.

An authorization approval isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.

Inflectra to be preferred infliximab product for adult commercial PPO members, beginning Nov. 1

Starting Nov. 1, 2019, Inflectra^® (infliximab-dyyb and HCPCS code Q5103) will be the preferred infliximab product for adult Blue Cross Blue Shield of Michigan commercial PPO members.

Action required

As of Nov. 1, 2019, adult PPO members with an active authorization for an infliximab product other than Inflectra must transition to Inflectra.

The infliximab products other than Inflectra are:

• Remicade^® (infliximab) — HCPCS code J1745
• Renflexis^® (infliximab-abda) — HCPCS code Q5104

This change doesn’t apply to:

• Pediatric members age 15 or younger
• Pediatric members age 18 or younger and weighing 50 kg or less
• Any member covered by Medicare Plus Blue^SM PPO, BCN Advantage^SM or a Federal Employee Program^® Service Benefit Plan.

Note: This change took effect for BCN HMO^SM commercial members on May 1, 2019.

The authorization requirements apply only to groups currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. Refer to the opt-out list for PPO groups that don’t require members to participate in the programs. To access the list, 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 on the right.
6. Click on BCBSM Medical Drug Prior Authorization Program list of groups that have opted out.

To access the medical policy on Inflectra:

1. Use the Medical Policies search tool.
2. Type "Inflectra" in the Policy/Topic Keyword field (not necessary to select a category).
3. Click Search.
4. Click the PDF, MEDICAL POLICY — INFLIXIMAB: REMICADE (J1745), RENFLEXIS (Q5104), INFLECTRA (Q5103).

On Nov. 1, the updated requirements for Inflectra will appear in the Blue Cross and BCN utilization management medical drug list.

Medicare Part B medical specialty drug prior authorization list changing in October

We’re adding the following medications to the Medicare Plus Blue^SM PPO and BCN Advantage^SM Part B specialty prior authorization drug list.

For dates of service on or after Oct. 1, 2019, the following medications will require prior authorization:

• J1599 Asceniv™
• J1301 Radicava^®
• J0584 Crysvita^®
• J0565 Zinplava™

Medicare Plus Blue PPO

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

We require prior authorization for these medications when you bill them as a professional service or as an outpatient facility service and you bill 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.

Reminders

• You must obtain authorization before administering these medications. Use the NovoLogix^® online tool to quickly submit your authorization 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 tool.
• For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

Blue Cross and BCN launch new Preferred Drug List for group employees

Blue Cross Blue Shield of Michigan and Blue Care Network now offer the Preferred Drug List, a lower-cost drug formulary for self-funded and large group employees.

The Preferred Drug List includes therapeutically effective medications that have the greatest clinical value at the lowest net cost. Our Pharmacy & Therapeutics Committee of physicians and pharmacists reviews and approves these medications based on clinical efficacy and safety. In addition, Blue Cross and BCN pharmacists review and update the drug list regularly to keep pace with the ever-changing prescription drug market.

The Preferred Drug List program features:

• Medications selected for their clinical effectiveness, safety and maximized savings
• Exclusions of certain medications that don’t provide greater clinical value than comparable or lower net cost alternatives. Examples include:
• Medications with lower-cost generic equivalents
• Medications with lower net cost brand or lower-cost generic alternatives with the same therapeutic outcomes

Click here to see the Preferred Drug List.

We’re adding medical benefit specialty drugs to prior authorization and site of care programs for PPO members, starting Oct. 1

The Medical Drug Prior Authorization and Site of Care programs are expanding for Blue Cross Blue Shield of Michigan commercial members to include:

Ocrevus (prior authorization and site of care)
We’ll require prior authorization for Ocrevus for members initiating therapy on or after Oct. 1, 2019. If your patient currently receives Ocrevus infusions at an outpatient hospital facility, you may need to discuss other infusion options. Members who currently receive Ocrevus at one of the following locations will be covered until Sept. 30, 2020:

• Doctor’s or other health care provider’s office
• The member’s home, from a home infusion therapy provider
• Ambulatory infusion center

Starting Oct. 1, 2020, these members will need an approval from Blue Cross before we’ll approve payment for Ocrevus.

Lemtrada and Tysabri (prior authorization only)

We’ll require prior authorization for Lemtrada and Tysabri for members initiating therapy on or after Oct. 1, 2019.

Members currently receiving therapy will be covered until Sept. 30, 2020, when received in the following locations:

• Doctor’s or other health care provider’s office
• The member’s home (from a home infusion therapy provider)
• Ambulatory infusion center
• Hospital outpatient facility

Starting Oct. 1, 2020, these members will need an approval from Blue Cross before we’ll approve payment for Lemtrada or Tysabri.

More about the authorization requirements

The prior authorization requirements apply only to groups currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. Refer to the opt-out list for PPO groups that don’t require members to participate in the programs. To access the list, log in to Provider Secured Services and follow these steps:

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

These changes don’t apply to Medicare Plus Blue^SM PPO or Federal Employee Program^® Service Benefit Plan members.

An authorization approval isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.

List of requirements

For a list of requirements related to drugs covered under the medical benefit, click here or visit this page on our ereferrals.bcbsm.com website.

The requirements that take effect on Oct. 1 will be reflected in the requirements list by that date.

Blue Cross reserves the right to review drugs for medical necessity before the effective dates listed in this message. We hope you’ll join our effort to keep health care affordable for all by supporting our members as they move to new infusion therapy locations.

Use American Heart Association chart to help your patients with medication adherence

Taking medication correctly might seem simple, but nonadherence is a complicated and common problem for many patients. Some patients don’t realize that not taking their asthma, diabetes or cardiovascular medications as prescribed puts them at risk for respiratory arrest, kidney failure or stroke.

The Health Resource and Service Administration found that the following percentage of people with these chronic conditions don’t take their medication as directed:

• Coronary heart disease — 40 to 50%
• Hypertension — 16 to 22%
• Diabetics prescribed insulin — 37%
• Asthma — 25 to 75%

Not taking medication as prescribed also results in 10% of total hospital admissions, 22% of nursing home admissions and is associated with 125,000 deaths, according to the HRSA. This results in $100 billion a year in unnecessary hospital charges and costs the U.S. economy $300 billion a year.

The American Heart Association developed a printable medication chart** to help patients with medication adherence.

An FEP^® reminder

The Federal Employee Program^® provides registered nurses and online health coaches to help members manage their chronic conditions. FEP members can call Customer Service at 1-800-482-3600 for assistance or go online at www.fepblue.org.

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

Oncology management program for MA plans begins in January

A new utilization management program for medical oncology for Medicare Plus Blue^SM PPO and BCN Advantage^SM members will begin in January 2020. Providers will need to obtain authorizations from AIM Specialty Health^® for certain medical oncology and supportive care medications.

The program, which became effective for BCN HMO^SM commercial members in August, includes the following benefits:

• Synchronization with Blue Cross Blue Shield of Michigan’s and Blue Care Network’s medical policies
• Access to the AIM ProviderPortal^SM 24 hours a day, seven days a week for automated clinical appropriateness review and access to the AIM contact center personnel, including oncology nurses and oncologists, during business hours
• Actionable information, including a comprehensive set of current, evidence-based AIM Cancer Treatment Pathways for more than 80 clinical scenarios
• Enhanced reimbursement when choosing an AIM Cancer Treatment Pathway regimen when clinically appropriate (to be billed using designated S-codes)

Providers can view a list of medications managed by AIM at ereferrals.bcbsm.com.

Join a webinar to learn more

Learn about the new medical oncology program and how to use the AIM ProviderPortal^SM by attending a webinar for non-clinical provider staff.

To attend the webinar, click on your preferred date and time below and then click Add to my calendar. (If the time displays in Pacific time when you click on the link, simply save it to your calendar and it should automatically change to Eastern time.)

Thursday, Oct. 24, 9 to 10 a.m.

Thursday, Nov. 21, 9 to 10 a.m.

Thursday, Dec. 12, 9 to 10 a.m.

Wednesday, Dec. 18, noon to 1 p.m.

Thursday, Jan. 9, 2020, 9 to 10 a.m.

Wednesday, Jan. 22, 2020, noon to 1 p.m.

For more information

• Clinicians who would like to learn more can go to aimspecialtyhealth.com/oncology.**
• To view a short video — Clinician Overview — Medical Oncology Program — that describes the need for clinical pathways and how they were developed, use the password AIMONCOLOGY.

We’ll be providing additional information as we near the effective date.

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

Remind your patients of the importance of colorectal cancer screening

According to the American Cancer Society, colorectal cancer is the third most common cancer diagnosed in both men and women in the United States. Your patients may be under the assumption that a colonoscopy is the only way to test for colorectal cancer, but there are many screenings available to choose from. Talk to your patients about the importance of early detection and the types of tests available, including those that are noninvasive.

It’s important for providers to document the type of screening performed or any exclusions in the patient’s medical record. Exclusions for this measure have changed to include advanced illness and frailty of the patient.

Providers should ensure they order the most appropriate colorectal screen indicated based on the patient’s status.

View the Colorectal Cancer Screening tip sheet to learn more about the measure, information to include in a patient’s record, CPT codes that should be included in claims, and tips for talking with patients.

Star Measure Tips posted on web-DENIS

A series of 15 Star Measure Tips has been posted on web-DENIS.

Each tip sheet focuses on a specific measure related to the Centers for Medicare & Medicaid Services’ five-star quality rating system.

A health plan’s rating is based on measures in five categories, including:

• Staying healthy (screenings tests and vaccines)
• Managing chronic conditions
• Member experience with the health plan

By meeting these quality measures, we can help improve the quality of care for Medicare beneficiaries and make it easier for them to compare health plans.

Keep in mind that most of the Star measures featured in the series are HEDIS^® measures** as well. We wrote about our HEDIS measure tip sheets in an August Record article.

You can access both the Star Measure Tips and HEDIS Measure Tips from the homepage of web-DENIS by following these steps:

• Click on BCBSM Provider Publications and Resources in the left column.
• Click on Newsletters & Resources.
• Click on Clinical Quality Corner on the left-hand side of the page under Other Resources.

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

Gain office efficiencies by encouraging patients to use the Blue Cross mobile app

When our members actively use their health plan account’s app, they’re more prepared when they need to communicate with you and receive care. It can save doctors and office staff time with fewer patient inquiries and follow-up calls.

A small amount of encouragement from you can make a big difference in increasing patient engagement with this useful tool.

Order the toolkit to get started

The Blue Cross mobile app awareness toolkit can help you spread the word to patients about the conveniences of using the app. The kit includes postcards, an acrylic stand that holds the postcards and a poster to display in your lobby or exam rooms. If you already have a kit, you can order just posters and postcards using the Mobile app supplies order form.

What’s great about the app

Blue Cross Blue Shield of Michigan and Blue Care Network members can access the app right from your office to securely connect to their personal online account.

This immediate access to their account allows the member to:

• Provide their virtual member ID card for services.
• Check copayment amounts.
• Help doctors and office staff verify current prescriptions (if they have pharmacy coverage).

The app also gives patients the tools they need — without having to call you — when they want to:

• Confirm specialists are in our network.
• Verify the status of referrals and authorizations.
• Check what’s covered.
• Review their explanation of benefits to pay bills.

Use the Mobile app supplies order form to order your toolkit today and start spreading the word.

Sign up for additional training webinars

Provider Experience is continuing its series of training webinars for health care providers and staff. The webinars are designed to help you work more efficiently with Blue Cross Blue Shield of Michigan and Blue Care Network.

Here’s information on upcoming webinars:

Blues 201 webinars provide in-depth learning opportunities for providers, building on information shared in our Blues 101: Understanding the Basics webinar.

As additional training webinars become available, we’ll communicate about them through web-DENIS or The Record.

How can we improve our online tools?

Blue Cross Blue Shield of Michigan and Blue Care Network want to know how we can make our online tools easier to use and more useful for you, our partner providers. We specifically want to know about your experience using online provider tools and services, including the tools available when you log in to our secure provider website at bcbsm.com.

Can you spare eight minutes to share your thoughts? Your input will help us focus future improvements that are most helpful to you.

This survey will be available through the end of September 2019. Thank you for sharing your opinions. Your responses will be confidential.

Blue Cross Coordinated Care to launch in 2020

Next year, Blue Cross Blue Shield of Michigan and Blue Care Network will launch a new approach to care management called Blue Cross^® Coordinated Care. The program is intended to support health care providers in their efforts to provide the best possible care for patients.

Blue Cross Coordinated Care 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, BCN, group and individual customers, and Medicare Advantage members.

Specially designated nurse care managers will lead multidisciplinary teams to:

• Help patients understand their treatment plan and options.
• Answer any questions patients may have regarding their chronic conditions.
• Help coordinate your patient’s care with you and other health care providers, including pharmacists, behavioral health clinicians and social workers.
• Assist in getting additional resources patients may need for their specific health care needs, such as transportation.
• Co-manage patients who are already part of a provider care management program, such as Provider-Delivered Care Management, to provide additional support and resources.

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 that ran in the May – June 2019 issue of Hospital and Physician Update.

We’re making changes to increase security on Provider Secured Services, effective Sept. 12

Your online security is important to us, so we’re making some changes to Provider Secured Services to help make your information and transactions more secure.

The following changes will go into effect Sept. 12:

• Your user ID will be deactivated after 90 days of inactivity.
• We’ll maintain a password history of six passwords. When you change your password, it must be different from your previous six passwords.
• Password length is changing to a minimum of eight characters.
• New passwords must contain at least one:
• Number
• Upper case letter
• Lower case letter
• Special character
• Your password can’t be the same as your user ID.
• You’ll need to change your password every 60 days. The system will prompt you when it’s time to do so.

Signing in after Sept. 12

Users will be able to sign on with their current passwords after we make our security changes.

How to restore access if your user ID has been disabled

Your user ID will be disabled if you enter your password incorrectly three times. To re-enable your ID, you must answer your security questions accurately. If you answer them wrong three times, the account will be locked, and you’ll need to call the Web Support Help Desk to unlock your ID.

You can reach the Web Support Help Desk at 1-877-258-3932 from 8 a.m. to 8 p.m. Monday through Friday.

If your account has been deactivated

We’ll have a new process for restoring access to an account that’s been deactivated.

Complete and fax the Provider Secured Services ID Reassignment form to us. Directions for faxing it are on the form.

Questions?

If you have questions or have trouble logging in, call the Web Support Help Desk at 1-877-258-3932.

How to request prior authorization through New Directions for behavioral health, substance abuse benefits for State of Michigan enrollees

New Directions Behavioral Health will manage behavioral health and substance use disorder benefits on behalf of Blue Cross Blue Shield of Michigan for State of Michigan enrollees (group number 007000562), effective Oct. 1, 2019.

Their services were previously managed by Magellan Health. This change affects services provided on or after Oct. 1, 2019.

New Directions will be responsible for prior authorizations, as well as approvals and denials of all behavioral health and substance use disorder admissions. This includes outpatient services for applied behavioral analysis, or ABA, and intensive outpatient, or IOP, services. New Directions will also provide case management services.

Prior authorizations

You’ll have to log in to WebPass** on the New Directions website to request prior authorizations for State of Michigan members. To learn how to use WebPass, go to New Directions’ WebPass site and click on either To watch the Facility WebPass tutorial click here or To watch the ABA Provider WebPass tutorial click here.

Reminders

• Medical necessity criteria for New Directions is available on web-DENIS.
• Be sure to check your patients’ member ID cards and web-DENIS for eligibility and prior authorization information.

More information

For more information on current claims, prior authorizations and fee schedule, refer to the August 2019 Record article.

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

September is Suicide Prevention Awareness Month

Each year, more than 41,000 individuals die by suicide, according to the National Alliance on Mental Illness. That’s why NAMI has designated September as Suicide Prevention Awareness Month.

It’s a time for sharing information and resources about this public health crisis as part of an effort to decrease suicide rates. In addition to the resources provided by NAMI**, we encourage you to check out:

• The Mental health awareness section of Blue Cross Blue Shield of Michigan’s Engage page, which offers an array of resources suitable for sharing with employees or patients. There are three articles on suicide awareness and prevention posted under Educational materials and five posters in the Posters section.
• Our MI Blues Perspectives blog, which will cover such topics as the shortage of behavioral health providers in rural Michigan and how we can change the language we use to discuss suicide to reduce stigma during the month of September. We’ll also have a presence on our Facebook, Twitter and LinkedIn accounts.
• Columns about suicide prevention in the September/October issues of Hospital and Physician Update and BCN Provider News.

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

New advanced illness and frailty exclusions for certain HEDIS^® star measures

The National Committee for Quality Assurance now allows providers to exclude patients from select Medicare Star Rating System measures that are also HEDIS^® measures** due to advanced illness and frailty. NCQA acknowledges that some measured services won’t benefit patients who are in declining health.

You can now submit claims with advanced illness and frailty codes to exclude patients who meet the criteria from these measures. Using the appropriate codes also reduces the number of medical record requests you may receive for HEDIS data collection purposes.

For a description of the criteria and a list of HEDIS-approved billing codes, view the 2019 HEDIS^® Advanced Illness and Frailty Exclusions Guide.

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

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

Study calls incidence of untreated mental illness and substance abuse ‘staggering’
Hundreds of thousands of Michigan residents with a mental illness or substance use disorder are untreated, a crisis compounded by a shortage of health professionals and treatment facilities, according to the findings of a report** released July 30. Commissioned by the Michigan Health Endowment Fund, the analysis cites anxiety disorders, depression and alcohol use disorder as among conditions most left untreated. The fund is a grant-making arm of Blue Cross Blue Shield of Michigan.

Patients taking opioids could face health care access problems
Taking opioids for chronic pain may make it hard to find primary care, according to a University of Michigan Health Lab blog.** According to a new study, 40% of 194 primary care clinics contacted said they wouldn’t accept a new patient who takes Percocet daily for pain from a past injury, no matter what kind of health insurance they had. Another 17% said they would want more information before deciding whether to take on the patient. However, the team did find that larger clinics and those that offer safety net coverage were three times more likely than others to accept patients who currently take opioids for chronic pain. The findings were published in JAMA Network Open.**

Michigan doctors writing fewer opioid prescriptions
Michigan doctors wrote 1.4 million fewer opioid prescriptions in 2018 — a 15% drop — than they did in 2017, according to newly released data from state officials, MLive.com** reported July 1. Overall, the number of prescriptions of controlled substances dropped 11.5% in 2018. It's the biggest year-over-year decrease in prescriptions Michigan has seen in recent history; a decline that began in 2015. Part of that is due to the state's tracking system, called the Michigan Automated Prescription System, or MAPS, which launched in 2017.

Where did all the pain pills go?
New information provides a look at where the drugs responsible for the opioid epidemic ended up, the Detroit Free Press** reported July 19. Michigan was flooded with almost 3 billion prescription pain pills between 2006 and 2012, fueling the opioid crisis, according to a Washington Post analysis** of a government database. Ogemaw County, home to the northern Michigan communities of West Branch and Rose City, had the heaviest saturation of pills: 125.7 pills per person a year. Overall, it received just over 19 million pills.

Number of Michigan’s drug overdose deaths down slightly
Are the country’s united efforts to fight the opioid epidemic starting to have an effect? New information shows that may be the case. The Detroit Free Press** reported July 19 that the number of drug overdose deaths declined slightly in Michigan and across the nation in 2018, according to preliminary information released by the U.S. Centers for Disease Control and Prevention. Drug overdose deaths fell 3.7% in Michigan, from 2,690 in 2017 to 2,591 in 2018, according to the CDC report. Nationally, there were about 68,557 overdose deaths, a 5% decline from 72,224 deaths in 2017. It is the first decline in drug overdose deaths since 1990.

Helping expectant mothers with mental illness, substance abuse
Blue Cross recently awarded a $90,000 grant to Cherry Health in Grand Rapids to help fund services for high-risk expectant mothers with mental illness, substance use disorder or insufficient prenatal care. The grant supports Blue Cross’ mission to address the growing opioid epidemic in Michigan.

More than 100 Kent County residents died of an opioid overdose in 2017, said Kelley Root, West Michigan regional sales director at Blue Cross. We also know from the National Institute of Drug Abuse that untreated opioid use disorder during pregnancy can have devastating consequences on an unborn child.

Cherry Health is Michigan’s largest Federally Qualified Health Center. More than 20% of its patients are uninsured, and 95% earn below the federal poverty level.

The grant is part of Blue Cross’ Strengthening the Safety Net program. The program has provided more than $14 million in grants since 2005.

Prescribing opioids for a sprained ankle?
While ankle sprain injuries are common, a new report from Michigan Medicine** suggests that the rate of opioids prescribed to those patients has become uncommonly high. The authors urge fellow physicians to be aware of the current treatment guidelines.

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

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.

Quarterly update: Requirements changed for some commercial medical benefit drugs

Blue Cross Blue Shield of Michigan and Blue Care Network encourage proper utilization of high-cost medications that are covered under the medical benefit. As part of this effort, we maintain a comprehensive list of requirements for both PPO and HMO commercial members.

During April, May and June of 2019, the following medical drugs had authorization requirements updates, site-of-care updates or both:

**Will become a unique code.

For a more detailed list of requirements, review the Blue Cross or BCN Drugs Covered Under the Medical Benefit pages at ereferrals.bcbsm.com.

Additional notes
The authorization requirements apply only to groups that are currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. Refer to the opt-out list for PPO groups that don’t require members to participate in the programs. Follow these steps to access the list:

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 on the right.
6. Click on BCBSM Medical Drug Prior Authorization Program list of groups that have opted out.

These changes don’t apply to Medicare Plus Blue^SM PPO, Federal Employee Program^® Service Benefit Plan or BCN Advantage^SM members.

An authorization approval isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.

Inflectra to be preferred infliximab product for adult commercial PPO members, beginning Nov. 1

Starting Nov. 1, 2019, Inflectra^® (infliximab-dyyb and HCPCS code Q5103) will be the preferred infliximab product for adult Blue Cross Blue Shield of Michigan commercial PPO members.

Action required

As of Nov. 1, 2019, adult PPO members with an active authorization for an infliximab product other than Inflectra must transition to Inflectra.

The infliximab products other than Inflectra are:

• Remicade^® (infliximab) — HCPCS code J1745
• Renflexis^® (infliximab-abda) — HCPCS code Q5104

This change doesn’t apply to:

• Pediatric members age 15 or younger
• Pediatric members age 18 or younger and weighing 50 kg or less
• Any member covered by Medicare Plus Blue^SM PPO, BCN Advantage^SM or a Federal Employee Program^® Service Benefit Plan.

Note: This change took effect for BCN HMO^SM commercial members on May 1, 2019.

The authorization requirements apply only to groups currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. Refer to the opt-out list for PPO groups that don’t require members to participate in the programs. To access the list, 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 on the right.
6. Click on BCBSM Medical Drug Prior Authorization Program list of groups that have opted out.

To access the medical policy on Inflectra:

1. Use the Medical Policies search tool.
2. Type "Inflectra" in the Policy/Topic Keyword field (not necessary to select a category).
3. Click Search.
4. Click the PDF, MEDICAL POLICY — INFLIXIMAB: REMICADE (J1745), RENFLEXIS (Q5104), INFLECTRA (Q5103).

On Nov. 1, the updated requirements for Inflectra will appear in the Blue Cross and BCN utilization management medical drug list.

Medicare Part B medical specialty drug prior authorization list changing in October

We’re adding the following medications to the Medicare Plus Blue^SM PPO and BCN Advantage^SM Part B specialty prior authorization drug list.

For dates of service on or after Oct. 1, 2019, the following medications will require prior authorization:

• J1599 Asceniv™
• J1301 Radicava^®
• J0584 Crysvita^®
• J0565 Zinplava™

Medicare Plus Blue PPO

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

We require prior authorization for these medications when you bill them as a professional service or as an outpatient facility service and you bill 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.

Reminders

• You must obtain authorization before administering these medications. Use the NovoLogix^® online tool to quickly submit your authorization 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 tool.
• For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

Blue Cross and BCN launch new Preferred Drug List for group employees

Blue Cross Blue Shield of Michigan and Blue Care Network now offer the Preferred Drug List, a lower-cost drug formulary for self-funded and large group employees.

The Preferred Drug List includes therapeutically effective medications that have the greatest clinical value at the lowest net cost. Our Pharmacy & Therapeutics Committee of physicians and pharmacists reviews and approves these medications based on clinical efficacy and safety. In addition, Blue Cross and BCN pharmacists review and update the drug list regularly to keep pace with the ever-changing prescription drug market.

The Preferred Drug List program features:

• Medications selected for their clinical effectiveness, safety and maximized savings
• Exclusions of certain medications that don’t provide greater clinical value than comparable or lower net cost alternatives. Examples include:
• Medications with lower-cost generic equivalents
• Medications with lower net cost brand or lower-cost generic alternatives with the same therapeutic outcomes

Click here to see the Preferred Drug List.

We’re adding medical benefit specialty drugs to prior authorization and site of care programs for PPO members, starting Oct. 1

The Medical Drug Prior Authorization and Site of Care programs are expanding for Blue Cross Blue Shield of Michigan commercial members to include:

Ocrevus (prior authorization and site of care)
We’ll require prior authorization for Ocrevus for members initiating therapy on or after Oct. 1, 2019. If your patient currently receives Ocrevus infusions at an outpatient hospital facility, you may need to discuss other infusion options. Members who currently receive Ocrevus at one of the following locations will be covered until Sept. 30, 2020:

• Doctor’s or other health care provider’s office
• The member’s home, from a home infusion therapy provider
• Ambulatory infusion center

Starting Oct. 1, 2020, these members will need an approval from Blue Cross before we’ll approve payment for Ocrevus.

Lemtrada and Tysabri (prior authorization only)

We’ll require prior authorization for Lemtrada and Tysabri for members initiating therapy on or after Oct. 1, 2019.

Members currently receiving therapy will be covered until Sept. 30, 2020, when received in the following locations:

• Doctor’s or other health care provider’s office
• The member’s home (from a home infusion therapy provider)
• Ambulatory infusion center
• Hospital outpatient facility

Starting Oct. 1, 2020, these members will need an approval from Blue Cross before we’ll approve payment for Lemtrada or Tysabri.

More about the authorization requirements

The prior authorization requirements apply only to groups currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. Refer to the opt-out list for PPO groups that don’t require members to participate in the programs. To access the list, log in to Provider Secured Services and follow these steps:

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

These changes don’t apply to Medicare Plus Blue^SM PPO or Federal Employee Program^® Service Benefit Plan members.

An authorization approval isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.

List of requirements

For a list of requirements related to drugs covered under the medical benefit, click here or visit this page on our ereferrals.bcbsm.com website.

The requirements that take effect on Oct. 1 will be reflected in the requirements list by that date.

Blue Cross reserves the right to review drugs for medical necessity before the effective dates listed in this message. We hope you’ll join our effort to keep health care affordable for all by supporting our members as they move to new infusion therapy locations.

We’ve expanded our vaccine program for Medicare Plus Blue members

As you may have seen in a recent web-DENIS message, we’ve expanded the Medicare Plus Blue^SM Part B Vaccine Program as part of an effort to improve the satisfaction of our members.

All Blue Cross Blue Shield of Michigan Medicare Plus Blue PPO individual and group members with or without Part D drug coverage can get influenza and pneumococcal vaccines administered at any participating network pharmacy where the vaccines are available.

Our network includes more than 60,000 pharmacies across the U.S. Pharmacies process and bill the vaccinations under members’ Medicare Plus Blue PPO Part B vaccine coverage at $0 cost share.

Members who receive these vaccines at network pharmacies can now avoid paying out of pocket for the full amount and filing a claim form to get reimbursed.

This expansion took place May 1, 2019.

Board-certified behavior analysts will need to be licensed by State of Michigan to be eligible for reimbursement

Starting Jan. 7, 2020, board-certified behavior analysts practicing in Michigan must have a current license from the State of Michigan to be eligible for reimbursement from Blue Cross Blue Shield of Michigan and Blue Care Network. Board-certified behavior analysts who aren’t licensed aren’t eligible for reimbursement for services provided on or after Jan. 7, 2020.

For information on the licensing process, refer to the Behavior Analysts webpage** of the Michigan Department of Licensing and Regulatory Affairs website.

**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.

Auditing will begin Sept. 1 for Medicare Plus Blue’s reimbursed diagnosis-related group claims

HMS^® will begin auditing Medicare Plus Blue^SM PPO’s reimbursed diagnosis-related group claims for clinical and coding validation, starting Sept. 1, 2019. HMS is an independent company working for Blue Cross Blue Shield of Michigan.

The audits will review medical records to ensure claims were billed in accordance with coding guidelines, and diagnoses were supported by documentation in the medical record.

Be ready to share medical charts for review. After an audit, HMS will send the findings and information on how you can ask for an appeal, if necessary.

The purpose of the clinical audit of the diagnosis-related group, or DRG, is to:

• Confirm compliance with national coding guidelines.
• Ensure documentation supports diagnoses and procedures reported.
• Detect, prevent and correct waste and abuse.
• Facilitate accurate claim payments.

HMS will be holding webinars for providers with information on the overall DRG clinical validation process and helpful tips. Schedules will be provided in a future web-DENIS message.

DRG clinical validation audits take a three-phase approach. See the scope of each phase and the data period for each phase in the chart below.

Questions?
During an audit, call 1-866-875-1749 to speak with an HMS representative.

Quarterly update: Requirements changed for some commercial medical benefit drugs

Blue Cross Blue Shield of Michigan and Blue Care Network encourage proper utilization of high-cost medications that are covered under the medical benefit. As part of this effort, we maintain a comprehensive list of requirements for both PPO and HMO commercial members.

During April, May and June of 2019, the following medical drugs had authorization requirements updates, site-of-care updates or both:

**Will become a unique code.

For a more detailed list of requirements, review the Blue Cross or BCN Drugs Covered Under the Medical Benefit pages at ereferrals.bcbsm.com.

Additional notes
The authorization requirements apply only to groups that are currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. Refer to the opt-out list for PPO groups that don’t require members to participate in the programs. Follow these steps to access the list:

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 on the right.
6. Click on BCBSM Medical Drug Prior Authorization Program list of groups that have opted out.

These changes don’t apply to Medicare Plus Blue^SM PPO, Federal Employee Program^® Service Benefit Plan or BCN Advantage^SM members.

An authorization approval isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.

Inflectra to be preferred infliximab product for adult commercial PPO members, beginning Nov. 1

Starting Nov. 1, 2019, Inflectra^® (infliximab-dyyb and HCPCS code Q5103) will be the preferred infliximab product for adult Blue Cross Blue Shield of Michigan commercial PPO members.

Action required

As of Nov. 1, 2019, adult PPO members with an active authorization for an infliximab product other than Inflectra must transition to Inflectra.

The infliximab products other than Inflectra are:

• Remicade^® (infliximab) — HCPCS code J1745
• Renflexis^® (infliximab-abda) — HCPCS code Q5104

This change doesn’t apply to:

• Pediatric members age 15 or younger
• Pediatric members age 18 or younger and weighing 50 kg or less
• Any member covered by Medicare Plus Blue^SM PPO, BCN Advantage^SM or a Federal Employee Program^® Service Benefit Plan.

Note: This change took effect for BCN HMO^SM commercial members on May 1, 2019.

The authorization requirements apply only to groups currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. Refer to the opt-out list for PPO groups that don’t require members to participate in the programs. To access the list, 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 on the right.
6. Click on BCBSM Medical Drug Prior Authorization Program list of groups that have opted out.

To access the medical policy on Inflectra:

1. Use the Medical Policies search tool.
2. Type "Inflectra" in the Policy/Topic Keyword field (not necessary to select a category).
3. Click Search.
4. Click the PDF, MEDICAL POLICY — INFLIXIMAB: REMICADE (J1745), RENFLEXIS (Q5104), INFLECTRA (Q5103).

On Nov. 1, the updated requirements for Inflectra will appear in the Blue Cross and BCN utilization management medical drug list.

Medicare Part B medical specialty drug prior authorization list changing in October

We’re adding the following medications to the Medicare Plus Blue^SM PPO and BCN Advantage^SM Part B specialty prior authorization drug list.

For dates of service on or after Oct. 1, 2019, the following medications will require prior authorization:

• J1599 Asceniv™
• J1301 Radicava^®
• J0584 Crysvita^®
• J0565 Zinplava™

Medicare Plus Blue PPO

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

We require prior authorization for these medications when you bill them as a professional service or as an outpatient facility service and you bill 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.

Reminders

• You must obtain authorization before administering these medications. Use the NovoLogix^® online tool to quickly submit your authorization 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 tool.
• For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

We’re adding medical benefit specialty drugs to prior authorization and site of care programs for PPO members, starting Oct. 1

The Medical Drug Prior Authorization and Site of Care programs are expanding for Blue Cross Blue Shield of Michigan commercial members to include:

Ocrevus (prior authorization and site of care)
We’ll require prior authorization for Ocrevus for members initiating therapy on or after Oct. 1, 2019. If your patient currently receives Ocrevus infusions at an outpatient hospital facility, you may need to discuss other infusion options. Members who currently receive Ocrevus at one of the following locations will be covered until Sept. 30, 2020:

• Doctor’s or other health care provider’s office
• The member’s home, from a home infusion therapy provider
• Ambulatory infusion center

Starting Oct. 1, 2020, these members will need an approval from Blue Cross before we’ll approve payment for Ocrevus.

Lemtrada and Tysabri (prior authorization only)

We’ll require prior authorization for Lemtrada and Tysabri for members initiating therapy on or after Oct. 1, 2019.

Members currently receiving therapy will be covered until Sept. 30, 2020, when received in the following locations:

• Doctor’s or other health care provider’s office
• The member’s home (from a home infusion therapy provider)
• Ambulatory infusion center
• Hospital outpatient facility

Starting Oct. 1, 2020, these members will need an approval from Blue Cross before we’ll approve payment for Lemtrada or Tysabri.

More about the authorization requirements

The prior authorization requirements apply only to groups currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. Refer to the opt-out list for PPO groups that don’t require members to participate in the programs. To access the list, log in to Provider Secured Services and follow these steps:

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

These changes don’t apply to Medicare Plus Blue^SM PPO or Federal Employee Program^® Service Benefit Plan members.

An authorization approval isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.

List of requirements

For a list of requirements related to drugs covered under the medical benefit, click here or visit this page on our ereferrals.bcbsm.com website.

The requirements that take effect on Oct. 1 will be reflected in the requirements list by that date.

Blue Cross reserves the right to review drugs for medical necessity before the effective dates listed in this message. We hope you’ll join our effort to keep health care affordable for all by supporting our members as they move to new infusion therapy locations.

Reminder: Update or review your demographic data twice a year

Our Blue Cross Blue Shield of Michigan and Blue Care Network members rely on the online provider directory for accurate, up-to-date provider information, so it’s important that you regularly confirm your demographic data.

Twice a year, our Provider Enrollment and Data Management team mails you your demographic data. When you receive this mailing:

• Review and confirm the accuracy of your demographic information.
• Respond to each mailing.

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

As data changes or updates are needed, send them to us via:

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

If you have questions or need support with updating your data, go to bcbsm.com/providers or call Provider Enrollment at 1-800-822-2761.