TurningPoint musculoskeletal authorization program to expand in January

We’ll add Blue Cross Blue Shield of Michigan commercial members to the TurningPoint Healthcare Solutions, LLC musculoskeletal program for spine, pain management and joint replacement surgeries and related procedures for dates of service on or after Jan. 1, 2021. At that time, the program will also expand to include pain management procedures for Blue Care Network commercial, BCN Advantage^SM and Medicare Plus Blue^SM members

In addition, spinal procedures for Medicare Plus Blue members will transition from being managed by eviCore healthcare^® to being managed by TurningPoint.

Providers can begin submitting authorization requests for the expanded procedures starting Dec. 1, 2020, for dates of service on or after Jan. 1, 2021.

In the September Record, we’ll provide information about the procedure codes that are affected by these changes and upcoming webinars for health care providers and their office staff. The information will also appear in a future issue of BCN Provider News.

Background

As reported in the July Record, health care providers should submit authorization requests through TurningPoint for musculoskeletal surgical procedures with a date of service on or after July 1, 2020, for BCN commercial, Medicare Plus Blue and BCN Advantage members. This includes spine and joint replacement surgeries and related procedures.

However, lumbar spinal fusion surgeries for Medicare Plus Blue members will continue to be managed by eviCore through 2020. You can find the codes for these procedures in the Lumbar spinal fusion surgery procedures requiring authorization by eviCore table in the Procedures that require authorization by eviCore healthcare document. The document is located on the ereferrals.bcbsm.com website. To locate it, click on Blue Cross and then on eviCore-Managed Procedures.

For more information

• See the e-referral webpages for Blue Cross and BCN.
• Find procedure codes for orthopedic and spinal procedures managed by TurningPoint on ereferrals.bcbsm.com as follows:
  • Orthopedic
  • Spinal
• Refer to the Frequently asked questions for providers document on our ereferrals.bcbsm.com website.

eviCore simplifies authorization process for radiation oncology

Beginning July 1, 2020, eviCore healthcare^® simplified the authorization process for radiation oncology so that you’ll see fewer clinical questions on authorization requests.

As part of the process, eviCore will be asking clinical decision support questions, rather than traditional clinical questions. This change applies to authorizations for breast, prostate and non-small-cell lung cancer.

What you need to do
The steps to submit authorization requests to eviCore won’t change. You’ll log in to the eviCore portal at evicore.com,** initiate a request for Clinical Certification for Radiation Therapy and enter information about the member.

For breast, prostate and non-small-cell lung cancer, the system will prompt you to answer the CDS clinical questions. Then you’ll select a treatment regimen from provided options or enter a custom treatment regimen.

Additional information
eviCore manages authorizations for radiation oncology for most fully insured Blue Cross commercial groups and for Medicare Plus Blue^SM, BCN commercial and BCN Advantage^SM members.

For more information, see the Blue Cross eviCore-Managed Procedures or the BCN eviCore-Managed Procedures pages of the ereferrals.bcbsm.com website.

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

New and updated questionnaires started opening in June

In June, new and updated questionnaires started opening in the e‑referral system for certain procedures. In addition, we added and updated preview questionnaires on the ereferrals.bcbsm.com website as new and updated questionnaires were released.

As background, we use your answers to the questionnaires, along with our authorization criteria and medical policies, when making utilization management determinations on your authorization requests.

New questionnaires
On June 14, 2020, we replaced the Pregnancy termination 1 — Medically necessary or elective questionnaire with the following two questionnaires for adult Blue Care Network commercial members:

• Pregnancy termination 1 — Medically necessary. Applicable procedure codes: *01966, *59100, *59840, *59841, *59850, *59851, *59852, *59855, *59856, *59857, *59866, S0190, S0191, S0199, S2260, S2265, S2266, S2267.
• Pregnancy termination 3 — Elective. Applicable procedure codes: *01966, *59100, *59840, *59841, *59850, *59851, *59852, *59855, *59856, *59857, *59866, S0190, S0191, S0199, S2260, S2265, S2266, S2267.

Updated questionnaire
On June 28, 2020, we updated the Vascular embolization or occlusion questionnaire for BCN commercial, BCN AdvantageSM and Medicare Plus BlueSM members.

Preview questionnaires
The preview questionnaires show the questions you’ll need to answer in the actual questionnaires that open in the e-referral system. This can help you prepare your answers ahead of time.

You can access preview questionnaires at ereferrals.bcbsm.com. To find the preview questionnaires:

• For BCN: Click on BCN and then on Authorization Requirements & Criteria. Scroll down and look under the Authorization criteria and preview questionnaires heading.
• For Medicare Plus Blue: Click on Blue Cross and then on Authorization Requirements & Criteria. In the Medicare Plus Blue PPO members section, look under the Authorization criteria and preview questionnaires heading.

Authorization criteria and medical policies
The pertinent authorization criteria and medical policies are available on the Authorization Requirements & Criteria pages of ereferrals.bcbsm.com.

Medicare Plus Blue expands prior authorization program to include genetic and molecular testing

Blue Cross Blue Shield of Michigan will expand its prior authorization program with eviCore healthcare later this year to include genetic and molecular testing services for our Medicare Plus Blue^SM members who live in Michigan and use Michigan providers.

eviCore’s well-established Laboratory Management solution serves 22 clients and more than 19 million members across the nation. The expansion of prior authorization is intended to eliminate the use of certain tests that aren’t medically necessary to improve patient care and manage health care costs. Providers will need to request prior authorization for these services from eviCore.

We’ll provide more details about these changes in future issues of The Record. We’ll also announce opportunities for training on the prior authorization expansion through web-DENIS broadcast messages.

eviCore has updated corePath for physical and occupational therapy authorizations

Effective immediately, eviCore healthcare^® has made changes to the corePath^SM therapy authorization model for initial authorization requests for new episodes of treatment. This change applies to:

• Physical therapy providers in categories B and C
• Occupational therapists in category B

Here’s what changed

For providers in categories B and C: When initial authorization requests meet certain conditions, eviCore is approving a greater number of visits over a longer authorization duration period. The logic in eviCore’s corePath model determines the number of visits and authorization duration based on the patient’s condition and complexity of the condition.

For more information about how this affects occupational therapy providers, see eviCore’s Physical Therapy Practitioner Performance Summary and Provider Category FAQs document.** Information is located under How does my category impact my authorization requirements for occupational therapy?

Note: There haven’t been any changes to the number of visits granted or the authorization duration period for providers in category A.

Additional information

To learn more about category assignments, see eviCore’s Physical Therapy Practitioner Performance Summary and Provider Category FAQs document.**

You can find additional information on the ereferrals.bcbsm.com website:

• On Blue Care Network’s Outpatient PT, OT, ST page
• On Blue Cross’ eviCore-Managed Procedures page. Look in the Medicare Plus Blue PPO members section.

As a reminder, eviCore manages physical therapy and occupational therapy services for non-autism diagnoses for Medicare Plus Blue^SM, BCN commercial and BCN Advantage^SM members. eviCore also manages physical therapy and occupational therapy services for adult BCN commercial members ages 19 and older with autism diagnoses.

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

Here are some clinical editing tips to keep in mind

Reporting and coding debridement of skin ulcers

• Debridement CPT codes *11043, *11044, *11046 and *11047 are specific to muscle, fascia or bone and shouldn’t be used when codes *11042 or *11045 are more appropriate.
• Codes *11042 and *11045 should be used when the debridement is performed on the subcutaneous tissue, including the epidermis and dermis (but not muscle, fascia or bone).
• These codes should be billed with a diagnosis code. Blue Cross Blue Shield of Michigan will review the diagnoses reported on these claims to make sure they’re appropriate for the corresponding CPT code description.
• Diagnosis codes should be reported with the appropriate stage of the pressure ulcer or non-pressure chronic ulcer diagnosis.

Diagnosis code specificity

• The diagnosis reported on claims should be specific and best reflect the condition for which the patient is being treated. Blue Cross performs clinical editing on services that may not have a diagnosis code reported at the highest level of specificity available.

If you have questions about the Blue Cross’ claim editing process, contact Provider Inquiry — Professional at 1-800-344-8525 or Provider Inquiry — Facility at 1-800-249-5103.

Medicare Part B medical specialty drug prior authorization list changing

We’re making changes to the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue^SM and BCN Advantage^SM members. The specialty medications on this list are administered by a health care professional in a provider’s office, at the member’s home, in an off-campus outpatient hospital or in an ambulatory surgical center (place of service 11, 12, 19, 22 or 24).

New authorization requirements

For dates of service on or after July 9, 2020, the following medication for wet age-related macular degeneration will require authorization through the NovoLogix^® online tool:

• Abicipar pegol, HCPCS code J3590

For dates of service on or after Aug. 21, 2020, the following medications will require authorization through NovoLogix:

• Roctavian™ (valoctocogene roxaparvovec), a gene therapy for hemophilia A, HCPCS code J3590
• Uplizna™ (inebilizumab-cdon), HCPCS code J3590
• Avsola™ (infliximab-axxq), HCPCS code Q5121
  
  Note: We published earlier communications stating that Avsola doesn’t require prior authorization. However, for dates of service on or after Aug. 21, 2020, Avsola will require prior authorization.

For dates of service on or after Sept. 28, 2020, the following medications will require prior authorization through NovoLogix:

• Ilaris^® (canakinumab), HCPCS code J0638
• Cutaquig^® (immune globulin subcutaneous [human] – hipp), HCPCS code J1599
• Xembify^® (immune globulin subcutaneous [human] – klhw), HCPCS code J1558

Authorization requirement removed
For dates of service on or after Aug. 1, 2020, the following medications for osteoporosis and other diagnoses involving bone health will no longer require authorization:

• Boniva^® (ibandronate), HCPCS code J1740
• Aredia^® (pamidronate), HCPCS code J2430

How to bill
For Medicare Plus Blue and BCN Advantage, we require authorization for the places of service referenced above when you bill these medications as follows:

• Electronically through an 837P transaction or on a professional CMS-1500 claim form, or
• Electronically through an 837I transaction or by using the UB-04 claim form for a hospital outpatient type of bill 013x

Reminder
Submit authorization requests through NovoLogix. It offers real-time status checks and immediate approvals for certain medications. For Medicare Plus Blue and BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

If you need to request access to Provider Secured Services, complete the Provider Secured Access Application form and fax it to the number on the form.

List of requirements
For a list of requirements for drugs covered under the medical benefit, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue^SM PPO and BCN Advantage^SM members.

Effective Oct. 1, Nivestym and Zarxio are preferred filgrastim products

For dates of service on or after Oct. 1, 2020, the preferred filgrastim products for all Blue Cross Blue Shield of Michigan commercial, Blue Care Network commercial, Medicare Plus Blue^SM and BCN Advantage^SM members will be Nivestym^® (filgrastim-aafi; HCPCS code Q5110) and Zarxio^® (filgrastim-sndz; HCPCS code Q5101).

For commercial members, these requirements apply only to groups currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. They don’t apply to:

• Non-Medicare members covered through the UAW Retiree Medical Benefits Trust
• Members covered by the Federal Employee Program^® Service Benefit Plan

Patients should take the preferred drugs when possible
Keep this in mind about members prescribed these drugs:

• Members starting treatment on or after Oct. 1 should use a preferred filgrastim product.
• Members currently receiving one of the filgrastim products listed below should transition to Nivestym or Zarxio:
  • Neupogen^® (filgrastim; HCPCS code J1442)
  • Granix^® (tbo-filgrastim; HCPCS code J1447)

We’ll notify commercial members currently taking the nonpreferred drugs and encourage them to discuss treatment options with you.

Here are the authorization requirements for members starting or transitioning to the preferred drugs:

• For Blue Cross commercial members, the preferred drugs don’t require authorization.
• For BCN commercial, Medicare Plus Blue and BCN Advantage members, the preferred drugs require authorization through AIM Specialty Health^®.

Request authorization for patients who must take the nonpreferred drugs
Here are the requirements for members you feel need to take Neupogen or Granix:

• For Blue Cross’ PPO members, authorization is required. Submit request through the NovoLogix^® online tool.
• For BCN commercial, Medicare Plus Blue and BCN Advantage members, both step therapy and authorization are required. Submit the request through AIM Specialty Health.

More about the authorization requirements
Authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

For additional information on requirements related to drugs covered under the medical benefit, see:

• Blue Cross and BCN commercial: Blue Cross and BCN utilization management medical drug list
• Medicare Advantage: Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members

We’ll update the requirements lists with the new information before Oct. 1, 2020.

FEP members have access to resources for managing diabetes, hypertension and other chronic conditions

Our Federal Employee Program^® Service Benefit Plan members have access to a wide range of health care resources, including diabetes and hypertension management programs.

Despite the increasing availability of effective treatments for diabetes and hypertension, many patients aren’t controlling their blood pressure or blood sugar levels adequately. One of the major reasons is that they’re not following their provider’s treatment plan.

FEP provides a wide range of educational resources and support services to complement the provider’s treatment plan and help patients manage their chronic conditions.

Below are several examples of health care resources Service Benefit Plan members can access at fepblue.org or by calling the Customer Service number on the back of their member ID card.

Resources for providers
Here are three good resources for health care providers who want more information on preventing and slowing the progression of diabetes and hypertension in their patients:

• The Michigan Quality Improvement Consortium has clinical guidelines for diabetes and hypertension to help mitigate complications.
• The Centers for Medicare & Medicaid Services offers a directory of resources** for diabetes management, access to continuing education courses and apps such as the
  ADA Standards of Care.**
• The American Heart Association offers several resources** to health care professionals for hypertension management. Information includes a hypertension treatment algorithm** and a hypertension guideline toolkit.**

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

On-demand training available

Provider Experience is continuing to offer training resources for health care providers and staff. We’ve posted recordings of webinars delivered so far this year on the Learning Opportunities and Provider Training pages. Additional video and eLearning modules are available on specific topics. The on-demand courses can help you work more efficiently with Blue Cross Blue Shield of Michigan and Blue Care Network.

For Blue Cross:

1. Log in to Provider Secured Services.
2. Click on BCBSM Provider Publications and Resources.
3. Click on BCBSM Newsletters and Resources.
4. Click on Provider Training.
5. In the Featured Links section of the page, check out 2020 Provider Training Webinars.

For more information about online training, presentations and videos, click on the E-Learning icon at the top of the page.

For BCN:

1. Log in to Provider Secured Services.
2. Go to BCN Provider Publications and Resources.
3. Under Other Resources, click on Learning Opportunities.
4. Find the most recent webinars under 2020 Provider Training Webinars.

As additional training webinars become available, we’ll let you know through web-DENIS or The Record.

Providers find Blues Brief helpful and easy to read

Earlier this year, we conducted an online survey to find out how satisfied you are with the monthly professional, quarterly facility and specialty versions of Blues Brief. Blues Brief is a two-page newsletter that offers a quick summary of several key articles in The Record and BCN Provider News.

Most survey respondents were subscribers to the monthly professional version of Blues Brief. Some of the comments we received indicated that the newsletter was helpful and easy to read. Other findings:

• Seventy-six percent received Blues Brief in the last 12 months.
• Fifty-eight percent prefer to read Blues Brief through their email subscription, which takes them directly to the articles online.
• Eighty-one percent read every publication of Blues Brief.
• Ninety-six percent said there’s the right amount of detail included in the publication.
• Fifty-one percent said they also read The Record.

As a reminder, you can subscribe to Blues Brief two ways:

1. Click the Manage Subscriptions link at the bottom of your email version of The Record or BCN Provider News. Once you make changes to your subscriptions, simply click on Update and we’ll process the changes. Our system doesn’t automatically acknowledge your changes, but we’ll add you to the distribution list.
2. Visit our subscription page to choose your preferred Blues Brief versions.

Keep in mind that Blues Brief isn’t intended to be a replacement for The Record. It’s important to review the entire publication each month to make sure you have all the information you need to do business with us.

TurningPoint musculoskeletal authorization program to expand in January

We’ll add Blue Cross Blue Shield of Michigan commercial members to the TurningPoint Healthcare Solutions, LLC musculoskeletal program for spine, pain management and joint replacement surgeries and related procedures for dates of service on or after Jan. 1, 2021. At that time, the program will also expand to include pain management procedures for Blue Care Network commercial, BCN Advantage^SM and Medicare Plus Blue^SM members

In addition, spinal procedures for Medicare Plus Blue members will transition from being managed by eviCore healthcare^® to being managed by TurningPoint.

Providers can begin submitting authorization requests for the expanded procedures starting Dec. 1, 2020, for dates of service on or after Jan. 1, 2021.

In the September Record, we’ll provide information about the procedure codes that are affected by these changes and upcoming webinars for health care providers and their office staff. The information will also appear in a future issue of BCN Provider News.

Background

As reported in the July Record, health care providers should submit authorization requests through TurningPoint for musculoskeletal surgical procedures with a date of service on or after July 1, 2020, for BCN commercial, Medicare Plus Blue and BCN Advantage members. This includes spine and joint replacement surgeries and related procedures.

However, lumbar spinal fusion surgeries for Medicare Plus Blue members will continue to be managed by eviCore through 2020. You can find the codes for these procedures in the Lumbar spinal fusion surgery procedures requiring authorization by eviCore table in the Procedures that require authorization by eviCore healthcare document. The document is located on the ereferrals.bcbsm.com website. To locate it, click on Blue Cross and then on eviCore-Managed Procedures.

For more information

• See the e-referral webpages for Blue Cross and BCN.
• Find procedure codes for orthopedic and spinal procedures managed by TurningPoint on ereferrals.bcbsm.com as follows:
  • Orthopedic
  • Spinal
• Refer to the Frequently asked questions for providers document on our ereferrals.bcbsm.com website.

Medicare Plus Blue expands prior authorization program to include genetic and molecular testing

Blue Cross Blue Shield of Michigan will expand its prior authorization program with eviCore healthcare later this year to include genetic and molecular testing services for our Medicare Plus Blue^SM members who live in Michigan and use Michigan providers.

eviCore’s well-established Laboratory Management solution serves 22 clients and more than 19 million members across the nation. The expansion of prior authorization is intended to eliminate the use of certain tests that aren’t medically necessary to improve patient care and manage health care costs. Providers will need to request prior authorization for these services from eviCore.

We’ll provide more details about these changes in future issues of The Record. We’ll also announce opportunities for training on the prior authorization expansion through web-DENIS broadcast messages.

We use InterQual criteria, not ‘two-midnight rule,’ for inpatient acute care admissions

Blue Cross Blue Shield of Michigan’s Utilization Management department makes determinations on authorization requests for inpatient acute care admissions of members based on InterQual^® criteria, not the “two-midnight rule.” This applies to all lines of business.

We’re clarifying this because we recently received questions from providers about the two-midnight rule. Providers should do the following:

• Refer to the InterQual criteria for the type of admission and to the associated Blue Cross and Blue Care Network Local Rules.
  
  Note: These rules are available on the Blue Cross Authorization Requirements & Criteria page and the BCN Authorization Requirements & Criteria page of the ereferrals.bcbsm.com website.

• Disregard any information about the two-midnight rule that we may have published in previous communications since that information is no longer current.

We’re updating the provider manuals to include a statement clarifying that we don’t use the two-midnight rule in making determinations on authorization requests for inpatient acute care admissions.

Medicare Part B medical specialty drug prior authorization list changing

We’re making changes to the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue^SM and BCN Advantage^SM members. The specialty medications on this list are administered by a health care professional in a provider’s office, at the member’s home, in an off-campus outpatient hospital or in an ambulatory surgical center (place of service 11, 12, 19, 22 or 24).

New authorization requirements

For dates of service on or after July 9, 2020, the following medication for wet age-related macular degeneration will require authorization through the NovoLogix^® online tool:

• Abicipar pegol, HCPCS code J3590

For dates of service on or after Aug. 21, 2020, the following medications will require authorization through NovoLogix:

• Roctavian™ (valoctocogene roxaparvovec), a gene therapy for hemophilia A, HCPCS code J3590
• Uplizna™ (inebilizumab-cdon), HCPCS code J3590
• Avsola™ (infliximab-axxq), HCPCS code Q5121
  
  Note: We published earlier communications stating that Avsola doesn’t require prior authorization. However, for dates of service on or after Aug. 21, 2020, Avsola will require prior authorization.

For dates of service on or after Sept. 28, 2020, the following medications will require prior authorization through NovoLogix:

• Ilaris^® (canakinumab), HCPCS code J0638
• Cutaquig^® (immune globulin subcutaneous [human] – hipp), HCPCS code J1599
• Xembify^® (immune globulin subcutaneous [human] – klhw), HCPCS code J1558

Authorization requirement removed
For dates of service on or after Aug. 1, 2020, the following medications for osteoporosis and other diagnoses involving bone health will no longer require authorization:

• Boniva^® (ibandronate), HCPCS code J1740
• Aredia^® (pamidronate), HCPCS code J2430

How to bill
For Medicare Plus Blue and BCN Advantage, we require authorization for the places of service referenced above when you bill these medications as follows:

• Electronically through an 837P transaction or on a professional CMS-1500 claim form, or
• Electronically through an 837I transaction or by using the UB-04 claim form for a hospital outpatient type of bill 013x

Reminder
Submit authorization requests through NovoLogix. It offers real-time status checks and immediate approvals for certain medications. For Medicare Plus Blue and BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

If you need to request access to Provider Secured Services, complete the Provider Secured Access Application form and fax it to the number on the form.

List of requirements
For a list of requirements for drugs covered under the medical benefit, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue^SM PPO and BCN Advantage^SM members.

Effective Oct. 1, Nivestym and Zarxio are preferred filgrastim products

For dates of service on or after Oct. 1, 2020, the preferred filgrastim products for all Blue Cross Blue Shield of Michigan commercial, Blue Care Network commercial, Medicare Plus Blue^SM and BCN Advantage^SM members will be Nivestym^® (filgrastim-aafi; HCPCS code Q5110) and Zarxio^® (filgrastim-sndz; HCPCS code Q5101).

For commercial members, these requirements apply only to groups currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. They don’t apply to:

• Non-Medicare members covered through the UAW Retiree Medical Benefits Trust
• Members covered by the Federal Employee Program^® Service Benefit Plan

Patients should take the preferred drugs when possible
Keep this in mind about members prescribed these drugs:

• Members starting treatment on or after Oct. 1 should use a preferred filgrastim product.
• Members currently receiving one of the filgrastim products listed below should transition to Nivestym or Zarxio:
  • Neupogen^® (filgrastim; HCPCS code J1442)
  • Granix^® (tbo-filgrastim; HCPCS code J1447)

We’ll notify commercial members currently taking the nonpreferred drugs and encourage them to discuss treatment options with you.

Here are the authorization requirements for members starting or transitioning to the preferred drugs:

• For Blue Cross commercial members, the preferred drugs don’t require authorization.
• For BCN commercial, Medicare Plus Blue and BCN Advantage members, the preferred drugs require authorization through AIM Specialty Health^®.

Request authorization for patients who must take the nonpreferred drugs
Here are the requirements for members you feel need to take Neupogen or Granix:

• For Blue Cross’ PPO members, authorization is required. Submit request through the NovoLogix^® online tool.
• For BCN commercial, Medicare Plus Blue and BCN Advantage members, both step therapy and authorization are required. Submit the request through AIM Specialty Health.

More about the authorization requirements
Authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

For additional information on requirements related to drugs covered under the medical benefit, see:

• Blue Cross and BCN commercial: Blue Cross and BCN utilization management medical drug list
• Medicare Advantage: Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members

We’ll update the requirements lists with the new information before Oct. 1, 2020.

On-demand training available

Provider Experience is continuing to offer training resources for health care providers and staff. We’ve posted recordings of webinars delivered so far this year on the Learning Opportunities and Provider Training pages. Additional video and eLearning modules are available on specific topics. The on-demand courses can help you work more efficiently with Blue Cross Blue Shield of Michigan and Blue Care Network.

For Blue Cross:

1. Log in to Provider Secured Services.
2. Click on BCBSM Provider Publications and Resources.
3. Click on BCBSM Newsletters and Resources.
4. Click on Provider Training.
5. In the Featured Links section of the page, check out 2020 Provider Training Webinars.

For more information about online training, presentations and videos, click on the E-Learning icon at the top of the page.

For BCN:

1. Log in to Provider Secured Services.
2. Go to BCN Provider Publications and Resources.
3. Under Other Resources, click on Learning Opportunities.
4. Find the most recent webinars under 2020 Provider Training Webinars.

As additional training webinars become available, we’ll let you know through web-DENIS or The Record.

Providers find Blues Brief helpful and easy to read

Earlier this year, we conducted an online survey to find out how satisfied you are with the monthly professional, quarterly facility and specialty versions of Blues Brief. Blues Brief is a two-page newsletter that offers a quick summary of several key articles in The Record and BCN Provider News.

Most survey respondents were subscribers to the monthly professional version of Blues Brief. Some of the comments we received indicated that the newsletter was helpful and easy to read. Other findings:

• Seventy-six percent received Blues Brief in the last 12 months.
• Fifty-eight percent prefer to read Blues Brief through their email subscription, which takes them directly to the articles online.
• Eighty-one percent read every publication of Blues Brief.
• Ninety-six percent said there’s the right amount of detail included in the publication.
• Fifty-one percent said they also read The Record.

As a reminder, you can subscribe to Blues Brief two ways:

1. Click the Manage Subscriptions link at the bottom of your email version of The Record or BCN Provider News. Once you make changes to your subscriptions, simply click on Update and we’ll process the changes. Our system doesn’t automatically acknowledge your changes, but we’ll add you to the distribution list.
2. Visit our subscription page to choose your preferred Blues Brief versions.

Keep in mind that Blues Brief isn’t intended to be a replacement for The Record. It’s important to review the entire publication each month to make sure you have all the information you need to do business with us.

Medicare Part B medical specialty drug prior authorization list changing

We’re making changes to the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue^SM and BCN Advantage^SM members. The specialty medications on this list are administered by a health care professional in a provider’s office, at the member’s home, in an off-campus outpatient hospital or in an ambulatory surgical center (place of service 11, 12, 19, 22 or 24).

New authorization requirements

For dates of service on or after July 9, 2020, the following medication for wet age-related macular degeneration will require authorization through the NovoLogix^® online tool:

• Abicipar pegol, HCPCS code J3590

For dates of service on or after Aug. 21, 2020, the following medications will require authorization through NovoLogix:

• Roctavian™ (valoctocogene roxaparvovec), a gene therapy for hemophilia A, HCPCS code J3590
• Uplizna™ (inebilizumab-cdon), HCPCS code J3590
• Avsola™ (infliximab-axxq), HCPCS code Q5121
  
  Note: We published earlier communications stating that Avsola doesn’t require prior authorization. However, for dates of service on or after Aug. 21, 2020, Avsola will require prior authorization.

For dates of service on or after Sept. 28, 2020, the following medications will require prior authorization through NovoLogix:

• Ilaris^® (canakinumab), HCPCS code J0638
• Cutaquig^® (immune globulin subcutaneous [human] – hipp), HCPCS code J1599
• Xembify^® (immune globulin subcutaneous [human] – klhw), HCPCS code J1558

Authorization requirement removed
For dates of service on or after Aug. 1, 2020, the following medications for osteoporosis and other diagnoses involving bone health will no longer require authorization:

• Boniva^® (ibandronate), HCPCS code J1740
• Aredia^® (pamidronate), HCPCS code J2430

How to bill
For Medicare Plus Blue and BCN Advantage, we require authorization for the places of service referenced above when you bill these medications as follows:

• Electronically through an 837P transaction or on a professional CMS-1500 claim form, or
• Electronically through an 837I transaction or by using the UB-04 claim form for a hospital outpatient type of bill 013x

Reminder
Submit authorization requests through NovoLogix. It offers real-time status checks and immediate approvals for certain medications. For Medicare Plus Blue and BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

If you need to request access to Provider Secured Services, complete the Provider Secured Access Application form and fax it to the number on the form.

List of requirements
For a list of requirements for drugs covered under the medical benefit, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue^SM PPO and BCN Advantage^SM members.

Effective Oct. 1, Nivestym and Zarxio are preferred filgrastim products

For dates of service on or after Oct. 1, 2020, the preferred filgrastim products for all Blue Cross Blue Shield of Michigan commercial, Blue Care Network commercial, Medicare Plus Blue^SM and BCN Advantage^SM members will be Nivestym^® (filgrastim-aafi; HCPCS code Q5110) and Zarxio^® (filgrastim-sndz; HCPCS code Q5101).

For commercial members, these requirements apply only to groups currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. They don’t apply to:

• Non-Medicare members covered through the UAW Retiree Medical Benefits Trust
• Members covered by the Federal Employee Program^® Service Benefit Plan

Patients should take the preferred drugs when possible
Keep this in mind about members prescribed these drugs:

• Members starting treatment on or after Oct. 1 should use a preferred filgrastim product.
• Members currently receiving one of the filgrastim products listed below should transition to Nivestym or Zarxio:
  • Neupogen^® (filgrastim; HCPCS code J1442)
  • Granix^® (tbo-filgrastim; HCPCS code J1447)

We’ll notify commercial members currently taking the nonpreferred drugs and encourage them to discuss treatment options with you.

Here are the authorization requirements for members starting or transitioning to the preferred drugs:

• For Blue Cross commercial members, the preferred drugs don’t require authorization.
• For BCN commercial, Medicare Plus Blue and BCN Advantage members, the preferred drugs require authorization through AIM Specialty Health^®.

Request authorization for patients who must take the nonpreferred drugs
Here are the requirements for members you feel need to take Neupogen or Granix:

• For Blue Cross’ PPO members, authorization is required. Submit request through the NovoLogix^® online tool.
• For BCN commercial, Medicare Plus Blue and BCN Advantage members, both step therapy and authorization are required. Submit the request through AIM Specialty Health.

More about the authorization requirements
Authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

For additional information on requirements related to drugs covered under the medical benefit, see:

• Blue Cross and BCN commercial: Blue Cross and BCN utilization management medical drug list
• Medicare Advantage: Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members

We’ll update the requirements lists with the new information before Oct. 1, 2020.

Here’s new information about electronic prior authorization for drugs covered under pharmacy benefits

If you use an electronic prior authorization, or ePA, tool to request authorization for drugs that are covered under pharmacy benefits, here’s what you need to know.

ePA for Medicare Advantage members, too

Starting Aug. 3, you can use CoverMyMeds and other free ePA tools such as Surescripts^® and ExpressPAth^® to submit requests for most of these drugs for our Medicare Advantage members. These are members who have coverage through Medicare Plus Blue^SM or BCN Advantage^SM plans.

You can already submit ePA requests for members who have Blue Cross Blue Shield of Michigan or Blue Care Network commercial coverage.

New feature in CoverMyMeds

For those who use CoverMyMeds to submit ePA requests, there’s a new feature that helps ensure you’re identifying the correct insurance plan.

In the Plan or PBM Name field, you can now enter the bank identification number, or RxBIN, and the RxGroup found on the member’s ID card.

To locate the correct plan for one of our members, enter this information:

• 610014 as the RxBIN for both Blue Cross and BCN.
• One of these RxGroups:
  • Blue Cross commercial: BCBSMRX1 or BCBSMAN
  • BCN commercial: MiBCNRX
  • Medicare Plus Blue: BCBSMAN
  • BCN Advantage: BCNRXPD

Remember to look for the RxBIN and RxGroup on the member’s ID card.

Reminder: Submitting ePA requests using CoverMyMeds

To complete an ePA request using your CoverMyMeds online account, follow these steps:

1. Go to covermymeds.com/epa/express-scripts.** (Create a free account if you don’t already have one.)
2. Start a prior authorization request:
   • Click New Request and select Michigan in the Patient Insurance State field.
   • New: In the Plan or PBM Name field, enter the RxBIN andthe RxGroup found on the patient’s member ID card.
   • Enter the medication, select the appropriate form and click on Start Request.
3. Complete the request:
   • Complete all information fields marked Required and click on Send to Plan.
   • CoverMyMeds displays a list of patient-specific, clinical questions. Answer all questions that are marked Required.
4. Confirm the request:
   • Click Send to Plan again to confirm that you’ve submitted the request.

After Blue Cross or BCN has reviewed the prior authorization request you submitted, the determination will appear in your CoverMyMeds account.

CoverMyMeds often returns approval decisions within minutes of submission, depending on the complexity of the request or the need for additional review.

More about ePA

You can use CoverMyMeds or other ePA tools instead of submitting requests by fax or phone. This allows you to spend less time on administrative tasks and more time on patient care.

Other benefits of using ePA tools include:

• Automatic approvals for select drugs and improved turnaround time for review and decisions
• Easy use by prescribers, nurses and office staff
• All documentation and requests kept conveniently in one place

Here are some answers to frequently asked questions about ePA.

• Why should I use ePA?
  
  You’ll save time. You can send 11 ePA requests in the time it takes to fax just one (based on Comcast and Verizon broadband rates and a fax speed of 33.6 kbps) and patients can receive medications faster.
  
  The process is easy and intuitive. Providers and their authorized personnel can log in online, submit requests and access determinations.

• What about ePA tools within the electronic health record?
  
  Using an ePA tool within your electronic health record, or EHR, makes it even easier to submit electronic requests and gives you:
  • Clear direction on clinical requirements
  • Streamlined questions that are specific to the prior authorization request you’re submitting
  • The ability to attach required documentation
  • Secure and efficient authorization administration all in one place
  • The capability of renewing existing authorizations proactively, up to 60 days before they expire

  Typically, an ePA tool can be integrated into your current EHR workflow. Check with your vendor to ensure you have software that accommodates an ePA tool.

  If an ePA tool isn’t available within the EHR you use, you can always create a free online account through CoverMyMeds or other ePA tools, such as Surescripts^® and ExpressPAth^®, to submit requests. Registration takes only a few minutes.

Questions?
If you have questions, call the Pharmacy Clinical Help Desk at 1-800-437-3803.

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

Second-quarter HCPCS update: New codes added, deleted

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

Injections

Injections/chemotherapy

Injections/anti-hemophilia drugs

Outpatient Prospective Payment System/injection

Outpatient Prospective Payment System/surgery

Outpatient Prospective Payment System/medical surgical supplies/devices/other implants

Outpatient Prospective Payment System/medicine

Outpatient Prospective Payment System/radiology

Outpatient Prospective Payment System/surgery/skin substitute

Surgery

Skin substitute

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.

HCPCS replacement codes established

J0223 replaces J3490, J3590 and C9056 when billing for Givlaari (givosiran)

The Centers for Medicare & Medicaid Services has established a permanent procedure code for Givlaari^®.

All services through June 30, 2020, will continue to be reported with code J3490, J3590 or C9056. All services performed on and after July 1, 2020, must be reported with J0223.

Prior authorization is required for all groups unless they are opted out of the prior authorization program.

For groups that have opted out of the prior authorization program, this code requires manual review for individual consideration.

J0691 replaces J3490 when billing for Xenleta (lefamulin)

CMS has established a permanent procedure code for Xenleta™.

All services through June 30, 2020, will continue to be reported with code J3490. All services performed on and after July 1, 2020, must be reported with J0691.

Prior authorization is required for all groups unless they are opted out of the prior authorization program.

For groups that have opted out of the prior authorization program, this code requires manual review for individual consideration.

J0791 replaces J3490, J3590 and C9053 when billing for Adakveo (crizanlizumab-tmca)

CMS has established a permanent procedure code for Adakveo^®.

All services through June 30, 2020, will continue to be reported with code J3490, J3590 or C9053. All services performed on and after July 1, 2020, must be reported with J0791.

Prior authorization is required for all groups unless they are opted out of the prior authorization program.

J0896 replaces J3490 and J3590 when billing for Reblozyl (luspatercept-aamt)

CMS has established a permanent procedure code for Reblozyl^®.

All services through June 30, 2020, will continue to be reported with code J3490 or J3590. All services performed on and after July 1, 2020, must be reported with J0896.

Prior authorization is required for all groups unless they are opted out of the prior authorization program.

For groups that have opted out of the prior authorization program, this code requires manual review for individual consideration.

J1429 replaces J3490 and J3590 when billing for Vyondys 53 (golodirsen)

CMS has established a permanent procedure code for Vyondys 53.

All services through June 30, 2020, will continue to be reported with code J3490 or J3590. All services performed on and after July 1, 2020, must be reported with J1429.

Prior authorization is required for all groups unless they are opted out of the prior authorization program.

For groups that have opted out of the prior authorization program, this code requires manual review for individual consideration.

J1558 replaces J1599 when billing for Xembify (immune globulin subcutaneous, human-klhw)

CMS has established a permanent procedure code for Xembify^®.

All services through June 30, 2020, will continue to be reported with code J1599. All services performed on and after July 1, 2020, must be reported with J1558.

Prior authorization is required for all groups unless they are opted out of the prior authorization program.

J3399 replaces J3490, J3590 and C9399 when billing for Zolgensma (onasemnogene abeparvovec-xioi) 

CMS has established a permanent procedure code for Zolgensma^®.

All services through June 30, 2020, will continue to be reported with code J3490, J3590 or C9399. All services performed on and after July 1, 2020, must be reported with J3399.

Prior authorization is required for all groups unless they are opted out of the prior authorization program.

For groups that have opted out of the prior authorization program, this code requires manual review for individual consideration.

Q5121 replaces J3490 and J3590 when billing for Avsola (infliximab-axxq)

CMS has established a permanent procedure code for Avsola™.

All services through June 30, 2020, will continue to be reported with code J3490 or J3590. All services performed on and after July 1, 2020, must be reported with Q5121.

Prior authorization is required for all groups unless they are opted out of the prior authorization program.

For groups that have opted out of the prior authorization program, this code requires manual review for individual consideration.

J0742 replaces J3490 and J3590 when billing for Recarbrio (imipenem, cilastatin and relebactam)

CMS has established a permanent procedure code for Recarbrio™.

All services through June 30, 2020, will continue to be reported with code J3490 or J3590. All services performed on and after July 1, 2020, must be reported with J0742.

J1201 replaces J3490, J3590 and C9057 when billing for Quzyttir (cetirizine hydrochloride injection)

CMS has established a permanent procedure code for Quzyttir^®.

All services through June 30, 2020, will continue to be reported with code J3490, J3590 or C9057. All services performed on and after July 1, 2020, must be reported with J1201.

J7169 replaces J3490 and C9041 when billing for Andexxa

CMS has established a permanent procedure code for Andexxa^®.

All services through June 30, 2020, will continue to be reported with code J3490 or C9041. All services performed on and after July 1, 2020, must be reported with J7169.

J7204 replaces J3490 when billing for Esperoct

CMS has established a permanent procedure code for Esperoct^®.

All services through June 30, 2020, will continue to be reported with code J3490. All services performed on and after July 1, 2020, must be reported with J7204.

J9177 replaces J3490 and J3590 when billing for Padcev

CMS has established a permanent procedure code for Padcev™.

All services through June 30, 2020, will continue to be reported with code J3490 or J3590. All services performed on and after July 1, 2020, must be reported with J9177.

J9358 replaces J3490 and J3590 when billing for ENHERTU (fam-trastuzumab deruxtecan-nxki)

CMS has established a permanent procedure code for ENHERTU^®.

All services through June 30, 2020, will continue to be reported with code J3490 or J3590. All services performed on and after July 1, 2020, must be reported with J9358.

Q5119 replaces J3590 when billing for Ruxience (rituximab-pvvr)

CMS has established a temporary procedure code for Ruxience^®.

All services through June 30, 2020, will continue to be reported with code J3590. All services performed on and after July 1, 2020, must be reported with Q5119.

Q5120 replaces J3490, J3590 and C9058 when billing for Ziextenzo (pegfilgrastim-bmez)

CMS has established a temporary procedure code for Ziextenzo^®.

All services through June 30, 2020, will continue to be reported with code J3490, J3590 or C9058. All services performed on and after July 1, 2020, must be reported with Q5120.

Checking the status of temporary measures for COVID‑19

In June, some of the temporary measures we put in place for the COVID-19 crisis concluded.

For the latest status of all temporary measures — including those related to utilization management, telehealth, billing and more — see the Temporary changes due to the COVID‑19 pandemicdocument, which shows the start and end dates for each measure.

You can find this and related documents on our coronavirus webpage, which is available through Provider Secured Services and on our public website at bcbsm.com/coronavirus.

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.