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June 2020

All Providers

Meeting members’ behavioral health needs in a time of crisis

Blue Cross Blue Shield of Michigan and Blue Care Network want to make it easier for you to care for your patients during the COVID-19 pandemic. We also want to encourage our members to continue to seek care with you during this crisis and we want to make them feel safe while doing so.

As a result, we’ve made the following changes to meet members’ behavioral health needs.

Note: Several of these changes involve telemedicine. For additional information about telemedicine services for behavioral health providers, see the Telehealth for behavioral health providers document.

Telemedicine incentives

Through the Physician Group Incentive Program, or PGIP, we introduced incentives to assist behavioral health providers with funding the adoption of telemedicine.

Member cost share waived

Through June 30, 2020, we’re waiving cost share for the most common behavioral health services when delivered via telehealth for Blue Cross and BCN commercial members.

Through Dec. 31, 2020, we’re waiving cost share for the most common behavioral health services when delivered via telehealth for Medicare Plus BlueSM and BCN AdvantageSM members. In addition, cost share is waived through Dec. 31 for in-person behavioral health services for our Medicare Advantage members. Some self-funded groups are still making decisions on this waiver; watch for a web-DENIS message with more information.

Examples of common behavioral health services are counseling and medication reviews. For a list of specific procedure codes for which we’re waiving cost share, see the Telehealth procedure codes for COVID-19 document.

Group therapy sessions via telemedicine

Some of our provider partners are offering group therapy sessions via telemedicine that are focused on addressing stress related to COVID-19. If you’re offering COVID-19-related group therapy sessions via telemedicine, let us know by calling 1‑800‑482‑5982. We’ll share your information with members in your area who inquire about these services.
Members can call the appropriate phone number to contact Behavioral Health for more information:

  • Blue Cross’ PPO members: 1-800-762-2382
  • Medicare Plus BlueSM PPO members: 1-888-803-4960
  • BCN HMOSM members: 1-800-482-5982
  • BCN AdvantageSM members: 1-800-431-1059

Crisis hotline

We established a 24-hour behavioral health crisis hotline to provide emotional support to members and non-members during this crisis. The hotline is staffed by New Directions®, a company that provides behavioral health services for most of our Blue Cross members.

The phone number for the hotline is 1-833-848-1764.

Autism services via telemedicine

With the release of our updated Telemedicine Medical Policy, the following autism services are covered when delivered via telemedicine.

  • *97151: Assessments. Temporary change: During this crisis and until further notice, we’re allowing providers to perform assessments via telehealth. This will allow them to collect information via interviews, questionnaires, rating scales, etc.
  • *97155: Protocol modification. Temporary change: During this crisis and until further notice, a parent/caregiver can perform this service in place of a technician 100% of the time. In addition, a licensed behavior analyst, or LBA, may troubleshoot treatment protocols directly with the parent/caregiver.
  • *97156: Caregiver training, which can be provided using telehealth for up to 100% of the time during which services are provided.
  • *97157: Multi-family caregiver training, which can be provided using telehealth for up to 100% of the time during which services are provided.

Psychiatric illnesses and substance use disorders

We’ve enabled providers to conduct intensive outpatient programs, or IOP, and partial hospital programs, or PHP, via telemedicine. This allows providers to continue to serve the acute needs of members with psychiatric illnesses or substance use disorders that require a higher level of care.

Also, we support using outpatient protocols for detoxification and delivering outpatient services via telemedicine when medically appropriate. The Outpatient detoxification and follow-up-care protocols for treating substance use disorders document provides information that will help providers develop detoxification programs and follow-up care for patients being treated for substance use disorders.

Blue Cross® Coordinated Care

Blue Cross Coordinated Care staff are reaching out to members who are high risk, seniors or those affected by the virus to check on their welfare during this time of social isolation.

Also, the Wellframe mobile app now includes COVID-19 modules. (Wellframe is the mobile app through which care teams communicate with members.)

Provider-Delivered Care Management

Through June 30, 2020, we expanded Provider-Delivered Care Management options for Blue Cross members to include the following:

  • Helping to connect members to their families to have important discussions about their care and get updates from hospital providers and the care team
  • Directing family members to appropriate behavioral health resources

Through June 30, care coordination services that typically must be delivered in a face-to-face setting can be delivered via telemedicine (audiovisual or telephone). PDCM procedure codes *98961, *98962, G9001 and G9002 are affected by this temporary change.

As a reminder, nurses, social workers and other licensed providers who are working as part of the care team can bill under the physician’s provider identification number, as described in the PDCM billing guidelines. Medical assistants and other non-licensed professionals can bill telephone-only codes under the guidance of a care team.

myStrength program

The myStrength program is an online tool offered through Livongo®, an independent company that works closely with Blue Cross and BCN. The program includes a module specifically for coping with COVID-19; it provides stress management strategies, parenting tips and emotional support tools, and covers the following topics:

  • Coping skills during COVID-19
  • Mental wellness and resilience in difficult times
  • Keeping your relationships strong
  • Staying connected while social distancing
  • Simple ways to practice mindfulness

Through Dec. 31, 2020, all Blue Cross and BCN members have access to the myStrength program at no cost.

To get started with myStrength, members can go to bh.mystrength.com/bcbsmcvd19 and create a free myStrength account.


At war with a virus: A roundup of recent news about the COVID‑19 pandemic

Blue Cross Blue Shield of Michigan and Blue Care Network have made many changes to support health care providers and protect members during the COVID‑19 public health crisis. These changes date back to a few days before the first Michigan cases of COVID‑19 were reported. Since then, we’ve focused our efforts on facilitating testing and treatment, expanding telehealth services, reducing utilization management requirements, ensuring patients have access to the medications they need and extending many deadlines to support you and our members.

View a list of COVID‑19 temporary changes

To make it easy for you to find and understand the changes we’ve made, we created a document, Temporary changes due to the COVID‑19 pandemic, which lists each temporary change, along with the start and end date of the change. We’re updating this document as additional changes are made or if dates are extended.

See COVID‑19 resources and information for providers, below, for instructions on how to find this document and other COVID‑19 materials.

Gov. Gretchen Whitmer appoints Blue Cross director to Michigan Coronavirus Task Force on Racial Disparities

Bridget Hurd, senior director of Diversity and Inclusion at Blue Cross Blue Shield of Michigan, will serve on a state task force investigating racial disparities related to COVID‑19 outcomes in Michigan. The task force will make recommendations that address transparent reporting data, reducing medical bias in testing and treatment and reducing barriers to physical and mental health care, among other issues.

“It is a great opportunity to focus on the short- and long-term needs of underserved populations and address the health and health care disparities that have been around for a very long time,” Hurd said.

Blue Cross Blue Shield of Michigan employees volunteer to join the frontline against COVID‑19

More than 30 Blue Cross and Blue Care Network health care specialists, including M.D.s and nurses, among others, volunteered to assist in treating COVID‑19 patients. The company received more than 25 applications the first day after announcing the request. “We’re immensely grateful to every health care professional fighting this pandemic, caring for those affected and saving lives throughout Michigan and beyond,” said Blue Cross President and CEO Daniel J. Loepp.

Blue Cross Blue Shield of Michigan and 35 Michigan hospitals join effort to collect comprehensive COVID‑19 data

Blue Cross Blue Shield of Michigan and 35 Michigan hospitals are collecting comprehensive clinical data on COVID‑19 patients to be included in an extensive registry that will provide insight into best practices in treating patients with the virus. The data, collected from hospitals throughout the state, will provide a comprehensive clinical picture that’s not typically available from smaller registries that contain data from just one hospital or health system. The initiative, called MI-COVID19, hopes to identify factors associated with higher levels of critical COVID‑19 illness as well as what patient characteristics and treatments led to improved outcomes.

COVID‑19 resources and information for providers

Michigan Blue Cross and BCN providers can visit bcbsm.com/coronavirus and click the For Providers tab. Log in to Provider Secured Services for your best Blue Cross resources for the coronavirus. You'll find the most up-to-date information there.

For the latest COVID‑19 information from Michigan State Medical Society, visit its COVID‑19 Resource Center for Physicians and Patients** webpage.

The Michigan Osteopathic Association also has a COVID‑19 resources** webpage.

The Centers for Disease Control and Prevention provides updated COVID‑19 information for health care providers on its Coronavirus Disease 2019 (COVID‑19)** page.

The American Medical Association provides helpful tools for providers on its  COVID‑19: Frequently asked questions** page.

For more information about our efforts to support providers and members, see Meeting members’ behavioral health needs in a time of crisis, also in this issue.

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


We’re implementing temporary sequestration relief, DRG enhancement for Medicare Advantage providers treating COVID‑19 patients

In accordance with our provider agreements and changes to Original Medicare payments under the federal CARES Act, Blue Cross Blue Shield of Michigan and Blue Care Network are implementing temporary sequestration relief and diagnosis-related group, or DRG, enhancement for Medicare Advantage health care providers. This includes network and non-network providers.

These actions will offer financial relief to health care providers during the COVID-19 pandemic. They will apply to services provided to members with Medicare Plus BlueSM and BCN AdvantageSM coverage.

We announced these changes through a web-DENIS message on April 20, 2020. Here’s what you need to know:

Temporary sequestration relief

Background information: Since 2013, 2% sequestration reimbursement reductions have been in place for our Medicare Advantage professional and facility providers. This is in accordance with the terms of our Medicare Advantage provider agreements that pay according to Original Medicare methodologies.

The 2% reimbursement adjustment is applied after determining any applicable member deductible, copayment or other required member cost sharing.

What’s changing: Consistent with Original Medicare, Blue Cross and BCN will temporarily suspend the 2% sequestration. This means that reimbursement to applicable provider types will increase by 2% effective for dates of service beginning May 1, 2020, through Dec. 31, 2020.

Reimbursement to providers who haven’t been affected by sequestration previously, such as durable medical equipment, end-stage renal disease and lab providers, won’t be affected by this change.

The 2% sequestration reimbursement reduction is expected to be reinstated on Jan. 1, 2021.

DRG enhancements for inpatient treatment of COVID-19 patients

The CARES Act includes a temporary 20% increase in the weighting factor for inpatient diagnosis-related group payments for Medicare patients diagnosed with COVID-19 during the COVID-19 emergency period. Blue Cross and BCN are working toward implementing the increased payments in the coming weeks.

Once implemented, the increased payments will affect discharges retroactively, dating back to discharges occurring on or after the emergency declaration on Jan. 27, 2020. Any affected claims will be reprocessed with no additional action needed by facilities.


We’re issuing new alphanumeric contract numbers in 2021 for Blue Cross, BCN members

Blue Cross Blue Shield of Michigan and Blue Care Network will issue alphanumeric contract numbers to new members starting sometime in 2021. This is a change from the previously announced start date, which was July 1, 2020. We’ll update our provider manuals and related documents to reflect the delay in implementation.

The alphanumeric contract numbers will be issued to all new Blue Cross and BCN members, including our Medicare Advantage members. Existing members will keep the contract numbers they now have.

The new contract numbers will include the letter M after the standard prefix. For example, an existing enrollee ID looks like this: XYH912345678. The prefix is XYH and the contract number (nine digits) is 912345678.

The new enrollee ID will follow this format: XYHM91234567. The prefix is XYH and the alphanumeric contract number of nine characters is M91234567. When providers check a member’s eligibility or benefits in web-DENIS, for example, they should use the nine-character alphanumeric contract number once this change goes into effect.

We’ll publish additional information on this topic once the exact implementation date is identified.


COVID-19 HCPCS update: New codes added

The Centers for Medicare & Medicaid Services has added two 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.

Code Change Coverage comments Effective date
U0003 Added Covered April 14, 2020
U0004 Added Covered April 14, 2020

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.


COVID-19 CPT update: New codes added

Pathology and Laboratory

Code Change Coverage comments Effective date
86328 Added Covered April 10, 2020
86769 Added Covered April 10, 2020

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


Billing chart: Blues highlight medical, benefit policy changes

You’ll find the latest information about procedure codes and Blue Cross Blue Shield of Michigan billing guidelines in the following chart.

This billing chart is organized numerically by procedure code. Newly approved procedures will appear under the New Payable Procedures heading. Procedures for which we have changed a billing guideline or added a new payable group will appear under Updates to Payable Procedures. Procedures for which we are clarifying our guidelines will appear under Policy Clarifications. New procedures that are not covered will appear under Experimental Procedures.

You will also see that descriptions for the codes are no longer included. This is a result of recent negotiations with the AMA on use of the codes.

We will publish information about new BCBS groups or changes to group benefits under the Group Benefit Changes heading.

For more detailed descriptions of the BCBSM policies for these procedures, please check under the Medical/Payment Policy tab in Explainer on web-DENIS. To access this online information:

  • Log in to web-DENIS.
  • Click on BCBSM Provider Publications & Resources.
  • Click on Benefit Policy for a Code.
  • Click on Topic.
  • Under Topic Criteria, click on the drop-down arrow next to Choose Identifier Type and then click on HCPCS Code.
  • Enter the procedure code.
  • Click on Finish.
  • Click on Search.
Code* BCBSM changes to:
Basic Benefit and Medical Policy, Group
Variations Payment Policy, Guidelines
NEW PAYABLE PROCEDURES

0523T

Basic benefit and medical policy

*0523T is payable

Code *0523T is payable effective Jan. 1, 2019.

Payment policy:

Modifiers 26 and TC don’t apply, and it isn’t payable as a stand-alone service.

Value code 86
Value code 87
Value code 90

Basic benefit and medical policy

Changes for value codes

Value code 86 is discontinued, effective March 31, 2020.

Value codes 87 and 90 are effective April 1, 2020.
UPDATES TO PAYABLE PROCEDURES
J0695

Basic benefit and medical policy

Zerbaxa

Zerbaxa, procedure code J0695, is payable for the new FDA-approved indications. The indications have been updated to include the following treatments:

  • Hospital-acquired bacterial pneumonia
  • Ventilator-associated bacterial pneumonia

J3490
J3590

Basic benefit and medical policy

Tepezza (teprotumumab-trbw)

Tepezza (teprotumumab-trbw) is payable when billed for FDA-approved indications, effective Jan. 21, 2020. Tepezza (teprotumumab-trbw) should be reported with procedure code J3490 or J3590 and the appropriate National Drug Code until a permanent code is established.

URMBT groups are excluded from coverage of this drug. 

Tepezza (teprotumumab-trbw) is an insulin-like growth factor-1 receptor inhibitor indicated for the treatment of thyroid eye disease.

Dosage and administration:

  • Initiate dosing with 10 mg/kg for first infusion, followed by 20 mg/kg every three weeks for seven additional infusions
  • Administer Tepezza by intravenous infusion over 60 to 90 minutes

Dosage forms and strengths:

For injection: 500 mg lyophilized powder in a single-dose vial for reconstitution

J3490
J3590

Basic benefit and medical policy

Quzyttir (cetirizine)

Quzyttir (cetirizine) is payable when billed for FDA-approved indications, effective Oct. 1, 2019. Quzyttir (cetirizine) should be reported with procedure code J3490 or J3590 and the appropriate National Drug Code until a permanent code is established.

URMBT groups are excluded from coverage of this drug.

Quzyttir (cetirizine) is a histamine-1 (H1) receptor antagonist indicated for the treatment of acute urticaria in adults and children ages 6 months and older.

Limitations of use:
Not recommended in pediatric patients less than 6 years of age with impaired renal or hepatic function.

Dosage and administration:
For intravenous administration only

Recommended dosages:

  • Adults and adolescents ages 12 and older: 10 mg
  • Children ages 6 to 11 years old: 5 mg or 10 mg 
  • Children ages 6 months to 5 years: 2.5 mg

J7297

Basic benefit and medical policy

Liletta

Liletta (levonorgestrel-releasing intrauterine system), procedure code J7297, is payable for the new FDA‑approved indications. The indications have been updated to include prevention of pregnancy for up to six years.
POLICY CLARIFICATIONS
94799

Basic benefit and medical policy

Inhaled Nitric Oxide policy

The criteria have been updated for the Inhaled Nitric Oxide policy. This policy is effective Nov. 1, 2019.

The safety and effectiveness of the use of inhaled nitric oxide have been established. It may be considered a useful therapeutic option for patients meeting specific patient selection criteria.

Inclusions:

The following patients may be considered appropriate candidates for inhaled nitric oxide, or iNO, therapy:

  • When used as a component of treatment of hypoxic respiratory failure in neonates born at more than 34 weeks of gestation. (Hypoxic respiratory failure is defined as an oxygenation index of at least 25 on two measurements made at least 15 minutes apart.)
  • iNO therapy for post-operative management of pulmonary hypertensive crisis in infants and children with congenital heart disease.
  • iNO therapy as a method of assessing pulmonary vaso-reactivity in people with pulmonary hypertension.

Exclusions:

Other indications for inhaled nitric oxide are experimental including, but not limited to, its use in:

  • Premature neonates born at less than or equal to 34 weeks of gestation
  • Adults and children with acute respiratory distress syndrome or acute hypoxemic respiratory failure
  • Patients with sickle cell disease
  • Patients following elective LVAD insertion surgery
  • In lung transplantation, during or after graft reperfusion

For the above conditions, it hasn’t been scientifically demonstrated to be as safe and effective as conventional treatment for these conditions.

Informational guidelines:

  • The oxygenation index, or OI, is calculated as the mean airway pressure times the fraction of inspired oxygen divided by the partial pressure of arterial oxygen times 100. An OI of 25 is associated with a 50% risk of requiring extracorporeal membrane oxygenation, or ECMO, or dying. An OI of 40 is often used as a criterion to initiate ECMO therapy.
  • Prolonged use of iNO (inhaled NO) beyond one to two weeks hasn’t been shown to improve outcomes. Use of iNO beyond two weeks of treatment is therefore not recommended.
  • If ECMO is initiated in near-term neonates who qualify for and are receiving treatment with iNO, the iNO should be discontinued as there is no benefit to combined treatment.

J0202

Basic benefit and medical policy

Lemtrada (alemtuzumab)

Effective Oct. 29, 2019, Lemtrada (alemtuzumab) is payable for the following updated indications:

Lemtrada (alemtuzumab) is a CD52-directed cytolytic monoclonal antibody indicated for the treatment of relapsing forms of multiple sclerosis, to include relapsing-remitting disease and active secondary progressive disease, in adults. Because of its safety profile, the use of Lemtrada (alemtuzumab) should generally be reserved for patients who have had an inadequate response to two or more drugs indicated for the treatment of MS.

Limitations of use:

Lemtrada (alemtuzumab) isn’t recommended for use in patients with clinically isolated syndrome because of its safety profile.

Dosage and administration:

  • Baseline laboratory tests are required before treatment.
  • Administer Lemtrada (alemtuzumab) by intravenous infusion over four hours for two or more treatment courses:
    • Initial treatment of two courses:
      • First course: 12 mg/day on five consecutive days.
      • Second course: 12 mg/day on three consecutive days 12 months after first treatment course. 
    • Subsequent treatment courses of 12 mg per day on three consecutive days (36 mg total dose) may be administered, as needed, at least 12 months after the last dose of any prior treatment course.
  • Premedicate with corticosteroids prior to Lemtrada (alemtuzumab) infusion for the first three days of each treatment course.
  • Administer antiviral agents for herpetic prophylaxis starting on the first day of Lemtrada (alemtuzumab) dosing and continuing for a minimum of two months after completion of Lemtrada (alemtuzumab) dosing or until CD4+ lymphocyte count is more than 200 cells per microliter, whichever occurs later.
  • It must be diluted before administration.

J0584

Basic benefit and medical policy

Crysvita (burosumab-twza)

Effective Sept. 17, 2019, Crysvita (burosumab-twza) is payable for pediatric patients ages 6 months and older.

FDA-approved indication/diagnosis: X-linked hypophosphatemia, or XLH, in adult and pediatric patients ages 6 months and older

Coverage of Crysvita (burosumab-twza) is provided when all the following are met:

  • FDA-approved age
  • Diagnosis of X-linked hypophosphatemia confirmed by one of the following:
    • Genetic testing
    • Elevated serum fibroblast growth factor 23 (FGF23) level > 30 pg/mL
  • Prescribed by endocrinologist
  • Serum phosphorus < 2.5 mg/dL
  • Presence of clinical signs and symptoms of the disease (e.g., rickets, growth retardation, musculoskeletal pain, bone fractures)
  • Measurable bone/joint pain (≥ 4 BPI-Q3 Worst Pain)
  • Trial and failure of the preferred products as specified in the Blue Cross Blue Shield of Michigan and Blue Care Network utilization management medical drug list

Crysvita (burosumab-twza) is considered experimental when used for all other conditions including, but not limited to, tumor induced osteomalacia.

Dosing:

Pediatric XLH: Starting dose regimen is 0.8 mg/kg of body weight rounded to the nearest 10 mg, administered every two weeks. The minimum starting dose is 10 mg up to a maximum dose of 90 mg. Dose may be increased up to approximately 2 mg/kg (maximum 90 mg), administered every two weeks to achieve normal serum phosphorus.
 

Adult XLH: Dose regimen is 1 mg/kg body weight rounded to the nearest 10 mg up to a maximum dose of 90 mg administered every four weeks.

J2323

Basic benefit and medical policy

Tysabri (natalizumab)

Effective Aug. 5, 2019, Tysabri (natalizumab) is payable for the following updated indications for multiple sclerosis:

Tysabri (natalizumab) is indicated as monotherapy for the treatment of relapsing forms of multiple sclerosis, to include clinically isolated syndrome, relapsing-remitting disease and active secondary progressive disease in adults.

Dosage:

  • 300 mg infused intravenously over one hour, every four weeks 

Pharmacy requires prior authorization of this drug.   

J2796

Basic benefit and medical policy

Nplate (romiplostim)

Effective Oct. 17, 2019, Nplate (Romiplostim) is payable for the updated indications.

Nplate is a thrombopoietin receptor agonist indicated for the treatment of thrombocytopenia in:

  • Adult patients with immune thrombocytopenia, known as ITP, who have had an insufficient response to corticosteroids, immunoglobulins or splenectomy.
  • Pediatric patients ages 1 and older with ITP for at least six months who have had an insufficient response to corticosteroids, immunoglobulins or splenectomy.

Limitations of use:

  • Nplate isn’t indicated for the treatment of thrombocytopenia due to myelodysplastic syndrome, or MDS, or any cause of thrombocytopenia other than chronic ITP.
  • Nplate should be used only in patients with ITP whose degree of thrombocytopenia and clinical condition increases the risk for bleeding.
  • Nplate shouldn’t be used in an attempt to normalize platelet counts.

J3490
J3590

Basic benefit and medical policy

Beovu (brolucizumab)

Beovu (brolucizumab) is considered established, effective Oct. 8, 2019.

Beovu (brolucizumab) is a human vascular endothelial growth factor, or VEGF, inhibitor indicated for the treatment of neovascular (wet) age-related macular degeneration, or AMD.

Dosing information:

Beovu (brolucizumab) is administered by intravitreal injection. The recommended dose for Beovu (brolucizumab) is 6 mg (0.05 mL of 120 mg/mL solution) monthly (approximately every 25-31 days) for the first three doses, followed by one dose of 6 mg (0.05 mL) every eight to 12 weeks.

Pharmacy requires preauthorization of this drug.

This drug isn’t a benefit for URMBT. 

The National Drug Code is 00078-0827-61.

J3490
J3590

Basic benefit and medical policy

Reblozyl (luspatercept-aamt)

Reblozyl (luspatercept-aamt) is considered established, effective Nov. 8, 2019.

Reblozyl (luspatercept-aamt) is an erythroid maturation agent indicated for the treatment of anemia in:

  • Adult patients with beta thalassemia who require regular red blood cell transfusions.

Dosage and administration:

  • The recommended starting dose is 1 mg/kg once every three weeks by subcutaneous injection.
  • Review hemoglobin results before each administration.

This drug isn’t a benefit for URMBT. 

The National Drug Codes are:

  • 59572-0711-01
  • 59572-0775-01

J3490

Basic benefit and medical policy

XENLETA (lefamulin)

XENLETA (lefamulin) is a pleuromutilin antibacterial indicated for the treatment of adults with community-acquired bacterial pneumonia, known as CABP, caused by susceptible microorganisms.
 
To reduce the development of drug resistant bacteria and maintain the effectiveness of XENLETA (lefamulin) and other antibacterial drugs, XENLETA (lefamulin) should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria.

Dosing information:

For treatment of adults with CABP, the recommended dosage of XENLETA is as follows:

  • For the duration, 150 mg every 12 hours by intravenous infusion over 60 minutes** for five to seven days
  • 600 mg orally every 12 hours for five days

 **With option to switch to XENLETA Tablets 600 mg every 12 hours to complete the treatment course

  • Patients with hepatic impairment: Reduce the dosage of XENLETA injection to 150 mg infused over 60 minutes every 24 hours in patients with severe hepatic impairment (Child-Pugh Class C). XENLETA tablets haven’t been studied in and aren’t recommended for patients with moderate (Child-Pugh Class B) or severe hepatic impairment.
  • Administration instruction for XENLETA tablets: Take at least one hour before a meal or two hours after a meal. Swallow XENLETA tablets whole with water (six to eight ounces).
  • Administration instruction for XENLETA injection: Infuse over 60 minutes.

See full prescribing information for additional details on the administration and preparation of XENLETA tablets and injection.

Pharmacy doesn’t require preauthorization of this drug.

This drug isn’t a benefit for URMBT. 

The National Drug Codes are:

  • 72000-0120-01
  • 72000-0120-06
  • 72000-0110-30

J3490
J3590

Basic benefit and medical policy

Ziextenzo (pegfilgrastim-bmez)

Ziextenzo (pegfilgrastim-bmez) is considered established, effective Nov. 4, 2019.

Ziextenzo (pegfilgrastim-bmez) is a leukocyte growth factor indicated to decrease the incidence of infection, as manifested by febrile neutropenia, in patients with nonmyeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a clinically significant incidence of febrile neutropenia.

Limitations of use:

Ziextenzo (pegfilgrastim-bmez) isn’t indicated for the mobilization of peripheral blood progenitor cells for hematopoietic stem cell transplantation.

Dosage and administration:

Patients with cancer receiving myelosuppressive chemotherapy:

  • 6 mg administered subcutaneously once per chemotherapy cycle.
  • Don’t administer between 14 days before and 24 hours after administration of cytotoxic chemotherapy.
  • Use weight-based dosing for pediatric patients weighing less than 45 kg.

This drug isn’t a benefit for URMBT.

The NDC is 61314-0866-01.

J7185

Basic benefit and medical policy

Xyntha antihemophilic factor (recombinant)

Effective Oct. 17, 2019, Xyntha antihemophilic factor (recombinant) is payable for the updated indications.

Xyntha is a recombinant antihemophilic factor indicated in adults and children with hemophilia A for on-demand treatment and control of bleeding episodes and for perioperative management.

Xyntha isn’t indicated in patients with von Willebrand's disease.

Pharmacy doesn’t require prior authorization of this drug.

Q9950

Basic benefit and medical policy

Lumason (sulfur hexafluoride lipid-type A microspheres)

Blue Cross Blue Shield of Michigan has adopted the revised FDA-approved indications for Lumason (sulfur hexafluoride lipid-type A microspheres), the ultrasound contrast agent indicated for use in:

  • Echocardiography to opacify the left ventricular chamber and to improve the delineation of the left ventricular endocardial border in adult and pediatric patients with suboptimal echocardiograms
  • Ultrasonography of the liver for characterization of focal liver lesions in adult and pediatric patients
  • Ultrasonography of the urinary tract for the evaluation of suspected or known vesicoureteral reflux in pediatric patients

Condition code A7

Basic benefit and medical policy

Condition code A7

The National Uniform Billing Committee approved new condition code A7, effective April 1, 2020.

Professional

Provider symposium transitions to virtual format

The 2020 provider symposium, A Prescription for Success, is transitioning to a virtual format due to current social distancing recommendations. We have notified everyone who registered for the original sessions and closed the registration links that were in the April Record article.

We’ve scheduled virtual sessions throughout the months of June and July, as follows, for physician office staff and coders. Keep in mind that you can register for more than one session.

Sessions for physician office staff responsible for closing gaps in care related to quality measures and creating a positive patient experience:

Topic Date and time Registration link
HEDIS®/Star measures — details and exclusions, Consumer Assessment of Healthcare Providers and Systems Survey and Health Outcomes Survey June 11 at 8 a.m. Click here to register.
June 16 at 8 a.m. Click here to register.
July 14 at noon Click here to register.
July 16 at noon Click here to register.
July 22 at noon Click here to register.
July 29 at 8 a.m. Click here to register.

Patient experience: Expectations for convenience in a dynamic health care environment June 11 at noon Click here to register.
June 16 at noon Click here to register.
July 14 at 8 a.m. Click here to register.
July 16 at 8 a.m. Click here to register.
July 22 at 8 a.m. Click here to register.
July 29 at noon Click here to register.

Sessions for coders, billers and administrative staff:

Topic Date and time Registration link
Updates on telehealth and CPT, ICD‑10‑CM and evaluation and management codes June 2 at 8 a.m. Click here to register.
June 10 at noon Click here to register.
June 24 at noon Click here to register.
July 15 at 8 a.m. Click here to register.
July 21 at noon Click here to register.
July 30 at 8 a.m. Click here to register.

New this year: Nurses, in addition to coders, can receive continuing education credits for attending the sessions.

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


Blue Cross using Signify Health for URMBT’s Health & Well-Being Call program

Blue Cross Blue Shield of Michigan is using Signify Health for the UAW Retiree Medical Benefits Trust, or URMBT, Health & Well-Being Call program.

Through this program, a licensed doctor or nurse practitioner calls eligible URMBT subscribers and spouses to discuss their health status and identify any gaps in care. The call includes a basic check on the member’s well-being, an opportunity for the member to ask medical questions and a chance for the practitioner to share COVID-19 information and care resources available to the member during this time.

We want you to be aware of this program because Signify Health will contact you if it is scheduled to call a patient who identifies you as their primary care physician. Following the call, Signify Health will send you a copy of the completed health assessment with any recommendations it made to your patient regarding their health and follow-up care.

The program is available to URMBT members who have one of our Medicare Advantage plans (either Medicare Plus BlueSM or BCN AdvantageSM), as well as newly retired URMBT members who have Blue Cross Blue Shield of Michigan’s Enhanced Care Plan, or ECP.


Outpatient psychiatric centers can submit telemedicine claims to Blue Cross using their OPC NPIs

Blue Cross Blue Shield of Michigan’s commercial PPO can now accept telemedicine claims from outpatient psychiatric centers using the OPC facility NPI. This previously wasn’t possible, but we’ve revised our systems to make it easier for you to submit claims. The change was effective in April and brings the PPO commercial billing guidelines in line with those of Blue Care Network.

OPC providers no longer need to submit claims for telemedicine services using their individual professional NPI or bill under the NPI of a supervising physician for Blue Cross commercial PPO claims. As a reminder, OPCs always bill professional claims.

For telemedicine visits that include both audio and visual
Continue to bill the behavioral health procedure codes currently approved for OPC providers and append the appropriate modifiers. OPC providers should include modifiers on the claim in this order:

  • The modifier that indicates the licensure level (level of care) for the rendering provider (such as: AH, AJ, HO) should be listed first.
  • The telemedicine modifier (either GT or 95) should be listed second.
  • Then include place of service code 02.

For telephone-only visits (audio only)
OPC providers should include the rendering provider modifier, as appropriate, and place of service code 02.

Medicare Plus BlueSM OPC claims should continue to be submitted using the OPC NPI. OPCs should bill for professional services rendered by practitioners for Medicare Plus Blue using the OPC NPI in the billing provider field.

For more information on telehealth
See the Telehealth for behavioral health providers guide, which is available in the telehealth sections of our coronavirus webpages. Here’s how to find these pages:

  • For the most up-to-date and comprehensive information, log in as a provider at bcbsm.com and click on Coronavirus (COVID-19).
  • If you don’t have access to Provider Secured Services, visit bcbsm.com/coronavirus (click on For Providers).

Recommendations for submitting authorization requests for medical oncology drugs to AIM

Here are some recommendations to follow when submitting authorization requests for medical oncology drugs to AIM Specialty Health®

  • Wait to submit the request until you have all the pertinent information, including but not limited to:
    • Tumor testing results
    • Information on tumor staging and prior therapy regimens
  • Wait to submit the request until you have all the pertinent information, including but not limited to, tumor testing results, information on tumor staging and prior therapy regimens.
  • Provide all the clinical information needed for clinical review, including the rationale for the requested regimen.
  • Ensure that the phone number you provide is accurate so AIM can contact you to schedule a peer-to-peer consultation if they need more information to establish medical necessity.

When you follow these guidelines, the process of reviewing authorization requests goes more smoothly and takes less time.

The information in this article applies to all members whose plans require authorization of medical oncology drugs by AIM:

  • Medicare Advantage plans: Medicare Plus BlueSM and BCN AdvantageSM
  • Commercial plans: BCN HMOSM and select Blue Cross PPO groups

How to submit authorization requests
For medical oncology drugs, submit authorization requests to AIM, using one of the following methods:

For information about registering for and accessing the AIM ProviderPortal, see the Frequently asked questions page on the AIM Specialty Health website.**

Lists of requirements
To see the requirements related to drugs covered under the medical benefit, including medical oncology drugs, refer to the following documents.

The specialty medications on these lists are administered in outpatient sites of care, including a physician’s office, an outpatient facility or a member’s home.

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


Updated: We’ve added site-of-care requirements for Lemtrada and Tysabri for commercial members

We’re updating an article published in the March 2020 issue of The Record. We’re providing a link to an FAQ — Lemtrada® and Tysabri® site-of-care program: Frequently asked questions for providers — that contains additional program information and details on authorized administration sites in Michigan and elsewhere in the U.S. Please refer to this article for the most up-to-date information.

As of May 1, 2020, the medical drug site-of-care program expanded for Blue Cross’ PPO (commercial) and BCN HMOSM (commercial) members to include:

  • Lemtrada (alemtuzumab, HCPCS code J0202)
  • Tysabri (natalizumab, HCPCS code J2323)

Through April 30, 2020, members who received these drugs in one of the following locations are authorized to continue treatment:

  • Doctor’s office or other health care provider’s office
  • Ambulatory infusion center
  • Hospital outpatient facility

Starting May 1, 2020, infusions of Tysabri and Lemtrada may not be covered at hospital outpatient facilities.** Members receiving these medications at a hospital outpatient facility should talk to their doctors about arranging to receive infusion services at one of the following locations:

  • Doctor’s office or other health care provider’s office
  • Ambulatory infusion center

More about the authorization requirements
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. These changes don’t apply to the Federal Employee Program® Service Benefit Plan members.

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

List of requirements
For a list of requirements related to drugs covered under the medical benefit, please see the Blue Cross and BCN utilization management medical drug list document located on our ereferrals.bcbsm.com website:

We’ve updated the requirements list with the new information about Lemtrada and Tysabri.

**Based on Risk Evaluation and Mitigation Strategies program restrictions, administration of Lemtrada and Tysabri is limited to authorized locations. For Lemtrada, we’ll restrict transitions to select locations that have safety protocols in place for adverse reactions. To aid member transition, refer to Lemtrada and Tysabri site-of-care program: Frequently asked questions for providers, a document that contains additional program information and details on authorized administration sites in Michigan and elsewhere in the U.S.


Sarclisa requires prior authorization for Medicare Plus Blue PPO, BCN Advantage and BCN HMO members

We recently expanded the prior authorization program for specialty drugs covered under the medical benefit for Medicare Plus BlueSM, BCN AdvantageSM and BCN HMOSM members.

For dates of service on or after May 15, 2020, Sarclisa® (isatuximab-irfc, HCPCS codes J3490, J3590 and J9999) requires authorization through AIM Specialty Health®.

How to submit authorization requests
For this drug, submit authorization requests to AIM using one of the following methods:

For information about registering for and accessing the AIM ProviderPortal, see Frequently asked questions.**

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:

We’ve updated the requirements lists with the new information about Sarclisa.

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


Guidelines, recommendations for management of acute low back pain in adults

Low back pain is one of the most common complaints expressed by patients in the primary care setting. In the past decade, multiple guidelines and recommendations have been published to help health care providers identify when imaging for patients with low back pain is appropriate during the first six weeks of treatment.

Patients sometimes will complain of low back pain along with symptoms such as unexplained weight loss, sudden bowel or bladder dysfunction, acute dysesthesia or weakness of the legs. These are red flags for more serious conditions and imaging within the first six weeks may be necessary.

However, most patients with low back pain don’t have these red flag symptoms and imaging in the first six weeks of treatment isn’t recommended. The risks to patients receiving routine imaging not only include increased radiation exposure but also a decrease in the patient’s sense of well-being. Studies have shown patients who had an early MRI were 2 to 8 times more likely to undergo surgery.

MQIC guideline updated
For additional guidance, review the Michigan Quality Improvement Consortium’s Management of Acute Low Back Pain in Adults,** which has been updated for 2020.

Also, Choosing Wisely®,** an initiative of the American Board of Internal Medicine Foundation, offers recommendations on when to use imaging for low back pain here.**

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


Use appropriate modifier for unplanned and unrelated surgical procedures performed within surgical global period

Add modifier 78 for unplanned procedures
It may be necessary to indicate that another procedure was performed by the same physician during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first and requires the use of an operating or procedure room, report it by adding modifier 78 to the related procedure.  

Add modifier 79 for unrelated procedures or services  
The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. Report this situation by using modifier 79.

Contact Provider Inquiry at 1-800-344-8525 or 1-800-249-5103 if you have any questions.


Webinar recordings now available for 2020 sessions

Provider Experience is continuing to offer training resources to help clinical and administrative staffs work more efficiently with Blue Cross Blue Shield of Michigan and Blue Care Network.

You can now access recordings of the provider training webinars we’ve delivered so far in 2020 through web-DENIS. Follow these steps:

For Blue Cross

  1. Click on BCBSM Newsletters and Resources.
  2. Click on Newsletters & Resources.
  3. Click on Provider Training under Popular Links.
  4. Find the webinar you want in the Featured Links section.

For BCN

  1. Go to BCN Provider Publications and Resources.
  2. Click on Learning opportunities under Other Resources.
  3. Click on the link you want under 2020 Provider Training Webinars.

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

Facility

We’re revising our Participating Hospital Agreement

With input from the hospital industry and the Michigan Health & Hospital Association, Blue Cross Blue Shield of Michigan is in the process of updating its model Participating Hospital Agreement. Due to current events, this course of action could be subject to change.

The new PHA model will modernize contractual language, define processes and augment future efforts to address affordability issues.

PHA revisions include:

  • Eliminate Blue Cross interim payments for all hospitals.(See the third question on the frequently asked questions document, which we link to below.)
  • Eliminate the annual settlement process.
  • Streamline the appeals process.
  • Update the contract administration process.
  • Simplify Peer Group 5 administration.
  • Eliminate Exhibit B and references to reimbursement for hospitals in Peer Group 1 through 4.

How do I learn more about the PHA changes?
Refer to the FAQ document for additional information or contact your contracting team.


Outpatient psychiatric centers can submit telemedicine claims to Blue Cross using their OPC NPIs

Blue Cross Blue Shield of Michigan’s commercial PPO can now accept telemedicine claims from outpatient psychiatric centers using the OPC facility NPI. This previously wasn’t possible, but we’ve revised our systems to make it easier for you to submit claims. The change was effective in April and brings the PPO commercial billing guidelines in line with those of Blue Care Network.

OPC providers no longer need to submit claims for telemedicine services using their individual professional NPI or bill under the NPI of a supervising physician for Blue Cross commercial PPO claims. As a reminder, OPCs always bill professional claims.

For telemedicine visits that include both audio and visual
Continue to bill the behavioral health procedure codes currently approved for OPC providers and append the appropriate modifiers. OPC providers should include modifiers on the claim in this order:

  • The modifier that indicates the licensure level (level of care) for the rendering provider (such as: AH, AJ, HO) should be listed first.
  • The telemedicine modifier (either GT or 95) should be listed second.
  • Then include place of service code 02.

For telephone-only visits (audio only)
OPC providers should include the rendering provider modifier, as appropriate, and place of service code 02.

Medicare Plus BlueSM OPC claims should continue to be submitted using the OPC NPI. OPCs should bill for professional services rendered by practitioners for Medicare Plus Blue using the OPC NPI in the billing provider field.

For more information on telehealth
See the Telehealth for behavioral health providers guide, which is available in the telehealth sections of our coronavirus webpages. Here’s how to find these pages:

  • For the most up-to-date and comprehensive information, log in as a provider at bcbsm.com and click on Coronavirus (COVID-19).
  • If you don’t have access to Provider Secured Services, visit bcbsm.com/coronavirus (click on For Providers).

Recommendations for submitting authorization requests for medical oncology drugs to AIM

Here are some recommendations to follow when submitting authorization requests for medical oncology drugs to AIM Specialty Health®

  • Wait to submit the request until you have all the pertinent information, including but not limited to:
    • Tumor testing results
    • Information on tumor staging and prior therapy regimens
  • Wait to submit the request until you have all the pertinent information, including but not limited to, tumor testing results, information on tumor staging and prior therapy regimens.
  • Provide all the clinical information needed for clinical review, including the rationale for the requested regimen.
  • Ensure that the phone number you provide is accurate so AIM can contact you to schedule a peer-to-peer consultation if they need more information to establish medical necessity.

When you follow these guidelines, the process of reviewing authorization requests goes more smoothly and takes less time.

The information in this article applies to all members whose plans require authorization of medical oncology drugs by AIM:

  • Medicare Advantage plans: Medicare Plus BlueSM and BCN AdvantageSM
  • Commercial plans: BCN HMOSM and select Blue Cross PPO groups

How to submit authorization requests
For medical oncology drugs, submit authorization requests to AIM, using one of the following methods:

For information about registering for and accessing the AIM ProviderPortal, see the Frequently asked questions page on the AIM Specialty Health website.**

Lists of requirements
To see the requirements related to drugs covered under the medical benefit, including medical oncology drugs, refer to the following documents.

The specialty medications on these lists are administered in outpatient sites of care, including a physician’s office, an outpatient facility or a member’s home.

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


Sarclisa requires prior authorization for Medicare Plus Blue PPO, BCN Advantage and BCN HMO members

We recently expanded the prior authorization program for specialty drugs covered under the medical benefit for Medicare Plus BlueSM, BCN AdvantageSM and BCN HMOSM members.

For dates of service on or after May 15, 2020, Sarclisa® (isatuximab-irfc, HCPCS codes J3490, J3590 and J9999) requires authorization through AIM Specialty Health®.

How to submit authorization requests
For this drug, submit authorization requests to AIM using one of the following methods:

For information about registering for and accessing the AIM ProviderPortal, see Frequently asked questions.**

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:

We’ve updated the requirements lists with the new information about Sarclisa.

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


Webinar recordings now available for 2020 sessions

Provider Experience is continuing to offer training resources to help clinical and administrative staffs work more efficiently with Blue Cross Blue Shield of Michigan and Blue Care Network.

You can now access recordings of the provider training webinars we’ve delivered so far in 2020 through web-DENIS. Follow these steps:

For Blue Cross

  1. Click on BCBSM Newsletters and Resources.
  2. Click on Newsletters & Resources.
  3. Click on Provider Training under Popular Links.
  4. Find the webinar you want in the Featured Links section.

For BCN

  1. Go to BCN Provider Publications and Resources.
  2. Click on Learning opportunities under Other Resources.
  3. Click on the link you want under 2020 Provider Training Webinars.

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

Pharmacy

Recommendations for submitting authorization requests for medical oncology drugs to AIM

Here are some recommendations to follow when submitting authorization requests for medical oncology drugs to AIM Specialty Health®

  • Wait to submit the request until you have all the pertinent information, including but not limited to:
    • Tumor testing results
    • Information on tumor staging and prior therapy regimens
  • Wait to submit the request until you have all the pertinent information, including but not limited to, tumor testing results, information on tumor staging and prior therapy regimens.
  • Provide all the clinical information needed for clinical review, including the rationale for the requested regimen.
  • Ensure that the phone number you provide is accurate so AIM can contact you to schedule a peer-to-peer consultation if they need more information to establish medical necessity.

When you follow these guidelines, the process of reviewing authorization requests goes more smoothly and takes less time.

The information in this article applies to all members whose plans require authorization of medical oncology drugs by AIM:

  • Medicare Advantage plans: Medicare Plus BlueSM and BCN AdvantageSM
  • Commercial plans: BCN HMOSM and select Blue Cross PPO groups

How to submit authorization requests
For medical oncology drugs, submit authorization requests to AIM, using one of the following methods:

For information about registering for and accessing the AIM ProviderPortal, see the Frequently asked questions page on the AIM Specialty Health website.**

Lists of requirements
To see the requirements related to drugs covered under the medical benefit, including medical oncology drugs, refer to the following documents.

The specialty medications on these lists are administered in outpatient sites of care, including a physician’s office, an outpatient facility or a member’s home.

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


Updated: We’ve added site-of-care requirements for Lemtrada and Tysabri for commercial members

We’re updating an article published in the March 2020 issue of The Record. We’re providing a link to an FAQ — Lemtrada® and Tysabri® site-of-care program: Frequently asked questions for providers — that contains additional program information and details on authorized administration sites in Michigan and elsewhere in the U.S. Please refer to this article for the most up-to-date information.

As of May 1, 2020, the medical drug site-of-care program expanded for Blue Cross’ PPO (commercial) and BCN HMOSM (commercial) members to include:

  • Lemtrada (alemtuzumab, HCPCS code J0202)
  • Tysabri (natalizumab, HCPCS code J2323)

Through April 30, 2020, members who received these drugs in one of the following locations are authorized to continue treatment:

  • Doctor’s office or other health care provider’s office
  • Ambulatory infusion center
  • Hospital outpatient facility

Starting May 1, 2020, infusions of Tysabri and Lemtrada may not be covered at hospital outpatient facilities.** Members receiving these medications at a hospital outpatient facility should talk to their doctors about arranging to receive infusion services at one of the following locations:

  • Doctor’s office or other health care provider’s office
  • Ambulatory infusion center

More about the authorization requirements
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. These changes don’t apply to the Federal Employee Program® Service Benefit Plan members.

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

List of requirements
For a list of requirements related to drugs covered under the medical benefit, please see the Blue Cross and BCN utilization management medical drug list document located on our ereferrals.bcbsm.com website:

We’ve updated the requirements list with the new information about Lemtrada and Tysabri.

**Based on Risk Evaluation and Mitigation Strategies program restrictions, administration of Lemtrada and Tysabri is limited to authorized locations. For Lemtrada, we’ll restrict transitions to select locations that have safety protocols in place for adverse reactions. To aid member transition, refer to Lemtrada and Tysabri site-of-care program: Frequently asked questions for providers, a document that contains additional program information and details on authorized administration sites in Michigan and elsewhere in the U.S.


Sarclisa requires prior authorization for Medicare Plus Blue PPO, BCN Advantage and BCN HMO members

We recently expanded the prior authorization program for specialty drugs covered under the medical benefit for Medicare Plus BlueSM, BCN AdvantageSM and BCN HMOSM members.

For dates of service on or after May 15, 2020, Sarclisa® (isatuximab-irfc, HCPCS codes J3490, J3590 and J9999) requires authorization through AIM Specialty Health®.

How to submit authorization requests
For this drug, submit authorization requests to AIM using one of the following methods:

For information about registering for and accessing the AIM ProviderPortal, see Frequently asked questions.**

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:

We’ve updated the requirements lists with the new information about Sarclisa.

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

DME

We’ve updated modifier requirements for HCPCS codes for segmental pneumatic appliances

Effective Feb. 1, 2020, the specified HCPCS codes for segmental pneumatic appliances must be reported on separate lines with the appropriate LT or RT modifier. If the modifiers aren’t reported, the claim will reject as provider liable.

The system will allow payment for one LT and one RT modifier for each of the HCPCS codes every five years. The HCPCS codes are below:

  • E0655
  • E0660
  • E0665
  • E0666
  • E0667
  • E0668
  • E0669
  • E0670
  • E0671
  • E0672
  • E0673

Clarification: Billing guidelines for enteral and parenteral nutrition therapy services

Health care providers must include modifier BO on all claims submitted for nutrients and supplies for Blue Cross Blue Shield of Michigan members who are fed orally.

In addition, providers should include the GA modifier on all claims, along with a GY or GZ modifier, which will acknowledge that: 

  • The services are expected to be rejected.
  • The member was informed and agreed to accept total responsibility.
  • An Advance Notice of Member Responsibility form was signed before services were given and is on file.

If providers don’t include the GA modifier on claims appended with a GY or GZ modifier, those providers will be held responsible for the cost of the services.

Providers must present a written notice to Blue Cross members before providing medical services or supplies that are expected to be rejected. For the notice to be acceptable, a provider must:

  • Complete the responsibility form in its entirety.
  • Clearly identify the particular item or service that is expected to be denied.
  • State the specific reason that Blue Cross will deny payment for the particular item or service.
  • Indicate the estimated cost of the item or service that is associated with the denied claim and the member is responsible.

The following are the HCPCS codes for enteral and parenteral nutrition therapy services:

  • B4149  
  • B4150  
  • B4152  
  • B4153
  • B4154
  • B4155  
  • B4158 
  • B4159  
  • B4160
  • B4161

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2019 American Medical Association. All rights reserved.