Blueprint for Affordability gets more traction

We’re pleased to announce the second wave of health care provider organizations that have agreed to sign risk-sharing arrangements with Blue Cross Blue Shield of Michigan as part of Blueprint for Affordability. They are:

• Affinia – West Michigan
• Genesys – Mid-Michigan
• Great Lakes OSC – Mid-Michigan
• Holland PHO – West Michigan
• Northern Physician Organization – Northern Michigan
• St. Mary’s PHO – Mid-Michigan
• Wexford PHO/Munson – Northern Michigan

In January, we told you about this new payment model, what it is, how it works and how we expect it to help us transform health care.

Blueprint is the next generation of value-based programs where we work with doctors and hospitals to keep the focus on the patient, align care and reduce duplication, re-admissions and complications.

We’ll continue to update you as Blueprint for Affordability evolves. For now, you can read more about it at BlueprintForAffordability.com.

We invite you to join PGIP as an organized system of care

Blue Cross Blue Shield of Michigan encourages our participating network physicians and organized systems of care to get involved in the Physician Group Incentive Program, which has been improving the quality and efficiency of health care in Michigan for more than 12 years. That’s why we’re pleased to announce that we’ll accept applications from new OSCs from April 1 through April 30, 2020.

About OSCs

An organized system of care is a community of caregivers with a shared commitment to quality and cost-effective health care delivery for a defined population. These caregivers have committed to:

• Deliver high-quality, cost-effective health care for a specific population.
• Provide care and treatment to a patient population attributed to the community’s primary care physicians.
• Join forces with one or more hospitals and other entities to share collective responsibility for a defined population of patients.

For more details about OSCs, visit the Models of Care section of our website.

If you represent an OSC and would like to join PGIP, send an email to valuepartnerships@bcbsm.com.

About PGIP physician organizations

A PGIP physician organization consists of physicians working together to:

• Transform systems of care to effectively manage patient populations.
• Build the infrastructure needed to optimize, measure and monitor quality of care.

Physician organizations promote collaborative relationships and support the most cost-effective delivery of services to improve patient outcomes.

Criteria for physicians joining PGIP

Network primary and specialty care physicians:

• Can only join as part of a PGIP physician organization and must be affiliated with a PGIP physician organization to be a member of an organized system of care
• Should contact a PGIP-participating physician organization directly to discuss specific membership criteria
• Here’s a current list of the 40 PGIP physician organizations. Each physician organization has its own criteria for membership. A physician can only be a member of one physician organization for the purposes of PGIP.

To participate in PGIP, a network physician must:

• Participate in the Blue Cross PPO, TRUST or Traditional lines of business.
• Be in good standing with the network.
• Be a medical doctor, doctor of osteopathy, doctor of chiropractic, doctor of podiatric medicine or fully licensed psychologist.

If you’re interested in participating in PGIP as an individual practitioner, send an email to valuepartnerships@bcbsm.com.

More information about PGIP

PGIP is an innovative provider program developed with input from physicians across Michigan to help improve the quality and efficiency of health care in the state. PGIP facilitates change through approximately 20 initiatives, including our nationally recognized Patient-Centered Medical Home program. It offers incentives to participating physicians, physician organizations and organized systems of care for improving health care delivery. For more information, visit valuepartnerships.com.

New quantity limits for morphine start May 1, 2020

Effective, May 1, 2020, certain long-acting morphine products will require new quantity limits for Blue Cross Blue Shield of Michigan and Blue Care Network commercial members.

A prior authorization is required for members who receive a prescription on or after May 1, 2020, under the new quantity limits. Members with current prescriptions for these medications aren’t affected.

Long-acting morphine products with the new quantity limits are:

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.

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

We’re expanding CAQH ProView 3.0

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

The purpose of the expansion is to:

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

The automated data feed process between CAQH ProView 3.0 and Portico, the Blue Cross provider data repository, will streamline the process of maintaining provider data and reduce duplication of data submission for the delegated groups.

You’re still required to complete a supplemental document or form to submit any Blue Cross required documentation, such as contract signature documents, certifications and tax ID numbers. We’ll notify you of additional requirements in a future issue of The Record.

Beta testing is expected to begin with the University of Michigan Medical Group and Genesys PHO for initial enrollment and changes in the first quarter of 2020 and recredentialing during summer 2020.  

If you have questions, contact Provider Enrollment and Data Management at
1-800-822-2761 from 8 a.m. to 4 p.m. Monday through Friday.

Updated e-referral system questionnaires released for Medicare Plus Blue, BCN in February 2020

In the January issue of The Record, we listed the questionnaires that we expected to release in the e-referral system by Jan. 26, 2020.

Most of the questionnaires listed in the articles were updated on Dec. 8, 2019. However, we had to postpone the release of the following questionnaires to Feb. 2:

• Breast reduction — We combined the Breast reduction, adult and the Breast reduction, adolescent questionnaires for BCN and BCN Advantage^SM members into a single questionnaire for both adult and adolescent members.
• Spinal cord stimulator or epidural or intrathecal catheter (trial or permanent placement) — We replaced this questionnaire with the following three questionnaires:
• Spinal cord stimulator — For BCN members
• Spinal cord stimulator — For Medicare Plus Blue^SM and BCN Advantage members
• Intrathecal catheter — For Medicare Plus Blue, BCN and BCN Advantage members

In addition, we updated the following questionnaire Feb. 2:

• Sleep studies — Opens only for BCN and BCN Advantage members

Here’s some additional information you need to know:

• We updated the preview questionnaires, authorization criteria and medical policies on the ereferrals.bcbsm.com website for the questionnaire updates.
• We use our authorization criteria and medical policies and your answers to the questionnaires when making utilization management determinations on your authorization requests.
• For all of these services, you can access preview questionnaires at ereferrals.bcbsm.com. 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. To find the preview questionnaires:
• For Medicare Plus Blue: Click on Blue Cross and then click on Authorization Requirements & Criteria. In the Medicare Plus Blue PPO members section, look under the Authorization criteria and preview questionnaires — Medicare Plus Blue PPO heading.
• For BCN: Click BCN and then click on Authorization Requirements & Criteria. Scroll down and look under the Authorization criteria and preview questionnaires heading.

Sign up for upcoming training webinars

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

Here’s how to register for upcoming training webinars:

Blue Cross 201 — Claims Appeals Overview provides in-depth learning opportunities for providers, building on information shared in our Blue Cross 101: Understanding the Basics webinar. This session focuses on the claims and appeals process for Blue Cross, BCN, Medicare Plus Blue^SM and BCN Advantage^SM facility and professional claims.

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

Radiation therapy services for A9590 require prior authorization for all Blue Cross, BCN members starting April 1

For dates of service on or after April 1, 2020, services associated with HCPCS code A9590 (iodine i-131, iobenguane, 1 millicurie) require prior authorization by eviCore healthcare.

This applies to all Blue Cross Blue Shield of Michigan and Blue Care Network members with plans subject to eviCore healthcare authorization requirements:

• Blue Cross’ PPO
• Medicare Plus Blue^SM PPO
• BCN commercial
• BCN Advantage^SM

We’ve updated the document titled Procedures that require authorization by eviCore healthcare to reflect this new requirement.

How to submit authorization requests

Submit authorization requests to eviCore in one of these ways:

• Preferred: Use eviCore’s provider portal at evicore.com.**
• Alternative: Call eviCore at 1-855-774-1317.
• Alternative: Fax to eviCore at 1-800-540-2406.

Additional information

For more information, refer to the document titled Frequently asked questions about requesting authorization from eviCore healthcare.

You can find this document and other resources on our ereferrals.bcbsm.com website:

• The Procedures Managed by eviCore for BCN webpage
• The Procedures Managed by eviCore for Blue Cross webpage

**Blue Cross and BCN don’t own or control this website.

TurningPoint to manage authorizations for musculoskeletal procedures with dates of service on or after June 1 for certain members

In a January Record article, we let you know that providers will need to submit authorization requests through TurningPoint Healthcare Solutions LLC for inpatient and outpatient musculoskeletal surgical procedures for Blue Care Network commercial members, as well as BCN Advantage^SM and Medicare Plus Blue^SM members.

Here’s additional information you need to know:

• Providers should submit authorization requests for all surgical procedures related to musculoskeletal conditions scheduled to occur on or after June 1, 2020, to TurningPoint starting May 1.
• This pertains to procedures currently managed by Blue Cross Blue Shield of Michigan or BCN.
• These changes don’t apply to Blue Cross commercial plans.
• eviCore healthcare^® will continue to manage lumbar spinal fusion surgeries for Medicare Plus Blue members throughout 2020. You can find the codes for these procedures by going to ereferrals.bcbsm.com and following these steps:
  1. Click on Blue Cross and then eviCore-Managed Procedures.
  2. Click on Procedures that require authorization by eviCore healthcare.
  3. Scroll down to the Lumbar spinal fusion surgery procedures requiring authorization by eviCore table.
• You can find procedure codes for orthopedic and spinal procedures managed by TurningPoint on ereferrals.bcbsm.com. The direct links are:
• Orthopedic
• Spinal

For more information, refer to our frequently asked questions document on ereferrals.bcbsm.com on the following pages:

• Blue Cross Musculoskeletal Services page
• BCN Musculoskeletal Services page

Portal registration and access
To register for the TurningPoint portal, go to myturningpoint-healthcare.com and click on Register for Access under the Login Now button. From there, you’ll need to fill out a validation form and submit your request to TurningPoint.

Note: Only professional providers can register for the portal at this time. Providers can request an authorization through the portal and then provide the appropriate facility with the authorization number. Facilities can view the status of an authorization request through the e-referral system 24 hours after TurningPoint makes a determination.

If you have any questions or need assistance, email TurningPoint at  portalregistration@turningpoint-healthcare.com.

Provider offices can also access the TurningPoint provider portal by following these steps:

1. Visit bcbsm.com/providers and log in to Provider Secured Services.
2. Click on the Musculoskeletal Service Authorizations through TurningPoint link
3. Enter your NPI.

If you’re having trouble accessing the TurningPoint provider portal using this process, contact the Blue Cross Web Support Help Desk at 1-877-258-3932.

Note for out-of-state providers: Log in to your home plan's website and select an ID card prefix from Michigan. This will take you to the Blue Cross Blue Shield of Michigan website. You can then follow the instructions above to access the TurningPoint provider portal.

Webinar training
We’ll offer a training webinar for professional providers and facilities in April. To register for training on TurningPoint’s clinical model and the TurningPoint provider portal, click on the appropriate link below:

• Professional providers can register for training here.
• Facility providers can register for training here.

Physical, occupational and speech therapy outpatient professional claims to require appropriate modifier

Effective May 1, 2020, physical, occupational and speech therapy providers must append the appropriate modifier to procedure codes for all outpatient professional claims for physical, occupational and speech therapy services. Therapy providers are encouraged to begin billing with the modifiers as soon as possible.

The Blue Cross Blue Shield of Michigan claims processing system is being updated to reject all outpatient professional claims for therapy services that are submitted without a modifier as follows:

• Speech-language therapy — bill with the GN modifier
• Occupational therapy — bill with the GO modifier
• Physical therapy — bill with the GP modifier

We notified providers about this new requirement in an October 2019 Record article and followed up with a web-DENIS message in January. Outpatient professional claims billed without a therapy modifier will be rejected as provider liable.

We’re adding site-of-care requirements for Lemtrada and Tysabri for commercial members, starting May 1

Starting May 1, 2020, the medical drug site-of-care program is expanding to include the following drugs for Blue Cross Blue Shield of Michigan and Blue Care Network commercial members:  

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

Through April 30, 2020, members who receive 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 won’t be covered at hospital outpatient facilities.** Before May 1, talk to your patients about making arrangements to receive infusion services at one of the following locations:

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

**Based on Risk Evaluation and Mitigation Strategies, or REMS, program restrictions, administration of Lemtrada and Tysabri is limited to authorized locations. We’ll post information about in-state and nationally authorized administration sites to our ereferrals.bcbsm.com website soon to aid in member transition. We’ll provide an update when this information is available.

More about the authorization requirements
The authorization requirements apply only to groups that are currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. These changes don’t apply to 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, see the Blue Cross and BCN utilization management medical drug list document located on our ereferrals.bcbsm.com website:

• The Blue Cross Drugs Covered Under the Medical Benefit webpage
• The BCN Drugs Covered Under the Medical Benefit webpage

We’ll update the requirements list for the drugs listed above before May 1, 2020.

Update: Requirements changed for some commercial medical benefit drugs

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

From July 2019 to December 2019, the following medical drugs had authorization requirements updates, site-of-care updates or both:

**Will become a unique code.

For a detailed list of requirements, see the Blue Cross and BCN utilization management medical drug list. You can access this list from the following pages on the ereferrals.bcbsm.com website.

• Blue Cross Drugs Covered Under the Medical Benefit page
• BCN Drugs Covered Under the Medical Benefit page

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

To access the list:

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

These changes don’t apply to Federal Employee Program^® Service Benefit Plan members.

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

Starting May 1, we’ll no longer cover Soma products

Our goal at Blue Cross Blue Shield of Michigan and Blue Care Network is to provide our members with safe, high quality, cost-effective prescription drugs. To do this, we’re making some changes to drugs we cover.

Starting May 1, 2020, Blue Cross and BCN will no longer cover the following Soma^® products:

• Soma and its generic, carisoprodol
• Soma compound and its generic, carisoprodol with aspirin
• Soma compound with codeine and its generic
  

If members fill a prescription for one of these drugs on or after May 1, 2020, they’ll be responsible for the full cost. We’ll cover the following alternatives that have similar effectiveness, quality and safety:

• Flexeril^® (cyclobenzaprine)
• Norflex^® (orphenadrine)
• Robaxin^® (methocarbamol)
• Parafon Forte DSC (chlorzoxazone)
• Zanaflex^® (tizanidine)

We’ll mail notification letters to members about this change. The letters will also encourage members to talk to their doctors about getting a prescription for one of the covered alternatives.

Important information about peer-to-peer reviews and appeals

When we deny your request to authorize an inpatient or outpatient service, you can ask for a peer-to-peer review or you can appeal the denial.

Whether you’re requesting a peer-to-peer review or submitting an appeal, there’s important information you need to know.

Differences to be aware of

• For Medicare Advantage authorizations denied before a service or admission is provided, you can only submit an appeal. You’ll be able to talk to a Blue Cross Blue Shield of Michigan or Blue Care Network medical director during the appeal process:
• For Medicare Plus Blue^SM, you can ask to talk to a medical director anytime during the appeal process.
• For BCN Advantage^SM, you’ll have an opportunity to talk to a medical director during the panel review.
• For Medicare Advantage authorizations (either Medicare Plus Blue or BCN Advantage) denied during or after a service or admission is provided, you can either request a peer-to-peer review or submit an appeal.
• For Blue Cross or BCN commercial authorizations denied before, during or after a service or admission is provided, you can either request a peer-to-peer review or submit an appeal.

For any denied authorization, if you decide to submit an appeal, follow the appeal process outlined in the denial letter you receive.

Requesting a peer-to-peer review

• Purpose. A peer-to-peer review is a conversation between the member’s health care provider and a Blue Cross or BCN medical director about the clinical nuances of the member’s medical condition and the medical necessity of the services.
• Process. The process for submitting a request for a peer-to-peer review is outlined in the document titled How to request a peer‑to‑peer review with a Blue Cross or BCN medical director. The process differs by type of service and line of business.

We can’t accept peer-to-peer request forms about more than one member
When you request a peer-to-peer review using the Physician peer‑to‑peer request form, you must submit a separate form for each request.

We can’t accept a form that has information about more than one member. We also can’t accept a form used as a face sheet with information about different members attached to it.

When you fax a form to us, we upload it to the member’s case in the e-referral system, along with any attachments you’ve sent with it. If a form uploaded to one member’s case has information about other members on it or attached to it, it’s a violation of the Health Insurance Portability and Accountability Act.

Don’t submit clinical information after an authorization is denied
Submission of clinical information after an authorization request is denied results in the initiation of an appeal. Once that occurs, it’s no longer possible to have a peer-to-peer review, for most members.

Missed peer-to-peer reviews won’t be rescheduled
If you miss a peer-to-peer review that was scheduled with a medical director, you won’t be able to reschedule it. You’ll have to file an appeal.

How to file an appeal
When we deny an authorization request you’ve submitted, you’ll receive a letter explaining how to file an appeal.

If you want to appeal our determination, we recommend that you review the letter carefully and follow the directions about filing an appeal.

Additional information
For additional information, we encourage you to review the newsletter article we recently published:

• We’re aligning peer-to-peer review request processes for acute non-behavioral health non-elective inpatient admissions in the January 2020 issue of The Record.

Urgent care centers need to enroll as an urgent care center provider type

Urgent care center providers need to identify themselves as such during the enrollment process. Previously, some providers who offer urgent care services enrolled as group practitioners, most likely because of the hours of operation requirement. We’ve subsequently relaxed our hours of operation requirement for urgent care providers.

New hours of operation requirements

Blue Cross Blue Shield of Michigan’s hours of operation requirements stipulate that an urgent care center must be open to serve members a minimum of 24 morning, evening or weekend hours each week. These hours must be in addition to regular hours of 9 a.m. to 4 p.m. Monday through Friday. This adjustment provides more flexibility for providers to determine their weekly schedule.

Benefits of enrolling as an urgent care center

Benefits include:

• Increasing access to potential patients by being appropriately listed in the urgent care provider directory
• Making sure the correct urgent care benefit is applied to patient claims

If you’re an urgent care center, review your enrollment status to make sure you’re correctly identified. For current requirements and other details, refer to the provider manual or enrollment form.

Fully licensed psychologists can be reimbursed for ABA services

Blue Cross Blue Shield of Michigan and Blue Care Network can reimburse fully licensed psychologists for applied behavior analysis services if the services are within their education, training and experience.

To qualify to be reimbursed for ABA services, the psychologist must:

• Be contracted with Blue Cross or BCN to provide behavioral health services
• Have a doctoral degree in psychology (Ph.D., Ed.D. or Psy.D.)
• Have a full license to practice psychology in the state of Michigan
• Have education, training and experience in providing ABA services

Submit an attestation form
Psychologists who believe they qualify for ABA reimbursement must complete a form stating that they have educational background, training and experience in providing ABA services.

Access this form as follows:

• On the Blue Cross Autism page within Provider Secured Services:
1. Go to bcbsm.com/providers.
2. Click on Login.
3. Log in to Provider Secured Services.
4. Click on BCBSM Provider Publications and Resources, at the right.
5. Click on Newsletter & Resources
6. Click on Clinical Criteria & Resources.
7. Click on Autism (in the Resources section).
8. Look under the Autism provider resource materials heading.
• On BCN’s Autism webpage at ereferrals.bcbsm.com. Look under the Autism provider resource materials heading.
• On BCN’s Autism page within Provider Secured Services:
1. Visit bcbsm.com/providers.
2. Click on Login.
3. Log in to Provider Secured Services.
4. Click on BCN Provider Publications and Resources at the right.
5. Click on Autism.
6. Look under the Autism provider resource materials heading.

Complete the form and follow the instructions on the form to submit it.

We’ll notify each psychologist by email as to whether he or she can bill for ABA services.

Additional information
This applies to services for Blue Cross and BCN commercial members since it is typically these members who have autism coverage under their plans.

When billing ABA services, psychologists should use the autism billing codes along with modifier AH.

See the following documents for more information:

• Applied Behavior Analysis Billing Guidelines and Procedure Codes — You can access this document on both Blue Cross and BCN Autism pages within Provider Secured Services. Follow the directions given earlier in this article to access those webpages.
• Blue Cross fee schedule — To access this document, visit bcbsm.com/providers, click on Login, log in to Provider Secured Services using your user name and password and click on Blue Cross Provider Publications and Resources on the right side of the Provider Secured Services welcome page. Click on Newsletters & Resources, then click on Entire Fee Schedules and Fee Changes.Click on Accept, then click on either Professional Fee Schedules or Facility Fee Schedules. Locate the appropriate fee schedule and click to open it.
• BCN Behavioral health fee schedule — To access this document, visit bcbsm.com/providers, click on Login, log in to Provider Secured Services using your user name and password and click on BCN Provider Publications and Resources on the right side of the Provider Secured Services welcome page. Then click on Behavioral Health on the left and look under the General resources heading.

Reminder: Use Blue Cross editing process for FEP claims

In December 2018, Blue Cross Blue Shield of Michigan updated its professional and outpatient facility PPO claim editing process. Unique clinical editing reason codes were added to the 835 response files and provider vouchers.

When billing PPO claims for Federal Employee Program^® members, follow the same guidelines:

• The American Medical Association’s Current Procedural Terminology, or CTP, code set regarding:
• Correct modifier usage
• Evaluation and Management reporting guidelines
• National bundling edits
• National specialty societies, such as:
• American College of Surgeons
• American College of Radiology
• American Association of Neuromuscular and Electrodiagnostic Medicine
• American Cancer Society

As part of their contract with Blue Cross, health care providers affiliated with the PPO network agree to bill according to guidelines and requirements set by the AMA and select specialty societies.

If you have questions about FEP claim editing for professional and facility providers, call the FEP Customer Service line at 1-800-482-3600.

Non-medical behavioral health practitioners can now be reimbursed for prolonged psychotherapy services

For dates of services on or after Feb. 1, 2020, non-medical behavioral health practitioners are eligible for reimbursement of services associated with procedure codes *99354 and *99355.

These apply to evaluation and management-related psychotherapy services in the office or other outpatient setting when they require direct patient contact beyond the usual time:

• Use *99354 to bill the first hour of a prolonged service.
• Use *99355 to bill each additional half hour of a prolonged service. 

Here’s additional information you need to know:

• These codes must be billed on the same day and by the same practitioner as the companion evaluation and management or psychotherapy codes.
• You can bill these codes for BCN commercial, BCN Advantage^SM or Medicare Plus Blue^SM members only. You can’t bill them for Blue Cross’ commercial members at this time; watch for updates.
• For BCN commercial members, standard referral requirements currently apply. However, we’re reconfiguring our systems so that, in the near future, no referral will be required. Watch for more information on this in an upcoming web-DENIS message and in articles in future issues of our provider newsletters.
• These services don’t require authorization for any member.
• The following licensed providers can bill these codes for services related to behavioral health:
• Board-eligible or board-certified psychiatrists
• Psychologists who have a doctoral or master’s degree and a full or limited license
• Master’s-level social workers and professional counselors who have a master’s degree and a full license
• Marriage and family therapists who have a master’s degree and a full license
• Clinical nurse specialists and nurse practitioners who are certified and licensed 
• Physician assistants who have a master’s degree and are licensed
• You must comply with the American Medical Association’s billing guidelines.
• The medical record must clearly show the medical necessity for using these codes. 
• You should document your intervention and revise the member’s treatment plan, as needed, if the member needs these interventions frequently. You can also request consultation if the member isn’t making progress.
• We’re reviewing our medical policies to include these codes for a broader range of services than currently reflected.

Plan to attend our 2020 provider symposiums

Blue Cross Blue Shield of Michigan and Blue Care Network’s 2020 provider symposiums, A Treatment for Success, are scheduled to begin in late April and early May.

The morning session is targeted to physician office staff responsible for closing gaps related to quality measures and the importance of a positive patient experience. Topics include:

• The latest information about HEDIS^® updates to close gaps in care, Consumer Assessment of Healthcare Providers and Systems, and the Health Outcomes Survey.
• Why patient experience matters. The impact to your patients and your office and what you can do to focus on, and improve, patient experience and satisfaction.

The afternoon session will be for coders, billers and administrative staff. It will cover:

• New coding guidelines for evaluation and management visits
• Scenarios
• Coding tips

These forums provide crucial information to keep your staff up to date on the latest developments.

Schedule of events:

• Registration begins at 8 a.m.
• The morning session starts at 8:30 a.m., (except in Marquette where the schedule will be 30 minutes later) includes a continental breakfast and ends at 11:30 a.m.
• Lunch is from 11:30 a.m. to 12:15 p.m.
• The afternoon session is from 12:15 to 1:15 p.m.

Right now, scheduled symposiums include:

• April 29 in Frankenmuth
• May 5 in Ann Arbor
• May 12 in Kalamazoo
• June 2 in Traverse City
• June 3 in Mt. Pleasant

We’re adding more every day, so check the April Record for more dates, locations and details about the symposiums and how to register. We look forward to seeing you soon.

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

Reminder: PPO inpatient admission requests submitted through e-referral may be subject to clinical review

As we notified you in the January Record, inpatient acute care admissions for Blue Cross Blue Shield of Michigan commercial members submitted through e-referral may be subject to clinical review, effective January 2020. It’s a process we were already following for Medicare Plus Blue^SM  inpatient acute care admissions and certain other members.

Clinical reviews are necessary to make sure inpatient admissions are medically necessary. These reviews also help Blue Cross verify patient stays are appropriate and billed correctly based on diagnosis and condition.

Throughout 2020, select facilities must submit medical inpatient stays through e-referral. These stays will be subject to full clinical review from the first day of admission and subject to non-approval by clinical professionals, using InterQual guidelines.

Behavioral health authorization requests and clinical reviews will continue to follow the current process with the assigned behavioral health management vendor. However, inpatient admission authorization requests processed through New Directions will be subject to full clinical review from the first day of admission and subject to non-approval.

Facilities that need to submit reviews starting in October will be notified midyear.

If you aren’t familiar with e-referral or how the process works, contact your provider consultant.

Reminder: Annual physical and associated lab services

As you’ve read before, Blue Cross Blue Shield of Michigan must fully cover specific preventive services under the Affordable Care Act.

Examples of preventive services are those that are included in annual exams, such as annual physical exams (sometimes called health maintenance exams) and associated lab services. There are certain lab services, such as vitamin D and vitamin B12 testing, that are not covered as preventive when ordered as part of the annual physical. Ordering these can result in cost to the member. Only tests that are classified as category “A or B” under the United States Preventive Services Task Force are routinely covered under an annual exam.

Here are more details about these two tests that aren’t covered when performed in the context of an annual exam:

• Vitamin D screening — The United States Preventive Services Task Force  concludes that the current evidence is insufficient to assess the balance of benefit and harm of screening for vitamin D deficiency in asymptomatic adults. As such, Blue Cross doesn’t cover vitamin D lab as preventive when ordered during the annual physical.
• Vitamin B12 screening — No major medical organizations, including the USPSTF, have published guidelines on screening asymptomatic or low-risk adults for vitamin B12.

A list of preventive service codes with no member cost sharing is posted on web-DENIS. Here’s how to find it:

• Click on Newsletters and Resources.
• Click on Health Reform Information.

How can you help?

• Let your patients know that your practice orders tests in alignment with current clinical practice guidelines. This helps to minimize patient confusion, control out-of-pocket costs and ensure that patients receive appropriate care while avoiding unnecessary tests.
• If you decide during an annual exam that vitamin D or B12 testing is necessary, based on the patient’s symptoms and exam results, be sure to bill it with the appropriate diagnosis code. The member should be counseled on the possibility that they will incur out-of-pocket costs associated with the testing.

We value our provider partners in helping us to improve patient experience and ensure that all care delivery is necessary and appropriate.

None of the information included herein is intended to be medical advice.

Life’s Simple 7 gives patients tips to manage heart health

The American Heart Association’s Life’s Simple 7^® identifies seven risk factors patients can manage through lifestyle changes to improve their cardiovascular health.

Life’s Simple 7 recommends the following:

• Manage blood pressure
• Control cholesterol
• Reduce blood sugar
• Get active
• Eat better
• Lose weight
• Stop smoking

The American Heart Association also offers posters and other resources you can share with your patients on each topic. Click here** to visit the AHA website.

More heart health from FEP

The Federal Employee Program^® offers members additional resources and tools to help take the first steps to improve their cardiovascular health:

• Coordinated Care Program — 1-800-775-BLUE (2583)
• 24/7 Nurse Line — 1-888-258-3432
• Diabetic Meter Program — 1-855-582-2024
• Hypertension Management Program — 1-800-482-3600
• Telehealth for nutritional counseling — 1-855-636-1579
• Online programs at www.fepblue.org
• Online health coach
• Tobacco cessation program
• Telehealth
• Personal Health Record to track, update and store health-related information

For additional assistance, FEP members can call Customer Service at 1-800-482-3600.

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

Sign up for upcoming training webinars

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

Here’s how to register for upcoming training webinars:

Blue Cross 201 — Claims Appeals Overview provides in-depth learning opportunities for providers, building on information shared in our Blue Cross 101: Understanding the Basics webinar. This session focuses on the claims and appeals process for Blue Cross, BCN, Medicare Plus Blue^SM and BCN Advantage^SM facility and professional claims.

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

Radiation therapy services for A9590 require prior authorization for all Blue Cross, BCN members starting April 1

For dates of service on or after April 1, 2020, services associated with HCPCS code A9590 (iodine i-131, iobenguane, 1 millicurie) require prior authorization by eviCore healthcare.

This applies to all Blue Cross Blue Shield of Michigan and Blue Care Network members with plans subject to eviCore healthcare authorization requirements:

• Blue Cross’ PPO
• Medicare Plus Blue^SM PPO
• BCN commercial
• BCN Advantage^SM

We’ve updated the document titled Procedures that require authorization by eviCore healthcare to reflect this new requirement.

How to submit authorization requests

Submit authorization requests to eviCore in one of these ways:

• Preferred: Use eviCore’s provider portal at evicore.com.**
• Alternative: Call eviCore at 1-855-774-1317.
• Alternative: Fax to eviCore at 1-800-540-2406.

Additional information

For more information, refer to the document titled Frequently asked questions about requesting authorization from eviCore healthcare.

You can find this document and other resources on our ereferrals.bcbsm.com website:

• The Procedures Managed by eviCore for BCN webpage
• The Procedures Managed by eviCore for Blue Cross webpage

**Blue Cross and BCN don’t own or control this website.

TurningPoint to manage authorizations for musculoskeletal procedures with dates of service on or after June 1 for certain members

In a January Record article, we let you know that providers will need to submit authorization requests through TurningPoint Healthcare Solutions LLC for inpatient and outpatient musculoskeletal surgical procedures for Blue Care Network commercial members, as well as BCN Advantage^SM and Medicare Plus Blue^SM members.

Here’s additional information you need to know:

• Providers should submit authorization requests for all surgical procedures related to musculoskeletal conditions scheduled to occur on or after June 1, 2020, to TurningPoint starting May 1.
• This pertains to procedures currently managed by Blue Cross Blue Shield of Michigan or BCN.
• These changes don’t apply to Blue Cross commercial plans.
• eviCore healthcare^® will continue to manage lumbar spinal fusion surgeries for Medicare Plus Blue members throughout 2020. You can find the codes for these procedures by going to ereferrals.bcbsm.com and following these steps:
  1. Click on Blue Cross and then eviCore-Managed Procedures.
  2. Click on Procedures that require authorization by eviCore healthcare.
  3. Scroll down to the Lumbar spinal fusion surgery procedures requiring authorization by eviCore table.
• You can find procedure codes for orthopedic and spinal procedures managed by TurningPoint on ereferrals.bcbsm.com. The direct links are:
• Orthopedic
• Spinal

For more information, refer to our frequently asked questions document on ereferrals.bcbsm.com on the following pages:

• Blue Cross Musculoskeletal Services page
• BCN Musculoskeletal Services page

Portal registration and access
To register for the TurningPoint portal, go to myturningpoint-healthcare.com and click on Register for Access under the Login Now button. From there, you’ll need to fill out a validation form and submit your request to TurningPoint.

Note: Only professional providers can register for the portal at this time. Providers can request an authorization through the portal and then provide the appropriate facility with the authorization number. Facilities can view the status of an authorization request through the e-referral system 24 hours after TurningPoint makes a determination.

If you have any questions or need assistance, email TurningPoint at  portalregistration@turningpoint-healthcare.com.

Provider offices can also access the TurningPoint provider portal by following these steps:

1. Visit bcbsm.com/providers and log in to Provider Secured Services.
2. Click on the Musculoskeletal Service Authorizations through TurningPoint link
3. Enter your NPI.

If you’re having trouble accessing the TurningPoint provider portal using this process, contact the Blue Cross Web Support Help Desk at 1-877-258-3932.

Note for out-of-state providers: Log in to your home plan's website and select an ID card prefix from Michigan. This will take you to the Blue Cross Blue Shield of Michigan website. You can then follow the instructions above to access the TurningPoint provider portal.

Webinar training
We’ll offer a training webinar for professional providers and facilities in April. To register for training on TurningPoint’s clinical model and the TurningPoint provider portal, click on the appropriate link below:

• Professional providers can register for training here.
• Facility providers can register for training here.

Physical, occupational and speech therapy outpatient professional claims to require appropriate modifier

Effective May 1, 2020, physical, occupational and speech therapy providers must append the appropriate modifier to procedure codes for all outpatient professional claims for physical, occupational and speech therapy services. Therapy providers are encouraged to begin billing with the modifiers as soon as possible.

The Blue Cross Blue Shield of Michigan claims processing system is being updated to reject all outpatient professional claims for therapy services that are submitted without a modifier as follows:

• Speech-language therapy — bill with the GN modifier
• Occupational therapy — bill with the GO modifier
• Physical therapy — bill with the GP modifier

We notified providers about this new requirement in an October 2019 Record article and followed up with a web-DENIS message in January. Outpatient professional claims billed without a therapy modifier will be rejected as provider liable.

Starting May 1, we’ll no longer cover Soma products

Our goal at Blue Cross Blue Shield of Michigan and Blue Care Network is to provide our members with safe, high quality, cost-effective prescription drugs. To do this, we’re making some changes to drugs we cover.

Starting May 1, 2020, Blue Cross and BCN will no longer cover the following Soma^® products:

• Soma and its generic, carisoprodol
• Soma compound and its generic, carisoprodol with aspirin
• Soma compound with codeine and its generic
  

If members fill a prescription for one of these drugs on or after May 1, 2020, they’ll be responsible for the full cost. We’ll cover the following alternatives that have similar effectiveness, quality and safety:

• Flexeril^® (cyclobenzaprine)
• Norflex^® (orphenadrine)
• Robaxin^® (methocarbamol)
• Parafon Forte DSC (chlorzoxazone)
• Zanaflex^® (tizanidine)

We’ll mail notification letters to members about this change. The letters will also encourage members to talk to their doctors about getting a prescription for one of the covered alternatives.

Important information about peer-to-peer reviews and appeals

When we deny your request to authorize an inpatient or outpatient service, you can ask for a peer-to-peer review or you can appeal the denial.

Whether you’re requesting a peer-to-peer review or submitting an appeal, there’s important information you need to know.

Differences to be aware of

• For Medicare Advantage authorizations denied before a service or admission is provided, you can only submit an appeal. You’ll be able to talk to a Blue Cross Blue Shield of Michigan or Blue Care Network medical director during the appeal process:
• For Medicare Plus Blue^SM, you can ask to talk to a medical director anytime during the appeal process.
• For BCN Advantage^SM, you’ll have an opportunity to talk to a medical director during the panel review.
• For Medicare Advantage authorizations (either Medicare Plus Blue or BCN Advantage) denied during or after a service or admission is provided, you can either request a peer-to-peer review or submit an appeal.
• For Blue Cross or BCN commercial authorizations denied before, during or after a service or admission is provided, you can either request a peer-to-peer review or submit an appeal.

For any denied authorization, if you decide to submit an appeal, follow the appeal process outlined in the denial letter you receive.

Requesting a peer-to-peer review

• Purpose. A peer-to-peer review is a conversation between the member’s health care provider and a Blue Cross or BCN medical director about the clinical nuances of the member’s medical condition and the medical necessity of the services.
• Process. The process for submitting a request for a peer-to-peer review is outlined in the document titled How to request a peer‑to‑peer review with a Blue Cross or BCN medical director. The process differs by type of service and line of business.

We can’t accept peer-to-peer request forms about more than one member
When you request a peer-to-peer review using the Physician peer‑to‑peer request form, you must submit a separate form for each request.

We can’t accept a form that has information about more than one member. We also can’t accept a form used as a face sheet with information about different members attached to it.

When you fax a form to us, we upload it to the member’s case in the e-referral system, along with any attachments you’ve sent with it. If a form uploaded to one member’s case has information about other members on it or attached to it, it’s a violation of the Health Insurance Portability and Accountability Act.

Don’t submit clinical information after an authorization is denied
Submission of clinical information after an authorization request is denied results in the initiation of an appeal. Once that occurs, it’s no longer possible to have a peer-to-peer review, for most members.

Missed peer-to-peer reviews won’t be rescheduled
If you miss a peer-to-peer review that was scheduled with a medical director, you won’t be able to reschedule it. You’ll have to file an appeal.

How to file an appeal
When we deny an authorization request you’ve submitted, you’ll receive a letter explaining how to file an appeal.

If you want to appeal our determination, we recommend that you review the letter carefully and follow the directions about filing an appeal.

Additional information
For additional information, we encourage you to review the newsletter article we recently published:

• We’re aligning peer-to-peer review request processes for acute non-behavioral health non-elective inpatient admissions in the January 2020 issue of The Record.

Urgent care centers need to enroll as an urgent care center provider type

Urgent care center providers need to identify themselves as such during the enrollment process. Previously, some providers who offer urgent care services enrolled as group practitioners, most likely because of the hours of operation requirement. We’ve subsequently relaxed our hours of operation requirement for urgent care providers.

New hours of operation requirements

Blue Cross Blue Shield of Michigan’s hours of operation requirements stipulate that an urgent care center must be open to serve members a minimum of 24 morning, evening or weekend hours each week. These hours must be in addition to regular hours of 9 a.m. to 4 p.m. Monday through Friday. This adjustment provides more flexibility for providers to determine their weekly schedule.

Benefits of enrolling as an urgent care center

Benefits include:

• Increasing access to potential patients by being appropriately listed in the urgent care provider directory
• Making sure the correct urgent care benefit is applied to patient claims

If you’re an urgent care center, review your enrollment status to make sure you’re correctly identified. For current requirements and other details, refer to the provider manual or enrollment form.

Fully licensed psychologists can be reimbursed for ABA services

Blue Cross Blue Shield of Michigan and Blue Care Network can reimburse fully licensed psychologists for applied behavior analysis services if the services are within their education, training and experience.

To qualify to be reimbursed for ABA services, the psychologist must:

• Be contracted with Blue Cross or BCN to provide behavioral health services
• Have a doctoral degree in psychology (Ph.D., Ed.D. or Psy.D.)
• Have a full license to practice psychology in the state of Michigan
• Have education, training and experience in providing ABA services

Submit an attestation form
Psychologists who believe they qualify for ABA reimbursement must complete a form stating that they have educational background, training and experience in providing ABA services.

Access this form as follows:

• On the Blue Cross Autism page within Provider Secured Services:
1. Go to bcbsm.com/providers.
2. Click on Login.
3. Log in to Provider Secured Services.
4. Click on BCBSM Provider Publications and Resources, at the right.
5. Click on Newsletter & Resources
6. Click on Clinical Criteria & Resources.
7. Click on Autism (in the Resources section).
8. Look under the Autism provider resource materials heading.
• On BCN’s Autism webpage at ereferrals.bcbsm.com. Look under the Autism provider resource materials heading.
• On BCN’s Autism page within Provider Secured Services:
1. Visit bcbsm.com/providers.
2. Click on Login.
3. Log in to Provider Secured Services.
4. Click on BCN Provider Publications and Resources at the right.
5. Click on Autism.
6. Look under the Autism provider resource materials heading.

Complete the form and follow the instructions on the form to submit it.

We’ll notify each psychologist by email as to whether he or she can bill for ABA services.

Additional information
This applies to services for Blue Cross and BCN commercial members since it is typically these members who have autism coverage under their plans.

When billing ABA services, psychologists should use the autism billing codes along with modifier AH.

See the following documents for more information:

• Applied Behavior Analysis Billing Guidelines and Procedure Codes — You can access this document on both Blue Cross and BCN Autism pages within Provider Secured Services. Follow the directions given earlier in this article to access those webpages.
• Blue Cross fee schedule — To access this document, visit bcbsm.com/providers, click on Login, log in to Provider Secured Services using your user name and password and click on Blue Cross Provider Publications and Resources on the right side of the Provider Secured Services welcome page. Click on Newsletters & Resources, then click on Entire Fee Schedules and Fee Changes.Click on Accept, then click on either Professional Fee Schedules or Facility Fee Schedules. Locate the appropriate fee schedule and click to open it.
• BCN Behavioral health fee schedule — To access this document, visit bcbsm.com/providers, click on Login, log in to Provider Secured Services using your user name and password and click on BCN Provider Publications and Resources on the right side of the Provider Secured Services welcome page. Then click on Behavioral Health on the left and look under the General resources heading.

Reminder: Use Blue Cross editing process for FEP claims

In December 2018, Blue Cross Blue Shield of Michigan updated its professional and outpatient facility PPO claim editing process. Unique clinical editing reason codes were added to the 835 response files and provider vouchers.

When billing PPO claims for Federal Employee Program^® members, follow the same guidelines:

• The American Medical Association’s Current Procedural Terminology, or CTP, code set regarding:
• Correct modifier usage
• Evaluation and Management reporting guidelines
• National bundling edits
• National specialty societies, such as:
• American College of Surgeons
• American College of Radiology
• American Association of Neuromuscular and Electrodiagnostic Medicine
• American Cancer Society

As part of their contract with Blue Cross, health care providers affiliated with the PPO network agree to bill according to guidelines and requirements set by the AMA and select specialty societies.

If you have questions about FEP claim editing for professional and facility providers, call the FEP Customer Service line at 1-800-482-3600.

Non-medical behavioral health practitioners can now be reimbursed for prolonged psychotherapy services

For dates of services on or after Feb. 1, 2020, non-medical behavioral health practitioners are eligible for reimbursement of services associated with procedure codes *99354 and *99355.

These apply to evaluation and management-related psychotherapy services in the office or other outpatient setting when they require direct patient contact beyond the usual time:

• Use *99354 to bill the first hour of a prolonged service.
• Use *99355 to bill each additional half hour of a prolonged service. 

Here’s additional information you need to know:

• These codes must be billed on the same day and by the same practitioner as the companion evaluation and management or psychotherapy codes.
• You can bill these codes for BCN commercial, BCN Advantage^SM or Medicare Plus Blue^SM members only. You can’t bill them for Blue Cross’ commercial members at this time; watch for updates.
• For BCN commercial members, standard referral requirements currently apply. However, we’re reconfiguring our systems so that, in the near future, no referral will be required. Watch for more information on this in an upcoming web-DENIS message and in articles in future issues of our provider newsletters.
• These services don’t require authorization for any member.
• The following licensed providers can bill these codes for services related to behavioral health:
• Board-eligible or board-certified psychiatrists
• Psychologists who have a doctoral or master’s degree and a full or limited license
• Master’s-level social workers and professional counselors who have a master’s degree and a full license
• Marriage and family therapists who have a master’s degree and a full license
• Clinical nurse specialists and nurse practitioners who are certified and licensed 
• Physician assistants who have a master’s degree and are licensed
• You must comply with the American Medical Association’s billing guidelines.
• The medical record must clearly show the medical necessity for using these codes. 
• You should document your intervention and revise the member’s treatment plan, as needed, if the member needs these interventions frequently. You can also request consultation if the member isn’t making progress.
• We’re reviewing our medical policies to include these codes for a broader range of services than currently reflected.

Reminder: PPO inpatient admission requests submitted through e-referral may be subject to clinical review

As we notified you in the January Record, inpatient acute care admissions for Blue Cross Blue Shield of Michigan commercial members submitted through e-referral may be subject to clinical review, effective January 2020. It’s a process we were already following for Medicare Plus Blue^SM  inpatient acute care admissions and certain other members.

Clinical reviews are necessary to make sure inpatient admissions are medically necessary. These reviews also help Blue Cross verify patient stays are appropriate and billed correctly based on diagnosis and condition.

Throughout 2020, select facilities must submit medical inpatient stays through e-referral. These stays will be subject to full clinical review from the first day of admission and subject to non-approval by clinical professionals, using InterQual guidelines.

Behavioral health authorization requests and clinical reviews will continue to follow the current process with the assigned behavioral health management vendor. However, inpatient admission authorization requests processed through New Directions will be subject to full clinical review from the first day of admission and subject to non-approval.

Facilities that need to submit reviews starting in October will be notified midyear.

If you aren’t familiar with e-referral or how the process works, contact your provider consultant.

Reminder: Annual physical and associated lab services

As you’ve read before, Blue Cross Blue Shield of Michigan must fully cover specific preventive services under the Affordable Care Act.

Examples of preventive services are those that are included in annual exams, such as annual physical exams (sometimes called health maintenance exams) and associated lab services. There are certain lab services, such as vitamin D and vitamin B12 testing, that are not covered as preventive when ordered as part of the annual physical. Ordering these can result in cost to the member. Only tests that are classified as category “A or B” under the United States Preventive Services Task Force are routinely covered under an annual exam.

Here are more details about these two tests that aren’t covered when performed in the context of an annual exam:

• Vitamin D screening — The United States Preventive Services Task Force  concludes that the current evidence is insufficient to assess the balance of benefit and harm of screening for vitamin D deficiency in asymptomatic adults. As such, Blue Cross doesn’t cover vitamin D lab as preventive when ordered during the annual physical.
• Vitamin B12 screening — No major medical organizations, including the USPSTF, have published guidelines on screening asymptomatic or low-risk adults for vitamin B12.

A list of preventive service codes with no member cost sharing is posted on web-DENIS. Here’s how to find it:

• Click on Newsletters and Resources.
• Click on Health Reform Information.

How can you help?

• Let your patients know that your practice orders tests in alignment with current clinical practice guidelines. This helps to minimize patient confusion, control out-of-pocket costs and ensure that patients receive appropriate care while avoiding unnecessary tests.
• If you decide during an annual exam that vitamin D or B12 testing is necessary, based on the patient’s symptoms and exam results, be sure to bill it with the appropriate diagnosis code. The member should be counseled on the possibility that they will incur out-of-pocket costs associated with the testing.

We value our provider partners in helping us to improve patient experience and ensure that all care delivery is necessary and appropriate.

None of the information included herein is intended to be medical advice.

Reminder: Submitting completed facility provider application required for recredentialing process

Blue Cross Blue Shield of Michigan and Blue Care Network recredentials our participating health care facilities to ensure continued compliance with Blue Cross and BCN qualification standards.

As part of this process, participating facilities are required to complete and submit a facility provider application. We’ll also use data collected from the recredentialing application to verify and update facility demographic information that’s stored in our provider payment database and in our directories.

Click here for the recredentialing form for freestanding radiology centers, clinical independent laboratories, durable medical equipment suppliers, retail health centers and urgent care centers recredentialing.

Completion of the application is a Blue Cross and BCN program requirement. Failure to complete and return this application will result in termination of your participation agreement with Blue Cross and BCN.

After receiving and completing the application, submit it within 30 days:

• By mail:
  Corporate Credentialing and Program Support
  Mail Code H201
  Blue Care Network
  20500 Civic Center
  Southfield, MI 48076

• By fax:
  1-866-900-0250 (When faxing, please attach the Blue Cross cover letter as the first page.)

If you have any questions about this process, call Corporate Credentialing and Program Support at 248-226-5274 or 248-327-5023 from 8 a.m. to 4 p.m. Monday through Friday, send an email to profcredentialing@bcbsm.com or click here.

Blue Distinction Specialty Care program launches Substance Use Treatment and Recovery designation

According to the Centers for Disease Control and Prevention, 130 Americans die every day from an opioid overdose, a statistic that highlights the seriousness of the opioid epidemic and how crucial it is for patients to receive comprehensive care.

To help address this issue, the Blue Distinction^® Specialty Care program has added a Blue Distinction^® Center designation for Substance Use Treatment and Recovery. It requires designated facilities to deliver coordinated multidisciplinary care to patients and provide timely access to quality medical and psychosocial care in all phases of treatment. Designated facilities must also offer medication-assisted treatment — a way to treat opioid addiction that includes a medication component and behavioral therapy.

About Blue Distinction Centers
Blue Distinction Centers are nationally designated facilities that show a commitment to delivering improved patient safety and better health outcomes, based on objective measures that were developed with input from the community and leading accreditation and quality organizations. In addition to this new designation, the Blue Distinction Specialty Care program is helping people find quality specialty care in the areas of bariatric surgery, cancer care, cardiac care, cellular immunotherapy, fertility care, gene therapy, knee and hip replacements, maternity care, spine surgery and transplants.

For more information about Blue Distinction Specialty Care and for a complete listing of designated facilities in 11 areas of specialty care, visit bcbsm.com/bluedistinction.

Two medical drugs going on commercial site-of-care program, starting April 1

Starting April 1, 2020, the site of care program for specialty drugs covered under the medical benefit is expanding. This applies to Blue Cross Blue Shield of Michigan and Blue Care Network commercial members for the following drugs:

• Hemlibra^® (emicizumab-kxwh, HCPCS code J7170)
• Onpattro^® (patisiran, HCPCS code J0222)

What to do by April 1
Before April 1, encourage your patients who have commercial coverage to select one of the following infusion locations instead of using a hospital outpatient facility:

• A doctor’s office or other health care provider’s office
• An ambulatory infusion center
• The member’s home, from a home infusion therapy provider

If members currently receive infusions for these drugs at a hospital outpatient facility, providers must:

• Obtain prior authorization for that location.
• Check the directory of participating home infusion therapy providers and infusion centers to see where the member may be able to continue infusion therapy.

If the infusion therapy provider can accommodate the member, they’ll work with the member and the member’s practitioner to make this change easy. The member may also contact the ordering practitioner directly for help with the change.

More about authorization requirements
The authorization requirements apply only to groups currently taking part in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. These changes don’t apply to members covered by the Federal Employee Program^® Service Benefit Plan.

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, see the Blue Cross and BCN utilization management medical drug list.

You can also find the list on either of the two following ereferrals.bcbsm.com webpages:

• Blue Cross Drugs Covered Under the Medical Benefit
• BCN Drugs Covered Under the Medical Benefit

We’ll update the requirements list for these drugs before April 1.

We’re adding site-of-care requirements for Lemtrada and Tysabri for commercial members, starting May 1

Starting May 1, 2020, the medical drug site-of-care program is expanding to include the following drugs for Blue Cross Blue Shield of Michigan and Blue Care Network commercial members:  

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

Through April 30, 2020, members who receive 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 won’t be covered at hospital outpatient facilities.** Before May 1, talk to your patients about making arrangements to receive infusion services at one of the following locations:

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

**Based on Risk Evaluation and Mitigation Strategies, or REMS, program restrictions, administration of Lemtrada and Tysabri is limited to authorized locations. We’ll post information about in-state and nationally authorized administration sites to our ereferrals.bcbsm.com website soon to aid in member transition. We’ll provide an update when this information is available.

More about the authorization requirements
The authorization requirements apply only to groups that are currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. These changes don’t apply to 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, see the Blue Cross and BCN utilization management medical drug list document located on our ereferrals.bcbsm.com website:

• The Blue Cross Drugs Covered Under the Medical Benefit webpage
• The BCN Drugs Covered Under the Medical Benefit webpage

We’ll update the requirements list for the drugs listed above before May 1, 2020.

Update: Requirements changed for some commercial medical benefit drugs

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

From July 2019 to December 2019, the following medical drugs had authorization requirements updates, site-of-care updates or both:

**Will become a unique code.

For a detailed list of requirements, see the Blue Cross and BCN utilization management medical drug list. You can access this list from the following pages on the ereferrals.bcbsm.com website.

• Blue Cross Drugs Covered Under the Medical Benefit page
• BCN Drugs Covered Under the Medical Benefit page

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

To access the list:

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

These changes don’t apply to Federal Employee Program^® Service Benefit Plan members.

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

Starting May 1, we’ll no longer cover Soma products

Our goal at Blue Cross Blue Shield of Michigan and Blue Care Network is to provide our members with safe, high quality, cost-effective prescription drugs. To do this, we’re making some changes to drugs we cover.

Starting May 1, 2020, Blue Cross and BCN will no longer cover the following Soma^® products:

• Soma and its generic, carisoprodol
• Soma compound and its generic, carisoprodol with aspirin
• Soma compound with codeine and its generic
  

If members fill a prescription for one of these drugs on or after May 1, 2020, they’ll be responsible for the full cost. We’ll cover the following alternatives that have similar effectiveness, quality and safety:

• Flexeril^® (cyclobenzaprine)
• Norflex^® (orphenadrine)
• Robaxin^® (methocarbamol)
• Parafon Forte DSC (chlorzoxazone)
• Zanaflex^® (tizanidine)

We’ll mail notification letters to members about this change. The letters will also encourage members to talk to their doctors about getting a prescription for one of the covered alternatives.

Two medical drugs going on commercial site-of-care program, starting April 1

Starting April 1, 2020, the site of care program for specialty drugs covered under the medical benefit is expanding. This applies to Blue Cross Blue Shield of Michigan and Blue Care Network commercial members for the following drugs:

• Hemlibra^® (emicizumab-kxwh, HCPCS code J7170)
• Onpattro^® (patisiran, HCPCS code J0222)

What to do by April 1
Before April 1, encourage your patients who have commercial coverage to select one of the following infusion locations instead of using a hospital outpatient facility:

• A doctor’s office or other health care provider’s office
• An ambulatory infusion center
• The member’s home, from a home infusion therapy provider

If members currently receive infusions for these drugs at a hospital outpatient facility, providers must:

• Obtain prior authorization for that location.
• Check the directory of participating home infusion therapy providers and infusion centers to see where the member may be able to continue infusion therapy.

If the infusion therapy provider can accommodate the member, they’ll work with the member and the member’s practitioner to make this change easy. The member may also contact the ordering practitioner directly for help with the change.

More about authorization requirements
The authorization requirements apply only to groups currently taking part in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. These changes don’t apply to members covered by the Federal Employee Program^® Service Benefit Plan.

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, see the Blue Cross and BCN utilization management medical drug list.

You can also find the list on either of the two following ereferrals.bcbsm.com webpages:

• Blue Cross Drugs Covered Under the Medical Benefit
• BCN Drugs Covered Under the Medical Benefit

We’ll update the requirements list for these drugs before April 1.