Blue Cross and BCN take action to support providers and protect members during COVID‑19 pandemic

Days before the first Michigan cases of COVID‑19 were reported, Blue Cross Blue Shield of Michigan and Blue Care Network began taking action to support providers and protect members. Here are some of the temporary actions we’ve taken:

• Waived authorization requirements and member cost sharing for diagnostic lab testing for COVID‑19
• Waived member copayments, deductibles and coinsurance for COVID-19 treatment
• Changed clinical review to plan notification for admissions to all Michigan acute care hospitals for all diagnoses and for the first three days of all skilled nursing facility transfers from acute care
• Expanded laboratory testing for COVID-19 to any laboratory provider in Michigan, regardless of network status
• Added influenza testing to physician in-office laboratory testing to rule out flu
• Waived early refill limits on 30-day prescription maintenance medications with the exception of opioids
• Facilitated the use of telehealth by revising our policies and creating an incentive for offices to participate in telehealth
• Granted a 90-day extension to claim submission time limits for original claims with submission dates of Jan. 1, 2020, and after until further notice

Expanded use of telehealth

The COVID-19 pandemic brought a spotlight to telehealth as a method to safely provide medical care to patients who aren’t able to come in for a face-to-face office visit. Blue Cross and BCN have focused efforts on making telehealth easier for both our providers and our members. We have done this by:

• Removing the BCN originating site requirement for telehealth
• Waiving member cost sharing for telehealth services through at least June 30, 2020, on the most common medical office visits, hospitalization follow-up visits and common behavioral health therapy (see Telehealth procedure codes for COVID‑19)
• Announcing that all Blue Cross and BCN members — including all self-funded groups — now have coverage for telemedicine services (those offered by our network providers). Most, but not all, members also have access to Blue Cross Online Visits^SM (operated by Amwell).
• Expanding no-cost telehealth services to now include common behavioral health therapy for members with our behavioral health benefits
• Temporarily relaxing HIPAA requirements to allow for alternative channels, such as Skype and Apple FaceTime
• Expanding access to our 24-hour nurse hotline for members
• Creating telehealth guides to help providers begin using telehealth
• Introducing incentives through Blue Cross’ Physician Group Incentive Program to encourage physician offices to use telehealth, when applicable

If your office is not yet using telehealth, take a few minutes to learn how easy it can be to add a telehealth option. We have two guides that explain telehealth:

• Telehealth for medical providers
• Telehealth for behavioral health providers

There’s also an eLearning available on our Coronavirus webpage.

Find more information

To find our telehealth guides and the latest developments on the COVID-19 pandemic, go to our Coronavirus (COVID-19) information updates for providers webpage, which is linked from BCBSM Newsletters and Resources as well as BCN Provider Publications and Resources within our secure provider website at bcbsm.com.

While the most comprehensive list of communications is available within our secure provider website, we also have a public webpage for providers who don’t have a login and password to our website and for out-of-state providers. This website is available at bcbsm.com/coronavirus. Click on For Providers.

Here are some COVID‑19 billing guidelines

The Centers for Disease Control and Prevention has introduced a new diagnosis code for confirmed COVID‑19 cases, effective April 1, 2020.

For more information, refer to the announcement from the CDC about the new ICD‑10‑CM code.

For the latest information about COVID‑19, including billing tips, go to our Coronavirus information updates for providers page. Log in to Provider Secured Services, click on BCBSM Provider Publications and Resources and then on Newsletters and Resources. (Or you can find it on BCN Provider Publications and Resources.) You can also find information at bcbsm.com/coronavirus by clicking on For Providers.

Clinical Quality Corner: Follow-up After Hospitalization for Mental Illness

The Follow‑up After Hospitalization for Mental Illness HEDIS^® measure** looks at the percentage of discharges for members age 6 or older who were hospitalized in an acute inpatient setting for treatment of mental illness or intentional self-harm and who had an outpatient visit, intensive outpatient encounter or partial hospitalization with a mental health practitioner within seven and 30 days after discharge.

Follow-up visits can also include a community mental health center visit, telehealth visit, observation visit, transitional care management services or electroconvulsive therapy.

Why is this measure important?

Following up in a timely manner may:

• Lower the chance of re‑hospitalization
• Detect adverse responses to medications early on
• Ensure progress made during hospitalization is retained
• Offer continued support

How can I ensure my patients are getting follow‑up visits?

If you are the discharging hospital or the mental health practitioner accepting the patient for outpatient follow‑up:

• Make sure the patient has a follow‑up visit scheduled within seven days before leaving your facility and that the outpatient provider has the capacity to see the patient within these seven days. Include this visit information in the discharge information that you send or share with Blue Cross Blue Shield of Michigan or Blue Care Network.
• Educate the member about the importance of keeping the appointment so they can avoid readmission and continue to make progress.
• Remember that patients are vulnerable after discharge from a psychiatric hospitalization. Continued care after stabilization in the hospital setting is important for them to maintain stability as they transition back into their environment.
• Cooperate with efforts by Blue Cross, BCN or New Directions Behavioral Health (a company that provides behavioral health services for most Blue Cross members)  to confirm that follow-up appointments were made and kept. Case managers sometimes provide additional reminders or follow-up calls to ensure member compliance with these appointments.

For more information
Check out the recently updated 2020 HEDIS Tip Sheet for this measure. It’s also posted on web-DENIS in the Clinical Quality Corner section of BCBSM Newsletters and Resources. See the article, “HEDIS measure tip sheets updated for 2020,” also in this issue, for more details.

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

We’re working to ensure providers are available to care for our Michigan members

During national emergencies, such as COVID-19, that are declared by the federal and state government, Blue Cross Blue Shield of Michigan and Blue Care Network — as directed by the government agencies — allow licensed practitioners to provide services to our members outside of their state of provider licensure. We’ve temporarily waived the requirement that out-of-state practitioners be licensed in Michigan when they are licensed in another state.

In addition, we’re relaxing certain requirements for enrollment and credentialing for practitioners joining multiple practice locations, as well as practitioners coming out of retirement to assist with the care of members.

These procedures are effective until the statewide emergency has been lifted.

Other important information

For in-state providers who plan to work at a different location and bill under a different Type 2 NPI or tax ID during this pandemic, the group bringing in the temporary physician will need to add him or her to their group through our enrollment self-service tool.

Follow these guidelines:

• The originating practice should not delete the physician’s association with their group unless this is a permanent change.
• We recommend that practices consider waiting one week before submitting new claims associated with a change. (This applies to in-state providers making changes through self-service.)
• Be advised that sending in a paper form to execute this process will take longer than five business days.

For out-of-state providers

If you’re an out-of-state provider with questions about credentialing and enrollment, email Zachary Lucas at  zlucas@bcbsm.com.

When you receive confirmation on your submission, we recommend that you wait 10 business days before submitting claims for out-of-state providers. (This applies to out-of-state providers joining in-state groups.)

2020 second‑quarter CPT early release codes

Category III
Surgery

Category III
Surgery

Category III
Surgery

Category III
Medicine

Category III
Medicine

Category III
Medicine

Category III
Laboratory

Category III
Radiology

Category III
Diagnostic services

Category III
DME

Category III
Medicine

Category III
Medicine

Category III
Diagnostic radiology

Multianalyte assays with algorithmic analyses
Pathology and laboratory
Administrative codes

HCPCS update: New codes added, deleted

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

Annual
Physical/Occupational therapy visit

First quarter
Professional/Data gathering codes

First quarter
Injections C-codes

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.

May is Mental Health Month

May is Mental Health Month, a good time to remind your patients of the important role that good mental health plays in overall wellness.

As we did last year, Blue Cross Blue Shield of Michigan will be supporting Mental Health Month in various ways. For example, you can:

• Check out mibluesperspectives.com and the Mind section of ahealthiermichigan.org for blogs about depression, anxiety and other mental health issues.
• Follow Blue Cross on Facebook and Twitter for up-to-date mental health information.
• Access the educational materials and posters in the Mental Health Awareness section of the Engage page. While developed primarily for our group customers, the page offers many useful resources suitable for sharing with your patients.

New toolkit for providers
We also partnered with New Directions, a company that provides behavioral health services for most Blue Cross members, to develop a Primary Care Provider Toolkit. You can learn all about it in the article, “Help connect your patients to behavioral health resources with PCP toolkit,” also in this issue.

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.

Help connect your patients to behavioral health resources with PCP toolkit

As a primary care physician, you’re most likely working with your patients to improve their mental health as well as their physical health. Addressing mental health concerns while managing medical treatment is important to the overall well-being of your patients. Consider these statistics:**

• 1 in 5 primary care visits address mental health concerns.
• 10 to 20% of the general population will consult a primary care doctor for a mental health problem in the course of a year.
• 10 to 40% of primary care patients have a diagnosable mental disorder.
• 40 to 50% of primary care patients who are high utilizers exhibit significant psychological distress.

To help you coordinate behavioral health care, Blue Cross Blue Shield of Michigan has partnered with New Directions to create a PCP toolkit for behavioral health. Using this toolkit, you can help your patients address mental health and substance use issues, with resources that include:

• Screening tools to determine patient treatment and referral needs
• Physician Help Line for psychiatry (medication) consults
• Resources for patient referrals and augmented treatment options, such as behavioral health care management services
• Condition-specific tools to identify and appropriately treat patients who exhibit:
• Depression
• Anxiety
• Suicidal thoughts
• Substance abuse
• Chronic pain
• PTSD

To learn more, go to ndbh.com/PCP*** or call 1-877-233-3262.

**Statistics are from the Centers for Disease Control and Prevention and the National Academy of Sciences.

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

We’re making a professional payment policy change for select procedures done in ambulatory surgical facilities

Blue Cross Blue Shield of Michigan recognizes that for certain procedures, additional effort is required and additional costs are incurred when performed outside of a hospital setting. Effective July 1, 2020, the PPO physician reimbursement policy will increase allowed amounts by 15% for select procedures when done in an ambulatory surgical facility. For a preliminary list of the CPT codes for these procedures, click here.

We’ll continue to closely monitor our list of eligible procedures and adjust it based on provider input and other factors, including the effectiveness of the policy. Any other procedures not listed will be paid at the published rate.

Update: Providers must submit authorization requests to TurningPoint for musculoskeletal surgical procedures scheduled on or after July 1 for certain members

As we reported in previous issues of The Record, providers will need to submit authorization requests through TurningPoint Healthcare Solutions LLC for Blue Care Network commercial, BCN Advantage^SM and Medicare Plus BlueS^SM PPO members.

Due to the COVID-19 pandemic, we’re delaying the date on which TurningPoint will begin managing authorizations. TurningPoint will now begin managing authorizations for dates of service on or after July 1, 2020.

Providers must submit authorization requests for all surgical procedures related to musculoskeletal conditions to TurningPoint. This is effective for procedures scheduled on or after July 1, 2020.

See this article in the March Record for detailed information.

You’ll be able to submit authorization requests to TurningPoint starting on June 1, 2020. For information about the duration of authorizations during the COVID-19 pandemic, see the Changes to authorization durations for elective and non-urgent procedures, including PT, OT and ST, during the COVID-19 pandemic message that we posted to our public website at bcbsm.com/coronavirus.

We’ll continue to offer webinar training for providers and facilities.

Use the links below to register for webinars:

• Training for professional providers
• Training for facility providers

Important information for facilities

Facilities should have an authorization before scheduling surgery.

Facility providers won’t be able to access the TurningPoint portal until fourth-quarter 2020 to get a status on authorization requests. In the meantime, we’re recommending that the ordering physicians secure the required authorization and provide the authorization numbers to the rendering facilities or providers.

Facilities can look up the status of an authorization request by checking on ereferrals.bcbsm.com. The authorization will show in our system one business day after TurningPoint has made a decision. To check the status of an authorization request directly with TurningPoint, call 1-833-217-9670.

Include only procedure codes authorized for musculoskeletal procedures on your claims

For inpatient professional claims, make sure to include only the procedure codes TurningPoint authorized on your claim.

On a quarterly basis, Blue Cross Blue Shield of Michigan and Blue Care Network will review paid inpatient claims from professional providers to ensure that the procedure codes on the claims match the procedure codes TurningPoint authorized. If we find overpayments because the claim included codes that TurningPoint didn’t authorize, we’ll pursue payment recoveries as necessary.

You can request that TurningPoint add procedure codes to an authorization, but you must do this prior to submitting your claim. For more information about updating procedure codes on an authorization, see the FAQ document referenced below.

Where to find more information

For more information about TurningPoint, see the Blue Cross or BCN Musculoskeletal Services pages on the ereferrals.bcbsm.com website. On these pages, you can find procedure codes for orthopedic and spinal procedures managed by TurningPoint. The links are below:

• Orthopedic
• Spinal

You can also refer to the frequently asked questions document on these pages.

Collaborative care codes now payable with no member cost sharing

Effective July 1, 2020, we’ll reimburse medical practices that perform collaborative care, and there will be no member cost share for collaborative care services. These changes apply to the following collaborative care codes for treating Blue Cross Blue Shield of Michigan commercial, Blue Care Network commercial, BCN Advantage^SM and Medicare Plus Blue^SM members:

*99492
*99493
*99494
*99484 (the general behavioral health integration code)

Collaborative care includes mental and behavioral health and substance abuse services provided in a primary care setting with the assistance of psychiatric consultations. Case managers coordinate the services and interventions of providers outside the primary care setting so that the entire team is working for the best possible outcomes for members.

“These codes allow for reimbursement to the medical practice for behavioral health case management and psychiatric consultation to the practice to coordinate the best holistic care for members’ medical and behavioral health needs,” said William Beecroft, M.D., BCN medical director.

Collaborative care is designed to improve outcomes, while empowering patients and their families, Beecroft said. This style of practice has been shown to alleviate provider burnout, increase behavioral health access and improve outcomes for members’ medical and behavioral health issues, leading to improvement in their health and quality of life.

Check web-DENIS for benefits, eligibility and policy limitations.

Quarterly update: Requirements changed for some commercial medical benefit drugs

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

During January, February and March 2020, the following medical drugs had authorization requirement updates, site-of-care updates or both for Blue Cross’ PPO members:

For a detailed list of requirements, see the Blue Cross Drugs Covered Under the Medical Benefit page at ereferrals.bcbsm.com.

Additional notes

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. To view the list of PPO groups that don’t require members to participate in the program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List. This list is available on the Blue Cross Drugs Covered Under the Medical Benefit page at ereferrals.bcbsm.com.

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.

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

We’re adding medications to the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue^SM PPO and BCN Advantage^SM members. These specialty medications are administered by health care professionals in outpatient sites of care, such as physician’s offices, members’ homes, off-campus outpatient hospitals or ambulatory surgical centers (sites of care 11, 12, 19, 22 and 24).

For dates of service on or after June 15, 2020, the following medications will require prior authorization through NovoLogix^®:

• J1428 Exondys 51^®
• J3490 Vyondys 53^™
• J3490 Givlaari^®
• J3590 Tepezza^™
• J3590 Vyepti^™

How to bill

For Medicare Plus Blue and BCN Advantage, we require authorization for all outpatient sites of care when you bill these medications as a professional service or as an outpatient facility service:

• Electronically through an 837P transaction or on a professional CMS-1500 claim form
• Electronically through an 837I transaction or by using the UB04 claim form for a hospital outpatient type of bill 013x

Important reminder

For these drugs, submit authorization requests through the NovoLogix online tool. It offers real-time status checks and immediate approvals for certain medications. Also note:

• For Medicare Plus Blue, if you have a Type 1 individual NPI and you checked the Medical Drug PA box when you completed the Provider Secured Access Application form, you already have access to NovoLogix. If you didn’t check that box, you can complete an Addendum “P" form to request access to NovoLogix and fax it to the number on the form.
• For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

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

List of requirements

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

Starting May 1, 2020, we’ll change how we cover some drugs for HIV-1 PrEP

The U.S. Preventive Services Task Force has recommended that providers offer pre-exposure prophylaxis with effective antiretroviral therapy to people at high risk for HIV. The Centers for Disease Control and Prevention reports that when taken daily, PrEP is highly effective for preventing HIV-1.

In complying with this recommendation, Blue Cross Blue Shield of Michigan and Blue Care Network will change how we cover Truvada^® and Descovy^®, the only two drugs indicated for HIV-1 pre-exposure prophylaxis. Members currently on Descovy won’t be affected by this change.

If a member is newly prescribed Descovy for PrEP on or after May 1, 2020, we won’t cover the prescription unless prior authorization criteria are met. In such situations, prescribers should submit a prior authorization request. Otherwise, the prescription claim won’t be covered at the pharmacy.

We’ll only approve a PA for Descovy for PrEP if there is documentation of:

• A creatinine clearance, or CrCl, <60 mL/min
• Osteoporosis 

Members using Descovy to treat HIV will receive their medication for their applicable copay.

Effective July 1, 2020, Blue Cross will cover Truvada for PrEP at $0 cost share for commercial members at high risk. We’ll cover generic Truvada for PrEP at $0 cost share when it is available.

Truvada and Descovy are very similar and both contain tenofovir and emtricitabine. Each tenofovir component is formulated as a prodrug. After administration, it’s metabolized within the body into an active drug.

Differences in prodrug formulation and subsequent half-life differences don’t affect efficacy but can affect side-effect profiles. Descovy demonstrated non-inferiority to Truvada in the DISCOVER trial, which means both drugs are equally efficacious in preventing the transmission of HIV-1.

Both drugs are contraindicated as PrEP in patients with unknown or positive HIV status. Using Descovy or Truvada for PrEP without confirmation of negative HIV status may increase the risk of developing HIV-1 resistance substitutions.

We’ll pay inpatient facility claims for Zulresso for Blue Cross members, starting July 1

Starting July 1, 2020, we’ll pay only inpatient facility claims for Zulresso^™ (brexanolone), HCPCS code C9055, for Blue Cross Blue Shield of Michigan commercial members.

We’ll deny Blue Cross commercial claims that indicate a place of service other than an inpatient facility.

This applies only to our in-state providers.

We made changes to coverage for infliximab biosimilar products for Medicare Advantage members

Blue Cross Blue Shield of Michigan removed authorization requirements for certain infliximab biosimilar drugs and designated preferred infliximab biosimilar drugs for Medicare Plus Blue^SM and BCN Advantage^SM members. This change started in April 2020.

Removing authorization requirements

For dates of service on or after April 3, 2020, we no longer require authorization for the following infliximab biosimilars for Remicade^® for Medicare Plus Blue and BCN Advantage members:

• Q5103 Inflectra^®
• Q5104 Renflexis^®

Designating preferred biosimilar drugs

Since April 20, 2020, we’ve designated the following drugs as preferred infliximab biosimilar products for Medicare Plus Blue and BCN Advantage members:

• J3590 Avsola^™
• Q5103 Inflectra
• Q5104 Renflexis

As part of our shared commitment to keeping health care affordable for all, we encourage you to switch members to one of the preferred infliximab biosimilar products.

Important: Remicade won’t be considered a preferred biosimilar and will continue to require authorization for Medicare Plus Blue and BCN Advantage members.

List of requirements

We’ve updated the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members with these changes.

The specialty medications on this list can be administered in outpatient sites of care, a physician’s office, an outpatient facility or a member’s home.

Sign up for training webinar

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.

Register for the upcoming training webinar:

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

HEDIS measure tip sheets updated for 2020

We’ve updated our HEDIS^® tip sheets** for 2020 and posted them on the Clinical Quality Corner page of web-DENIS, along with a series of Star Measure Tips that were posted earlier this year. The tip sheets were developed to assist health care providers and their staff in their efforts to improve overall health care quality and prevent or control diseases and chronic conditions.

The Star Measure Tips highlight select measures related to the Centers for Medicare & Medicaid Services’ five-star quality rating system. Most of the Star measures are also HEDIS measures. HEDIS is one of the most widely used performance improvement tools in the U.S.

Accessing the tip sheets

These HEDIS Measure Tip Sheets and the Star Measure Tips are housed on the Clinical Quality Corner page of web-DENIS. You can get there by following these steps:

• From the homepage of web-DENIS, click on BCBSM Provider Publications and Resources in the left column. (You can also access them from the BCN Provider Publications and Resources section of web-DENIS.)
• Click on Newsletters & Resources.
• Click on Clinical Quality Corner on the left-hand side of the page under Other Resources.

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

Two UAW groups have similar names, causing some confusion

There continues to be some confusion among providers about whether the UAW Retiree Health Care Trust (sometimes referred to as URHCT) requires prior authorization from AIM Specialty Health^® for select outpatient medical diagnostic services. The answer is that it does not. Neither does the UAW International Staff.

However, the UAW Retiree Medical Benefits Trust, commonly referred to as URMBT, does require prior authorization for select outpatient medical diagnostic services for their commercial members. Any confusion among providers may be the result of the UAW Retiree Medical Benefits Trust and UAW Retiree Health Care Trust having similar names.

The following needs to be considered when determining prior authorization requirements for AIM:

Prior authorization not required from AIM

• UAW Retiree Health Care Trust, or URHCT — group number 70605
• UAW International Staff — group number 71714

Prior authorization required from AIM

• UAW Retiree Medical Benefits Trust, or URMBT — group numbers 71400, 71435 and 71436

The information above is provided as a guide to help eliminate confusion. As always, you should check eligibility and benefits through web-DENIS.

We’ve updated the guidelines for cosmetic and reconstructive surgery

The Joint Uniform Medical Policy Committee, known as JUMP, updated the guidelines for the Cosmetic and Reconstructive Surgery medical policy. This policy is effective May 1, 2020.

Medical policy statement

Reconstructive surgery is an established service when it involves the restoration of a patient to a normal functional status, or when it is done to repair a defect arising from congenital defects, developmental abnormalities, trauma, infection, involutional defects, tumors or disease. It may be a therapeutic option when indicated.

Cosmetic surgery is performed solely to preserve or enhance appearance or self-esteem. It is considered not medically necessary.

Guidelines

In the absence of a functional deficit, reconstructive surgery may be used to restore a patient’s appearance to the state of normalcy that existed before the illness, traumatic injury or surgery.

Declaration of medical necessity to justify surgery should be supported by medical documentation. Categories of conditions that may be included as part of the contractual definition of reconstructive services include the following:

• Post-surgery (including breast reconstruction)
• Accidental trauma or injury
• Diseases
• Congenital anomalies
• Post-chemotherapy
• Massive weight loss causing functional impairment. This includes, but isn’t limited to, severe rashes or intertrigo, skin ulceration or pain (such as backache due to a large panniculus) that hasn’t responded to conventional therapy.

The following procedures may be considered either cosmetic or reconstructive in nature based on the indications for the surgery. (Note: This list is not all-inclusive.)

Reminder: Additional radiology procedures for commercial and Medicare Plus Blue members to require prior authorization

The PPO Radiology Management Program, administered by AIM Specialty Health^®, will require prior authorization for additional radiology procedures beginning May 1, 2020. This change will apply to Blue Cross Blue Shield of Michigan commercial, Blue Care Network commercial and Medicare Plus Blue^SM members.

The procedures, which include myocardial imaging and positron emission tomography, involve the following procedure codes:

• *78429
• *78430
• *78431
• *78432
• *78433

These codes will require preauthorization for both office settings and hospital outpatient locations. A list of the codes is available at aimspecialtyhealth.com.** You can also refer to Blue Cross’ online provider manuals.

Providers can get authorization through the provider portal or by contacting AIM at 1-800-728-8008.

Reminder: Keep in mind that not all our members require prior authorization through AIM. Benefit Explainer will let you know if a service requires authorization when you enter the patient’s contract number and the procedure code for a service.

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

Help FEP members avoid emergency room costs for non‑emergency care

Emergency rooms are an important part of our health care system but can be costly.  When members choose the right level of care, they save time and out-of-pocket costs.

FEP members’ choices for care

The Federal Employee Program^® provides care choices for members in multiple settings. Members can speak to a health care provider by phone, online or in person.

Print and distribute the Know Where to Go guide to FEP Service Benefit Plan members to help them decide which level of care is best suited for their health care needs. The guide also provides information on a member’s copayment for each benefit option.

If members have questions about their care options, they can call Customer Service at 1-800-482-3600.

We’re making a professional payment policy change for select procedures done in ambulatory surgical facilities

Blue Cross Blue Shield of Michigan recognizes that for certain procedures, additional effort is required and additional costs are incurred when performed outside of a hospital setting. Effective July 1, 2020, the PPO physician reimbursement policy will increase allowed amounts by 15% for select procedures when done in an ambulatory surgical facility. For a preliminary list of the CPT codes for these procedures, click here.

We’ll continue to closely monitor our list of eligible procedures and adjust it based on provider input and other factors, including the effectiveness of the policy. Any other procedures not listed will be paid at the published rate.

Update: Providers must submit authorization requests to TurningPoint for musculoskeletal surgical procedures scheduled on or after July 1 for certain members

As we reported in previous issues of The Record, providers will need to submit authorization requests through TurningPoint Healthcare Solutions LLC for Blue Care Network commercial, BCN Advantage^SM and Medicare Plus BlueS^SM PPO members.

Due to the COVID-19 pandemic, we’re delaying the date on which TurningPoint will begin managing authorizations. TurningPoint will now begin managing authorizations for dates of service on or after July 1, 2020.

Providers must submit authorization requests for all surgical procedures related to musculoskeletal conditions to TurningPoint. This is effective for procedures scheduled on or after July 1, 2020.

See this article in the March Record for detailed information.

You’ll be able to submit authorization requests to TurningPoint starting on June 1, 2020. For information about the duration of authorizations during the COVID-19 pandemic, see the Changes to authorization durations for elective and non-urgent procedures, including PT, OT and ST, during the COVID-19 pandemic message that we posted to our public website at bcbsm.com/coronavirus.

We’ll continue to offer webinar training for providers and facilities.

Use the links below to register for webinars:

• Training for professional providers
• Training for facility providers

Important information for facilities

Facilities should have an authorization before scheduling surgery.

Facility providers won’t be able to access the TurningPoint portal until fourth-quarter 2020 to get a status on authorization requests. In the meantime, we’re recommending that the ordering physicians secure the required authorization and provide the authorization numbers to the rendering facilities or providers.

Facilities can look up the status of an authorization request by checking on ereferrals.bcbsm.com. The authorization will show in our system one business day after TurningPoint has made a decision. To check the status of an authorization request directly with TurningPoint, call 1-833-217-9670.

Include only procedure codes authorized for musculoskeletal procedures on your claims

For inpatient professional claims, make sure to include only the procedure codes TurningPoint authorized on your claim.

On a quarterly basis, Blue Cross Blue Shield of Michigan and Blue Care Network will review paid inpatient claims from professional providers to ensure that the procedure codes on the claims match the procedure codes TurningPoint authorized. If we find overpayments because the claim included codes that TurningPoint didn’t authorize, we’ll pursue payment recoveries as necessary.

You can request that TurningPoint add procedure codes to an authorization, but you must do this prior to submitting your claim. For more information about updating procedure codes on an authorization, see the FAQ document referenced below.

Where to find more information

For more information about TurningPoint, see the Blue Cross or BCN Musculoskeletal Services pages on the ereferrals.bcbsm.com website. On these pages, you can find procedure codes for orthopedic and spinal procedures managed by TurningPoint. The links are below:

• Orthopedic
• Spinal

You can also refer to the frequently asked questions document on these pages.

Quarterly update: Requirements changed for some commercial medical benefit drugs

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

During January, February and March 2020, the following medical drugs had authorization requirement updates, site-of-care updates or both for Blue Cross’ PPO members:

For a detailed list of requirements, see the Blue Cross Drugs Covered Under the Medical Benefit page at ereferrals.bcbsm.com.

Additional notes

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. To view the list of PPO groups that don’t require members to participate in the program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List. This list is available on the Blue Cross Drugs Covered Under the Medical Benefit page at ereferrals.bcbsm.com.

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.

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

We’re adding medications to the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue^SM PPO and BCN Advantage^SM members. These specialty medications are administered by health care professionals in outpatient sites of care, such as physician’s offices, members’ homes, off-campus outpatient hospitals or ambulatory surgical centers (sites of care 11, 12, 19, 22 and 24).

For dates of service on or after June 15, 2020, the following medications will require prior authorization through NovoLogix^®:

• J1428 Exondys 51^®
• J3490 Vyondys 53^™
• J3490 Givlaari^®
• J3590 Tepezza^™
• J3590 Vyepti^™

How to bill

For Medicare Plus Blue and BCN Advantage, we require authorization for all outpatient sites of care when you bill these medications as a professional service or as an outpatient facility service:

• Electronically through an 837P transaction or on a professional CMS-1500 claim form
• Electronically through an 837I transaction or by using the UB04 claim form for a hospital outpatient type of bill 013x

Important reminder

For these drugs, submit authorization requests through the NovoLogix online tool. It offers real-time status checks and immediate approvals for certain medications. Also note:

• For Medicare Plus Blue, if you have a Type 1 individual NPI and you checked the Medical Drug PA box when you completed the Provider Secured Access Application form, you already have access to NovoLogix. If you didn’t check that box, you can complete an Addendum “P" form to request access to NovoLogix and fax it to the number on the form.
• For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

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

List of requirements

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

We’ve added site-of-care requirements for Adakveo, Givlaari for Blue Cross’ PPO members

The site-of-care program for specialty drugs covered under the medical benefit has expanded as of April 1, 2020. This applies to Blue Cross Blue Shield of Michigan’s PPO members for the following drugs:

• Adakveo^® (crizanlizumab-tmca, HCPCS code C9053)
• Givlaari^® (givosiran, HCPCS code C9056)

Providers should encourage Blue Cross’ PPO members to select one of the following infusion locations instead of an outpatient hospital facility:

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

If Blue Cross’ PPO 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, the provider will 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 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 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 document located on the Blue Cross Medical Benefit Drugs – Pharmacy webpage of our ereferrals.bcbsm.com website.

We’ll pay inpatient facility claims for Zulresso for Blue Cross members, starting July 1

Starting July 1, 2020, we’ll pay only inpatient facility claims for Zulresso^™ (brexanolone), HCPCS code C9055, for Blue Cross Blue Shield of Michigan commercial members.

We’ll deny Blue Cross commercial claims that indicate a place of service other than an inpatient facility.

This applies only to our in-state providers.

We made changes to coverage for infliximab biosimilar products for Medicare Advantage members

Blue Cross Blue Shield of Michigan removed authorization requirements for certain infliximab biosimilar drugs and designated preferred infliximab biosimilar drugs for Medicare Plus Blue^SM and BCN Advantage^SM members. This change started in April 2020.

Removing authorization requirements

For dates of service on or after April 3, 2020, we no longer require authorization for the following infliximab biosimilars for Remicade^® for Medicare Plus Blue and BCN Advantage members:

• Q5103 Inflectra^®
• Q5104 Renflexis^®

Designating preferred biosimilar drugs

Since April 20, 2020, we’ve designated the following drugs as preferred infliximab biosimilar products for Medicare Plus Blue and BCN Advantage members:

• J3590 Avsola^™
• Q5103 Inflectra
• Q5104 Renflexis

As part of our shared commitment to keeping health care affordable for all, we encourage you to switch members to one of the preferred infliximab biosimilar products.

Important: Remicade won’t be considered a preferred biosimilar and will continue to require authorization for Medicare Plus Blue and BCN Advantage members.

List of requirements

We’ve updated the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members with these changes.

The specialty medications on this list can be administered in outpatient sites of care, a physician’s office, an outpatient facility or a member’s home.

Sign up for training webinar

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.

Register for the upcoming training webinar:

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

Two UAW groups have similar names, causing some confusion

There continues to be some confusion among providers about whether the UAW Retiree Health Care Trust (sometimes referred to as URHCT) requires prior authorization from AIM Specialty Health^® for select outpatient medical diagnostic services. The answer is that it does not. Neither does the UAW International Staff.

However, the UAW Retiree Medical Benefits Trust, commonly referred to as URMBT, does require prior authorization for select outpatient medical diagnostic services for their commercial members. Any confusion among providers may be the result of the UAW Retiree Medical Benefits Trust and UAW Retiree Health Care Trust having similar names.

The following needs to be considered when determining prior authorization requirements for AIM:

Prior authorization not required from AIM

• UAW Retiree Health Care Trust, or URHCT — group number 70605
• UAW International Staff — group number 71714

Prior authorization required from AIM

• UAW Retiree Medical Benefits Trust, or URMBT — group numbers 71400, 71435 and 71436

The information above is provided as a guide to help eliminate confusion. As always, you should check eligibility and benefits through web-DENIS.

Reminder: Additional radiology procedures for commercial and Medicare Plus Blue members to require prior authorization

The PPO Radiology Management Program, administered by AIM Specialty Health^®, will require prior authorization for additional radiology procedures beginning May 1, 2020. This change will apply to Blue Cross Blue Shield of Michigan commercial, Blue Care Network commercial and Medicare Plus Blue^SM members.

The procedures, which include myocardial imaging and positron emission tomography, involve the following procedure codes:

• *78429
• *78430
• *78431
• *78432
• *78433

These codes will require preauthorization for both office settings and hospital outpatient locations. A list of the codes is available at aimspecialtyhealth.com.** You can also refer to Blue Cross’ online provider manuals.

Providers can get authorization through the provider portal or by contacting AIM at 1-800-728-8008.

Reminder: Keep in mind that not all our members require prior authorization through AIM. Benefit Explainer will let you know if a service requires authorization when you enter the patient’s contract number and the procedure code for a service.

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

Quarterly update: Requirements changed for some commercial medical benefit drugs

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

During January, February and March 2020, the following medical drugs had authorization requirement updates, site-of-care updates or both for Blue Cross’ PPO members:

For a detailed list of requirements, see the Blue Cross Drugs Covered Under the Medical Benefit page at ereferrals.bcbsm.com.

Additional notes

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. To view the list of PPO groups that don’t require members to participate in the program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List. This list is available on the Blue Cross Drugs Covered Under the Medical Benefit page at ereferrals.bcbsm.com.

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.

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

We’re adding medications to the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue^SM PPO and BCN Advantage^SM members. These specialty medications are administered by health care professionals in outpatient sites of care, such as physician’s offices, members’ homes, off-campus outpatient hospitals or ambulatory surgical centers (sites of care 11, 12, 19, 22 and 24).

For dates of service on or after June 15, 2020, the following medications will require prior authorization through NovoLogix^®:

• J1428 Exondys 51^®
• J3490 Vyondys 53^™
• J3490 Givlaari^®
• J3590 Tepezza^™
• J3590 Vyepti^™

How to bill

For Medicare Plus Blue and BCN Advantage, we require authorization for all outpatient sites of care when you bill these medications as a professional service or as an outpatient facility service:

• Electronically through an 837P transaction or on a professional CMS-1500 claim form
• Electronically through an 837I transaction or by using the UB04 claim form for a hospital outpatient type of bill 013x

Important reminder

For these drugs, submit authorization requests through the NovoLogix online tool. It offers real-time status checks and immediate approvals for certain medications. Also note:

• For Medicare Plus Blue, if you have a Type 1 individual NPI and you checked the Medical Drug PA box when you completed the Provider Secured Access Application form, you already have access to NovoLogix. If you didn’t check that box, you can complete an Addendum “P" form to request access to NovoLogix and fax it to the number on the form.
• For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

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

List of requirements

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

We’ve added site-of-care requirements for Adakveo, Givlaari for Blue Cross’ PPO members

The site-of-care program for specialty drugs covered under the medical benefit has expanded as of April 1, 2020. This applies to Blue Cross Blue Shield of Michigan’s PPO members for the following drugs:

• Adakveo^® (crizanlizumab-tmca, HCPCS code C9053)
• Givlaari^® (givosiran, HCPCS code C9056)

Providers should encourage Blue Cross’ PPO members to select one of the following infusion locations instead of an outpatient hospital facility:

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

If Blue Cross’ PPO 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, the provider will 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 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 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 document located on the Blue Cross Medical Benefit Drugs – Pharmacy webpage of our ereferrals.bcbsm.com website.

Starting May 1, 2020, we’ll change how we cover some drugs for HIV-1 PrEP

The U.S. Preventive Services Task Force has recommended that providers offer pre-exposure prophylaxis with effective antiretroviral therapy to people at high risk for HIV. The Centers for Disease Control and Prevention reports that when taken daily, PrEP is highly effective for preventing HIV-1.

In complying with this recommendation, Blue Cross Blue Shield of Michigan and Blue Care Network will change how we cover Truvada^® and Descovy^®, the only two drugs indicated for HIV-1 pre-exposure prophylaxis. Members currently on Descovy won’t be affected by this change.

If a member is newly prescribed Descovy for PrEP on or after May 1, 2020, we won’t cover the prescription unless prior authorization criteria are met. In such situations, prescribers should submit a prior authorization request. Otherwise, the prescription claim won’t be covered at the pharmacy.

We’ll only approve a PA for Descovy for PrEP if there is documentation of:

• A creatinine clearance, or CrCl, <60 mL/min
• Osteoporosis 

Members using Descovy to treat HIV will receive their medication for their applicable copay.

Effective July 1, 2020, Blue Cross will cover Truvada for PrEP at $0 cost share for commercial members at high risk. We’ll cover generic Truvada for PrEP at $0 cost share when it is available.

Truvada and Descovy are very similar and both contain tenofovir and emtricitabine. Each tenofovir component is formulated as a prodrug. After administration, it’s metabolized within the body into an active drug.

Differences in prodrug formulation and subsequent half-life differences don’t affect efficacy but can affect side-effect profiles. Descovy demonstrated non-inferiority to Truvada in the DISCOVER trial, which means both drugs are equally efficacious in preventing the transmission of HIV-1.

Both drugs are contraindicated as PrEP in patients with unknown or positive HIV status. Using Descovy or Truvada for PrEP without confirmation of negative HIV status may increase the risk of developing HIV-1 resistance substitutions.

We’ll pay inpatient facility claims for Zulresso for Blue Cross members, starting July 1

Starting July 1, 2020, we’ll pay only inpatient facility claims for Zulresso^™ (brexanolone), HCPCS code C9055, for Blue Cross Blue Shield of Michigan commercial members.

We’ll deny Blue Cross commercial claims that indicate a place of service other than an inpatient facility.

This applies only to our in-state providers.

We made changes to coverage for infliximab biosimilar products for Medicare Advantage members

Blue Cross Blue Shield of Michigan removed authorization requirements for certain infliximab biosimilar drugs and designated preferred infliximab biosimilar drugs for Medicare Plus Blue^SM and BCN Advantage^SM members. This change started in April 2020.

Removing authorization requirements

For dates of service on or after April 3, 2020, we no longer require authorization for the following infliximab biosimilars for Remicade^® for Medicare Plus Blue and BCN Advantage members:

• Q5103 Inflectra^®
• Q5104 Renflexis^®

Designating preferred biosimilar drugs

Since April 20, 2020, we’ve designated the following drugs as preferred infliximab biosimilar products for Medicare Plus Blue and BCN Advantage members:

• J3590 Avsola^™
• Q5103 Inflectra
• Q5104 Renflexis

As part of our shared commitment to keeping health care affordable for all, we encourage you to switch members to one of the preferred infliximab biosimilar products.

Important: Remicade won’t be considered a preferred biosimilar and will continue to require authorization for Medicare Plus Blue and BCN Advantage members.

List of requirements

We’ve updated the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members with these changes.

The specialty medications on this list can be administered in outpatient sites of care, a physician’s office, an outpatient facility or a member’s home.

Bypass the manual review requirement for medically necessary insulin pumps

Effective March 1, 2020, health care providers must append the KX and TW modifiers to avoid the manual review process for a medically necessary replacement insulin pump.

To avoid the manual review process, all the following must apply:

• Insulin pump malfunctioned
• Manufacturer’s warranty has expired
• Blue Cross Blue Shield of Michigan’s five-year reasonable useful lifetime, or RUL, hasn’t been reached

By appending the KX and TW modifiers, you are certifying that the member’s insulin pump has malfunctioned after the manufacturer’s warranty period but before the five-year RUL and that the member meets Blue Cross medical criteria for an insulin pump.

Blue Cross to reject certain HCPCS codes for arch supports starting in June

Starting on June 1, 2020, Blue Cross Blue Shield of Michigan’s systems won’t consider certain HCPCS codes for arch supports a benefit. On June 1, Blue Cross systems will be updated to reject the following:

• L3040
• L3050
• L3060
• L3070
• L3080
• L3090
• L3100