New, secure provider website coming in 2021

In our April issue, we reported the results of our provider survey. You told us what you like about our current online tools and pointed out what you’d like to see improved. Since then, we’ve been working to address many of your concerns while keeping the features you like.

We’re pleased to announce that we’ll introduce a new, secure provider website in 2021. It’ll have additional online tools and functions designed to make it easier for you to do business with us. The new site will still provide access to many of the tools you currently use but will have a simple, fresh look, updated search features and improved performance.

Availity to operate new provider website
Availity, a company that operates a multi-payer platform, will offer easy-to-use online tools for health care providers. This means that you’ll be able to log in and request information for your patients who have coverage with several different health plans, including Blue Cross Blue Shield of Michigan and Blue Care Network.

We’ll keep you up to date about our progress in future issues of The Record.

Blue Cross, BCN commercial members to have preferred hereditary angioedema drugs, starting Nov. 1

Currently, all hereditary angioedema, or HAE, medications require prior authorization for Blue Cross Blue Shield of Michigan and Blue Care Network commercial members. Starting Nov. 1, 2020, Blue Cross and BCN will require their commercial PPO and HMO members to use preferred HAE drugs for acute treatment and preventive therapy.

For commercial members currently receiving a nonpreferred HAE drug:

• They’re authorized to continue their current therapy through Oct. 31, 2020.
• We’ve proactively authorized therapy with preferred medications from Nov. 1, 2020, through Oct. 31, 2021, to prevent interruptions in care.
• We encourage you to talk with our members to discuss any concerns they may have with the transition.
• We’ll be mailing letters to notify our Blue Cross and BCN members of these changes.

For HAE therapy covered under the medical benefit, the requirements outlined here apply only to groups currently participating in the standard commercial Medical Drug Prior-Authorization Program. Proactive authorizations for preferred drugs apply to members who have their pharmacy benefit with Blue Cross or BCN.

More information
For more information on requirements related to drugs for our commercial members, see:

• Medical benefit requirements
• Pharmacy benefit requirements

FY 2021 ICD-10-CM and PCS code updates now available

The FY 2021 ICD-10-CM and ICD-10-PCS code updates that will be effective with dates of service on or after Oct. 1, 2020, are available on the Centers for Medicare & Medicaid Services website.

This year’s updates include 1,032 new diagnosis and inpatient procedure codes being added, 47 CM and PCS code revisions and 58 CM and PCS deletions.

To check for the code updates, go to the CMS website.**

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

COVID-19 CPT codes added

The Centers for Medicare & Medicaid Services has added three COVID-19 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.

Pathology and laboratory

Proprietary laboratory analysis 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.

HCPCS update: COVID-19 code revision

The Centers for Medicare & Medicaid Services has revised a COVID-19 code as part of its quarterly Health Care Procedure Coding System updates. The code, effective date and Blue Cross Blue Shield of Michigan’s coverage decision are below.

Pathology and lab code

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

Billing chart: Blues highlight medical, benefit policy changes

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

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

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

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

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

• Log in to web-DENIS.
• Click on BCBSM Provider Publications & Resources.
• Click on Benefit Policy for a Code.
• Click on Topic.
• Under Topic Criteria, click on the drop-down arrow next to Choose Identifier Type and then click on HCPCS Code.
• Enter the procedure code.
• Click on Finish.
• Click on Search.

We’re temporarily allowing direct-line ABA interventions to be performed via telemedicine

During the COVID-19 crisis and until further notice, we’re temporarily allowing providers to perform direct-line ABA interventions (CPT code *97153) through telemedicine for dates of service on or after Aug. 3, 2020.

See the new Guidelines for ABA services delivered via telemedicine document for guidance on determining which members can benefit from direct-line ABA interventions performed via telemedicine.

We updated the following documents to reflect this change:

• Telehealth for behavioral health providers
• Telehealth procedure codes for COVID-19
• Temporary changes due to the COVID-19 pandemic

You can find these documents on our public website at bcbsm.com/coronavirus and through Provider Secured Services.

To check whether a member has an autism benefit, follow the instructions on these documents:

• Checking Blue Cross eligibility and autism benefits. Log in to Provider Secured Services, click on Blue Cross Provider Publications and Resources, click on Clinical Criteria & Resources, then click on Autism (in the Resources section). Finally, click to open the document.
• Checking BCN eligibility and autism benefits on web-DENIS. Log in to Provider Secured Services, click on BCN Provider Publications and Resources, then  click on Autism. Finally, click to open the document.

For authorization requirements related to autism services for various lines of business, refer to the Summary of utilization management programs for Michigan providers.

New program helps members understand treatment options

Blue Cross Blue Shield of Michigan is launching a program Jan. 1, 2021, to help our members understand and make decisions about high-cost, high-risk health conditions.

As part of an agreement with 2nd.MD,** members of select self-funded groups will have access to personalized second opinions and treatment options — by  video or phone — from medical specialists at top institutions. The program may be expanded to fully insured groups later in 2021.

This service can help members:

• Make better decisions and understand alternatives to surgery, if appropriate
• Find a high-quality, network local physician who’s experienced with the member’s specific condition

A member’s current provider may opt to consult with a 2nd.MD expert. Providers may also be asked to provide a patient’s medical records to 2nd.MD.

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

We are simplifying inquiry and appeal process

As part of our efforts to streamline processes and improve your overall experience with Blue Cross Blue Shield of Michigan, we’ll begin accepting your claim appeal verbally when you contact Provider Relations & Servicing, effective Oct. 1, 2020.   

You should continue to contact PRS at one of the telephone numbers listed below for any inquiry related to benefits, eligibility and claims. Beginning in October, if you’re not satisfied with the inquiry outcome about a claim determination, you may request an appeal while speaking with a Customer Service representative.

If you have additional information to include with your appeal, the representative will provide you with a number to fax your supporting documentation. A written response will be issued to you within 30 days of receipt of your documentation.

• Medical providers: 1-800-344-8525
• Vision and hearing providers: 1-800-482-4047
• Facility providers: 1-800-249-5103

Beginning Oct. 1, you won’t be able to submit a written appeal to Blue Cross Blue Shield of Michigan at Mail Code 1620 or fax it to 1-877-348-2210.

As a reminder, you may be eligible for a claim appeal when the following criteria are met:

• The member is enrolled in a Blue Cross commercial plan.
• The rendering provider is one of the following:
• A Blue Cross Blue Shield of Michigan participating provider located in Michigan
• An out-of-state provider who participates with Blue Cross Blue Shield of Michigan and has a Michigan PIN
• A nonparticipating provider located in Michigan who has accepted assignment on the claim, on a per claim basis
• The appeal is for a professional claim that was filed within 180 days from the date of service, or a facility claim that was filed within 365 days from the date of service.
• The appeal request is made within 180 days from the date of the original claim determination.
• The supporting documentation is submitted within 30 days of contacting PRS.
• A request for appeal wasn’t submitted previously on the same claim.

Reminders:

• If you received a nonpayment notice indicating a billing error, submit a new claim that includes the requested information.
• If your claim is denied for lack of authorization, request a retro-authorization within the allowed time frame. Reach out to the appropriate authorization team or vendor to initiate the review.

Oncology management program to include Blue Cross commercial members, starting in December

Beginning Dec. 1, 2020, Blue Cross Blue Shield of Michigan will expand its utilization management program for medical oncology to include all fully insured commercial members. Blue Cross commercial groups that are self-funded will have the option to add this program in 2021.

With this expansion, providers will need to request authorization from AIM Specialty Health^® for certain medical oncology and supportive care medications for PPO members.

This program is already in effect for Medicare Plus Blue^SM, Blue Care Network commercial and BCN Advantage^SM members and for UAW Retiree Medical Benefits Trust non-Medicare members.
Program benefits include:

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

You can request authorizations by going to the AIM ProviderPortal** or by calling AIM at 1-800-728-8008, beginning Nov. 16, 2020 (for services on or after Dec. 1, 2020).

For more information about our current AIM oncology program, go to aimproviders.com** or visit the Blue Cross AIM-Managed Procedures page at ereferrals.bcbsm.com. We’ll update this webpage with this new information later this year. We’ll also provide additional information about program requirements in future issues of this publication.

Also watch for information about training webinars. We’ll update you about webinar times and dates as well as how to register through web-DENIS messages and in news items on ereferrals.bcbsm.com.

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

MPSERS, State of Michigan groups extend COVID-19 cost-sharing waivers

Effective July 1, 2020, the Michigan Public School Employees’ Retirement System, or MPSERS, and State of Michigan Blue Cross retiree groups are extending member cost-sharing waivers for COVID-19 treatments.

The cost-sharing waivers that were in place through June 30, 2020, are now effective until Sept. 30, 2020.

This includes:

• Telehealth for medical and behavioral health services
• Primary care and behavioral health office visits
• In-office diagnostic X-ray and labs

These groups will continue to cover COVID-19-related services, such as physician and hospital evaluations, test administration and lab tests, as mandated by the government.

As we previously announced, some of our other self-funded commercial groups are continuing to waive member cost sharing for telehealth for dates of service March 16 through Dec. 31, 2020.

We’re encouraging providers to submit claims to Blue Cross Blue Shield of Michigan and Blue Care Network, and wait for the remittance advice before charging the member cost sharing, if applicable.

More information is available at bcbsm.com/coronavirus or through Provider Secured Services.

For MESSA members, no-cost telehealth services, including behavioral health, extended through Dec 31

To make it easier for Michigan Education Special Services Association members to receive care during the COVID-19 pandemic, MESSA is doing the following:

• Extending the waiving of member copays and cost sharing on telehealth services through Dec. 31, 2020, when MESSA members use network physicians or Blue Cross Online Visits^SM, powered by American Well^®. The waiving of copays and cost sharing on these services previously had an end date of June 30.
• Expanding no cost telehealth services to now include common behavioral health therapy for members with our behavioral health benefits. For more information, see the Telehealth procedure codes for COVID-19 document.
• Clarifying the specific telehealth services that have no member cost sharing. For more information, see the Telehealth procedure codes for COVID-19 document.

This affects all MESSA members (group numbers 71452, 71453, 71454, 71455).

When you check member eligibility and benefits in our system, the waiving of member cost sharing won’t be reflected as this is a temporary change. We recommend you submit your claim to Blue Cross and then wait to receive our voucher. For MESSA members, the voucher will reflect no member cost sharing through Dec. 31, 2020, for the services listed above, and providers will receive the member cost share directly from Blue Cross.

TurningPoint musculoskeletal procedure authorization program to expand in January

In an August Record article, we let you know that we’re expanding the TurningPoint Healthcare Solutions, LLC musculoskeletal authorization program. We want to share with you links to register for training webinars and other important information about this change.

With this expansion, TurningPoint will manage musculoskeletal surgical authorizations for the following groups and members for dates of service on or after Jan. 1, 2021:

• Pain management procedures — For all Blue Cross PPO fully insured groups, select Blue Cross PPO administrative service contract groups, all Medicare Plus Blue^SM PPO members, all BCN commercial members and all BCN Advantage^SM members
• Joint replacement surgeries and other related arthroscopic procedures — For all Blue Cross PPO fully insured groups and select Blue Cross PPO ASC groups
• Spinal procedures — For all Blue Cross PPO fully insured groups, select Blue Cross PPO ASC groups and all Medicare Plus Blue members

Additional information you need to know

• Starting Dec. 1, 2020, providers should submit authorization requests to TurningPoint for the above procedures for dates of service on or after Jan. 1, 2021.
• This change affects procedures currently managed by Blue Cross, BCN or eviCore healthcare^®.
• You can find procedure codes for pain management, orthopedic and spinal procedures managed by TurningPoint on the ereferrals.bcbsm.com website:
• Pain management procedure codes
• Orthopedic procedure codes
• Spinal procedure codes
• For more information about the TurningPoint program, see the following pages of the ereferrals.bcbsm.com website. Soon, we’ll update these pages and the documents to which they link to reflect the changes that are coming on Jan. 1.
• Blue Cross Musculoskeletal Services
• BCN Musculoskeletal Services

Webinar training

We’re offering training webinars for professional providers and facilities for musculoskeletal services managed by TurningPoint.

Click a link below to register.

Provider training

Facility training

Portal training

Health e-Blue guide explains how to access pharmacy data, identify cost-saving

Pharmacy Opportunities Focus: Health e-Blue Pharmacy 2020 is a step-by-step guide to help navigate Health e-Blue. The guide contains details on how to obtain pharmacy claims data as well as how to generate the pharmacy profile report of a primary care physician.

Below are recommendations when looking through pharmacy data to identify potential cost-savings opportunities:

• For moving from brand-name medications to generics: Compare pharmacy claims data with the drug lists.**
• For leveraging the preferred alternatives of a member’s respective drug list:
• Download the free ScriptVision™ Physician App through the App Store^® for your iPhone or iPad. In real time, see the member’s cost share, any plan requirements (for example, prior authorization, step therapy, quantity limit) and lower-cost alternatives.
• Review the spring 2020 opportunities handout for high-cost drugs and lower cost alternatives. It can serve as a quick reference.
• For improving the generic prescribing rates of primary care physicians: Use the physician profile report for details on certain drugs or members.
• For monitoring specialists who prescribe brand-name drugs when a generic is available or nonpreferred drugs when preferred alternatives are available: Identify the specialists and the approach for discussion.

The suggestions above are general guidelines. As always, use clinical judgment to determine the most appropriate option for each patient’s specific circumstances.

The information in this article applies to all members with Blue Cross Blue Shield of Michigan and Blue Care Network commercial pharmacy plans.

**The drug lists are updated on a monthly basis (for example, new drug approvals, new safety or efficacy data, clinical guideline updates). Please refer to the online documents for the most up-to-date versions.

Medical specialty drug prior authorization lists changing for Medicare Plus Blue, BCN commercial and BCN Advantage

We’re adding authorization requirements for three specialty drugs covered under the medical benefit for Medicare Plus Blue^SM PPO, BCN commercial and BCN Advantage^SM members.

For dates of service on or after Sept. 25, 2020, the following drugs will require authorization through AIM Specialty Health^®:

• Zepzelca™ (lurbinectedin) — HCPCS codes J3490, J3590, J9999
• Phesgo™ (pertuzumab/trastuzumab/hyaluronidase-zzxf) — HCPCS codes J3490, J3590, J9999
• Nyvepria™ (pegfilgrastim-apgf) — HCPCS codes J3490, J3590, J9999

How to submit authorization requests
Submit authorization requests to AIM using one of the following methods:

• Through the AIM provider portal**
• By calling the AIM Contact Center at 1-844-377-1278

For information about registering for and accessing the AIM ProviderPortal, see the Frequently Asked Questions page** on the AIM website.

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

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

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

We’ll update these lists with the new information about these drugs before the effective dates.

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

AllianceRx Walgreens Prime specialty pharmacy program starts Jan. 1 for most Blue Cross commercial members

AllianceRx Walgreens Prime will be the exclusive specialty pharmacy provider for Blue Cross Blue Shield of Michigan commercial members, effective Jan. 1, 2021. This change doesn’t apply to Medicare Advantage members.

The AllianceRx Walgreens Prime Care team, which includes pharmacists and patient care coordinators, will help provide your patients with clinical excellence. They can assist with convenient and easy access to the specialty medication you’ve prescribed.

We’ll send a letter about this change to your affected patients. AllianceRx Walgreens Prime will call and advise them to speak to you about getting new prescriptions.

You’ll need to give your patients new prescriptions before Jan. 1, 2021, if they don’t currently fill their specialty drug prescriptions at AllianceRx Walgreens Prime or a local Walgreens pharmacy location. If you don’t, your patients could be responsible for the full cost of their drugs.

If your Blue Cross patients currently receive their specialty drugs from AllianceRx Walgreens Prime or a Walgreens pharmacy, no action is required.

You can send new specialty medication prescriptions to AllianceRx Walgreens Prime by one of the following methods:

• Fax: 1-866-515-1356
• Electronically: E-prescribing name is AllianceRx WALGREENS PRIME-SPEC-MI
• Phone: 1-866-515-1355

For more information, go to alliancerxwp.com/hcp.**

For a current list of specialty drugs in this program, go to bcbsm.com/specialtydrug and scroll down to Filling a specialty drug prescription and click on Specialty Drug Program Rx Benefit Member Guide (PDF). This list is updated monthly.

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

IVIG dosing strategy changing for Medicare Part B medical specialty program, starting Dec. 7

Blue Cross Blue Shield of Michigan and Blue Care Network require authorization for immune globulin products covered under the medical benefit for Medicare Plus Blue^SM PPO and BCN Advantage^SM members.

As part of the authorization process, we’re updating our dosing strategy for intravenous and subcutaneous immune globulin therapy to minimize drug waste, reduce unnecessary drug exposure and decrease the risk of adverse events.

Effective Dec. 7, 2020, we’ll calculate doses using adjusted body weight for members when:

• The member’s body mass index is 30 kg/m² or greater.
• The member’s actual body weight is 20% higher than their ideal body weight.

This applies to all Medicare Plus Blue and BCN Advantage members who start therapy on or after Dec. 7, 2020, when the therapy is administered by a health care professional in a provider office, at the member’s home, in an off-campus outpatient hospital or in an ambulatory surgical center (sites of care 11, 12, 19, 22 and 24).

Members who currently receive immune globulin will continue to receive their current dose until their authorizations expire.

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

For Medicare Plus Blue and BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

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

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

We’re revising our policy on hypofractionation for breast and prostate cancer as part of our radiation oncology program

Blue Cross Blue Shield of Michigan and Blue Care Network have revised the radiation oncology program, managed through eviCore healthcare, to limit coverage for many breast and prostate cancers to hypofractionation, a shorter, equally effective regimen. This applies to requests submitted on or after Sept. 21.

The new policy applies to Blue Cross commercial, Medicare Plus Blue^SM, BCN commercial and BCN Advantage^SM. It doesn’t apply to Blue Cross self-funded groups.

These changes align with evidence-based guidelines, including those established by the National Comprehensive Cancer Network, or NCCN. They’re expected to result in less frequent visits for patients.

For breast cancer patients, the policy change means that hypofractionation will be covered in cases where the regional lymph nodes aren’t included in the treatment.

For external beam radiation, both hypofractionation (three to four weeks) and standard fractionation (six weeks) are currently allowed. Effective Sept. 21, only hypofractionation (the shorter regimen) will be allowed, although exceptions to this will be made on a case-by-case basis.

For prostate cancer patients, both hypofractionation (four to five weeks) and standard fractionation (nine weeks) are currently allowed. Effective Sept. 21, only hypofractionation (the shorter regimen) will be allowed. Exceptions will be made on a case-by-case basis.

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: For Blue Cross and Medicare Plus Blue members, call 1-877-917-2583. For BCN and BCN Advantage members, call eviCore at 1-855-774-1317.
• Alternative: Fax to eviCore at 1-800-540-2406.

For more information, refer to the document titled eviCore Management Program: Frequently Asked Questions.

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

• The BCN eviCore-Managed Procedures webpage
• The Blue Cross eviCore-Managed Procedures webpage

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

Resources available to help doctors, FEP members manage chronic conditions

Chronic conditions continue to be the leading cause of health care costs in the United States. Six in 10 adults have a chronic condition while 4 in 10 adults have two or more, according to the Centers for Disease Control and Prevention. Heart disease, chronic lung disease, stroke and diabetes are among the top conditions leading to disability and death.

Take advantage of the resources and support below for providers and Service Benefit Plan members to manage chronic conditions. 

Atherosclerotic cardiovascular disease

Atherosclerotic cardiovascular disease, or ASCVD, outcomes in recent decades have substantially improved. However, collaborative research from the American College of Cardiology and the American Heart Association found that ASCVD remains the leading cause of death for people in the U.S. To help curb this trend, the ACC developed a 10-year ASCVD risk estimation tool.** The tool is designed to help physicians identify patients at risk and facilitate clinician-patient discussion to optimize care and lower risks.

FEP Service Benefit Plan members can go to  fepblue.org/hearthealth to access heart health resources on nutrition, exercise and smoking cessation.

Asthma

In 2018, Michigan had the sixth highest number of people diagnosed with asthma in the U.S., according to the CDC. To assist doctors with the care of asthma patients, the National Institutes of Health, along with the National Heart, Lung, and Blood Institute, published a quick reference.**

FEP Service Benefit Plan members can go to fepblue.org/asthma to access asthma management resources, such as asthma assessment and tracker tools to help learn about and monitor their asthma condition.

Hypertension

When high blood pressure was redefined to 130/80, the prevalence of U.S. adults with high blood pressure jumped from 32% to nearly 46%, the AHA found. Accurate measurement and recordings of blood pressure are essential to determine blood pressure related to cardiovascular disease risks and guide care management.

Click here for the 2020 Blue Cross Blue Shield of Michigan star measure tip sheet on controlling high blood pressure. The tip sheet provides information on taking blood pressure readings in the office and talking with patients about maintaining a healthy blood pressure.

FEP Service Benefit Plan members can go to fepblue.org/hypertension for additional information, including how they can qualify for a free blood pressure monitor and incentives.

Diabetes

More than 7 million people in the U.S. have undiagnosed diabetes, the CDC reports. Additionally, approximately 1.5 million new cases were diagnosed in 2018. Guiding Principles** is a NIH resource for health care professionals that focuses on the care of people with diabetes or for those at risk. The principles emphasize the importance of diabetes self-management education and support.

FEP Service Benefit Plan members can find education and resources through their health plan. They have access to diabetes management support and incentive programs along with a free glucometer. Service Benefit Plan members can go to  fepblue.org/diabetes to find out how to qualify.

Providers and members can call the Customer Service line at 1-800-482-3600 or go to fepblue.org if they have questions about FEP benefits or wellness programs.

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

We are simplifying inquiry and appeal process

As part of our efforts to streamline processes and improve your overall experience with Blue Cross Blue Shield of Michigan, we’ll begin accepting your claim appeal verbally when you contact Provider Relations & Servicing, effective Oct. 1, 2020.   

You should continue to contact PRS at one of the telephone numbers listed below for any inquiry related to benefits, eligibility and claims. Beginning in October, if you’re not satisfied with the inquiry outcome about a claim determination, you may request an appeal while speaking with a Customer Service representative.

If you have additional information to include with your appeal, the representative will provide you with a number to fax your supporting documentation. A written response will be issued to you within 30 days of receipt of your documentation.

• Medical providers: 1-800-344-8525
• Vision and hearing providers: 1-800-482-4047
• Facility providers: 1-800-249-5103

Beginning Oct. 1, you won’t be able to submit a written appeal to Blue Cross Blue Shield of Michigan at Mail Code 1620 or fax it to 1-877-348-2210.

As a reminder, you may be eligible for a claim appeal when the following criteria are met:

• The member is enrolled in a Blue Cross commercial plan.
• The rendering provider is one of the following:
• A Blue Cross Blue Shield of Michigan participating provider located in Michigan
• An out-of-state provider who participates with Blue Cross Blue Shield of Michigan and has a Michigan PIN
• A nonparticipating provider located in Michigan who has accepted assignment on the claim, on a per claim basis
• The appeal is for a professional claim that was filed within 180 days from the date of service, or a facility claim that was filed within 365 days from the date of service.
• The appeal request is made within 180 days from the date of the original claim determination.
• The supporting documentation is submitted within 30 days of contacting PRS.
• A request for appeal wasn’t submitted previously on the same claim.

Reminders:

• If you received a nonpayment notice indicating a billing error, submit a new claim that includes the requested information.
• If your claim is denied for lack of authorization, request a retro-authorization within the allowed time frame. Reach out to the appropriate authorization team or vendor to initiate the review.

We’re extending fee schedule changes for home health care, home infusion therapy due to COVID-19

In response to the COVID-19 pandemic, Blue Cross Blue Shield of Michigan modified reimbursement policies that apply to practitioners who must deliver care in the members’ home rather than using telemedicine.

The increased rates, effective April 1, 2020, for the following categories will be maintained through the end of the year:

• All modalities included in the Home Health Care Facility Rate Schedule
• Nursing visits covered under home infusion therapy

In addition, professional provider fee increases were effective May 1, 2020, for the following codes, and will be maintained through Nov. 30, 2020.

• G9001
• G9002
• G9008
• *99484
• *99492
• *99493
• *99494

Any revisions needed after Nov. 30 will be published, and we’ll follow the 90-day notice requirements.

Find reimbursement for all procedures listed above in web-DENIS on the Fee Changes page by following these steps:

• Click on BCBSM Provider Publications and Resources.
• Click on Entire Fee Schedules and Fee Changes.

Skilled nursing facilities to follow new process to submit authorization requests for Blue Cross, BCN commercial members

Later this year, we’ll require skilled nursing facilities to submit authorization requests for members of our commercial plans through the e-referral system. Skilled nursing facilities will no longer be able to submit their requests by fax.

This updated submission process for skilled nursing facilities applies to requests for:

• Admissions
• Additional days

Sign up now to use e-referral system
To prepare for this change, it’s important that skilled nursing facilities sign up now for access to the e-referral system. Don’t wait to sign up, as it may take some time to get access.

You’ll also need to learn how to use the e-referral system, so you’re comfortable with it when this updated submission process goes into effect.

Everything you need to know is on our ereferrals.bcbsm.com website:

• To sign up for the e-referral system: Follow the instructions on the Sign up or change a user page.
• To learn how to use the e-referral system: Refer to the Training Tools page, where you’ll find the e-referral User Guide and Online Self-paced Learning Modules.

More information about the change
Currently, skilled nursing facilities are completing a form and submitting it by fax. When the new requirement goes into effect later this year, you’ll still need to complete the form, but you’ll attach it to the request in the e-referral system instead of faxing it.

This change affects members of Blue Cross Blue Shield of Michigan and Blue Care Network commercial plans.

Watch for more news about this change
We’ll communicate more details about this change in the coming weeks. Watch for web-DENIS messages as well as news items on our ereferrals.bcbsm.com website.

Oncology management program to include Blue Cross commercial members, starting in December

Beginning Dec. 1, 2020, Blue Cross Blue Shield of Michigan will expand its utilization management program for medical oncology to include all fully insured commercial members. Blue Cross commercial groups that are self-funded will have the option to add this program in 2021.

With this expansion, providers will need to request authorization from AIM Specialty Health^® for certain medical oncology and supportive care medications for PPO members.

This program is already in effect for Medicare Plus Blue^SM, Blue Care Network commercial and BCN Advantage^SM members and for UAW Retiree Medical Benefits Trust non-Medicare members.
Program benefits include:

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

You can request authorizations by going to the AIM ProviderPortal** or by calling AIM at 1-800-728-8008, beginning Nov. 16, 2020 (for services on or after Dec. 1, 2020).

For more information about our current AIM oncology program, go to aimproviders.com** or visit the Blue Cross AIM-Managed Procedures page at ereferrals.bcbsm.com. We’ll update this webpage with this new information later this year. We’ll also provide additional information about program requirements in future issues of this publication.

Also watch for information about training webinars. We’ll update you about webinar times and dates as well as how to register through web-DENIS messages and in news items on ereferrals.bcbsm.com.

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

MPSERS, State of Michigan groups extend COVID-19 cost-sharing waivers

Effective July 1, 2020, the Michigan Public School Employees’ Retirement System, or MPSERS, and State of Michigan Blue Cross retiree groups are extending member cost-sharing waivers for COVID-19 treatments.

The cost-sharing waivers that were in place through June 30, 2020, are now effective until Sept. 30, 2020.

This includes:

• Telehealth for medical and behavioral health services
• Primary care and behavioral health office visits
• In-office diagnostic X-ray and labs

These groups will continue to cover COVID-19-related services, such as physician and hospital evaluations, test administration and lab tests, as mandated by the government.

As we previously announced, some of our other self-funded commercial groups are continuing to waive member cost sharing for telehealth for dates of service March 16 through Dec. 31, 2020.

We’re encouraging providers to submit claims to Blue Cross Blue Shield of Michigan and Blue Care Network, and wait for the remittance advice before charging the member cost sharing, if applicable.

More information is available at bcbsm.com/coronavirus or through Provider Secured Services.

TurningPoint musculoskeletal procedure authorization program to expand in January

In an August Record article, we let you know that we’re expanding the TurningPoint Healthcare Solutions, LLC musculoskeletal authorization program. We want to share with you links to register for training webinars and other important information about this change.

With this expansion, TurningPoint will manage musculoskeletal surgical authorizations for the following groups and members for dates of service on or after Jan. 1, 2021:

• Pain management procedures — For all Blue Cross PPO fully insured groups, select Blue Cross PPO administrative service contract groups, all Medicare Plus Blue^SM PPO members, all BCN commercial members and all BCN Advantage^SM members
• Joint replacement surgeries and other related arthroscopic procedures — For all Blue Cross PPO fully insured groups and select Blue Cross PPO ASC groups
• Spinal procedures — For all Blue Cross PPO fully insured groups, select Blue Cross PPO ASC groups and all Medicare Plus Blue members

Additional information you need to know

• Starting Dec. 1, 2020, providers should submit authorization requests to TurningPoint for the above procedures for dates of service on or after Jan. 1, 2021.
• This change affects procedures currently managed by Blue Cross, BCN or eviCore healthcare^®.
• You can find procedure codes for pain management, orthopedic and spinal procedures managed by TurningPoint on the ereferrals.bcbsm.com website:
• Pain management procedure codes
• Orthopedic procedure codes
• Spinal procedure codes
• For more information about the TurningPoint program, see the following pages of the ereferrals.bcbsm.com website. Soon, we’ll update these pages and the documents to which they link to reflect the changes that are coming on Jan. 1.
• Blue Cross Musculoskeletal Services
• BCN Musculoskeletal Services

Webinar training

We’re offering training webinars for professional providers and facilities for musculoskeletal services managed by TurningPoint.

Click a link below to register.

Provider training

Facility training

Portal training

Medical specialty drug prior authorization lists changing for Medicare Plus Blue, BCN commercial and BCN Advantage

We’re adding authorization requirements for three specialty drugs covered under the medical benefit for Medicare Plus Blue^SM PPO, BCN commercial and BCN Advantage^SM members.

For dates of service on or after Sept. 25, 2020, the following drugs will require authorization through AIM Specialty Health^®:

• Zepzelca™ (lurbinectedin) — HCPCS codes J3490, J3590, J9999
• Phesgo™ (pertuzumab/trastuzumab/hyaluronidase-zzxf) — HCPCS codes J3490, J3590, J9999
• Nyvepria™ (pegfilgrastim-apgf) — HCPCS codes J3490, J3590, J9999

How to submit authorization requests
Submit authorization requests to AIM using one of the following methods:

• Through the AIM provider portal**
• By calling the AIM Contact Center at 1-844-377-1278

For information about registering for and accessing the AIM ProviderPortal, see the Frequently Asked Questions page** on the AIM website.

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

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

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

We’ll update these lists with the new information about these drugs before the effective dates.

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

AllianceRx Walgreens Prime specialty pharmacy program starts Jan. 1 for most Blue Cross commercial members

AllianceRx Walgreens Prime will be the exclusive specialty pharmacy provider for Blue Cross Blue Shield of Michigan commercial members, effective Jan. 1, 2021. This change doesn’t apply to Medicare Advantage members.

The AllianceRx Walgreens Prime Care team, which includes pharmacists and patient care coordinators, will help provide your patients with clinical excellence. They can assist with convenient and easy access to the specialty medication you’ve prescribed.

We’ll send a letter about this change to your affected patients. AllianceRx Walgreens Prime will call and advise them to speak to you about getting new prescriptions.

You’ll need to give your patients new prescriptions before Jan. 1, 2021, if they don’t currently fill their specialty drug prescriptions at AllianceRx Walgreens Prime or a local Walgreens pharmacy location. If you don’t, your patients could be responsible for the full cost of their drugs.

If your Blue Cross patients currently receive their specialty drugs from AllianceRx Walgreens Prime or a Walgreens pharmacy, no action is required.

You can send new specialty medication prescriptions to AllianceRx Walgreens Prime by one of the following methods:

• Fax: 1-866-515-1356
• Electronically: E-prescribing name is AllianceRx WALGREENS PRIME-SPEC-MI
• Phone: 1-866-515-1355

For more information, go to alliancerxwp.com/hcp.**

For a current list of specialty drugs in this program, go to bcbsm.com/specialtydrug. This list is updated monthly.

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

IVIG dosing strategy changing for Medicare Part B medical specialty program, starting Dec. 7

Blue Cross Blue Shield of Michigan and Blue Care Network require authorization for immune globulin products covered under the medical benefit for Medicare Plus Blue^SM PPO and BCN Advantage^SM members.

As part of the authorization process, we’re updating our dosing strategy for intravenous and subcutaneous immune globulin therapy to minimize drug waste, reduce unnecessary drug exposure and decrease the risk of adverse events.

Effective Dec. 7, 2020, we’ll calculate doses using adjusted body weight for members when:

• The member’s body mass index is 30 kg/m² or greater.
• The member’s actual body weight is 20% higher than their ideal body weight.

This applies to all Medicare Plus Blue and BCN Advantage members who start therapy on or after Dec. 7, 2020, when the therapy is administered by a health care professional in a provider office, at the member’s home, in an off-campus outpatient hospital or in an ambulatory surgical center (sites of care 11, 12, 19, 22 and 24).

Members who currently receive immune globulin will continue to receive their current dose until their authorizations expire.

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

For Medicare Plus Blue and BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

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

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

Medical specialty drug prior authorization lists changing for Medicare Plus Blue, BCN commercial and BCN Advantage

We’re adding authorization requirements for three specialty drugs covered under the medical benefit for Medicare Plus Blue^SM PPO, BCN commercial and BCN Advantage^SM members.

For dates of service on or after Sept. 25, 2020, the following drugs will require authorization through AIM Specialty Health^®:

• Zepzelca™ (lurbinectedin) — HCPCS codes J3490, J3590, J9999
• Phesgo™ (pertuzumab/trastuzumab/hyaluronidase-zzxf) — HCPCS codes J3490, J3590, J9999
• Nyvepria™ (pegfilgrastim-apgf) — HCPCS codes J3490, J3590, J9999

How to submit authorization requests
Submit authorization requests to AIM using one of the following methods:

• Through the AIM provider portal**
• By calling the AIM Contact Center at 1-844-377-1278

For information about registering for and accessing the AIM ProviderPortal, see the Frequently Asked Questions page** on the AIM website.

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

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

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

We’ll update these lists with the new information about these drugs before the effective dates.

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

AllianceRx Walgreens Prime specialty pharmacy program starts Jan. 1 for most Blue Cross commercial members

AllianceRx Walgreens Prime will be the exclusive specialty pharmacy provider for Blue Cross Blue Shield of Michigan commercial members, effective Jan. 1, 2021. This change doesn’t apply to Medicare Advantage members.

The AllianceRx Walgreens Prime Care team, which includes pharmacists and patient care coordinators, will help provide your patients with clinical excellence. They can assist with convenient and easy access to the specialty medication you’ve prescribed.

We’ll send a letter about this change to your affected patients. AllianceRx Walgreens Prime will call and advise them to speak to you about getting new prescriptions.

You’ll need to give your patients new prescriptions before Jan. 1, 2021, if they don’t currently fill their specialty drug prescriptions at AllianceRx Walgreens Prime or a local Walgreens pharmacy location. If you don’t, your patients could be responsible for the full cost of their drugs.

If your Blue Cross patients currently receive their specialty drugs from AllianceRx Walgreens Prime or a Walgreens pharmacy, no action is required.

You can send new specialty medication prescriptions to AllianceRx Walgreens Prime by one of the following methods:

• Fax: 1-866-515-1356
• Electronically: E-prescribing name is AllianceRx WALGREENS PRIME-SPEC-MI
• Phone: 1-866-515-1355

For more information, go to alliancerxwp.com/hcp.**

For a current list of specialty drugs in this program, go to bcbsm.com/specialtydrug. This list is updated monthly.

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

IVIG dosing strategy changing for Medicare Part B medical specialty program, starting Dec. 7

Blue Cross Blue Shield of Michigan and Blue Care Network require authorization for immune globulin products covered under the medical benefit for Medicare Plus Blue^SM PPO and BCN Advantage^SM members.

As part of the authorization process, we’re updating our dosing strategy for intravenous and subcutaneous immune globulin therapy to minimize drug waste, reduce unnecessary drug exposure and decrease the risk of adverse events.

Effective Dec. 7, 2020, we’ll calculate doses using adjusted body weight for members when:

• The member’s body mass index is 30 kg/m² or greater.
• The member’s actual body weight is 20% higher than their ideal body weight.

This applies to all Medicare Plus Blue and BCN Advantage members who start therapy on or after Dec. 7, 2020, when the therapy is administered by a health care professional in a provider office, at the member’s home, in an off-campus outpatient hospital or in an ambulatory surgical center (sites of care 11, 12, 19, 22 and 24).

Members who currently receive immune globulin will continue to receive their current dose until their authorizations expire.

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

For Medicare Plus Blue and BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

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

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

We are simplifying inquiry and appeal process

As part of our efforts to streamline processes and improve your overall experience with Blue Cross Blue Shield of Michigan, we’ll begin accepting your claim appeal verbally when you contact Provider Relations & Servicing, effective Oct. 1, 2020.   

You should continue to contact PRS at one of the telephone numbers listed below for any inquiry related to benefits, eligibility and claims. Beginning in October, if you’re not satisfied with the inquiry outcome about a claim determination, you may request an appeal while speaking with a Customer Service representative.

If you have additional information to include with your appeal, the representative will provide you with a number to fax your supporting documentation. A written response will be issued to you within 30 days of receipt of your documentation.

• Medical providers: 1-800-344-8525
• Vision and hearing providers: 1-800-482-4047
• Facility providers: 1-800-249-5103

Beginning Oct. 1, you won’t be able to submit a written appeal to Blue Cross Blue Shield of Michigan at Mail Code 1620 or fax it to 1-877-348-2210.

As a reminder, you may be eligible for a claim appeal when the following criteria are met:

• The member is enrolled in a Blue Cross commercial plan.
• The rendering provider is one of the following:
• A Blue Cross Blue Shield of Michigan participating provider located in Michigan
• An out-of-state provider who participates with Blue Cross Blue Shield of Michigan and has a Michigan PIN
• A nonparticipating provider located in Michigan who has accepted assignment on the claim, on a per claim basis
• The appeal is for a professional claim that was filed within 180 days from the date of service, or a facility claim that was filed within 365 days from the date of service.
• The appeal request is made within 180 days from the date of the original claim determination.
• The supporting documentation is submitted within 30 days of contacting PRS.
• A request for appeal wasn’t submitted previously on the same claim.

Reminders:

• If you received a nonpayment notice indicating a billing error, submit a new claim that includes the requested information.
• If your claim is denied for lack of authorization, request a retro-authorization within the allowed time frame. Reach out to the appropriate authorization team or vendor to initiate the review.