Blue Cross and Michigan Medicine expand cutting‑edge Hospital Care at Home Program

Blue Cross Blue Shield of Michigan and Michigan Medicine have expanded their Hospital Care at Home Program — a program that allows patients with certain acute conditions to be safely treated in the comfort of their own home.

The pilot program began last year for our Blue Cross and BCN commercial members as a way to treat patients with the following conditions who meet the criteria for an inpatient admission:

• Congestive heart failure
• Cellulitis
• Chronic obstructive pulmonary disease
• Pneumonia
• Urinary tract infection

The program subsequently has been expanded to include:

• Other acute care diagnoses that can be safely treated at home
• Our Medicare Advantage (Medicare Plus Blue℠ and BCN Advantage℠) members

The Hospital Care at Home program is the first of its kind to be deployed in Michigan. 

A major impetus for this program was to consider new ways of delivering care in anticipation of new demands that will be put on the health care system as baby boomers age.

“It’s an innovative approach to meeting people where their needs are, while being able to rest and recover in their own beds,” said Steve Anderson, vice president, Provider Contracting and Network Administration. “Blue Cross approached Michigan Medicine about collaborating on this pilot in 2019, with the goal of developing this new model of care, and they have enthusiastically embraced it. The program not only provides patient-centered care, but it can also be more cost‑effective.”

The program is currently limited to Washtenaw County and Belleville residents who present to the emergency room at Michigan Medicine.

How it works

• A patient goes to the emergency room at Michigan Medicine. He or she is examined, receives tests as necessary and, if appropriate, given the option of being admitted or to receiving further care at home.
• Once part of the program, a patient’s day might start with a visit from a nurse, who would come to the patient’s home to get samples for lab tests, assess their condition, administer medication as needed and perform any other necessary tasks.
• Based on the patient’s health status, adjustments in therapy could be made by a doctor or nurse practitioner. If necessary, the patient could receive a second nursing visit later in the day and be supported by physical therapists and home health aides.
• A typical recovery time may take three to five days.

“This has been a great collaborative effort,” said Fred Schaal, director of Hospital Contracting and Network Administration. “Throughout the course of the program, we’ve been discovering what works well, what doesn’t and adjusting the program as necessary.”

He pointed to one success story: a male patient with diverticulitis. He was in a great deal of pain and discomfort and had gone to an urgent care facility several times before finally going to the Michigan Medicine emergency room due to fear of going to a hospital during the COVID‑19 pandemic. During his ER visit, he was presented with the opportunity to be treated at home, which he gladly accepted. Within two days of at-home treatment, he was no longer experiencing symptoms.

“The patient was so happy with his experience that he went back to the hospital recently to thank those who had treated him,” Schaal said. “He said the program really met his needs at the time, and he was very grateful.”

Anderson said the Hospital Care at Home Program may be expanded to include other regions of Michigan and additional hospital systems in the future.

“This is the latest example of moves Blue Cross is taking to reduce the overall cost of care while maintaining quality of care for our members,” Anderson said.

HCPCS replacement codes established

J9348 replaces C9399, J3490, J3590 and J9999 when billing for Danyelza (naxitamab‑gqgk)

The Centers for Medicare & Medicaid Services has established a permanent procedure code for specialty medical drug Danyelza^® (naxitamab‑gqgk).

All services through June 30, 2021, will continue to be reported with code C9399, J3490, J3590 and J9999. All services performed on and after July 1, 2021, must be reported with J9348.

AIM Specialty Health^® prior authorization is required for all groups that opted in to the AIM prior authorization program.

For groups that aren’t in the AIM prior authorization program, this code is covered for the Food and Drug Administration‑approved indications.

J9353 replaces C9399, J3490, J3590 and J9999 when billing for Margenza (margetuximab‑cmkb)

CMS has established a permanent procedure code for specialty medical drug Margenza™ (margetuximab‑cmkb).

All services through June 30, 2021, will continue to be reported with code C9399, J3490, J3590 and J9999. All services performed on and after July 1, 2021, must be reported with J9353.

AIM prior authorization is required for all groups that opted in to the AIM prior authorization program.

For groups that aren’t in the AIM prior authorization program, this code is covered for the FDA‑approved indications.

Q5123 replaces J3490 and J3590 when billing for Riabni (rituximab‑arrx)

CMS has established a permanent procedure code for specialty medical drug Riabni™ (rituximab‑arrx).
All services through June 30, 2021, will continue to be reported with code J3490 and  J3590. All services performed on and after July 1, 2021, must be reported with Q5123.

AIM prior authorization is required for all groups that opted in to the AIM prior authorization program.

For groups that aren’t in the AIM prior authorization program, this code is covered for the FDA‑approved indications.

J0224 replaces J3490, J3590 and C9074 when billing for Oxlumo (lumasiran)

CMS has established a permanent procedure code for Oxlumo™ (lumasiran).

All services through June 30, 2021, will continue to be reported with code J3490, J3590 or C9074. All services performed on and after July 1, 2021, must be reported with J0224.

Prior authorization is required for all groups unless they are opted out of the Medical Benefit Drug Program.

J7168 replaces J3490, J3590 and C9132 when billing for Kcentra (prothrombin complex concentrate, human)

CMS has established a permanent procedure code for Kcentra^® (prothrombin complex concentrate, human).

All services through June 30, 2021, will continue to be reported with code J3490, J3590 or C9132. All services performed on and after July 1, 2021, must be reported with J7168.

Kcentra is covered for the following FDA-approved indication: For the urgent reversal of acquired coagulation factor deficiency induced by vitamin K antagonist (VKA, e.g., warfarin) therapy in adult patients with acute major bleeding or the need for an urgent surgery/invasive procedure.

J1951 replaces J3490 and J3590 when billing for Fensolvi (leuprolide acetate)

CMS has established a permanent procedure code for Fensolvi^® (leuprolide acetate).

All services through June 30, 2021, will continue to be reported with code J3490 or J3590. All services performed on and after July 1, 2021, must be reported with J1951.

Fensolvi is covered for the following FDA‑approved indication: For the treatment of pediatric patients age 2 years and older with central precocious puberty.

Second‑quarter 2021 HCPCS update: New and updated codes

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

Injections

Injections/chemotherapy

Surgery

Radiopharmaceuticals

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.

Second‑quarter 2021 CPT code update

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.

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.

Eligible patients can receive COVID‑19 vaccine at home

The COVID‑19 vaccine reimbursement has expanded to home health care agencies, allowing eligible patients to have the vaccine administered at their home. Home health care agencies have already begun administering vaccines to homebound patients.

Blue Cross Blue Shield of Michigan and Blue Care Network are following guidelines from the Centers for Medicare & Medicaid Services to determine which patients qualify for in‑home COVID‑19 vaccinations.

A patient qualifies if one of these scenarios apply:

• The patient has difficulty leaving the home to get the vaccine, which could mean any of these:

• They have a condition, due to an illness or injury, that restricts their ability to leave home without a supportive device or help from a caregiver.
• They have a condition that makes them more susceptible to contracting a pandemic disease such as COVID‑19.
• They are generally unable to leave the home, and if they do leave home, it requires a considerable effort

• The patient is hard to reach because they have a disability or face clinical, socioeconomic or geographical barriers to getting a COVID‑19 vaccine in settings other than their home. These patients face challenges that significantly reduce their ability to get vaccinated outside the home, such as challenges with transportation, communication or caregiving.

The provider must document in the patient’s medical record the clinical status or barriers that justify the patient’s need for an in‑home vaccination. The information described below and in the CMS links, regarding additional payment, applies if the only service provided during the home visit is administration of the COVID‑19 vaccine.

This temporary expansion of COVID‑19 vaccine coverage in the home for eligible patients was effective:

• June 8, 2021, for patients with Medicare coverage
• July 1, 2021, for patients with Blue Cross and BCN commercial coverage

This expansion will remain in place until further notice.

Here’s other information you need to know:

For eligible patients with commercial coverage
Follow these guidelines for eligible patients with Blue Cross or BCN commercial coverage:

• Contact us to enroll — Home health care agencies interested in administering the COVID‑19 vaccine to eligible commercial members in their homes need to contact Provider Enrollment and Data Management at 1‑800‑822‑2761 to enroll for this expanded service. You’ll receive notification when you can begin providing this service.
• Submit professional claims using standard vaccine administration codes plus M0201 — Once approved to provide this service, home health care agencies need to submit professional claims using standard COVID‑19 vaccine administration codes for dates of service July 1, 2021, and after.

In addition, home health care agencies approved for this service should include HCPCS Level II code M0201 to receive additional payment in recognition of the cost agencies incur for traveling to the patient’s home. We posted a web‑DENIS message regarding reimbursement for M0201 on July 15.
For M0201 to be payable, these requirements must be met:

• The service is provided to a patient who meets the above requirements.
• The provider documents justification for the service in the patient’s record.
• The only service provided was COVID‑19 vaccine administration.
• The service is administered in a home location (see Medicare Payment for COVID-19 Vaccination Administration in the Home for more information.)
• The code is reported only once per individual home per date of service.

The COVID‑19 vaccine administration codes are available on our COVID‑19 webpages within our provider portal or on our public website at bcbsm.com/coronavirus. Refer to COVID‑19 vaccine information for providers and COVID‑19 vaccine billing information at a glance for more information.

For eligible patients with Medicare primary or Medicare Advantage coverage:
Follow CMS guidelines for patients with Medicare Advantage coverage (Medicare Plus Blue℠ and BCN Advantage℠) and coverage with Medicare primary. More information is available at these links:

• MLN Connects^® special edition: Biden Administration Continues Efforts to Increase Vaccinations by Bolstering Payments for At‑Home COVID‑19 Vaccinations for Medicare Beneficiaries**
• Medicare COVID‑19 Vaccine Shot Payment webpage**
• Medicare Billing for COVID‑19 Vaccine Shot Administration**

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

Inflammation side effect of COVID‑19 vaccine can cause inaccurate mammogram results

Before scheduling screening mammograms for patients, ask if they’ve received a COVID‑19 vaccine in the last four to six weeks. The Centers for Disease Control and Prevention** suggests scheduling any screening mammograms before getting a COVID-19 vaccination. Patients who already received the vaccine should schedule their screening mammogram four to six weeks after getting their complete vaccination dose, according to the CDC’s recommendation.

The COVID‑19 vaccine, similar to other vaccines, including vaccines for influenza and pneumococcus, can cause temporary swelling of lymph nodes in the underarm area, or axilla, near where a patient received the shot. The swelling may produce a false positive result on a mammogram performed too soon after the vaccine. These false positive results may lead to repeat studies and member anxiety.

Waiting for a period of time after getting the vaccine will reduce unnecessary callbacks for more diagnostic screenings and radiation exposure.

If patients ask questions about the vaccination, reassure them that:

• The COVID‑19 vaccine isn’t associated with breast cancer.
• The lymph node inflammation is normal and means the immune system is working.

If patients want more information, they can find it on the CDC’s website: COVID‑19 Vaccination and Other Medical Procedures.**

Another good source of information on this topic is from Johns Hopkins: COVID‑19 Vaccine: Can It Affect Your Mammogram Results?**

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

We invite you to join PGIP as a physician organization

This article was previously published in the July-August issue of Hospital and Physician Update. We’re reprinting it here in case you missed it. To subscribe to Hospital and Physician Update or any of our other provider publications, click here.

We’re pleased to announce that we’ll accept applications for the Physician Group Incentive Program from new physician organizations from Aug. 1 through Aug. 31, 2021.

PGIP offers incentives to participating practitioners, physician organizations and organized systems of care for improving health care delivery.

To request application materials, send an email to valuepartnerships@bcbsm.com.

About PGIP

The Physician Group Incentive Program was developed with input from providers across Michigan to help improve the quality and efficiency of health care in the state. PGIP facilitates change through a wide range of initiatives, including our nationally recognized Patient-Centered Medical Home program. Through PGIP we reward physician organizations for improving health care delivery to their attributed patient population.

A PGIP physician organization consists of physicians participating in our PPO or Traditional network, working together to:

• Transform systems of care to effectively manage patient populations.
• Build the infrastructure needed to optimize, measure and monitor quality of care.
• Promote collaborative relationships.
• Support the most cost-effective delivery of services to improve patient outcomes.

To learn more

• If you’re interested in participating in PGIP as an individual practitioner, click here to learn more about PGIP physician organizations.
• For more information on PGIP and its initiatives, visit the Physician Group Incentive Program section of valuepartnerships.com.

Clinical tips from the American Psychiatric Association for treatment of major depressive disorder

One of the most common mental disorders in the U.S. is major depression, according to the National Institute of Mental Health. Major depression can be defined as a period of at least two weeks when a person experienced a depressed mood or loss of interest or pleasure in daily activities, and had a majority of specified symptoms, such as problems with sleep, eating, energy, concentration or self‑worth.

Blue Cross Blue Shield of Michigan and Blue Care Network are committed to helping ensure that our recommendations and policies for the treatment of behavioral health conditions follow evidence‑based guidelines. Following are several clinical tips based on current recommendations of the American Psychiatric Association that we thought you might find useful.

Begin with a thorough evaluation. Many medical problems can present with comorbid depressive symptoms. Diabetes, heart disease, chronic pain, endocrine disorders and sleep apnea are just a few of the many medical problems that share similar symptoms with major depression.

Use of the PHQ-9 screening tool provides an objective measure of severe depression symptoms and can be repeated to measure progress to remission. The pneumonic SIG E CAPS is another good tool for diagnosis. The acronym stands for S (suicidal ideation), I (lack of interest or initiative), G (excessive guilt), E (lack of energy), C (change in cognition), A (sad affect or apathy/appetite change), P (psychomotor agitation or slowing), S (somatization/sleep disturbance).

Use of the PHQ‑2 or 9 provides an objective measure of severe depression symptoms and can be repeated to measure progress to remission. Other useful tools include the Zung Depression Scale or the Beck Depression Inventory, which aren’t as commonly used.

Initiate a course of cognitive behavioral psychotherapy at the outset of treatment.  Psychotherapy (sometimes referred to as counseling, therapy or “talk therapy”) can help a patient to think through events and consequences they’ve experienced and see them in new ways. Psychotherapy can also help patients learn new responses to circumstances and change the way they think about themselves and their value to themselves and others.

Initiate an antidepressant medication. Consider prescribing a selective serotonin reuptake inhibitor, selective serotonin and norepinephrine reuptake inhibitor or an atypical (bupropion, mirtazapine), titrate the medication to full Food and Drug Administration-approved dose or highest tolerated dose for a full four weeks.

Recommend a diet and exercise regimen. Moderate exercise can help increase chemicals in your brain that are similar to the effect of certain medications. Usually, doing 30 to 45 minutes of aerobic exercise three to five times per week helps a patient to think more clearly, sleep better at night, digest their food better and helps cardiac and lung function as a side benefit.

Diet is important to create the needed building blocks of the chemicals in the brain that can improve mood. A good balanced diet is adequate but adding two fatty fish‑containing meals a week is even better. Salmon, walleye, perch, bass and tilapia are examples.

Reevaluate the patient at the four to six week interval. At this time, readminister the same objective scale along with a clinical examination. If there is no or only minimal change in depression symptoms, seriously consider increasing the dose/frequency of the current medication or consider changing to another class of antidepressant. Confirm they are taking it and participating in therapy in addition to following the recommendations for diet and exercise.

Reevaluate the patient again after four to six weeks. If there is still no improvement, you might request a psychiatric consultation for diagnostic confirmation and possible use of augmentation agents. These agents might include such medications as lithium, thyroid hormone (t3), an atypical antipsychotic agent (Seroquel or Abilify) or a psychostimulant. Each of these has literature to support their use but should be initiated by a specialist or at least in consultation with one.

Continue to reevaluate with objective scales. Doing this may help identify progress that would be missed using only subjective evaluations even by the most experienced provider.

Additional steps. There are additional steps in the algorithm that the specialist
can progress to as indicated. For people who don’t attain remission with the first few steps in treatment, a specialist can assist with more advanced interventions. These may include combinations of medications and somatic treatments, such as electroconvulsive therapy, transcranial magnetic stimulation, vagal nerve stimulation, esketamine nasal inhaled treatment and deep-brain stimulation (considered investigational).

Full remission of symptoms is the goal, and it’s very important to keep working toward that goal until it’s achieved. Once achieved, continue maintenance as decreasing or discontinuing treatment can lead to lack of response to treatment if symptoms recur.  That risk is very high as more than 50% of people will experience a lack of response. More than 70% of people with a history of multiple depressive episodes will have a recurrence if treatment is stopped.  

Educating the patient about the importance of medication adherence, diet, exercise and psychotherapy, along with spiritual resources and mindfulness practices, is an important aspect of the relationship that providers have with their patients. Providing guidance and hope can be a powerful intervention.

Note: For purposes of this article, we’ve augmented the American Psychiatric Association’s tips with information about the PHQ‑9 screening tool. This evidence-based tool is freely available and incorporated into many electronic medical records.

Certain radiology codes for Blue Cross commercial, Medicare Plus Blue to require prior authorization from AIM

For dates of service on or after Sept. 1, 2021, the services associated with radiology codes *70554 and *70555 will require prior authorization from AIM Specialty Health^®.

This applies to:

• All Blue Cross Blue Shield of Michigan commercial members, including UAW Retiree Medical Benefits Trust non‑Medicare members and Blue Cross and Blue Shield Federal Employee Program^® Michigan members
• All Medicare Plus Blue℠ members  

Note: Blue Care Network commercial and BCN Advantage℠ already require prior authorization from AIM for these services.

We’ll update the AIM codes lists with this new information before the effective date of the change.

You can find the AIM codes lists and additional information about submitting prior authorization requests to AIM at ereferrals.bcbsm.com on the Blue Cross AIM‑Managed Procedures webpage.

We previously published a web‑DENIS message informing providers about this change, and also listed it as a news item at ereferrals.bcbsm.com.

We’ve updated pain management questionnaires and Postservice change request form for submitting requests to TurningPoint

Blue Cross Blue Shield of Michigan, Blue Care Network and TurningPoint Health Care Solutions, LLC continue to identify ways to enhance your experience with the TurningPoint surgical quality and safety management program.

The following enhancements became available as of July 2021:

• For pain management procedures: We updated questions on the questionnaires you complete when you request authorizations.
• For all orthopedic, pain management and spinal procedures: We updated the Postservice change request form.

Pain management questionnaires
To simplify the process of submitting prior authorization requests, we updated most questions on the following questionnaires to require a “yes” or “no” response:

• Epidural steroid injections
• Facet joint injections
• Neuroablation procedures
• Sacroiliac joint injections

These questions appear on the questionnaires in the TurningPoint Provider Portal and in the fax forms for submitting prior authorization requests.

Postservice change request form
We updated the Postservice change request fax form as follows:

• Added information about procedure code substitutions to help you identify situations where you can substitute a different procedure code for the procedure code TurningPoint authorized
• Added the following questions:
• “Have you submitted a claim to Blue Cross or BCN?”
• “Have you submitted an appeal to Blue Cross or BCN?”

Your answers to these questions will streamline the steps required to process postservice change requests.

Where to find fax forms for the TurningPoint program
You can find all fax forms for the TurningPoint program on the following pages of the ereferrals.bcbsm.com website, along with other resources:

• Blue Cross Musculoskeletal services
• BCN Musculoskeletal services

Information about previous enhancements to this program
To read about other enhancements to the TurningPoint program, see:

• The article titled “We’re enhancing TurningPoint surgical quality and safety management program to improve your experience” in the June 2021 issue of The Record
• The Provider Alert titled “Additional enhancements to the TurningPoint musculoskeletal surgical quality and safety management program”

Additional information
As a reminder, TurningPoint manages authorizations for orthopedic, pain management and spinal procedures for the following:

• Blue Cross commercial** — All fully insured groups, select self‑funded groups and all members with individual coverage
• Medicare Plus Blue℠ members
• BCN commercial members
• BCN Advantage℠ members

**To determine whether you need to submit prior authorization requests for Blue Cross commercial members, see the document titled “Determining whether Blue Cross commercial members require prior authorization for musculoskeletal surgeries and related procedures.”

Questionnaires updated in e‑referral system

On June 27, 2021, the following questionnaires were updated in the e‑referral system:

• Artificial heart, total — For adult and pediatric Blue Care Network commercial members. This questionnaire now opens for procedure code *33995 and continues to open for other codes listed in the Artificial heart, total preview questionnaire. This questionnaire no longer opens for procedure code *33929.
• Hammertoe correction surgery — For adult Medicare Plus Blue℠, BCN Advantage℠ and adult BCN commercial members. This questionnaire no longer opens for procedure code *28160. It continues to open for the other procedures codes listed in the Hammertoe correction surgery preview questionnaire.
• Pediatric feeding — For BCN commercial members ages 18 and younger.

We’ve also updated the corresponding preview questionnaires and authorization criteria on the ereferrals.bcbsm.com website.

Remember that our authorization criteria, our medical policies and your answers to the questionnaires in the e‑referral system are used to make utilization management determinations on your authorization requests.

Preview questionnaires
You can access preview questionnaires at ereferrals.bcbsm.com to see the questions you’ll need to answer in the actual questionnaires that open in the e‑referral system. This can help you prepare your answers ahead of time.

The preview questionnaires can be found here:

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

Authorization criteria and medical policies
The pertinent authorization criteria and medical policies are also available on the Authorization Requirements & Criteria page.

Job aid helps you determine if a Blue Cross commercial member requires prior authorization for DME/POS through Northwood

Northwood, Inc., manages durable medical equipment, prosthetics, orthotics and medical supplies, or DME/POS, for some Blue Cross commercial members. To help you determine whether a Blue Cross commercial member requires prior authorization for DME/POS through Northwood, a new job aid is available at ereferrals.bcbsm.com that walks you through the steps:

• Determining whether Blue Cross commercial members require prior authorization for DME/POS through Northwood

For more information about the Northwood program and how it works, refer to the following documents:

• Durable medical equipment and prosthetics and orthotics: For authorization determinations
• Northwood DME/POS Management Program FAQ
• Northwood DME/POS Management Program Procedure Codes Requiring Prior Authorization

If you have questions about the Northwood DME/POS management program, contact Northwood Provider Relations at 1‑800‑447‑9599 between 8:30 a.m. and 5 p.m. Eastern time Monday through Friday.

Submitting Medicare Plus Blue post‑service claims for home health care

For home health care services received in Michigan by Medicare Plus Blue℠ members:

• Post‑service claims must include the CareCentrix^®-assigned health insurance prospective payment system, or HIPPS, code.

• The HIPPS code on the post-service claim must match the HIPPS code on the Request for Anticipated Payment, or RAP, claim.

This doesn’t affect home health care claims for BCN Advantage℠ members.

Keep reading to learn more.

CareCentrix‑assigned HIPPS code required when submitting post‑service claims

You must include the CareCentrix‑assigned HIPPS code when you submit post‑service claims for home health care for Medicare Plus Blue members to Blue Cross Blue Shield of Michigan. Otherwise, claims will be rejected.

CareCentrix assigns the Health Insurance Prospective Payment System code in alignment with guidelines from the Centers for Medicare & Medicaid Services.

Obtaining the HIPPS code

• If the Outcome and Assessment Information Set, or OASIS, assessment is available: Complete the HIPPS questionnaire when you submit the prior authorization request. You’ll find the HIPPS code for the approved authorization on the Authorization Status screen in the CareCentrix HomeBridge^® portal.
  
  The HIPPS questionnaire is available in the HomeBridge portal. Refer to your OASIS assessment to complete the questionnaire.

• If the OASIS assessment isn’t available when you submit the authorization request: Fax it to CareCentrix at 1‑877‑414‑1087 as soon as possible. CareCentrix will assign a HIPPS code, which you can find on the Authorization Status screen in the HomeBridge portal.



If you submitted an OASIS assessment and haven’t received an HIPPS code, call CareCentrix at 1‑833‑409‑1280 to request the code — or check the Authorization Status screen in the HomeBridge portal for the code — before you submit the post‑service claim to Blue Cross.

Submitting the OASIS assessment
The steps to submit the OASIS assessment vary based on when you submit it:

• When submitting the assessment with the prior authorization request: Upload the assessment as a separate document. Don’t include it within the medical record.
• When submitting the assessment after submitting the prior authorization request: Fax the assessment to CareCentrix at 1‑877‑414‑1087.

Note: You must submit the OASIS assessment before the end of each episode of care. We recommend you submit it as soon as it’s available.

CareCentrix‑assigned HIPPS codes on post‑service claims must match the HIPPS codes on RAP claims

When you submit a Medicare Plus Blue post-service claim for home health care, the CareCentrix‑assigned HIPPS code must match the HIPPS code on the RAP claim. Blue Cross will deny Medicare Plus Blue claims for home health care services when the CareCentrix‑assigned HIPPS code doesn’t match the HIPPS code on the RAP claim.

If the HIPPS code on the post-service claim doesn’t match the HIPPS code on the RAP claim that you submitted prior to providing services, submit a corrected RAP claim with the post‑service claim.

This requirement is in keeping with standard billing processes and is in alignment with the Centers for Medicare & Medicaid Services requirements. For more information, see the following resources:

• Medicare Claims Processing Manual Chapter 10 – Home Health Agency Billing**

• The “Claims Submission Data Elements” section of the Submitting a Final Claim under the Home Health Patient‑Driven Groupings Model** page on the cgsmedicare.com website

Additional information

For more information about the CareCentrix home health care program, see the document titled Home health care: Frequently asked questions for providers.

As a reminder, CareCentrix manages prior authorizations for home health care services for Medicare Plus Blue and BCN Advantage members as follows:

• For episodes of care that start on or after June 1, 2021
• For episodes of care that started before June 1, 2021, when one of the following occurs on or after June 1: Recertification is needed, resumption of care is needed or there’s a significant change in condition

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

Claim editing enhancements coming later this year to Medicare Plus Blue claims

To promote correct coding and assist with payment accuracy, Blue Cross Blue Shield of Michigan will enhance its claim editing process for Medicare Plus Blue℠ claims with the following updates later this year. However, we encourage you to follow these guidelines now:

• Primary diagnosis only — Certain diagnosis codes can only be billed in the first-listed or primary diagnosis code field on claims, according to the International Classification of Disease, or ICD. There is an identifier in some ICD‑10‑CM manuals for these codes. We’ll edit the claim line if a primary‑only diagnosis code is billed in a position other than the first‑listed or primary position.
• Surgical procedures requiring anatomical modifiers — CPT codes in the range *10000‑*69999, having a Medicare Physician Fee Schedule, or MPFS, bilateral indicator “1” denote that the surgical code is eligible to be billed on both sides of the body. We’ll edit the surgical code when anatomical modifiers (50, LT, RT, E1, E2, E3, E4, F1, F2, F3, F4, F5, F6, F7, F8, F9, FA, T1, T2, T3, T4, T5, T6, T7, T8, T9, TA, LC, LD, RC, LM, RI) are appropriate, but haven’t been appended to the claim line. For details, refer to the Medicare Claims Processing Manual, Chapter 23, Section 20.9.3.2.
• High‑level E/M codes billed with preventive medicine services — We’ll edit high‑level evaluation and management services (CPT codes *99204, *99205, *99214, *99215) when billed for the same patient on the same date of service as a preventive evaluation and management service (CPT codes *99381 through *99387 and *99391 through *99397). For details, refer to the Medicare Claims Processing Manual, Chapter 12, Section 30.6.

We’ll provide updates on other pertinent information, including when these edits will be effective, in future communications.

Note: The appeal process won’t change. Continue to submit appeals on the Clinical Editing Appeal Form with the necessary supporting documentation. Also, continue to fax one appeal at a time to avoid processing delays.

Optum to provide enhanced prospective claim editing for Blue Cross commercial claims

Starting in November 2021, Blue Cross Blue Shield of Michigan will begin working with Optum, a data, analytics and consulting group, for enhanced prospective claim editing for services provided to our commercial members. We anticipate that this change will help promote correct coding and support payment accuracy.

At Blue Cross, we’re committed to implementing payment integrity solutions and will begin performing enhanced prepayment claim reviews with the help of Optum. As a result, health care providers may be asked for medical records and billing documents that support the charges billed.

The prepayment claim reviews will apply to professional, outpatient facility and inpatient facility claim types. The reviews will look for any overutilization of services or other practices that directly or indirectly result in unnecessary costs.

Detailed instructions on how to submit medical records will be included in each Optum medical record request letter. Providers who don’t submit the requested documentation in the allocated time frame may receive a payment denial until all information necessary to adjudicate the claim is received.

If medical records received don’t support the billed service, the service will be denied. If medical records received support the claims, the claims will automatically be processed for payment without the need for them to be resubmitted. As outlined in your contracts with us, providers retain their right to dispute results of reviews.

Unique clinical editing reason codes will appear on the 835 response files or provider vouchers. Over the coming months, you’ll receive additional details about this program.

As a reminder, when billing Blue Cross commercial claims, you should follow guidelines from:

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

As part of your contract with us, health care providers affiliated with our PPO commercial network agree to supply services to Blue Cross members and bill according to guidelines and requirements set by the American Medical Association and select specialty societies.

If you have questions about the Blue Cross claim editing process, contact Provider Inquiry. Professional providers should call 1‑800‑344‑8525, while facility providers should call 1‑800‑249‑5103.

Claim editing update coming this year to Medicare Advantage PPO claims with modifier 59

Beginning later in 2021, Medicare Advantage PPO will be updating our edits applied to claim lines when modifier 59 or related “X” modifiers are appended. We’re enhancing our claim editing to promote the appropriate use of modifier 59 and to improve claim payment accuracy.

About Modifier 59
Modifier 59 is used to indicate that a procedure or service was distinct or independent from other services that aren’t normally reported together but are performed on the same day. For our Medicare Plus Blue℠ patients, we’ll no longer automatically allow payment of procedures billed with modifier 59 and related “X” modifiers when billed with a procedure code on the Centers for Medicare & Medicaid Services’ Procedure‑to‑Procedure NCCI List.

This change aligns with CMS guidelines and it’s also consistent with the Department of Health and Human Services Office of Inspector General’s recommendation that payers conduct prepayment reviews of the use of modifier 59.

We’ll provide updates in future communications on when these edits will take effect, along with any other pertinent information.

About the appeal process
The appeal process won’t change. Appeals should continue to be submitted on the Clinical Editing Appeal Form with the necessary supporting documentation. Continue to fax one appeal at a time to avoid processing delays.

Before filing an appeal, validate that you are using modifier 59 appropriately. Examples of correct and incorrect use of modifier 59 are provided in this article** from CMS.

More information
In addition to modifier 59, these enhancements also apply to:

• XE: Separate encounter, a service that is distinct because it occurred during a separate encounter
• XP: Separate practitioner, a service that is distinct because it was performed by a different practitioner
• XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure
• XU: Unusual nonoverlapping service, the use of a service that is distinct because it does not overlap usual components of the main service

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

Blue Cross and BCN covering additional vaccines

To increase access to vaccines and decrease the risk of vaccine‑preventable disease outbreaks, Blue Cross Blue Shield of Michigan and Blue Care Network have added the following to our list of vaccines covered under the pharmacy benefit:

The following lists all vaccines covered under eligible members’ prescription drug plans. Most Blue Cross and BCN commercial (non‑Medicare) members with prescription drug coverage are eligible. If a member meets the coverage criteria, the vaccine is covered with no out‑of‑pocket cost.

If a member doesn’t meet the age requirement, Blue Cross and BCN won’t cover the vaccine under the prescription drug plan, and the claim will reject.

Aduhelm, Empaveli and Arcalyst to require prior authorization for Medicare Advantage members

The following medications will require prior authorization through the NovoLogix^® online tool for Medicare Plus Blue℠ and BCN Advantage℠ members for dates of service noted below:

• Aduhelm™ (aducanumab), HCPCS code J3590 — for dates of service on or after June 8, 2021
• Empaveli™ (pegcetacoplan), HCPCS codes J3490, J3590 — for dates of service on or after June 14, 2021
• Arcalyst^® (rilonacept), HCPCS code J2793 — for dates of service on or after Sept. 13, 2021

When prior authorization is required

For Medicare Advantage members, we require prior authorization for these drugs when they’re administered by a health care professional in a provider office, at the member’s home, in an off-campus or on‑campus outpatient hospital or in an ambulatory surgical center (place of service codes 11, 12, 19, 22 and 24) and billed as follows:

• Electronically through an 837P transaction or on a professional CMS1500 claim form
• Electronically through an 837I transaction or by using the UB04 claim form for a hospital outpatient type of bill 013x

Submitting prior authorization requests

Submit prior authorization requests for these drugs through NovoLogix. It offers real-time status checks and immediate approvals for certain medications.

If you have access to Provider Secured Services, you already have access to 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.

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’ll update the list to reflect these changes as they occur.

Lunch and learn webinars for physicians and coders focus on risk adjustment, coding

We’re offering additional webinars that provide updated information on risk adjustment documentation and coding of common challenging diagnoses.

All sessions start at 12:15 p.m. Eastern time and run for 15 to 30 minutes. They also provide physicians and coders with an opportunity to ask questions.

Click on a link below to sign up for a live webinar:

You can watch previously hosted sessions on our new provider training site:

Access to the training site differs slightly for new and existing users:

• New users must click here to register.
• Existing users can follow this link to log in.

Once logged in, users can access the modules in two ways:

• Look in the course catalog under Quality management.
• Enter “lunch and learn” in the search box at the top of the screen.

If you need assistance creating your login ID or navigating the site, email ProviderTraining@bcbsm.com.

If you have any questions about the sessions, contact April Boyce at aboyce@bcbsm.com. If you have questions regarding registration, email Patricia Scarlett at pscarlett@bcbsm.com.

New eLearning lesson about evaluation and management guidelines is available on provider training website

We’re encouraging you to review an eLearning lesson about the evaluation and management guidelines and scenarios for 2020 and beyond. You can follow the new evaluation and management guidelines outlined in the lesson as you prepare to submit claims.

The course includes a video summary of the important points with links to supporting documents from Blue Cross Blue Shield of Michigan.

The lesson is available on our new provider training website. Access to the site will differ slightly for new and existing users.

• New users must click here to register.
• Existing users can follow this link to log in.

Once logged in, users have two options for accessing the module:

• Option 1: Look in the course catalog under Medical record documentation and coding.
• Option 2: Enter “Evaluation” in the search box at the top of the screen.

If you need assistance creating your login ID or navigating the site, email ProviderTraining@bcbsm.com.

New on‑demand resources available on our provider training site

Provider Experience continues to offer training resources for health care providers and staff. Our on‑demand courses are designed to help you work more efficiently with us.

Our newest resources include:

• Updated Benefit Explainer course — Shows you how to verify benefits, check out‑of‑pocket costs and view other key benefit information
• Knowledge Center — A repository of learning resources organized by categories, and includes job aids, “quick guides” and website support documents

You’ll also find:

• Recordings of webinars previously presented this year
• Video and e‑learning modules on specific topics

As previously communicated in The Record, we launched our new provider training site in June to enhance your training experience. Watch this video for a preview of the site’s features.

Training courses and materials from 2019 through 2021 have moved from BCBSM Provider Training and BCN Learning Opportunities to the new training site. To request access, complete the following steps:

• Open the registration page.
• Complete the registration. We recommend using the same email you use to communicate with Blue Cross Blue Shield of Michigan for provider-related needs. This will become your login ID.
• Follow the link to log in.

If you need assistance creating your login ID or navigating the site, email ProviderTraining@bcbsm.com.

New eLearning training videos to focus on Medicare Star Ratings

The Quality and Provider Education team continues to offer important training resources to health care providers and staff. New eLearning training videos, designed for physician office staff responsible for closing gaps related to Medicare Star measures, will be available Aug. 15. The video series will discuss closing gaps and emphasize the importance of creating positive patient experiences.

Topics include:

• Clarifications on quality measure requirements
• Assistance with coding and documentation
• Tips for closing gaps
• Current information about HEDIS^® quality measures (Note: Many HEDIS measures are also Medicare Star Ratings measures.)
• The Consumer Assessment of Healthcare Providers and Systems and Health Outcomes Survey

The video series will be available on our new provider training site. Access to the site will differ slightly for new and existing users:

• New users must register here.  
• Existing users can log in here.  

Log in to access the module in the course catalog under Quality management or by entering “Star” in the search box at the top of the screen.

Watch this video to learn more about the provider training site. If you need assistance creating your login ID or navigating the site, email ProviderTraining@bcbsm.com.

Learn more about the HOS and CAHPS surveys

What are the Health Outcomes Survey and the CAHPS^® survey?

The Health Outcomes Survey asks patients to report on their health outcomes, while the Consumer Assessment of Healthcare Providers and Systems Survey asks patients to report on their experiences with a wide range of health care services.

Why are these surveys important?

The goal of the Health Outcomes Survey is to gather clinically meaningful health status data from Medicare Advantage patients about health outcomes. The data gleaned from the survey is used to support quality improvement activities, monitor health plan performance and improve the health of this patient population.

The Consumer Assessment of Healthcare Providers and Systems Survey gathers data from members about a wide range of health care services. According to the Agency for Healthcare Quality and Research,** a positive health care experience for patients is associated with positive clinical outcomes and better business outcomes, including improving patient loyalty, maximizing referrals and improving patient compliance.

To support discussions with your patients about their experiences, we began sending postcards to members in late July. The postcards remind patients to discuss their health care experiences and health‑related concerns with their health care provider or office staff member at their next visit.

How can a patient’s experiences with health care services affect their health?

The health care team at a doctor’s office not only includes physicians and medical assistants, but often includes nurses, customer service representatives, care managers and others. The entire team can affect the health of patients and how they assess their health care experience.

We encourage you to improve the experiences of your patients by addressing the following topics:

• Explain the benefits of getting COVID‑19 and flu vaccinations.
• Discuss the importance of checking blood pressure regularly for patients with hypertension.
• Explain the importance of checking Hgb A1c for patients with diabetes.
• Tell patients how to find their results after testing. Let patients know the time frame in which they will receive their test results and when to call if they haven’t received their results.
• Let them know to get a needed office appointment in a timely manner. Remind them that some appointments are routine or not urgent, so it’s OK to have them scheduled at some point in the future. Help them understand what “urgent” means.
• Perform an assessment of your patient’s physical activity and make recommendations on how to improve.
• For Medicare Advantage patients, perform an assessment of your patient’s fall risk, and discuss measures to prevent falls.
• For your Medicare Advantage patients, ask if they have urinary incontinence or urine leakage, and review options for treatment.
• Perform an assessment of a patient’s medication compliance and ability to pay for medications. Change prescriptions as appropriate. Let them know about avenues to explore if they need financial help.

We appreciate all you do to help keep your patients healthy and safe.

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

We now cover colorectal cancer screenings starting at age 45

As we reported in a web‑DENIS message posted June 15, the United States Preventive Services Task Force changed its recommendation for when to begin colorectal cancer screenings from age 50 to 45.

Effective July 1, 2021, Blue Cross Blue Shield of Michigan and Blue Care Network cover these screenings, beginning at age of 45, for members who are part of National Health Care Reform‑compliant groups.

As always, you’ll want to check web‑DENIS for information on your patients’ benefits and eligibility.

Remind your eligible patients to get regular mammograms

According to the American Cancer Society, 1 in 8 women in the United States will be diagnosed with invasive breast cancer in her lifetime. As a doctor, you can play an integral role in early detection by recommending regular screenings to your patients. Early detection through regular screenings is a key to better outcomes.

The Breast Cancer Screening, or BCS, HEDIS^® measure (also a Medicare Star Ratings measure) assesses female patients ages 52 to 74 who had a mammogram to screen for breast cancer within the past two years. Specifically, we look at those who had a mammogram two years prior to a date that falls within the measurement year of Oct. 1 through Dec. 31.

The National Committee for Quality Assurance now allows patients to be excluded from the measure due to advanced illness and frailty. The committee acknowledges that measured services most likely wouldn’t benefit patients who are in declining health.

Read the Breast Cancer Screening tip sheet to learn more about this measure, including information to include in medical records, codes to include on patient claims to exclude patients who had a mastectomy and tips for talking with patients about this measure.  

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

Here are resources on antibiotic resistance for patients and health care providers

This is part of an ongoing series of articles focusing on the tools and resources available to help FEP^® members manage their health.

Antibiotic resistance is one of the most urgent threats to the public health. Each year in the U.S., at least 2.8 million people are infected with antibiotic‑resistant bacteria or fungi, and more than 35,000 people die as a result.

Adult acute bronchitis treatment is one area where health care providers can often reduce the use of antibiotics. See the Michigan Quality Improvement Consortium’s guideline, Management of Uncomplicated Acute Bronchitis in Adults,** for up‑to‑date information on treating bronchitis.

The Be Antibiotics Aware brochure** can be used to help patients better understand when antibiotics should and shouldn’t be used, and their side effects. The Antibiotic Prescribing and Use** page on the Centers for Disease Control and Prevention website also provides resources and education for both patients and providers.

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

Updated: Refer our members to network DME suppliers only

We’ve updated this article since it ran in the July edition of The Record. Please use this version as your reference on this topic.

When obtaining durable medical equipment, or DME, for our members, you must use suppliers that are part of the Blue Cross Blue Shield of Michigan or Blue Care Network supplier network. Your contract with us obligates you to do this. The only exceptions are for emergencies or for other situations described in our policies.

Here are two guidelines to keep in mind:

• Don’t refer our members to DME suppliers who are outside of our network.
• Be sure you determine whether a particular DME supplier participates with the member’s plan before referring a member to the supplier.

Identifying a Blue Cross and BCN network DME supplier

• For all members, you can find a Blue Cross and BCN network DME supplier by using the Find a Doctor tool on bcbsm.com.

Identifying a Northwood network DME supplier

• For some members, you must use a supplier that’s part of the Northwood, Inc., network, which is a subset of our general DME supplier network. This applies to:
• Fully insured Blue Cross commercial members
• Medicare Plus Blue℠ members
• BCN commercial members
• BCN Advantage℠ members

You can find a Northwood DME supplier by using the Find a Doctor tool on bcbsm.com and filtering your search by “Northwood Provider.”

For additional help identifying a supplier in the Northwood network, call Northwood at
1‑800‑393‑6432.

What happens when you use an out‑of‑network DME supplier

When you use out‑of‑network DME suppliers, members may be responsible for additional out‑of‑pocket costs. They may also be subject to balance‑billing by the suppliers because the suppliers aren’t in the Blue Cross or BCN network or aren’t following medical necessity requirements for replenishing supplies.

Our goal

Our goal is to partner with you to ensure that our members have convenient access to appropriate high‑quality, cost‑effective DME supplies that meet their clinical needs and that are covered by the plan they have.

We’ve established new credentialing requirement for facilities that treat substance use disorders

Members with a diagnosis involving a substance use disorder must have their group counseling and didactic group sessions provided by one of the following:

• A professional who has a Certified Alcohol and Drug Counselor, or CADC, credential
• A registered nurse or someone with a higher credential

This change took effect July 1, 2021.

Additional information

This requirement applies to facilities that treat members who have coverage through these plans:

• Blue Cross Blue Shield of Michigan commercial
• Medicare Plus Blue℠
• Blue Care Network commercial
• BCN Advantage℠

This requirement applies to facilities that provide and bill for at least one of the following types of treatment for substance use disorders:

• Subacute detoxification
• Residential treatment
• Partial hospital program
• Intensive outpatient program
• Individual treatment

What to do when employees don’t have the CADC credential

Fully licensed mental health practitioners who are employed by these facilities and don’t meet our credentialing requirement can provide group counseling and didactic group sessions if they do the following:

• Within 30 days of hire, document the submission of an application to obtain the CADC credential. The application must be submitted to the Michigan Certification Board for Addiction Professionals.** MCBAP allows the submission of an application within 30 days of hire as part of the normal process of obtaining the CADC credential.
• Within the first 40 months of employment, obtain the CADC credential through MCBAP.

Notes:

• MCBAP indicates on its website that three years is generally provided or needed to obtain the credential, but we’re allowing an additional four months to accommodate any interruption of the process for sickness or for other issues that may temporarily interfere with completion of the educational program within the intended time frame.
• Group psychotherapy must be provided by a fully licensed mental health practitioner (for example, a Licensed Master Social Worker, or LMSW).

Provider manuals updated

We’ve updated the provider manuals to include this new information.

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

Certain radiology codes for Blue Cross commercial, Medicare Plus Blue to require prior authorization from AIM

For dates of service on or after Sept. 1, 2021, the services associated with radiology codes *70554 and *70555 will require prior authorization from AIM Specialty Health^®.

This applies to:

• All Blue Cross Blue Shield of Michigan commercial members, including UAW Retiree Medical Benefits Trust non‑Medicare members and Blue Cross and Blue Shield Federal Employee Program^® Michigan members
• All Medicare Plus Blue℠ members  

Note: Blue Care Network commercial and BCN Advantage℠ already require prior authorization from AIM for these services.

We’ll update the AIM codes lists with this new information before the effective date of the change.

You can find the AIM codes lists and additional information about submitting prior authorization requests to AIM at ereferrals.bcbsm.com on the Blue Cross AIM‑Managed Procedures webpage.

We previously published a web‑DENIS message informing providers about this change, and also listed it as a news item at ereferrals.bcbsm.com.

We’ve updated pain management questionnaires and Postservice change request form for submitting requests to TurningPoint

Blue Cross Blue Shield of Michigan, Blue Care Network and TurningPoint Health Care Solutions, LLC continue to identify ways to enhance your experience with the TurningPoint surgical quality and safety management program.

The following enhancements became available as of July 2021:

• For pain management procedures: We updated questions on the questionnaires you complete when you request authorizations.
• For all orthopedic, pain management and spinal procedures: We updated the Postservice change request form.

Pain management questionnaires
To simplify the process of submitting prior authorization requests, we updated most questions on the following questionnaires to require a “yes” or “no” response:

• Epidural steroid injections
• Facet joint injections
• Neuroablation procedures
• Sacroiliac joint injections

These questions appear on the questionnaires in the TurningPoint Provider Portal and in the fax forms for submitting prior authorization requests.

Postservice change request form
We updated the Postservice change request fax form as follows:

• Added information about procedure code substitutions to help you identify situations where you can substitute a different procedure code for the procedure code TurningPoint authorized
• Added the following questions:
• “Have you submitted a claim to Blue Cross or BCN?”
• “Have you submitted an appeal to Blue Cross or BCN?”

Your answers to these questions will streamline the steps required to process postservice change requests.

Where to find fax forms for the TurningPoint program
You can find all fax forms for the TurningPoint program on the following pages of the ereferrals.bcbsm.com website, along with other resources:

• Blue Cross Musculoskeletal services
• BCN Musculoskeletal services

Information about previous enhancements to this program
To read about other enhancements to the TurningPoint program, see:

• The article titled “We’re enhancing TurningPoint surgical quality and safety management program to improve your experience” in the June 2021 issue of The Record
• The Provider Alert titled “Additional enhancements to the TurningPoint musculoskeletal surgical quality and safety management program”

Additional information
As a reminder, TurningPoint manages authorizations for orthopedic, pain management and spinal procedures for the following:

• Blue Cross commercial** — All fully insured groups, select self‑funded groups and all members with individual coverage
• Medicare Plus Blue℠ members
• BCN commercial members
• BCN Advantage℠ members

**To determine whether you need to submit prior authorization requests for Blue Cross commercial members, see the document titled “Determining whether Blue Cross commercial members require prior authorization for musculoskeletal surgeries and related procedures.”

Submitting Medicare Plus Blue post‑service claims for home health care

For home health care services received in Michigan by Medicare Plus Blue℠ members:

• Post‑service claims must include the CareCentrix^®-assigned health insurance prospective payment system, or HIPPS, code.

• The HIPPS code on the post-service claim must match the HIPPS code on the Request for Anticipated Payment, or RAP, claim.

This doesn’t affect home health care claims for BCN Advantage℠ members.

Keep reading to learn more.

CareCentrix‑assigned HIPPS code required when submitting post‑service claims

You must include the CareCentrix‑assigned HIPPS code when you submit post‑service claims for home health care for Medicare Plus Blue members to Blue Cross Blue Shield of Michigan. Otherwise, claims will be rejected.

CareCentrix assigns the Health Insurance Prospective Payment System code in alignment with guidelines from the Centers for Medicare & Medicaid Services.

Obtaining the HIPPS code

• If the Outcome and Assessment Information Set, or OASIS, assessment is available: Complete the HIPPS questionnaire when you submit the prior authorization request. You’ll find the HIPPS code for the approved authorization on the Authorization Status screen in the CareCentrix HomeBridge^® portal.
  
  The HIPPS questionnaire is available in the HomeBridge portal. Refer to your OASIS assessment to complete the questionnaire.

• If the OASIS assessment isn’t available when you submit the authorization request: Fax it to CareCentrix at 1‑877‑414‑1087 as soon as possible. CareCentrix will assign a HIPPS code, which you can find on the Authorization Status screen in the HomeBridge portal.



If you submitted an OASIS assessment and haven’t received an HIPPS code, call CareCentrix at 1‑833‑409‑1280 to request the code — or check the Authorization Status screen in the HomeBridge portal for the code — before you submit the post‑service claim to Blue Cross.

Submitting the OASIS assessment
The steps to submit the OASIS assessment vary based on when you submit it:

• When submitting the assessment with the prior authorization request: Upload the assessment as a separate document. Don’t include it within the medical record.
• When submitting the assessment after submitting the prior authorization request: Fax the assessment to CareCentrix at 1‑877‑414‑1087.

Note: You must submit the OASIS assessment before the end of each episode of care. We recommend you submit it as soon as it’s available.

CareCentrix‑assigned HIPPS codes on post‑service claims must match the HIPPS codes on RAP claims

When you submit a Medicare Plus Blue post-service claim for home health care, the CareCentrix‑assigned HIPPS code must match the HIPPS code on the RAP claim. Blue Cross will deny Medicare Plus Blue claims for home health care services when the CareCentrix‑assigned HIPPS code doesn’t match the HIPPS code on the RAP claim.

If the HIPPS code on the post-service claim doesn’t match the HIPPS code on the RAP claim that you submitted prior to providing services, submit a corrected RAP claim with the post‑service claim.

This requirement is in keeping with standard billing processes and is in alignment with the Centers for Medicare & Medicaid Services requirements. For more information, see the following resources:

• Medicare Claims Processing Manual Chapter 10 – Home Health Agency Billing**

• The “Claims Submission Data Elements” section of the Submitting a Final Claim under the Home Health Patient‑Driven Groupings Model** page on the cgsmedicare.com website

Additional information

For more information about the CareCentrix home health care program, see the document titled Home health care: Frequently asked questions for providers.

As a reminder, CareCentrix manages prior authorizations for home health care services for Medicare Plus Blue and BCN Advantage members as follows:

• For episodes of care that start on or after June 1, 2021
• For episodes of care that started before June 1, 2021, when one of the following occurs on or after June 1: Recertification is needed, resumption of care is needed or there’s a significant change in condition

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

Claim editing enhancements coming later this year to Medicare Plus Blue claims

To promote correct coding and assist with payment accuracy, Blue Cross Blue Shield of Michigan will enhance its claim editing process for Medicare Plus Blue℠ claims with the following updates later this year. However, we encourage you to follow these guidelines now:

• Primary diagnosis only — Certain diagnosis codes can only be billed in the first-listed or primary diagnosis code field on claims, according to the International Classification of Disease, or ICD. There is an identifier in some ICD‑10‑CM manuals for these codes. We’ll edit the claim line if a primary‑only diagnosis code is billed in a position other than the first‑listed or primary position.
• Surgical procedures requiring anatomical modifiers — CPT codes in the range *10000‑*69999, having a Medicare Physician Fee Schedule, or MPFS, bilateral indicator “1” denote that the surgical code is eligible to be billed on both sides of the body. We’ll edit the surgical code when anatomical modifiers (50, LT, RT, E1, E2, E3, E4, F1, F2, F3, F4, F5, F6, F7, F8, F9, FA, T1, T2, T3, T4, T5, T6, T7, T8, T9, TA, LC, LD, RC, LM, RI) are appropriate, but haven’t been appended to the claim line. For details, refer to the Medicare Claims Processing Manual, Chapter 23, Section 20.9.3.2.
• High‑level E/M codes billed with preventive medicine services — We’ll edit high‑level evaluation and management services (CPT codes *99204, *99205, *99214, *99215) when billed for the same patient on the same date of service as a preventive evaluation and management service (CPT codes *99381 through *99387 and *99391 through *99397). For details, refer to the Medicare Claims Processing Manual, Chapter 12, Section 30.6.

We’ll provide updates on other pertinent information, including when these edits will be effective, in future communications.

Note: The appeal process won’t change. Continue to submit appeals on the Clinical Editing Appeal Form with the necessary supporting documentation. Also, continue to fax one appeal at a time to avoid processing delays.

Optum to provide enhanced prospective claim editing for Blue Cross commercial claims

Starting in November 2021, Blue Cross Blue Shield of Michigan will begin working with Optum, a data, analytics and consulting group, for enhanced prospective claim editing for services provided to our commercial members. We anticipate that this change will help promote correct coding and support payment accuracy.

At Blue Cross, we’re committed to implementing payment integrity solutions and will begin performing enhanced prepayment claim reviews with the help of Optum. As a result, health care providers may be asked for medical records and billing documents that support the charges billed.

The prepayment claim reviews will apply to professional, outpatient facility and inpatient facility claim types. The reviews will look for any overutilization of services or other practices that directly or indirectly result in unnecessary costs.

Detailed instructions on how to submit medical records will be included in each Optum medical record request letter. Providers who don’t submit the requested documentation in the allocated time frame may receive a payment denial until all information necessary to adjudicate the claim is received.

If medical records received don’t support the billed service, the service will be denied. If medical records received support the claims, the claims will automatically be processed for payment without the need for them to be resubmitted. As outlined in your contracts with us, providers retain their right to dispute results of reviews.

Unique clinical editing reason codes will appear on the 835 response files or provider vouchers. Over the coming months, you’ll receive additional details about this program.

As a reminder, when billing Blue Cross commercial claims, you should follow guidelines from:

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

As part of your contract with us, health care providers affiliated with our PPO commercial network agree to supply services to Blue Cross members and bill according to guidelines and requirements set by the American Medical Association and select specialty societies.

If you have questions about the Blue Cross claim editing process, contact Provider Inquiry. Professional providers should call 1‑800‑344‑8525, while facility providers should call 1‑800‑249‑5103.

Aduhelm, Empaveli and Arcalyst to require prior authorization for Medicare Advantage members

The following medications will require prior authorization through the NovoLogix^® online tool for Medicare Plus Blue℠ and BCN Advantage℠ members for dates of service noted below:

• Aduhelm™ (aducanumab), HCPCS code J3590 — for dates of service on or after June 8, 2021
• Empaveli™ (pegcetacoplan), HCPCS codes J3490, J3590 — for dates of service on or after June 14, 2021
• Arcalyst^® (rilonacept), HCPCS code J2793 — for dates of service on or after Sept. 13, 2021

When prior authorization is required

For Medicare Advantage members, we require prior authorization for these drugs when they’re administered by a health care professional in a provider office, at the member’s home, in an off-campus or on‑campus outpatient hospital or in an ambulatory surgical center (place of service codes 11, 12, 19, 22 and 24) and billed as follows:

• Electronically through an 837P transaction or on a professional CMS1500 claim form
• Electronically through an 837I transaction or by using the UB04 claim form for a hospital outpatient type of bill 013x

Submitting prior authorization requests

Submit prior authorization requests for these drugs through NovoLogix. It offers real-time status checks and immediate approvals for certain medications.

If you have access to Provider Secured Services, you already have access to 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.

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’ll update the list to reflect these changes as they occur.

Lunch and learn webinars for physicians and coders focus on risk adjustment, coding

We’re offering additional webinars that provide updated information on risk adjustment documentation and coding of common challenging diagnoses.

All sessions start at 12:15 p.m. Eastern time and run for 15 to 30 minutes. They also provide physicians and coders with an opportunity to ask questions.

Click on a link below to sign up for a live webinar:

You can watch previously hosted sessions on our new provider training site:

Access to the training site differs slightly for new and existing users:

• New users must click here to register.
• Existing users can follow this link to log in.

Once logged in, users can access the modules in two ways:

• Look in the course catalog under Quality management.
• Enter “lunch and learn” in the search box at the top of the screen.

If you need assistance creating your login ID or navigating the site, email ProviderTraining@bcbsm.com.

If you have any questions about the sessions, contact April Boyce at aboyce@bcbsm.com. If you have questions regarding registration, email Patricia Scarlett at pscarlett@bcbsm.com.

New on‑demand resources available on our provider training site

Provider Experience continues to offer training resources for health care providers and staff. Our on‑demand courses are designed to help you work more efficiently with us.

Our newest resources include:

• Updated Benefit Explainer course — Shows you how to verify benefits, check out‑of‑pocket costs and view other key benefit information
• Knowledge Center — A repository of learning resources organized by categories, and includes job aids, “quick guides” and website support documents

You’ll also find:

• Recordings of webinars previously presented this year
• Video and e‑learning modules on specific topics

As previously communicated in The Record, we launched our new provider training site in June to enhance your training experience. Watch this video for a preview of the site’s features.

Training courses and materials from 2019 through 2021 have moved from BCBSM Provider Training and BCN Learning Opportunities to the new training site. To request access, complete the following steps:

• Open the registration page.
• Complete the registration. We recommend using the same email you use to communicate with Blue Cross Blue Shield of Michigan for provider-related needs. This will become your login ID.
• Follow the link to log in.

If you need assistance creating your login ID or navigating the site, email ProviderTraining@bcbsm.com.

Blue Cross and BCN covering additional vaccines

To increase access to vaccines and decrease the risk of vaccine‑preventable disease outbreaks, Blue Cross Blue Shield of Michigan and Blue Care Network have added the following to our list of vaccines covered under the pharmacy benefit:

The following lists all vaccines covered under eligible members’ prescription drug plans. Most Blue Cross and BCN commercial (non‑Medicare) members with prescription drug coverage are eligible. If a member meets the coverage criteria, the vaccine is covered with no out‑of‑pocket cost.

If a member doesn’t meet the age requirement, Blue Cross and BCN won’t cover the vaccine under the prescription drug plan, and the claim will reject.

Aduhelm, Empaveli and Arcalyst to require prior authorization for Medicare Advantage members

The following medications will require prior authorization through the NovoLogix^® online tool for Medicare Plus Blue℠ and BCN Advantage℠ members for dates of service noted below:

• Aduhelm™ (aducanumab), HCPCS code J3590 — for dates of service on or after June 8, 2021
• Empaveli™ (pegcetacoplan), HCPCS codes J3490, J3590 — for dates of service on or after June 14, 2021
• Arcalyst^® (rilonacept), HCPCS code J2793 — for dates of service on or after Sept. 13, 2021

When prior authorization is required

For Medicare Advantage members, we require prior authorization for these drugs when they’re administered by a health care professional in a provider office, at the member’s home, in an off-campus or on‑campus outpatient hospital or in an ambulatory surgical center (place of service codes 11, 12, 19, 22 and 24) and billed as follows:

• Electronically through an 837P transaction or on a professional CMS1500 claim form
• Electronically through an 837I transaction or by using the UB04 claim form for a hospital outpatient type of bill 013x

Submitting prior authorization requests

Submit prior authorization requests for these drugs through NovoLogix. It offers real-time status checks and immediate approvals for certain medications.

If you have access to Provider Secured Services, you already have access to 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.

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’ll update the list to reflect these changes as they occur.

New eLearning training videos to focus on Medicare Star Ratings

The Quality and Provider Education team continues to offer important training resources to health care providers and staff. New eLearning training videos, designed for physician office staff responsible for closing gaps related to Medicare Star measures, will be available Aug. 15. The video series will discuss closing gaps and emphasize the importance of creating positive patient experiences.

Topics include:

• Clarifications on quality measure requirements
• Assistance with coding and documentation
• Tips for closing gaps
• Current information about HEDIS^® quality measures (Note: Many HEDIS measures are also Medicare Star Ratings measures.)
• The Consumer Assessment of Healthcare Providers and Systems and Health Outcomes Survey

The video series will be available on our new provider training site. Access to the site will differ slightly for new and existing users:

• New users must register here.  
• Existing users can log in here.  

Log in to access the module in the course catalog under Quality management or by entering “Star” in the search box at the top of the screen.

Watch this video to learn more about the provider training site. If you need assistance creating your login ID or navigating the site, email ProviderTraining@bcbsm.com.

Job aid helps you determine if a Blue Cross commercial member requires prior authorization for DME/POS through Northwood

Northwood, Inc., manages durable medical equipment, prosthetics, orthotics and medical supplies, or DME/POS, for some Blue Cross commercial members. To help you determine whether a Blue Cross commercial member requires prior authorization for DME/POS through Northwood, a new job aid is available at ereferrals.bcbsm.com that walks you through the steps:

• Determining whether Blue Cross commercial members require prior authorization for DME/POS through Northwood

For more information about the Northwood program and how it works, refer to the following documents:

• Durable medical equipment and prosthetics and orthotics: For authorization determinations
• Northwood DME/POS Management Program FAQ
• Northwood DME/POS Management Program Procedure Codes Requiring Prior Authorization

If you have questions about the Northwood DME/POS management program, contact Northwood Provider Relations at 1‑800‑447‑9599 between 8:30 a.m. and 5 p.m. Eastern time Monday through Friday.

Updated: Refer our members to network DME suppliers only

We’ve updated this article since it ran in the July edition of The Record. Please use this version as your reference on this topic.

When obtaining durable medical equipment, or DME, for our members, you must use suppliers that are part of the Blue Cross Blue Shield of Michigan or Blue Care Network supplier network. Your contract with us obligates you to do this. The only exceptions are for emergencies or for other situations described in our policies.

Here are two guidelines to keep in mind:

• Don’t refer our members to DME suppliers who are outside of our network.
• Be sure you determine whether a particular DME supplier participates with the member’s plan before referring a member to the supplier.

Identifying a Blue Cross and BCN network DME supplier

• For all members, you can find a Blue Cross and BCN network DME supplier by using the Find a Doctor tool on bcbsm.com.

Identifying a Northwood network DME supplier

• For some members, you must use a supplier that’s part of the Northwood, Inc., network, which is a subset of our general DME supplier network. This applies to:
• Fully insured Blue Cross commercial members
• Medicare Plus Blue℠ members
• BCN commercial members
• BCN Advantage℠ members

You can find a Northwood DME supplier by using the Find a Doctor tool on bcbsm.com and filtering your search by “Northwood Provider.”

For additional help identifying a supplier in the Northwood network, call Northwood at
1‑800‑393‑6432.

What happens when you use an out‑of‑network DME supplier

When you use out‑of‑network DME suppliers, members may be responsible for additional out‑of‑pocket costs. They may also be subject to balance‑billing by the suppliers because the suppliers aren’t in the Blue Cross or BCN network or aren’t following medical necessity requirements for replenishing supplies.

Our goal

Our goal is to partner with you to ensure that our members have convenient access to appropriate high‑quality, cost‑effective DME supplies that meet their clinical needs and that are covered by the plan they have.