Get ready for Availity: Find out which web browser to use

To prepare for moving to the Availity^® provider portal in the coming months, you should take a look at the internet browser you’re currently using.

Availity is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal services.

We shared technical requirements with you in the February 2021 issue of The Record. But since that time, there has been a change: Availity no longer supports Internet Explorer 11.

If you’re using Internet Explorer now, you’ll need to switch to a new browser. Otherwise, your experience on Availity will be affected.

The preferred browser for Availity is Google Chrome, but Microsoft Edge (version 79 or higher) and Firefox^® are also acceptable. You can download Google Chrome for free.**

For more information on Availity technical requirements, go to the Availity website.** Scroll down, and click on the Requirements tab.

Questions?
If you have questions about the move to Availity, check our Frequently asked questions document first. If your question isn’t already answered there, submit your question to ProviderPortalQuestions@bcbsm.com so we can consider adding it to the FAQ document.

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

Blue Cross updates continuity of care requirements to align with law

In 2020, the president signed the Consolidated Appropriations Act of 2021, or CAA, into law. That legislation had several health care-related provisions. Part of the legislation addresses continuity of care requirements.

Blue Cross Blue Shield of Michigan and Blue Care Network already allow for continuity of care for our members in Michigan as required by state law and the Affordable Care Act, and we are updating our policies to align with the requirements of the CAA.

What is continuity of care?

Sometimes, a contract between a health care provider and a health plan is modified (for example through departicipation, termination, etc.) and results in a loss or reduction of benefits for an individual. Through continuity of care, the individual is still able to see their health care provider under certain circumstances because their health situation requires it. In addition, the care would be provided as if there were no change to the contract.

What does the CAA say about continuity of care? 

According to the legislation, effective Jan. 1, 2022, if a health care provider changes network status, patients with complex care needs have the option of up to 90 days of continued coverage at in-network cost sharing to allow for a transition of care to an in-network health care provider.

Complex care circumstances where you can continue treatment

The circumstances below are similar to our existing continuity of care situations with some changes outlined in the CAA legislation. You can still see your patient if he or she is:

• Undergoing a course of treatment for a “serious and complex condition,” defined as:
• An acute illness — A condition that is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm; or
• A chronic illness or condition — A condition that is:
• Life-threatening, degenerative, potentially disabling or congenital; and
• Requires specialized medical care over a prolonged period of time
• Getting inpatient care.
• Scheduled to undergo nonelective surgery, including receipt of postoperative care for that surgery
• Pregnant and undergoing a course of treatment for the pregnancy
• Determined to be terminally ill (defined as “a medical prognosis that the individual’s life expectancy is six months or less”) and is receiving treatment for their illness.

Requirements to provide services under continuity of care

If you choose to treat your patient for a continuity of care period of time, you’re required to:

• Accept payment from Blue Cross as payment in full (less any required copays or deductibles).
• Adhere to Blue Cross’ standards for maintaining quality health care and provide Blue Cross with  necessary medical information related to your patient’s care.
• Adhere to Blue Cross’ policies and procedures, including, but not limited to, those concerning  utilization review, referrals, pre-authorizations and treatment plans.

For more information about continuity of care, see our online provider manuals on web-DENIS.   

Overview of care management and utilization management programs now available

Blue Cross Blue Shield of Michigan and Blue Care Network have implemented many care management programs for members and utilization management programs for providers.

• Care management programs provide patient support by identifying patients with health risks and working with them to improve or maintain their health.
• Utilization management programs focus on ensuring that patients get the right care at the right time in the right location through the authorization process.

These programs vary based on member coverage and may be administered by Blue Cross or BCN staff or by contracted vendors.

We recently published the Care management and utilization management programs: Overview for providers document to help you navigate these programs. This information may help you to identify services that could be useful to your patients or to learn more about programs in which your patients are participating.

In the overview document, we’ve:

• Categorized the programs and the services for which we have care management and utilization management programs.
• Listed who provides services within each category (Blue Cross or BCN staff, contracted vendors or both).
• Indicated whether services are available to Blue Cross commercial, Medicare Plus Blue℠, BCN commercial or BCN Advantage℠ members

To see more details about the programs, click a category heading. A document will open that provides:

• A summary of available services
• The groups and individual members to which services are available
• Resources for finding more information

You can access the overview document by going to ereferrals.bcbsm.com, clicking on the Quick Guides link (under Additional Resources) and then clicking on the Care management and utilization management programs: Overview for providers link.

We appreciate your efforts in helping us achieve high Medicare Star Ratings

As we reported in a web-DENIS message in October and a November-December Hospital and Physician Update article, the Centers for Medicare & Medicaid Services gave Blue Cross Blue Shield of Michigan and Blue Care Network high Medicare Star Ratings for 2022. Here are highlights:

• Our BCN Advantage℠ HMO plan received a 5-Star rating — the highest rating possible and the first 5-Star rating Blue Cross Blue Shield of Michigan has ever achieved.
• Our Medicare Plus Blue℠ PPO plan received a 4.5-Star rating, an increase of one full star over last year.

These ratings reflect improvements made in several key areas, including adherence to HEDIS^® measures and CAHPS^® survey results.** We appreciate all you’ve done over the last few years to help ensure that practitioners adhere to HEDIS measures and that members are satisfied with the care provided by you — the physicians and practice staff who care for our members directly.

For more details, see the article in the November-December issue of Hospital and Physician Update. We’ll also provide additional details on our 2022 Star Ratings performance in future issues of our provider publications. If you haven’t already done so, we encourage you to subscribe to Hospital and Physician Update or other provider newsletters at bcbsm.com/providers/newsletters/subscribe.html.

**HEDIS^®, which stands for Healthcare Effectiveness Data and Information Set, is a registered trademark of the National Committee for Quality Assurance. CAHPS^®, which stands for Consumer Assessment of Healthcare Providers and Systems, is a registered trademark of the Agency for Healthcare Quality and Research.

Benefit changes coming Jan. 1 for UAW Retiree Medical Benefits Trust members

There are several benefit changes that the UAW Retiree Medical Benefits Trust requested Blue Cross Blue Shield of Michigan make for its members starting Jan. 1, 2022. These include:

• Lower in-network deductible and out-of-pocket maximums for Enhanced Care Plan, or ECP, and Traditional Care Network, or TCN, members.
• For ECP members:
• In-network primary care office visit copay will be $10.
• Copays for in-network specialist visits will be $20. 
• For TCN members, acupuncture (for lower back pain only) will be an allowable service secondary to Medicare and subject to the appropriate cost share.
• For both ECP and TCN members:
• In-network allergy testing and ear wax removal are covered services, subject to the appropriate cost share.
• In-network chiropractic manipulations for subluxation of the spine are covered with a $20 copay (24 visit maximum).

There have also been changes for Medicare Plus Blue℠ members:

• Lower in-network deductible and out-of-pocket maximums.
• In-network primary care office visit copays will be $10.
• Copays for in-network specialist visits will be $20.
• Copay for in-network acupuncture will be $20 (20 visit limit).
• In-network outpatient rehabilitation services, outpatient mental health and substance use disorder, compression stockings and diabetic eye exams are covered at 100%.
• Skilled nursing facility is covered at 100% for days 1 through 50 and a $20 copay per day for days 51 through 100 in-network.
• Diabetic shoes have an enhanced benefit of two pairs per year.
• Wigs are covered at 100% up to a $250 annual maximum.

This benefit information will be updated on web-DENIS, so be sure to check there for member benefit and eligibility information.

Third-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

Skin Substitutes

DME/P&O/Medical Supplies

Transfusion Medicine/Miscellaneous Blood Products

Medicine Supplementary/Contraception/Devices and Supplies

Medicine Supplementary/Special Foods and Formulas

Surgery

Temporary Q Code/Unclassified

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 replacement codes, effective Oct. 1, 2021, established

J1305 replaces J3490, J3590 and C9079 when billing for Evkeeza (evinacumab-dgnb)

Effective Oct. 1, 2021, the Centers for Medicare and Medicaid Services has established a permanent procedure code for specialty medical drug Evkeeza™ (evinacumab-dgnb).

Services can continue to be reported with J3490, J3590 and C9079 through Sept. 30, 2021. All services performed on and after Oct. 1, 2021, must be reported with J1305.

Prior authorization is required by the Medical Benefit Drug Prior Authorization program for Evkeeza (evinacumab-dgnb), procedure code J1305, for all groups unless they opted out of the prior authorization program.

For groups that have opted out of the prior authorization program, this procedure requires manual review.

J1448 replaces J3490, J3590 and C9078 when billing for Cosela (trilaciclib)

Effective Oct. 1, 2021, CMS has established a permanent procedure code for specialty medical drug Cosela™ (trilaciclib dihydrochloride).

Services can continue to be reported with J3490, J3590 and C9078 through Sept. 30, 2021. All services performed on and after Oct. 1, 2021, must be reported with J1448.

Prior authorization is required by the Medical Benefit Drug Prior Authorization program for Cosela (trilaciclib dihydrochloride), procedure code J1448, for all groups unless they opted out of the prior authorization program.

For groups that have opted out of the prior authorization program, this procedure requires manual review.

J9247 replaces J3490, J3590 and C9080 when billing for Pepaxto (melphalan flufenamide)

Effective Oct. 1, 2021, CMS has established a permanent procedure code for specialty medical drug Pepaxto^® (melphalan flufenamide).

Services can continue to be reported with J3490, J3590 and C9080 through Sept. 30, 2021. All services performed on and after Oct. 1, 2021, must be reported with J9247.

Prior authorization is required through the AIM Oncology Management Authorization program for Pepaxto (melphalan flufenamide), procedure code J9247, for all groups unless are opted out of the prior authorization program.

Pepaxto (melphalan flufenamide) is covered for all groups not included in the AIM Oncology Management Authorization program as a chemotherapy benefit for malignant conditions.

J9318 replaces J3490, J3590 and C9065 when billing for romidepsin, non-lyophilized

Effective Oct. 1, 2021, CMS has established a permanent procedure code for specialty medical drug romidepsin, non-lyophilized.

Services can continue to be reported with J3490, J3590 and C9065 through September 30, 2021. All services performed on and after Oct. 1, 2021, must be reported with J9318.

Prior authorization is required through the AIM Oncology Management Authorization program for romidepsin, non-lyophilized, procedure code J9318, for all groups unless they opted out of the prior authorization program.

Romidepsin, non-lyophilized is covered for all groups not included in the AIM Oncology Management Authorization program as a chemotherapy benefit for malignant conditions.

Q2054 replaces J3490, J3590, J9999 and C9076 when billing for Breyanzi (lisocabtagene maraleucel)

Effective Oct. 1, 2021, CMS has established a permanent procedure code for specialty medical drug Breyanzi^® (lisocabtagene maraleucel).

Services can continue to be reported with J3490, J3590, J9999 and C9076 through Sept. 30, 2021. All services performed on and after Oct. 1, 2021, must be reported with Q2054.

Prior authorization is still required by the Medical Benefit Drug Prior Authorization program for Breyanzi (lisocabtagene maraleucel), procedure code Q2054, for all groups unless they opted out of the prior authorization program.

For groups that have opted out of the prior authorization program, this procedure requires manual review.

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: Blue Cross highlights 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.

None of the information included in this billing chart 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.

Starting Jan. 1, 2022, bill Medicare Advantage plans for administration of COVID‑19 vaccines and monoclonal antibody treatments

Beginning Jan. 1, 2022, the Centers for Medicare & Medicaid services will require Medicare Advantage plans to cover the cost to administer COVID-19 vaccines (including approved booster doses) and monoclonal antibody products to treat COVID-19, with no out-of-pocket costs for members.

For dates of service on or after Jan. 1, 2022, submit claims for the administration of vaccines and monoclonal antibody treatments to Blue Cross Blue Shield of Michigan or Blue Care Network for members with Medicare Plus Blue℠ or BCN Advantage℠ plans.

Note: If your patient scheduled an office visit on or after Jan. 1, 2022, for any other reason than getting the vaccine or monoclonal antibody treatments, bill the usual office visit charge.

More information

For more information on the COVID-19 vaccine, refer to CMS’ COVID-19 toolkit** for health care providers.
For more information on monoclonal antibody treatment, see the Monoclonal Antibody COVID-19 Infusion webpage** of CMS’ COVID-19 toolkit for health care providers.

Reminder

For dates of service on or after Oct. 1, 2021, cost share applies for any treatment related to COVID-19, other than monoclonal antibody treatment, for Medicare Plus Blue and BCN Advantage members.

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

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

Intensive outpatient program and partial hospital program services now payable on an ongoing basis when delivered through telemedicine

As previously communicated, Blue Cross Blue Shield of Michigan and Blue Care Network began allowing behavioral health intensive outpatient and partial hospital program services to be payable when provided by contracted facilities through telemedicine as a temporary measure during the COVID-19 pandemic.

Effective Nov. 1, 2021, we’re updating our Telemedicine Services medical policy to allow these services to be payable when delivered by contracted facility providers through synchronous (real-time) telemedicine on an ongoing basis, rather than as a temporary measure. We’re doing this to make it easier for members to receive these services beyond the COVID-19 pandemic.

For more information, including information about billing for these services, see the Telehealth for behavioral health providers document on our public website at bcbsm.com/coronavirus or within Provider Secured Services.

Reminders

• Facilities can provide behavioral health IOP and PHP services to BCN commercial and BCN Advantage℠ members only when their contracts specifically include IOP and PHP services.
• For Blue Cross commercial members, most plans don’t cover IOP services for mental health or PHP services for substance use disorders. IOP services for substance use disorders must be delivered by a substance abuse treatment facility. Be sure to check member eligibility and benefits through web-DENIS or by contacting Provider Inquiry before performing services.
• For Medicare Plus Blue℠ members, follow Centers for Medicare & Medicaid Services guidance.

Updated documents

We’ve updated the following documents to reflect this change:

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

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

You can view the updated Telemedicine Services medical policy through our Medical Policy & Pre-Cert/Pre-Auth Router on bcbsm.com.

Additional autism interventions delivered through telemedicine now payable

As previously communicated, Blue Cross Blue Shield of Michigan and Blue Care Network began allowing some services for autism spectrum disorder to be payable when delivered through telemedicine as a temporary measure during the COVID-19 pandemic.

Effective Nov. 1, 2021, we’re updating our Autism Spectrum Disorder Services medical policy to allow those telemedicine services to be payable on an ongoing basis. We’re also removing restrictions on protocol modification *97155.

These changes apply to members whose coverage includes an autism benefit. 

To determine which procedures can be performed through telemedicine for Medicare Plus Blue℠ members who have an autism benefit, see the Medicare-covered telehealth services for the COVID-19 PHE document.

Telemedicine services payable on an ongoing basis, effective Nov. 1

Per the updated medical policy, we’ll allow the following autism services to be delivered through synchronous (real time) telemedicine on an ongoing (no longer temporary) basis:

• Assessment, *97151
• Applied behavior analysis, or ABA, *97153

This service is allowed for children who meet appropriateness criteria. The Guidelines for autism interventions delivered through telemedicine document offers guidance in determining which members can benefit from direct-line ABA interventions delivered through telemedicine.

• Skills training, *97154
• Intensive skills training, *97158

Restrictions lifted on protocol modification

Per the updated medical policy, protocol modification *97155, will be allowed through real-time telemedicine visits 100% of the time. (Previously, this service was allowed to be delivered through telemedicine only 50% of the time.)

During the COVID-19 pandemic, for dates of service from April 14, 2020, through Oct. 31, 2021, we allowed licensed behavior analysts, or LBAs, to troubleshoot treatment protocols directly with the parent or caregiver functioning as the behavioral technician. With the Nov. 1, 2021, update to the Autism Spectrum Disorder medical policy, this temporary measure is no longer payable.

Reminder

The following services continue to be payable when delivered through real-time telemedicine: caregiver training (*97156), multi-family caregiver training (*97157), supervision (S5108) and caregiver training (S5111).

S5108 and S5111 are payable only to Michigan providers who deliver services to out-of-state members and can’t use the American Medical Association category 1 codes.

Updated documents

We’ve updated the following documents to reflect this change:

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

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

You can view the updated Telemedicine Services medical policy through our Medical Policy & Pre-Cert/Pre-Auth Router on bcbsm.com.

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.

Behavioral health services delivered through synchronous telemedicine

With the Nov. 1, 2021, updates to the following medical policies, additional behavioral health and autism spectrum disorder, or ASD, services are now payable when delivered through telemedicine:

• Telemedicine Services
• Autism Spectrum Disorder Services

Behavioral health and ASD services must be delivered synchronously (in real time), with the exception of *96130 and *96156, which can be delivered asynchronously.

Telemedicine asynchronous (store and forward) care generally isn’t payable for behavioral health services.

This applies to Blue Cross Blue Shield of Michigan commercial, Medicare Plus Blue℠, Blue Care Network commercial and BCN Advantage℠ members.

For more information about providing behavioral health and ASD services through telemedicine, see the Telehealth for behavioral health providers document, which is available on our public website at bcbsm.com/coronavirus or within Provider Secured Services.

You can view the updated medical policies through our Medical Policy &
Pre-Cert/Pre-Auth Router at bcbsm.com.

Acupuncturists invited to apply to be part of Blue Cross’ provider networks

Acupuncturists have the opportunity to participate in Blue Cross Blue Shield of Michigan’s Traditional and TRUST PPO networks, Medicare Plus Blue℠, BCN commercial and BCN Advantage℠, effective March 1, 2022.

How to join a Blue Cross network

Acupuncturists can find enrollment forms and practitioner agreements at bcbsm.com/providers, starting Dec. 1, 2021. To find enrollment information, click on Enroll to become a network provider. Specific qualification requirements are identified within each agreement.

All applicants must pass a credentialing review before participation. We’ll notify applicants in writing of their approval status.

Billing for services

Participating acupuncturists can bill their professional services using codes *97810, *97811, *97813 and *97814. They can receive direct reimbursement for covered services within the scope of their licensure at 85% of the applicable fee schedule, minus any member deductibles and copayments. 

This change, effective for outpatient services provided on or after March. 1, applies to Blue Cross and BCN benefit plans that cover services these providers are licensed to provide. To find out if a member has coverage, check web-DENIS for member benefits and eligibility or call Provider Inquiry at 1-800-344-8525.

Prior authorization and referrals

Prior authorization isn’t required for acupuncture services for any member. For BCN commercial members who have a primary care provider who is part of a medical care group based in the East or Southeast region, their primary care provider must submit a referral for a specialist office visit. Referrals aren’t required for other members.

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.

Services related to complementary and alternative therapies aren’t covered benefits

The use of complementary or alternative therapies, practices, medicine or supplements that aren’t supported by valid scientific studies is considered experimental. When there’s insufficient evidence in the current medical literature to show that these approaches are safe or as beneficial as the current standard of care, Blue Cross Blue Shield of Michigan doesn’t cover them.

Ancillary services, such as visits, imaging and testing, that are performed primarily to facilitate the delivery of an unproven or experimental service are also considered experimental in nature and aren’t a covered benefit. The effective date for this policy is Nov. 1, 2021.

“Alternative medicine” is a term that describes a broad range of treatments and practices that are used in place of traditional therapies. “Complementary medicine” is a term that describes treatments and practices that are used in conjunction with traditional therapies.

Other terms used to describe such practices include functional, integrative, herbalism, homeopathy, holistic, unconventional, nonconventional, nontraditional, new age and natural. “Traditional medicine” refers to the standard of practice that’s widely used by the medical community and has been proven safe and efficient.

Types of complementary and alternative medicine that lack evidence-based, clinical-decision support

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.

Coming soon: We’re changing how we issue value‑based reimbursements for PDCM outcomes

Effective Jan. 1, 2022, Blue Cross Blue Shield of Michigan will change the way it issues value-based reimbursements for outcomes related to Provider-Delivered Care Management.

No action is required from provider organizations or health care providers at this time. We simply want to make them aware of the process. 

Eligibility for value-based reimbursements for PDCM outcomes has already been determined, and changes in the process started Sept. 1, 2021.

Through Dec. 31, 2021, value-based reimbursements for PDCM outcomes will continue to be paid as they are today. Starting January 2022, and for each month thereafter, Blue Cross will produce a claim on behalf of eligible providers for each attributed member. The attribution will include:

• Members who have Blue Cross Blue Shield of Michigan coverage and live in Michigan
• Members who have coverage through another Blue plan

This value-based reimbursement claim for PDCM outcomes will be represented by one procedure code and not spread across multiple codes (as with the percentage VBR).

Keep the following in mind:

• Each month, Blue Cross will produce a claim on behalf of the eligible physician. The claim will include procedure code S0281, diagnosis code Z0289 and modifier 3P. 

• The value-based reimbursement amount is dependent on the VBR percentage the provider earned as of Sept. 1. 

• The dollar amount varies from $0.40 to $1.60 per attributed member per month, based on the chart below. 

• This change only affects value-based reimbursements for PDCM outcomes. All other value-based reimbursements will remain unchanged.

See the below charts for additional details:

Adults

Pediatric

Measure	Composite measure	Performance threshold	Potential rate	Improvement percent	Value-based reimbursement amount
Emergency department encounters (per 1,000 members per year)	N/A	164	55	10%	$0.40 per attributed member per month
Inpatient encounters (per 1,000 members per year)	N/A	13.5	1	9%	$0.40 per attributed member per month
Follow-up after emergency department visit for mental illness	PEDCOMP1	56%	N/A	N/A	$0.80 per attributed member per month
Follow-up care for children prescribed ADHD medication — continuation and maintenance phase	PEDCOMP1	47%	N/A	N/A
Asthma medication ratio — 5 to 11 ratio > 50%	PEDCOMP1	44%	N/A	N/A
Asthma medication ratio — 12 to 17 ratio > 50%	PEDCOMP1	65%	N/A	N/A

If you have any questions, send an email to ValuePartnerships@bcbsm.com.

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.

2022 member ID cards to display deductible, out‑of‑pocket maximum

Effective Jan. 1, 2022, ID cards issued to Blue Cross Blue Shield of Michigan and Blue Care Network commercial members will display their deductible and out-of-pocket maximum. This change applies to both the physical and electronic ID cards. The Consolidated Appropriations Act of 2021 requires us to provide this information on the ID cards issued to participants, beneficiaries or enrollees.

The new CAA mandate requires that issued ID cards contain the following:

• In-network and out-of-network individual and family deductibles
• Out-of-pocket maximums

The following is a sample card image:

Providers should continue to use webDENIS and PARS for benefit information.

In some cases, where member deductibles or out-of-pocket maximums aren’t available on the card, the card will show “See Benefits.” Members will be directed to access their benefits on bcbsm.com or the BCBSM mobile app.

In addition, for commercial members with prescription drug coverage, their ID cards will also show a new RxBIN to reflect our pharmacy benefit manager change from Express Scripts to OptumRx. This was announced in an article in the September 2021 Record and on Page 26 of the September-October 2021 BCN Provider News.

Remote Clinical Documentation Improvement program helps keep medical records accurate

Advantasure^® employs the Remote Clinical Documentation Improvement program to help providers accurately capture their patients’ severity of illness in their medical records.

The Centers for Medicare & Medicaid Services requires providers to document certain chronic conditions in the patient’s medical record at least once every calendar year.

The incentive-based Remote CDI program uses the Clinical Documentation Improvement Alert, a single-page guide to help providers perform CMS-compliant medical record documentation during face-to-face, audio and audiovisual telehealth visits. Advantasure will distribute CDI Alerts to providers up to three times a year that are based on:

• Actual diagnoses submitted on claims within the prior two calendar years
• Potential new diagnoses based on findings in the medical record or prior pharmacy and lab claims
• Star Ratings or quality measure gaps identified through claims data that may require tests or services to be ordered for your patient

How to earn the Remote CDI incentive

• Address all identified confirmation of diagnosisand clinical documentation improvement opportunities on your patients’ CDI Alerts by Dec. 31 each calendar year.
• Submit a completed CDI Alert with the office visit notes from the same date of service. (Healthy Blue portal closures do not qualify for the Remote CDI incentive.)
• Submit the alerts to Advantasure within 14 days of the patient visit.

Providers who close out 100% of the identified risk gaps listed on the CDI Alert are eligible to earn a $100 incentive for each attributed member.

For more information about the program or to request a brochure, contact:

• Tom Rybarczyk, clinical consultant, at 313-378-8259
• Denise McMillan, senior analyst, at 313-407-7529

Blue Cross has partnered with Advantasure on the Remote Clinical Documentation Improvement program. This program supports providers in accurately addressing conditions for their Medicare Advantage patients.

Our new, updated enrollment flyers assist providers joining our network

We’ve updated some of our enrollment flyers to help providers joining Blue Cross Blue Shield of Michigan or Blue Care Network. The Enrollment documents helpful hints flyers are step-by-step guides that walk providers through each section of their enrollment application. Depending on the classification type, providers may see different form fields on their application. Here are the three available flyers, with information on recent changes:

• The Enrollment documents helpful hints flyer now includes tips and hints for all provider types. Previously, this document was specific to behavioral health providers. This flyer can be found on the Provider enrollment page of bcbsm.com/providers.
• Outpatient psychiatric center information that was included in the original Enrollment helpful hints flyer has been separated into its own Enrollment documents helpful hints – New Outpatient Psychiatric Center flyer. Outpatient psychiatric centers can locate this flyer on their provider enrollment webpage after choosing Outpatient Psychiatric Care Facilities from the Facilities type list.
• An Enrollment documents helpful hints – New Ancillary Providers Located Outside of Michigan flyer was also created for those providers looking to enroll. This flyer can be found on the Provider enrollment page of bcbsm.com/providers.

Blue Cross enhances tools for electronically prescribing medications and submitting prior authorizations

Blue Cross Blue Shield of Michigan is committed to enhancing its electronic processes across the health care spectrum, including the processes used by prescribers.

As part of our transition to OptumRx as our new pharmacy benefit manager, we’re making some improvements to our provider-facing tools to assist with prescribing and submitting prior authorizations electronically. These enhancements will primarily take place behind the scenes and won’t have a major effect on how providers prescribe and submit prior authorizations or check on patients’ benefits.

As you read in a September Record article, the move from Express Scripts, Inc. to OptumRx will take place Jan. 1, 2022, for commercial individual and group members, and Jan. 1, 2023, for Medicare Advantage individual and group members. 

Continue to use your current electronic medical record system or CoverMyMeds^® to submit electronic prior authorizations for Blue Cross and Blue Care Network members. Keep in mind that the BIN number changes to 610011, effective Jan. 1, 2022, for all Blue Cross and BCN commercial members.

Electronic prior authorization, or ePA, replaces faxing and phone calls so you can focus less on administrative tasks and more on patient care. For more information on ePA and CoverMyMeds, see our ePA flyer. Once we launch Availity, our new secure provider portal, we’ll also provide a link to Prompt PA, another resource that can be used to submit electronic prior authorization requests for pharmacy benefit drugs.

Also, continue to use electronic medical records for electronic prescribing and real-time prescription benefit checks. Note: You may have heard of a tool called PreCheck MyScript. This is a product name that OptumRx uses for its real-time benefit check connectivity and programing with electronic medical record systems. From a provider perspective, the interface will look and feel much the same as what providers currently use with Express Scripts.

By using these tools, physicians get patient-specific pharmacy information up front. And the better physicians and patients understand the medication options and costs at the point of prescribing, the more likely patients are to fill prescriptions and adhere to their medication regimen.

The Pharmacy team is communicating about these enhancements at various provider-facing forums, including regional medical director meetings, BCN business administrator meetings and network performance improvement meetings.

If you have any questions, call the Pharmacy Help Desk at 1-800-437-3803.

Reminder: TurningPoint to review sites of care for total hip and knee surgeries for some members

For dates of service on or after Jan. 3, 2022, TurningPoint Healthcare Solutions, LLC will review the site of care for total hip and knee surgeries as part of each authorization determination. Based on medical necessity review, TurningPoint may approve authorization requests for select total hip and knee cases only when scheduled in an outpatient setting.

This applies to members with the following coverage:

• Medicare Plus Blue℠
• BCN commercial
• BCN Advantage℠

If TurningPoint approves an authorization for a hip or knee surgery in an outpatient setting and the member experiences a change in condition that requires an inpatient admission, you’ll need to submit an authorization request for the inpatient admission (procedure code *99222) through the e‑referral system; see the “Submit an inpatient authorization” section of the e-referral User Guide for more information. Blue Cross Blue Shield of Michigan or Blue Care Network will review the request, using InterQual^® criteria.

Performing total hip and knee surgeries in outpatient settings is supported by both evidence-based guidelines and the Centers for Medicare & Medicaid Services.

For more information about the TurningPoint musculoskeletal surgical quality and safety management program, see these pages on the ereferrals.bcbsm.com website:

• BCN Musculoskeletal Services
• Blue Cross Musculoskeletal Services

TurningPoint Healthcare Solutions, LLC is an independent company that handles authorizations for musculoskeletal surgical and other related procedures for Blue Cross Blue Shield of Michigan and Blue Care Network.

Reminder: Prior authorization requirements expanding for Medicare Advantage and BCN commercial on Jan. 1

We’re expanding our prior authorization requirements for Medicare Plus Blue℠, Blue Care Network commercial and BCN Advantage℠ members. For the procedure codes listed below, you’ll need to complete questionnaires in the e-referral system when you submit prior authorization requests for dates of service on or after Jan. 1, 2022.

We’ll update related documents to reflect this change before Jan. 1.

For Medicare Plus Blue members

Most of the procedure codes below already require prior authorization for BCN commercial and BCN Advantage members. But this requirement is new for Medicare Plus Blue members for requests submitted for dates of service on or after Jan. 1.

For BCN commercial and BCN Advantage members

The procedure codes below require prior authorization for BCN commercial and BCN Advantage, but aren’t associated with a questionnaire in the e-referral system. For dates of service on or after Jan. 1, you’ll need to complete a questionnaire when you request prior authorization for these codes.

For Medicare Plus Blue, BCN commercial and BCN Advantage members

For requests submitted for dates of service on or after Jan. 1, these procedure codes will require prior authorization for Medicare Plus Blue, BCN commercial and BCN Advantage members.

^aThis procedure code currently requires prior authorization for BCN commercial and BCN Advantage members. For dates of service on or after Jan. 1, 2022, this code will be associated with the new Blepharoplasty of the lower lid questionnaire. (For dates of service prior to Jan. 1, 2022, this code is associated with the Cosmetic or reconstructive surgery questionnaire.)

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.

Additional drugs require prior authorization for URMBT members with Blue Cross non‑Medicare plans

For dates of service on or after Jan. 27, 2022, we’re adding prior authorization requirements for the following drugs covered under the medical benefit for UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans:

• Blenrep™ (belantamab mafodotin-blmf), HCPCS code J9037
• Jemperli™ (dostarlimab-gxly), HCPCS codes J3490, J3590, J9999, C9082
• Monjuvi^® (tafasitamab-cxix), HCPCS code J9349
• Zynlonta^® (loncastuximab tesirine-lpyl), HCPCS codes J3490, J3590, J9999, C9084

Submit prior authorization requests through AIM Specialty Health^®, an independent company that contracts with Blue Cross Blue Shield of Michigan to provide benefit management services.

Prior authorization requirements apply when these drugs are administered in an outpatient setting.

This requirement doesn’t apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714).

How to submit authorization requests

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

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

Additional information

Authorization isn’t a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members.

For additional information on requirements related to drugs covered under the medical benefit for UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans, see:

• Medical oncology prior authorization list for UAW Retiree Medical Benefits Trust PPO non-Medicare members
• Medical Drug Management with Blue Cross for UAW Retiree Medical Benefit Trust PPO non-Medicare members

We’ll update the appropriate drug lists to reflect the information in this message prior to the effective date.

Accredo manages prior authorization requests for additional medical benefit drugs. Accredo is an independent company that works with the URMBT on specialty pharmacy services.

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

Blue Cross will provide physical therapy benefits for GM hourly employees under group number 83200

Effective Jan. 1, 2022, Blue Cross Blue Shield of Michigan will administer outpatient physical therapy benefits to GM hourly populations under group number 83200. TheraMatrix will no longer be the outpatient physical therapy provider for this group. 

Members will receive new ID cards in the mail with updated phone numbers so they can contact Customer Service if they have questions. Benefits and coverage will remain the same. Outpatient physical therapy and benefits don’t require a prior authorization. Nonparticipating providers aren’t covered.

On and after Jan. 1, 2022, contact Blue Cross if you have benefit and claims questions. You can also log in to Provider Secured Services to review benefits and submit claims. If you have questions, call Provider Relations and Servicing at the number on the back of the card or one of the following phone numbers:

• Physicians and other professional providers: 1-800-344-8525
• Hospital and facility providers: 1-800-249-5103

For processing or if you have questions about claims dated Dec. 31, 2021, and older, contact TheraMatrix at 1-888-638-8786 or theramatrix.com.** Theramatrix is an independent company that Blue Cross had contracted with to provide physical therapy services.

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

Get ready for welcome to Medicare and annual wellness visits for Medicare Plus Blue patients

The new year will bring new and existing Medicare Plus Blue℠ members to your medical practice for their annual wellness visits. These visits are at no cost to members and play an important role in helping maintain or improve their health.

Welcome to Medicare visit
New Medicare Plus Blue members should be scheduling their welcome to Medicare preventive visit, which is their Initial Preventive Physical Examination. This is a one-time appointment for new Medicare patients to be scheduled within their first 12 months of enrollment. Medicare pays for one welcome to Medicare visit per member, per lifetime.

This visit is a great way to get up-to-date information on health screenings, shot records, family medical history and other preventive care services. For more information on the components of a welcome to Medicare visit, see the Medicare Learning Network Educational Tool.**

The following is the billing code for the welcome to Medicare visit, also known as the Initial Preventive Physical Examination, or IPPE:

• G0402

Annual wellness visits

Existing Medicare Plus Blue℠ members should be scheduling their annual wellness visits. Medicare will cover an annual wellness visit every 12 months for patients who’ve been enrolled in Medicare for longer than 12 months.

The annual wellness visit is a chance for you to develop or update your patient’s personalized prevention plan based on his or her current health situation and risk factors. A health risk assessment is part of the annual wellness visit. It includes self-reported information from your patient to be completed before or during the visit. For more information on the components of an annual wellness visit, see the Medicare Learning Network Educational Tool.**

The following are billing codes for annual wellness visits, which include a personalized prevention plan of service:

• G0438 — First visit AWV; can only be billed one time, 12 months after a G0402 (IPPE)
• G0439 — Annual wellness visit (subsequent)

Note: G0438 or G0439 must not be billed within 12 months or previous billing of a G0402 (IPPE).
You can also offer to conduct virtual visits depending on your office’s capabilities.

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.

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

Helping to limit disability with osteoporosis management

Musculoskeletal conditions are the second largest contributor to disability, according to the World Health Organization.

The HEDIS^® measure** (also one of our Star measures) called Osteoporosis Management in Women who had a Fracture, or OMW, assesses women ages 67 through 85 who suffered a fracture and had either a bone mineral density test or received a prescription to treat osteoporosis within six months of the fracture.

Read the Osteoporosis Management in Women who had a Fracture tip sheet to learn more about this measure, including:

• Information to include in medical records
• ICD-10 codes to include on patient claims 

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

Register for Transitions of Care Medicare Star measure webinar

The four components of the HEDIS^® Transitions of Care measure will be added to the list of Medicare Star measures starting in 2022. Watch this short video about Blue Cross Blue Shield of Michigan and Blue Care Network’s training efforts to help you avoid gaps in care for this measure.

Register and attend a webinar

Learn more about Transitions of Care, including requirements and coding tips. To register, click on a sign-up link below.

Sign up for final live coding webinar of 2021; recent sessions now on‑demand

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.

More information

• 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.

Provider Experience delivers new on-demand training resources

Our online, on-demand, provider training courses are designed to help you work more efficiently with Blue Cross Blue Shield of Michigan and Blue Care Network.

The newest resources include:

• Claims Attachment Process video. This updated video guides you through the process of identifying services that need documentation, locating the Medical Record Routing Form and using it to correctly submit medical records or documentation.
• E-referral tutorials. We’ve made updates to several modules within the series. Tutorials review how to perform major tasks in the e-referral tool to manage referrals and authorizations. This series has moved from ereferrals.bcbsm.com to our new provider training site.
• 2021 lunch and learn webinar recordings. The newest topic added to the series, Updates for 2022 ICD-10 CM codes, reviews key changes for the ICD-10 CM codes and guidelines.

To request access to our training site, follow these steps:

1. Open the registration page.
2. Complete the registration. We recommend using the same email you use to communicate with Blue Cross and BCN for provider-related needs. This will become your login ID.
3. Follow the link to log in.

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

Help managing acute low back pain in adults

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

The Centers for Disease Control and Prevention estimates that 2.5 million Americans visit an outpatient clinical setting each year for the treatment of low back pain. To help doctors treat patients with this pain, the Michigan Quality Improvement Consortium developed a Management of Acute Low Back Pain in Adults** guideline.

The MQIC guideline focuses on assessment and conservative treatments for patients with no red flags of a more serious pathology. Diagnostic tests or imaging such as X-ray, CT scan or MRI are usually not required to treat low back pain in the first six weeks of onset. By avoiding imaging, exposure to radiation and health care costs are reduced.

To help patients recover from low back pain and for long-term protection, the American Academy of Orthopedic Surgeons developed a Spine Conditioning Program.** The program, developed in 2017, features a wide range of exercises designed to strengthen and support the spine.

Blue Cross and Blue Shield Federal Employee Program^® members can also access WebMD^® Interactive Resources with a MyBlue^® account. There, members can find information on the management and prevention of acute low back pain.

If you or members have questions about the online interactive resources and benefit information, call Customer Service at 1-800-482-3600.

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

Update: We’re aligning local rules for acute inpatient medical admissions

For certain conditions, authorization requests for acute medical admissions should be submitted only after the member has spent 48 hours in the hospital. Once the 48 hours has elapsed, the facility can submit the request to authorize an inpatient admission. You must provide clinical documentation that demonstrates that the InterQual^® criteria have been met at the time you submit the request.

Exception: When a member is receiving intensive care services that require an ICU setting, you can submit the request prior to completion of the 48-hour period, along with all clinical documentation supporting the critical level of care. 

We’re aligning our local rules for all lines of business to reflect this change.

Effective dates for this change

This update to local rules will go into effect as follows:

• For Medicare Plus Blue℠ and BCN Advantage℠ members: This change is effective for members admitted on or after Jan. 3, 2022.
• For Blue Care Network commercial members: This change is effective for members admitted on or after Feb. 1, 2022.
• For Blue Cross Blue Shield of Michigan commercial: This change is effective for members admitted on or after March 1, 2022.

Conditions this applies to

This applies to members with the following conditions:

How determinations will be made

Once the request has been received, Blue Cross and BCN will conduct a medical necessity review based on the clinical documentation you submitted. InterQual criteria will be applied based on the member’s condition at the time the clinical documentation is received:

• If InterQual criteria are met, the authorization request will be approved.
• If InterQual criteria aren’t met, the authorization request will be sent to the plan medical director for review.
• If the member hasn’t been in the hospital for 48 hours and isn’t in the ICU, Blue Cross and BCN will request that the facility wait until the member has been in the hospital for 48 hours to send additional information about the member’s condition. We’ll make the request through the Case Communication field in the e-referral system or by calling the facility, or both.

On the third day, Blue Cross and BCN will do the following:

• If the facility sent additional clinical information and it meets criteria, we’ll approve the request.
• If the facility hasn’t sent additional clinical information or has sent additional clinical information but it doesn’t meet criteria, we’ll refer the request to the medical director for review.

For requests that are nonapproved, Blue Cross and BCN will reimburse as observation. The hospital will need to submit a claim for observation reimbursement.

Reason for change

We expect that this change will:

• Reduce the number of communications that typically accompany these types of authorization requests.
• Decrease denials for lack of clinical information, because all clinical documentation in support of the admission would be received after 48 hours of hospital care.

Additional information

For most members, facilities can request peer-to-peer reviews, if desired. Refer to the document How to request a peer-to-peer review with a Blue Cross or BCN medical director.

In addition, facilities can appeal denial decisions as usual. Refer to the pertinent provider manual for information about how to submit an appeal.

Here’s what you need to know about DRG readmission processing and how to provide input

Blue Cross Blue Shield of Michigan is proposing an enhancement to DRG readmission processing. This improvement is scheduled for implementation on March 1, 2022, for Blue Cross commercial members. The program update will identify inpatient readmission claims prior to payment.

Currently, readmissions are identified by our clinical editing program and result in post-pay audits. This new process will eliminate the need for post-pay readmission audits.

What this means to hospitals

If a facility recognizes a readmission claim prior to billing Blue Cross for the second admission, it can rebill the first admission, including the services provided in the second admission, as noted in the online provider manual. This would eliminate the need for Blue Cross to deny the second admission.

If a claim qualifies as a readmission, based on the criteria outlined below, it will be denied, with further instructions. The provider will have the opportunity to resubmit all services from the original inpatient claim, along with services from the second claim.

If the facility disputes the determination that the readmission criteria was met, a level one appeal can be submitted. The appeal must include medical documentation that supports the rationale for payment of the denied claim. It’s the facility’s responsibility to rebill the original paid claim, combining the readmission services as outlined in the online provider manual.

When a patient is readmitted within 14 days, the following criteria will be used to determine if the first and second admissions match:

• Provider PIN
• Member ID
• Patient date of birth
• The same or similar DRG

The following services will be excluded from the first and second claims when a patient is readmitted within 14 days, based on guidelines from the Centers for Medicare & Medicaid Services:

• Chemo/immunotherapy procedure codes
• Discharge reason codes where patient left against medical advice
• Admissions to inpatient psychiatric, substance abuse, inpatient/outpatient rehabilitation and skilled nursing facilities

For more details, see our Blue Cross Commercial Provider Manual, which you can access through web-DENIS.

How to provide input

According to the Contract Administration Process — part of the Participating Hospital Agreement that went into effect July 1, 2021 — we will allow non-binding input from participating hospitals about this proposal.
Input from facilities is requested by Dec. 31, 2021. Send any input you may have to Liz Bowman at ebowman@bcbsm.com.

After input is received, Blue Cross has 30 calendar days to respond. 

Update: CADC, CAADC credentials not required for facilities that treat substance use disorders

Staff who work at facilities contracted with Blue Cross Blue Shield of Michigan and Blue Care Network for the treatment of substance use disorders aren’t required to have a Certified Alcohol and Drug Counselor, or CADC, or Certified Advanced Alcohol and Drug Counselor, or CAADC, credential.

This reverses our earlier communications on this topic, including an article in the August 2021 issue of The Record, an article in the September-October 2021 issue of BCN Provider News, a web-DENIS message posted July 1, 2021, and a news item posted in July on ereferrals.bcbsm.com.

Reason for the change

After we published the earlier communications, we had additional discussions with our contracted facilities and determined that requiring the CADC or CAADC credential creates hardships for facilities that are trying to recruit staff during the pandemic.   

As a result, Blue Cross and BCN are dropping the CADC and CAADC requirement and will defer to the agencies that accredit our contracted facilities, such as the Commission on Accreditation of Rehabilitation Facilities, The Joint Commission and similar agencies, to ensure that standards related to the education and credentialing of facility staff are met. 

It’s our hope that this will provide some relief as the pandemic continues and our contracted facilities continue to face challenges in recruiting clinical staff.

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

• Blue Cross commercial
• Medicare Plus Blue℠
• BCN commercial
• BCN Advantage℠

This applies to facilities that provide and bill for one or more of the following types of treatment for substance use disorders:

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

Starting Jan. 1, 2022, bill Medicare Advantage plans for administration of COVID‑19 vaccines and monoclonal antibody treatments

Beginning Jan. 1, 2022, the Centers for Medicare & Medicaid services will require Medicare Advantage plans to cover the cost to administer COVID-19 vaccines (including approved booster doses) and monoclonal antibody products to treat COVID-19, with no out-of-pocket costs for members.

For dates of service on or after Jan. 1, 2022, submit claims for the administration of vaccines and monoclonal antibody treatments to Blue Cross Blue Shield of Michigan or Blue Care Network for members with Medicare Plus Blue℠ or BCN Advantage℠ plans.

Note: If your patient scheduled an office visit on or after Jan. 1, 2022, for any other reason than getting the vaccine or monoclonal antibody treatments, bill the usual office visit charge.

More information

For more information on the COVID-19 vaccine, refer to CMS’ COVID-19 toolkit** for health care providers.
For more information on monoclonal antibody treatment, see the Monoclonal Antibody COVID-19 Infusion webpage** of CMS’ COVID-19 toolkit for health care providers.

Reminder

For dates of service on or after Oct. 1, 2021, cost share applies for any treatment related to COVID-19, other than monoclonal antibody treatment, for Medicare Plus Blue and BCN Advantage members.

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

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

Intensive outpatient program and partial hospital program services now payable on an ongoing basis when delivered through telemedicine

As previously communicated, Blue Cross Blue Shield of Michigan and Blue Care Network began allowing behavioral health intensive outpatient and partial hospital program services to be payable when provided by contracted facilities through telemedicine as a temporary measure during the COVID-19 pandemic.

Effective Nov. 1, 2021, we’re updating our Telemedicine Services medical policy to allow these services to be payable when delivered by contracted facility providers through synchronous (real-time) telemedicine on an ongoing basis, rather than as a temporary measure. We’re doing this to make it easier for members to receive these services beyond the COVID-19 pandemic.

For more information, including information about billing for these services, see the Telehealth for behavioral health providers document on our public website at bcbsm.com/coronavirus or within Provider Secured Services.

Reminders

• Facilities can provide behavioral health IOP and PHP services to BCN commercial and BCN Advantage℠ members only when their contracts specifically include IOP and PHP services.
• For Blue Cross commercial members, most plans don’t cover IOP services for mental health or PHP services for substance use disorders. IOP services for substance use disorders must be delivered by a substance abuse treatment facility. Be sure to check member eligibility and benefits through web-DENIS or by contacting Provider Inquiry before performing services.
• For Medicare Plus Blue℠ members, follow Centers for Medicare & Medicaid Services guidance.

Updated documents

We’ve updated the following documents to reflect this change:

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

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

You can view the updated Telemedicine Services medical policy through our Medical Policy & Pre-Cert/Pre-Auth Router on bcbsm.com.

Additional autism interventions delivered through telemedicine now payable

As previously communicated, Blue Cross Blue Shield of Michigan and Blue Care Network began allowing some services for autism spectrum disorder to be payable when delivered through telemedicine as a temporary measure during the COVID-19 pandemic.

Effective Nov. 1, 2021, we’re updating our Autism Spectrum Disorder Services medical policy to allow those telemedicine services to be payable on an ongoing basis. We’re also removing restrictions on protocol modification *97155.

These changes apply to members whose coverage includes an autism benefit. 

To determine which procedures can be performed through telemedicine for Medicare Plus Blue℠ members who have an autism benefit, see the Medicare-covered telehealth services for the COVID-19 PHE document.

Telemedicine services payable on an ongoing basis, effective Nov. 1

Per the updated medical policy, we’ll allow the following autism services to be delivered through synchronous (real time) telemedicine on an ongoing (no longer temporary) basis:

• Assessment, *97151
• Applied behavior analysis, or ABA, *97153

This service is allowed for children who meet appropriateness criteria. The Guidelines for autism interventions delivered through telemedicine document offers guidance in determining which members can benefit from direct-line ABA interventions delivered through telemedicine.

• Skills training, *97154
• Intensive skills training, *97158

Restrictions lifted on protocol modification

Per the updated medical policy, protocol modification *97155, will be allowed through real-time telemedicine visits 100% of the time. (Previously, this service was allowed to be delivered through telemedicine only 50% of the time.)

During the COVID-19 pandemic, for dates of service from April 14, 2020, through Oct. 31, 2021, we allowed licensed behavior analysts, or LBAs, to troubleshoot treatment protocols directly with the parent or caregiver functioning as the behavioral technician. With the Nov. 1, 2021, update to the Autism Spectrum Disorder medical policy, this temporary measure is no longer payable.

Reminder

The following services continue to be payable when delivered through real-time telemedicine: caregiver training (*97156), multi-family caregiver training (*97157), supervision (S5108) and caregiver training (S5111).

S5108 and S5111 are payable only to Michigan providers who deliver services to out-of-state members and can’t use the American Medical Association category 1 codes.

Updated documents

We’ve updated the following documents to reflect this change:

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

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

You can view the updated Telemedicine Services medical policy through our Medical Policy & Pre-Cert/Pre-Auth Router on bcbsm.com.

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.

Behavioral health services delivered through synchronous telemedicine

With the Nov. 1, 2021, updates to the following medical policies, additional behavioral health and autism spectrum disorder, or ASD, services are now payable when delivered through telemedicine:

• Telemedicine Services
• Autism Spectrum Disorder Services

Behavioral health and ASD services must be delivered synchronously (in real time), with the exception of *96130 and *96156, which can be delivered asynchronously.

Telemedicine asynchronous (store and forward) care generally isn’t payable for behavioral health services.

This applies to Blue Cross Blue Shield of Michigan commercial, Medicare Plus Blue℠, Blue Care Network commercial and BCN Advantage℠ members.

For more information about providing behavioral health and ASD services through telemedicine, see the Telehealth for behavioral health providers document, which is available on our public website at bcbsm.com/coronavirus or within Provider Secured Services.

You can view the updated medical policies through our Medical Policy &
Pre-Cert/Pre-Auth Router at bcbsm.com.

2022 member ID cards to display deductible, out‑of‑pocket maximum

Effective Jan. 1, 2022, ID cards issued to Blue Cross Blue Shield of Michigan and Blue Care Network commercial members will display their deductible and out-of-pocket maximum. This change applies to both the physical and electronic ID cards. The Consolidated Appropriations Act of 2021 requires us to provide this information on the ID cards issued to participants, beneficiaries or enrollees.

The new CAA mandate requires that issued ID cards contain the following:

• In-network and out-of-network individual and family deductibles
• Out-of-pocket maximums

The following is a sample card image:

Providers should continue to use webDENIS and PARS for benefit information.

In some cases, where member deductibles or out-of-pocket maximums aren’t available on the card, the card will show “See Benefits.” Members will be directed to access their benefits on bcbsm.com or the BCBSM mobile app.

In addition, for commercial members with prescription drug coverage, their ID cards will also show a new RxBIN to reflect our pharmacy benefit manager change from Express Scripts to OptumRx. This was announced in an article in the September 2021 Record and on Page 26 of the September-October 2021 BCN Provider News.

Our new, updated enrollment flyers assist providers joining our network

We’ve updated some of our enrollment flyers to help providers joining Blue Cross Blue Shield of Michigan or Blue Care Network. The Enrollment documents helpful hints flyers are step-by-step guides that walk providers through each section of their enrollment application. Depending on the classification type, providers may see different form fields on their application. Here are the three available flyers, with information on recent changes:

• The Enrollment documents helpful hints flyer now includes tips and hints for all provider types. Previously, this document was specific to behavioral health providers. This flyer can be found on the Provider enrollment page of bcbsm.com/providers.
• Outpatient psychiatric center information that was included in the original Enrollment helpful hints flyer has been separated into its own Enrollment documents helpful hints – New Outpatient Psychiatric Center flyer. Outpatient psychiatric centers can locate this flyer on their provider enrollment webpage after choosing Outpatient Psychiatric Care Facilities from the Facilities type list.
• An Enrollment documents helpful hints – New Ancillary Providers Located Outside of Michigan flyer was also created for those providers looking to enroll. This flyer can be found on the Provider enrollment page of bcbsm.com/providers.

Reminder: TurningPoint to review sites of care for total hip and knee surgeries for some members

For dates of service on or after Jan. 3, 2022, TurningPoint Healthcare Solutions, LLC will review the site of care for total hip and knee surgeries as part of each authorization determination. Based on medical necessity review, TurningPoint may approve authorization requests for select total hip and knee cases only when scheduled in an outpatient setting.

This applies to members with the following coverage:

• Medicare Plus Blue℠
• BCN commercial
• BCN Advantage℠

If TurningPoint approves an authorization for a hip or knee surgery in an outpatient setting and the member experiences a change in condition that requires an inpatient admission, you’ll need to submit an authorization request for the inpatient admission (procedure code *99222) through the e‑referral system; see the “Submit an inpatient authorization” section of the e-referral User Guide for more information. Blue Cross Blue Shield of Michigan or Blue Care Network will review the request, using InterQual^® criteria.

Performing total hip and knee surgeries in outpatient settings is supported by both evidence-based guidelines and the Centers for Medicare & Medicaid Services.

For more information about the TurningPoint musculoskeletal surgical quality and safety management program, see these pages on the ereferrals.bcbsm.com website:

• BCN Musculoskeletal Services
• Blue Cross Musculoskeletal Services

TurningPoint Healthcare Solutions, LLC is an independent company that handles authorizations for musculoskeletal surgical and other related procedures for Blue Cross Blue Shield of Michigan and Blue Care Network.

Additional drugs require prior authorization for URMBT members with Blue Cross non‑Medicare plans

For dates of service on or after Jan. 27, 2022, we’re adding prior authorization requirements for the following drugs covered under the medical benefit for UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans:

• Blenrep™ (belantamab mafodotin-blmf), HCPCS code J9037
• Jemperli™ (dostarlimab-gxly), HCPCS codes J3490, J3590, J9999, C9082
• Monjuvi^® (tafasitamab-cxix), HCPCS code J9349
• Zynlonta^® (loncastuximab tesirine-lpyl), HCPCS codes J3490, J3590, J9999, C9084

Submit prior authorization requests through AIM Specialty Health^®, an independent company that contracts with Blue Cross Blue Shield of Michigan to provide benefit management services.

Prior authorization requirements apply when these drugs are administered in an outpatient setting.

This requirement doesn’t apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714).

How to submit authorization requests

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

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

Additional information

Authorization isn’t a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members.

For additional information on requirements related to drugs covered under the medical benefit for UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans, see:

• Medical oncology prior authorization list for UAW Retiree Medical Benefits Trust PPO non-Medicare members
• Medical Drug Management with Blue Cross for UAW Retiree Medical Benefit Trust PPO non-Medicare members

We’ll update the appropriate drug lists to reflect the information in this message prior to the effective date.

Accredo manages prior authorization requests for additional medical benefit drugs. Accredo is an independent company that works with the URMBT on specialty pharmacy services.

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

Blue Cross will provide physical therapy benefits for GM hourly employees under group number 83200

Effective Jan. 1, 2022, Blue Cross Blue Shield of Michigan will administer outpatient physical therapy benefits to GM hourly populations under group number 83200. TheraMatrix will no longer be the outpatient physical therapy provider for this group. 

Members will receive new ID cards in the mail with updated phone numbers so they can contact Customer Service if they have questions. Benefits and coverage will remain the same. Outpatient physical therapy and benefits don’t require a prior authorization. Nonparticipating providers aren’t covered.

On and after Jan. 1, 2022, contact Blue Cross if you have benefit and claims questions. You can also log in to Provider Secured Services to review benefits and submit claims. If you have questions, call Provider Relations and Servicing at the number on the back of the card or one of the following phone numbers:

• Physicians and other professional providers: 1-800-344-8525
• Hospital and facility providers: 1-800-249-5103

For processing or if you have questions about claims dated Dec. 31, 2021, and older, contact TheraMatrix at 1-888-638-8786 or theramatrix.com.** Theramatrix is an independent company that Blue Cross had contracted with to provide physical therapy services.

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

Register for Transitions of Care Medicare Star measure webinar

The four components of the HEDIS^® Transitions of Care measure will be added to the list of Medicare Star measures starting in 2022. Watch this short video about Blue Cross Blue Shield of Michigan and Blue Care Network’s training efforts to help you avoid gaps in care for this measure.

Register and attend a webinar

Learn more about Transitions of Care, including requirements and coding tips. To register, click on a sign-up link below.

Sign up for final live coding webinar of 2021; recent sessions now on‑demand

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.

More information

• 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.

Provider Experience delivers new on-demand training resources

Our online, on-demand, provider training courses are designed to help you work more efficiently with Blue Cross Blue Shield of Michigan and Blue Care Network.

The newest resources include:

• Claims Attachment Process video. This updated video guides you through the process of identifying services that need documentation, locating the Medical Record Routing Form and using it to correctly submit medical records or documentation.
• E-referral tutorials. We’ve made updates to several modules within the series. Tutorials review how to perform major tasks in the e-referral tool to manage referrals and authorizations. This series has moved from ereferrals.bcbsm.com to our new provider training site.
• 2021 lunch and learn webinar recordings. The newest topic added to the series, Updates for 2022 ICD-10 CM codes, reviews key changes for the ICD-10 CM codes and guidelines.

To request access to our training site, follow these steps:

1. Open the registration page.
2. Complete the registration. We recommend using the same email you use to communicate with Blue Cross and BCN for provider-related needs. This will become your login ID.
3. Follow the link to log in.

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

Starting Jan. 1, 2022, bill Medicare Advantage plans for administration of COVID‑19 vaccines and monoclonal antibody treatments

Beginning Jan. 1, 2022, the Centers for Medicare & Medicaid services will require Medicare Advantage plans to cover the cost to administer COVID-19 vaccines (including approved booster doses) and monoclonal antibody products to treat COVID-19, with no out-of-pocket costs for members.

For dates of service on or after Jan. 1, 2022, submit claims for the administration of vaccines and monoclonal antibody treatments to Blue Cross Blue Shield of Michigan or Blue Care Network for members with Medicare Plus Blue℠ or BCN Advantage℠ plans.

Note: If your patient scheduled an office visit on or after Jan. 1, 2022, for any other reason than getting the vaccine or monoclonal antibody treatments, bill the usual office visit charge.

More information

For more information on the COVID-19 vaccine, refer to CMS’ COVID-19 toolkit** for health care providers.
For more information on monoclonal antibody treatment, see the Monoclonal Antibody COVID-19 Infusion webpage** of CMS’ COVID-19 toolkit for health care providers.

Reminder

For dates of service on or after Oct. 1, 2021, cost share applies for any treatment related to COVID-19, other than monoclonal antibody treatment, for Medicare Plus Blue and BCN Advantage members.

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

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

Blue Cross enhances tools for electronically prescribing medications and submitting prior authorizations

Blue Cross Blue Shield of Michigan is committed to enhancing its electronic processes across the health care spectrum, including the processes used by prescribers.

As part of our transition to OptumRx as our new pharmacy benefit manager, we’re making some improvements to our provider-facing tools to assist with prescribing and submitting prior authorizations electronically. These enhancements will primarily take place behind the scenes and won’t have a major effect on how providers prescribe and submit prior authorizations or check on patients’ benefits.

As you read in a September Record article, the move from Express Scripts, Inc. to OptumRx will take place Jan. 1, 2022, for commercial individual and group members, and Jan. 1, 2023, for Medicare Advantage individual and group members. 

Continue to use your current electronic medical record system or CoverMyMeds^® to submit electronic prior authorizations for Blue Cross and Blue Care Network members. Keep in mind that the BIN number changes to 610011, effective Jan. 1, 2022, for all Blue Cross and BCN commercial members.

Electronic prior authorization, or ePA, replaces faxing and phone calls so you can focus less on administrative tasks and more on patient care. For more information on ePA and CoverMyMeds, see our ePA flyer. Once we launch Availity, our new secure provider portal, we’ll also provide a link to Prompt PA, another resource that can be used to submit electronic prior authorization requests for pharmacy benefit drugs.

Also, continue to use electronic medical records for electronic prescribing and real-time prescription benefit checks. Note: You may have heard of a tool called PreCheck MyScript. This is a product name that OptumRx uses for its real-time benefit check connectivity and programing with electronic medical record systems. From a provider perspective, the interface will look and feel much the same as what providers currently use with Express Scripts.

By using these tools, physicians get patient-specific pharmacy information up front. And the better physicians and patients understand the medication options and costs at the point of prescribing, the more likely patients are to fill prescriptions and adhere to their medication regimen.

The Pharmacy team is communicating about these enhancements at various provider-facing forums, including regional medical director meetings, BCN business administrator meetings and network performance improvement meetings.

If you have any questions, call the Pharmacy Help Desk at 1-800-437-3803.

Additional drugs require prior authorization for URMBT members with Blue Cross non‑Medicare plans

For dates of service on or after Jan. 27, 2022, we’re adding prior authorization requirements for the following drugs covered under the medical benefit for UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans:

• Blenrep™ (belantamab mafodotin-blmf), HCPCS code J9037
• Jemperli™ (dostarlimab-gxly), HCPCS codes J3490, J3590, J9999, C9082
• Monjuvi^® (tafasitamab-cxix), HCPCS code J9349
• Zynlonta^® (loncastuximab tesirine-lpyl), HCPCS codes J3490, J3590, J9999, C9084

Submit prior authorization requests through AIM Specialty Health^®, an independent company that contracts with Blue Cross Blue Shield of Michigan to provide benefit management services.

Prior authorization requirements apply when these drugs are administered in an outpatient setting.

This requirement doesn’t apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714).

How to submit authorization requests

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

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

Additional information

Authorization isn’t a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members.

For additional information on requirements related to drugs covered under the medical benefit for UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans, see:

• Medical oncology prior authorization list for UAW Retiree Medical Benefits Trust PPO non-Medicare members
• Medical Drug Management with Blue Cross for UAW Retiree Medical Benefit Trust PPO non-Medicare members

We’ll update the appropriate drug lists to reflect the information in this message prior to the effective date.

Accredo manages prior authorization requests for additional medical benefit drugs. Accredo is an independent company that works with the URMBT on specialty pharmacy services.

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