No-cost COVID-19 treatment extended through March 31, 2021

As the pandemic continues, Blue Cross Blue Shield of Michigan and Blue Care Network want to ensure that members can get the care they need during these difficult times. We are extending the time frame for waiving the member cost share for COVID-19 treatment through March 31, 2021.

The coverage applies to Blue Cross, BCN, Medicare Plus Blue℠, BCN Advantage℠ and Medigap plans.

We’ll also continue to cover physician-approved testing and associated services for the duration of the public health emergency, as required by federal guidelines.

For more information, see our news release.

You can read about changes we’ve implemented for COVID-19 at bcbsm.com/coronavirus or log in to Provider Secured Services and click on Coronavirus (COVID-19).

Note: Some commercial self-funded groups are extending the waiver of member cost share. In addition, the Michigan Education Special Services Association, known as MESSA, and some Medicare Advantage groups have a different end date for the waiver of member cost share. Providers are encouraged to submit claims to Blue Cross and BCN and wait for the voucher before charging member cost share, if applicable.

Get ready for Availity: How to select an administrator

Blue Cross Blue Shield of Michigan and Blue Care Network will move to the Availity^® Provider Portal later in 2021. If you’re already an Availity user, you don’t need to do anything to access Blue Cross and BCN information once it’s available. If you’re not currently using Availity, here’s some information to help you prepare for the transition.

Choose a primary administrator
If your organization (office, practice or facility) doesn’t currently participate with Availity, you’ll need to select someone on your team to serve as the Availity primary administrator. The person selected for this role must be at least 18 years old. The primary administrator will handle access for other users, which will speed up their enrollment process. Every organization is required to have one primary administrator.

Select someone who knows each team member’s access needs, or create an internal process for the primary administrator to review and confirm access needs. The goal is to make sure team members have access only to the roles and permissions they need to do their jobs.

A primary administrator who controls access helps safeguard patient information, maintain compliance with federal privacy and security laws, and reduce opportunities for fraud and abuse. This ensures that:

• Your biller can check the status of claims.
• Your referral coordinator can submit authorization requests.
• The Availity experience is streamlined to focus on the tools team members need.

Also, your primary administrator will be able to add team members or change access needs with just a few keystrokes. This will replace having to fax a form for every change.

The primary administrator can have help
While each organization can only have one primary administrator who has access to all administrative functions, you can also delegate others to handle specific roles. These include:

• Administrator assistant — This individual can request change on behalf of the organization, but not on behalf of users. An example could be enrolling the organization in an electronic funds transfer.
• User administrator — This individual can request change on behalf of users, but not the organization. This includes adding or deleting users, and changing user roles.
• Administrator reports — This individual can pull Availity reports, such as user activity reports or transaction reports, on behalf of the organization.

Start thinking about the administrator structure that will work best for your organization, so you’ll be able to register in the coming months. Availity will make the administration tasks easy with training, forums and reports.

Questions?
We have a Frequently Asked Questions document about our move to Availity. If you have a question, check here first to see if it’s already been answered. If it hasn’t, you can submit your question to ProviderPortalQuestions@bcbsm.com, so we can answer your question and consider adding it to the FAQ document.

If you need immediate assistance or have a question specific to a certain member or situation, use our website resources or contact Provider Inquiry.

 Web resources:

• Log in as a provider at bcbsm.com.
• Find prior authorization information for Michigan providers at ereferrals.bcbsm.com.
• Find prior authorization information for non-Michigan providers and medical policy information by going to bcbsm.com/providers and clicking on Quick Links.

Provider Inquiry numbers are available at bcbsm.com/providers.

• Click on Contact Us.
• Click on the type of provider you are
• Click Provider Inquiry.

Call the Blue Cross Web Support Help Desk at 1-877-258-3932 if you have problems with the current Blue Cross Provider Secured Services site.

Blue Cross amends procedures eligible for pilot program to promote pain control through limiting post-operative opioid dispensing

In August 2018, Blue Cross Blue Shield of Michigan announced an initiative for select surgeries aimed at promoting effective pain control through care processes that limit opioid dispensing. In 2021, modifications will be made to the eligible surgical groupings by adding some groupings, extending some and retiring others.

The following surgical groupings will be eligible for the modifier 22 billing, effective Jan. 1, 2021, and will remain eligible through Dec. 31, 2022:

• Cesarean delivery
• Colectomy (laparoscopic or open)
• Hysterectomy (laparoscopic or open)
• Proctectomy (under new prescribing guidelines; see updated recommendations in the link below)

The following surgical groupings will be extended until Dec. 31, 2021

• Adrenalectomy
• Appendectomy (adult)
• Bariatric surgery
• Carpel tunnel release
• Carotid endarterectomy
• Endovascular aneurism repair
• Inguinal hernia repair
• Parathyroidectomy
• Pediatric appendectomy
• Thyroidectomy
• Umbilical hernia repair
• Ureteroscopy
• Vasectomy
• Ventral hernia repair

The following surgical groupings will no longer be eligible for modifier 22, effective April 1, 2021:

• Endoscopic sinus surgery and septoplasty
• Laparoscopic cholecystectomy

Using modifier 22

To submit your attestation statement indicating that appropriate protocols were included as part of the surgery, follow the process for submitting medical records and other claim attachments when appending modifier 22 to a qualifying procedure. For details, see the “Claims” chapter of the provider manual.

Also, to bill modifier 22 for adherence with the Pain Control Optimization Pathway, the physician agrees to follow the prescribing recommendations of the Michigan Opioid Prescribing Engagement Network, or Michigan-OPEN. For information, click here.**

The physician also agrees to the following guidelines:

• No additional pills are prescribed after the initial discharge prescription.
• No opioid prescriptions have been filled within 30 days before surgery, with certain exceptions.
• For procedures with limited opioids recommended after surgery, Blue Cross will allow up to 10% to have an additional fill for an opioid within 30 days after surgery to accommodate unexpected excessive pain.
• This pilot program is expected to last one to two years, based on results. We’ll announce further details in future Record articles.

Background

In 2018, the payment policy was modified to allow surgeons to report modifier 22 for an additional 35% reimbursement when pain control optimization protocols are used to support the surgery. The initial period of the pilot program included the following surgical categories:

• Laparoscopic cholecystectomy
• Inguinal hernia repair
• Thyroidectomy
• Endoscopic sinus surgery and septoplasty
• Prostatectomy
• Bariatric surgery

Due to the success of the pilot program, we expanded the program to also include the following surgical groupings in July 2019:

• Adrenalectomy
• Appendectomy (adult)
• Carpel tunnel release
• Carotid endarterectomy
• Endovascular aneurism repair
• Parathyroidectomy
• Pediatric appendectomy
• Umbilical hernia repair
• Ureteroscopy
• Vasectomy
• Ventral hernia repair

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

Blue Cross doesn’t reimburse providers for experimental drugs

Blue Cross Blue Shield of Michigan and Blue Care Network won’t reimburse providers for experimental drugs, effective Jan. 1, 2021. This applies to all claims submitted for Blue Cross commercial, Medicare Plus Blue℠, BCN commercial and BCN Advantage℠ members.

When you bill these types of drugs on a UB-04 for inpatient services, use the correct revenue code and modifiers for experimental drug usage. Use revenue code 0256 – experimental drugs, along with the appropriate Advance Beneficiary Notice of Noncoverage modifier (GA, GX, GY, GZ).

Health care providers may not bill members for such services unless, prior to the services, all these requirements are met:

• You provide the member with a cost estimate of the service.
• You have the member confirm in writing that he or she assumes financial responsibility for the service.

The member understands that Blue Cross won’t reimburse the provider for the service.

New ICD-10-CM/PCS COVID-19 diagnosis and procedure codes now available

The Centers for Medicare & Medicaid Services, in conjunction with the Centers for Disease Control and Prevention and the National Center for Health Statistics, has  released a January ICD-10-CM/PCS code update, which will be effective with dates of service on or after Jan. 1, 2021. The update was released in response to the national emergency that was declared due to the COVID-19 outbreak.

It includes six new ICD-10-CM (diagnosis) codes and 21 ICD-10-PCS (inpatient procedure) codes to capture COVID-19 diagnoses and inpatient procedures for COVID-19. We’ve created a document listing the new codes.

For more information, visit the ICD-10 section** of the CMS website:

• From the home page, click on 2021 ICD-10-CMS or 2021 ICD-10 PCS.
• In the Downloads section of the page, you can select Coding Guidelines, Code Descriptions or other key information you may need.

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

2021 HCPCS codes delayed, CPT Update document published

As you may have read in a web-DENIS message posted Nov. 18, the Centers for Medicare & Medicaid Services delayed release of its 2021 HCPCS codes.

Due to the delay in publishing the codes and the final rules, Blue Cross Blue Shield of Michigan anticipates a delay in updating its claims processing systems. We’re preparing a contingency plan to ensure that the codes are accepted and implemented as soon as possible.

2021 CPT codes

Each year, we publish our HCPCS Update document, containing new and deleted HCPCS and CPT codes, and post it on web-DENIS. But this year, because of the delay, we’re publishing a CPT codes-only document. Once the HCPCS codes are received and go through the appropriate Blue Cross review and implementation process, we’ll update the document to include both the CPT and the HCPCS codes for 2021.

To access the 2021 CPT Update from web-DENIS, follow these steps:

1. Click on BCBSM Provider Publications and Resources.
2. Click on Newsletters and Resources.
3. Click on Clinical Criteria & Resources.
4. Scroll down to HCPCS and CPT Updates.

We’ll provide updates via web-DENIS or The Record as soon as the document is updated to include HCPCS codes for 2021.

Learn to conduct a physical exam using telemedicine

Gretchen C. Goltz, D.O., a Blue Cross Blue Shield of Michigan medical director, has created a training video to help health care providers conduct thorough physical exams using audio and visual telemedicine. It covers the following aspects of the exam:

• Head, eyes, ears, nose and throat
• Skin
• Cardiopulmonary
• Abdominal and genitourinary
• Musculoskeletal
• Neurological

Click here to see the video.

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

Mi-COVID19 registry earns national recognition

Blue Cross Blue Shield of Michigan’s Collaborative Quality Initiative program was recently awarded the Blue Cross and Blue Shield Association’s Fast Network Best Practice Prize. We won the prize for the rapid development and implementation efforts of the Mi-COVID19 registry through the Hospital Medicine Safety, or HMS, Collaborative Quality Initiative.

The 2020 Fast Network Best Practice Prize recognized plans demonstrating innovations for improving health equity and addressing the effects of the COVID-19 pandemic. Blue Cross Blue Shield of Michigan was a finalist among 12 other Blue plans demonstrating the effectiveness of CQI programs in rapidly bringing together providers across the state to implement quality improvement initiatives, particularly in times of crisis.

The goal of HMS has been to improve the quality of care for hospitalized medical patients who are at risk for adverse events. In April 2020, within weeks of the pandemic hitting Michigan, HMS launched a clinical registry focused on Michigan patients hospitalized with COVID-19.

The purpose of this initiative was to quickly obtain data to understand this patient population and help support clinical decision-making across Michigan. The Mi-COVID19 initiative consisted of 40-plus hospitals and health systems across the state of Michigan. They worked together to share and learn best practices to improve care for patients with COVID-19.

Participating hospitals in the Mi-COVID19 clinical data registry have performed rigorous chart abstractions of patients hospitalized with COVID-19. Here are the goals of collecting data from the patients’ medical records:

• Identifying factors associated with critical illness and severe course, and outcomes
• Identifying patient characteristics, care practices and treatment regimens associated with improved outcomes
• Understanding the long-term complications for hospitalized patients, including readmission, mortality and returning to normal activities.
• Evaluating variability of care processes across Mi-COVID19 hospitals and identifying processes associated with improved outcomes

A recent study conducted through the COVID-19 initiative uncovered widespread unnecessary prescribing of antibiotics for early patients. When COVID-19 cases were peaking in the spring, more than half of hospitalized patients suspected of having the virus received antibiotics, just in case they had a bacterial infection. Yet testing showed that more than 96% of them only had the coronavirus — which isn’t affected by antibiotics.

Based on the study findings, inpatient COVID-19 treatment guidelines have been updated and can help providers across the country supply better care for patients.

The rapid speed in which the COVID-19 CQI could be pulled together is further proof that the platform and support provided by Blue Cross Blue Shield of Michigan can make a big difference when emerging health crises develop.

As the pandemic continues, HMS is launching a sepsis initiative across 15 pilot hospitals starting in first-quarter 2021. The initiative will incorporate key elements from the COVID-19 data collection into the quality improvement efforts for sepsis care.

About CQIs
Collaborative Quality Initiatives, or CQIs, are provider-led, statewide initiatives for quality improvement. They involve hospitals and physicians across the state collecting, sharing and analyzing data on patient risk factors, processes of care and outcomes of care, then designing and implementing changes to improve patient care.

The award-winning CQI model is the first of its kind nationally and is internationally recognized as an innovative approach to improving health care quality and value. CQI findings are routinely published in peer-reviewed literature, and best practices discovered in Michigan are widely implemented across the globe. 

The CQI platform has been profiled in presentations in more than 30 countries on five continents.

Click here for more information about the award-winning CQI model.

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.

Starting Jan. 1, Northwood is Blue Cross’ DME/POS program benefits manager

Starting Jan. 1, 2021, Northwood Inc. will administer and manage all aspects of durable medical equipment, prosthetics, orthotics and medical supply benefits for Blue Cross Blue Shield of Michigan commercial fully insured and individual members who reside in the state of Michigan.

Only members in groups enrolled in the program are required to participate. Blue Care Network, BCN Advantage℠, and Medicare Plus Blue℠ are already part of the tailored network arrangement with Northwood.

Northwood will administer:

• Prior authorizations
• Member services
• Claims payments
• Provider appeals, contracting, management and training
  

DME/POS program categories and examples of services include:

Standard equipment

• Requires little or no servicing by the member or provider
• CPAP, walkers, canes, crutches and commodes

Labor-intensive equipment

• Requires frequent servicing by trained professionals
• Oxygen or respiratory equipment, custom rehabilitation

Body supports and limbs

• Specifically fitted for the member’s needs
• Cervical collars, braces and limb replacement (prosthetics), orthotics

Medical or surgical supplies

• Essential for use with covered equipment
• Diabetic supplies, dressings, ostomy and urological

Prior authorization

• Out-of-state claims will go through NASCO and don’t require Northwood prior authorization.
• Northwood will be handling DME/POS prior authorization decisions.
• Northwood’s benefit coordinators will be your initial contact for requesting a prior  authorization.
• If product or service can’t be authorized by a benefit coordinator because it doesn’t immediately meet criteria, it’ll go to Northwood’s Case Review department.
• If Northwood’s medical director determines that the requested equipment or service doesn’t meet medical criteria, Northwood will issue a denial to the provider and member.

Participation
Blue Cross' DME/POS providers can contract with Northwood to provide these services to our commercial PPO membership. This includes providers already in the Northwood network.

If you’re interested in applying to the Northwood network, contact Northwood Provider Relations at 1‑800‑447‑9599 between 8:30 a.m. and 5 p.m. Eastern time Monday through Friday. Or email provideraffairs@northwoodinc.com.

You may also fill out an application online at northwoodinc.com.**

Additional information
For more information about the DME/POS program and how it works, refer to the following documents at bcbsm.com/providers:

• Northwood DMEPOS Management Program FAQ
• Northwood DMEPOS Management Program: Procedure Codes Requiring Prior Authorization

If you have additional questions about the 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.

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

We’re expanding access to diabetes monitoring products for commercial members, starting in January

Starting Jan. 1, 2021, diabetes monitoring products, such as glucometers and test strips, lancets, continuous glucose monitors and insulin delivery devices, will be added to the pharmacy benefit for Blue Cross Blue Shield of Michigan commercial and Blue Care Network commercial members.

Members will be able to obtain diabetes monitoring products or supplies through participating pharmacies or through durable medical equipment providers, as outlined below.

Participating pharmacies

Select glucometers and continuous glucose monitors will be available through members’ pharmacy benefit with no cost sharing.

Other diabetes supplies will be covered according to the drug list for the member’s plan. The appropriate pharmacy cost sharing or copayment will apply.

Glucometers and continuous glucose monitoring products that are available with no cost sharing include:

• OneTouch Verio Reflect^®
• OneTouch Verio Flex^®
• OneTouch Ultra^® 2
• Contour^®
• Contour Next
• Contour Next One
• Contour Next EZ
• Dexcom G5™ receivers and transmitters
• Dexcom G6™ receivers and transmitters

Durable medical equipment providers

Members can also obtain diabetes monitoring products through a DME provider. The process to locate DME providers varies depending on a member’s plan:

• Blue Cross commercial fully insured groups: These members must obtain their diabetes monitoring products through a Northwood Inc. network provider starting Jan. 1. To find a Northwood network provider, members can do one of the following:
• Log in to their Blue Cross member account through bcbsm.com or our mobile app and click on Find a Doctor.
• Go to bcbsm.com/dmesupplies and click on Find a Northwood provider.

A Northwood icon appears next to each Northwood network provider.

• Blue Cross commercial self-funded groups: To find a network provider, members can log in to their secure member account through bcbsm.com or our mobile app and click on Find a Doctor.
• BCN commercial members: To find a J&B Medical Supply network provider, members can do one of the following:
• Log in to their secure member account through bcbsm.com or our mobile app and click on Doctors & Hospitals. They can then click on the durable medical equipment link.
• Call J&B Medical Supply at 1-888-896-6233.

What this change means

This change effects members as follows:

• Blue Cross commercial fully insured groups: For these groups and members, we’re  moving to the Northwood network, beginning Jan. 1, 2021.
  
  Starting Jan. 1, if members use a provider in the Northwood network, their medical copayment, cost sharing, coinsurance or deductible won’t change. However, if members use a provider outside the Northwood network on or after Jan. 1, they may pay a higher copay, cost share, coinsurance or deductible. Members can obtain diabetes supplies and prescriptions from a participating network pharmacy or from a provider through the Northwood network.

• Blue Cross commercial self-funded groups: There’s no change to how members obtain DME. Members can continue to get diabetes supplies from the DME provider they’re using now under the pharmacy benefit.
• BCN commercial members: J&B Medical Supply is the diabetic supplies DME provider for BCN commercial members. There won’t be a negative effect on members who currently receive diabetes monitoring supplies under the medical benefit. This change simply expands access by allowing members to get diabetes supplies and prescriptions from participating network pharmacies, in addition to the DME providers they’re using now.

Reminder: We’re expanding our cardiology services authorization program with AIM for some members

Starting Jan. 1, 2021, we’re adding some cardiology services that will require authorization by AIM Specialty Health^® for Medicare Plus Blue℠, Blue Care Network commercial and BCN Advantage℠ members.

The services include cardiac implantable devices and arterial ultrasound for dates of service on or after Jan. 1, 2021. Please refer to the November 2020 Record article for more information.

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

Blue Cross Blue Shield of Michigan recognizes that for certain procedures, additional effort is required and additional costs are incurred when performed outside of a hospital setting. Starting Feb. 1, 2021, the PPO physician reimbursement policy will increase allowed amounts by 15% for select procedures when done in an ambulatory surgical facility. For a preliminary list of the CPT codes for these procedures, click here.

Note: This is in addition to the procedures identified in the May 2020 Record article, with payment policy that was adjusted in July 2020.

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

AIM to handle prior authorization for some high-tech radiology services for Michigan FEP members

Starting Feb. 1, 2021, AIM Specialty Health^® will handle select high-tech radiology services for Michigan Blue Cross and Blue Shield Federal Employee Program^® members receiving services in Michigan. AIM is an independent company that manages authorizations of select services for Blue Cross Blue Shield of Michigan.

Providers must request authorization from AIM prior to the services being performed. Authorization requests for these services can be submitted on and after Jan. 18, 2021, for services performed on or after Feb. 1, 2021.

Note: For dates of service prior to Feb. 1, 2021, prior authorization for high-tech radiology from AIM isn’t required for high-technology radiology services covered under the medical benefit for FEP Blue Cross and Blue Shield Service Benefit Plan  members.

• Verify members have active coverage on the date of service and that services are covered under the FEP Blue Cross and Blue Shield Service Benefit Plan.

AIM will review prior authorizations for the following — MRI, MRA, CT and PET. For a list of the procedure codes that require prior authorization through AIM, click here.

How to submit authorization requests

Submit authorization requests using one of the following methods:

• Online through the AIM provider portal**
• By calling AIM at 1-800-728-8008

As a reminder, requests should be submitted before the services are provided.

Questions?

If you have questions, call AIM at 1-800-728-8008 or visit the AIM website.** You can also contact your provider consultant.

Additional information

For requirements related to high-tech radiology services covered under the medical benefit for Blue Cross Blue Shield of Michigan commercial members and for Blue Care Network commercial members, refer to the ereferrals.bcbsm.com website.

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

Starting March 1, changes coming to site-of-care requirements for Blue Cross commercial and BCN commercial pediatric members

Beginning March 1, 2021, site-of-care exemptions will no longer apply to pediatric Blue Cross Blue Shield of Michigan commercial members and pediatric Blue Care Network commercial members for some drugs covered under the medical benefit.

This means all drugs that have site-of-care requirements for adult commercial members will have the same site-of-care requirements for pediatric commercial members.

For these drugs:

• Pediatric members who begin therapy at a hospital outpatient location before March 1 are authorized to continue treatment at the current location through Aug. 31, 2021. This will provide continuity of care and give members time to work with their providers during the transition period.
• Pediatric members who begin therapy on or after March 1 must have an authorization that includes a site-of-care approval. Members should talk to their doctors before March 1 to arrange to receive infusion services at one of the following locations:

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

Notes

• Pediatric members who begin therapy on or after March 1 will be authorized to receive the first dose at a hospital outpatient facility.
• If a member requires treatment in a hospital outpatient setting, the provider must submit clinical documentation to establish medical necessity; the plan will review the documentation and make a determination.

Definition of pediatric members

Pediatric members are defined as one of the following:

• 15 years old or younger, regardless of weight
• 16 through 18 years old who weigh 50 kilograms or less

More about the authorization requirements

• These authorization requirements apply only to groups that currently participate in the commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit.
• Authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

How to submit authorization requests

Submit authorization requests through the NovoLogix^® online tool. It offers real-time status checks and immediate approvals for certain medications.

To learn how to submit requests through NovoLogix, go to ereferrals.bcbsm.com and do the following:

• For BCN commercial members: Click on BCN and then click on Medical Benefit Drugs. In the BCN HMO (commercial) column, see “How to submit authorization requests electronically using NovoLogix.”
• For Blue Cross commercial members: Click on Blue Cross and then click on Medical Benefit Drugs. In the Blue Cross PPO (commercial) column, see “How to submit authorization requests electronically using NovoLogix.”

Lists of requirements
To view requirements for these drugs, see the following drug lists:

• Standard commercial medical drug program: Blue Cross and BCN utilization management medical drug list for Blue Cross PPO (commercial) and BCN HMO (commercial) members
• UAW Retiree Medical Benefits Trust non-Medicare members: Medical Drug Management with Blue Cross for UAW Retiree Medical Benefit Trust PPO non-Medicare members
• Blue Cross and Blue Shield Federal Employee Program^® non-Medicare members: Utilization management medical drug list for Blue Cross and Blue Shield Federal Employee Program^® non-Medicare members

Update: Oncology management program for Blue Cross fully insured commercial members doesn’t include codes S0353, S0354

We wrote in the September edition of The Record that Blue Cross Blue Shield of Michigan expanded its medical oncology management program to include all fully insured commercial members starting Dec. 1, 2020. The program is administered by AIM Specialty Health^®. However, because of an update to the program, providers can’t bill or receive the enhanced reimbursement for codes S0353 or S0354 for Blue Cross commercial fully insured members.

This change doesn’t apply to Medicare Plus Blue℠, Blue Care Network commercial and BCN Advantage℠ members or to UAW Retiree Medical Benefits Trust non-Medicare members. For those members, providers can bill and be reimbursed for codes S0353 and S0354.

The Oncology management program: Frequently asked questions for providers document has been updated to reflect this change. Look in the section titled “About enhanced reimbursement.” Find the FAQ at ereferrals.bcbsm.com on the Blue Cross AIM-Managed Procedures page.

Authorization for IOP treatment no longer required for State of Michigan enrollees starting in January

Providers will no longer need to obtain authorization for intensive outpatient services from New Directions Behavioral Health for State of Michigan enrollees (group number 007000562), starting Jan. 1, 2021. Previously, the State of Michigan was one of the few groups that required authorization for IOP services.

Authorization will continue to be required for all higher level of behavioral health care admissions for which State of Michigan enrollees have a benefit, including acute inpatient psychiatric, substance use disorder acute detox and residential care, psychiatric and SUD partial hospitalization, and outpatient applied behavioral analysis treatment for autism.

Providers and office staff can log in to WebPass** to request prior authorizations for State of Michigan members. Providers who’ve never utilized WebPass before can visit the website** to review a training tutorial on how WebPass works.

Reminder

• Medical necessity criteria for New Directions is available on web-DENIS.
• Log in to web-DENIS.
• Click on BCBSM Provider Publications and Resources on the left side of the page.
• Click on Newsletters and Resources.
• Click on Clinical Criteria & Resources under Popular Links.
• Scroll down to Behavioral Health Information and Current Behavioral Health Clinical Criteria — Use for admissions on or after Jan. 1, 2020.
• Be sure to check your patients’ member ID cards and web-DENIS for eligibility and prior authorization information. 

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

Reminder: Providers must submit authorization requests to TurningPoint for musculoskeletal procedures for most members

As we reported in the November issue of The Record and the November-December issue of BCN Provider News (Page 46), TurningPoint Healthcare Solutions LLC has expanded its surgical quality and safety management program for dates of service on or after Jan. 1, 2021.

You now need to submit authorization requests for orthopedic, pain management and spinal procedures to TurningPoint for the following groups and members:

• Blue Cross commercial — All fully insured groups and select self-funded groups
• Medicare Plus Blue℠ members
• BCN commercial members
• BCN Advantage℠ members

Some important reminders

• Facilities should have an authorization number before scheduling surgery. The ordering physician or provider office must secure the authorization and provide the authorization number to the facility.
• For inpatient professional claims, include only the procedure codes authorized by TurningPoint on claims for musculoskeletal procedures.
• For procedures affected by the Jan. 1 program expansion, TurningPoint began accepting authorization requests on Dec. 1, 2020.
• You have until April 30, 2021, to submit retroactive authorization requests to eviCore healthcare^® for:
• Spinal procedures for Blue Cross’ commercial fully insured groups and Medicare Plus Blue members for dates of service prior to Jan. 1
• Pain management procedures for all Blue Cross commercial fully insured groups, select Blue Cross commercial self-funded groups, all Medicare Plus Blue members, all BCN commercial members and all BCN Advantage members for dates of service prior to Jan. 1

Webinar training
We’ll continue to offer webinar training for providers, facilities and clinical staff. Use the links below to register.

Professional provider training includes information about TurningPoint’s clinical model, operational changes and provider portal.

Facility training includes information about TurningPoint’s clinical model and operational changes and the facility verification process.

Portal training includes information about using the TurningPoint provider portal.

Where to find more information
For more information about TurningPoint, see the following pages on the ereferrals.bcbsm.com website:

• Blue Cross Musculoskeletal Services
• BCN Musculoskeletal Services

To view the lists of codes for which TurningPoint manages authorizations, see Musculoskeletal procedure codes that require authorization by TurningPoint.

For detailed information, see Musculoskeletal procedure authorizations: Frequently asked questions for providers.

Medical specialty drug prior authorization list will change in January for Blue Cross commercial fully insured groups

For dates of service on or after Jan. 18, 2021, we’re adding prior authorization requirements for the following specialty drugs covered under the medical benefit for Blue Cross Blue Shield of Michigan commercial fully insured groups, with the exception of the Michigan Education Special Services Association and the Blue Cross and Blue Shield Federal Employee Program^®:

• Blenrep (belantamab mafodotin-blmf), HCPCS codes J3490, J3590, J9999, C9399
• Monjuvi™ (tafasitamab-cxix), HCPCS codes J3490, J3590, J9999, C9399

Providers must request prior authorization for these drugs through AIM Specialty Health^®.

How to submit authorization requests

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

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

For information about registering for and accessing the AIM ProviderPortal℠, see the Frequently asked questions page** on the AIM website.

More about authorization requirements

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

For additional information on requirements related to drugs covered under the medical benefit, see the Blue Cross and BCN utilization management medical drug list and the Medical oncology prior authorization list.

We’ll update these lists to reflect these changes prior to the effective dates.

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

Changes coming Jan. 1 for preferred, clinical, custom and custom select drug lists

We recently published an article that detailed changes to the Preferred Drug List, starting Jan. 1, 2021. We’re making an update to the exclusion information: Cimzia^® and Kevzara^® will remain on the Preferred Drug List. These drugs won’t be excluded.

Preferred Drug List changes
The following tables show the Preferred Drug List changes that are effective Jan. 1, 2021.

Drugs no longer covered – Preferred Drug List
We’ll no longer cover the following brand-name and generic drugs. If a member fills a prescription for one of these drugs on or after Jan. 1, 2021, he or she will be responsible for the full cost. The list below shows preferred alternatives that have similar effectiveness, quality and safety. Unless noted, we won’t cover both the brand-name and available generic equivalents. The example brand names of preferred alternatives are for your reference. When a prescription is filled, the generic equivalent is dispensed, if available.

Drugs with a higher copayment – Preferred Drug List
The brand-name drugs with a higher copayment are listed below along with the preferred alternatives with similar effectiveness, quality and safety. The example brand names of preferred alternatives are for your reference. When a prescription is filled, the generic equivalent is dispensed, if available.

Drugs with quantity limits – Preferred Drug List
These drugs have changes to the amount that can be filled.

Clinical, Custom and Custom Select Drug List changes
The following tables show the changes that are effective starting Jan. 1, 2021, for the Clinical, Custom or Custom Select Drug lists.

Drugs no longer covered – Clinical and Custom Drug lists
We’ll no longer cover the following brand-name and generic drugs. If a member fills a prescription for one of these drugs on or after Jan. 1, 2021, he or she will be responsible for the full cost. The list shows preferred alternatives that have similar effectiveness, quality and safety. Unless noted, we won’t cover both the brand-name and available generic equivalents. The example brand names of preferred alternatives are for your reference. When a prescription is filled, the generic equivalent is dispensed, if available.

Drugs with a higher copayment – Custom Drug List
The brand-name drugs with a higher copayment are listed below along with the preferred alternatives that have similar effectiveness, quality and safety. The example brand names of preferred alternatives are for your reference. When a prescription is filled, the generic equivalent is dispensed, if available.

Drugs no longer covered – Custom Select Drug List
We’ll no longer cover the following brand-name and generic drugs. If a member fills a prescription for one of these drugs on or after Jan. 1, 2021, he or she will be responsible for the full cost. The list shows preferred alternatives with similar effectiveness, quality and safety. Unless noted, we won’t cover both the brand-name and available generic equivalents. The example brand names of preferred alternatives are for your reference. When a prescription is filled, the generic equivalent is dispensed, if available.

Drugs with quantity limits – Clinical, Custom and Custom Select Drug lists
These drugs have changes to the amount that can be filled:

**Represents drugs that have brand names without generic equivalents. These may be considered “authorized generics,” which are the same as brand-name drugs but aren’t true generic drugs.

***Doesn’t apply to members whose plans use the Custom Select Drug List.

Manufacturer discontinues Zostavax shingles vaccine

Pharmaceutical company Merck announced it has discontinued the Zostavax^® vaccine, a vaccine for the prevention of shingles in adults age 60 and older. All remaining product had an expiration date of November 2020, and Zostavax is no longer available for use in the United States.

On Dec. 1, 2020, Blue Cross Blue Shield of Michigan and Blue Care Network commercial pharmacy stopped covering the Zostavax vaccine. Pharmacy claims for Zostavax will reject at the point of sale as of Dec. 1, 2020.

Blue Cross and BCN will continue to offer the Shingrix^® shingles prevention vaccine for adults age 50 and older.

Expansion of drug waste avoidance program starts March 1

To minimize drug waste, reduce unnecessary drug exposure and decrease the risk of adverse events, we’re expanding our waste avoidance program to include additional drugs, effective March 1, 2021.

This change affects Blue Cross Blue Shield of Michigan commercial and Blue Care Network commercial members who receive these drugs:

• Onpattro^®, HCPCS code J0222
• Orencia^®,** HCPCS code J0129
• Stelara^®, HCPCS code J3357
• Stelara IV^®,** HCPCS code J3358
• Soliris^®, HCPCS code J1300
• Ultomiris^®, HCPCS code J1303

When this change takes effect, dosing for these therapies will be based on weight and will be specific to:

• The dosing guidelines of the U.S. Food and Drug Administration and the manufacturer
• Current medical best practices

This change will apply to members who start therapy and members whose authorizations are renewed on or after March 1. Members whose current authorizations for these drugs extend past March 1, 2021, can continue at their current dose until their authorization expires.

Members not affected by this change

This change doesn’t apply to:

• Blue Cross and Blue Shield Federal Employee Program^® members
• BCN Advantage℠ members
• Medicare Plus Blue℠ members

Lists of requirements

To view the requirements for these drugs, see the following drug lists:

• Standard commercial medical drug program
• UAW Retiree Medical Benefits Trust non-Medicare members
• Blue Cross and Blue Shield FEP non-Medicare members

We’ll update these drug lists with this information about the change in dosing strategy before March 1.

**In addition to Blue Cross commercial and BCN commercial members, the dosing strategy change for this drug applies to UAW Retiree Medical Benefits Trust non-Medicare members.

Revision to Medicare Plus Blue payment policy for transvaginal and pelvic ultrasounds

Beginning April 1, 2021, for Medicare Plus Blue℠ members, we won’t pay for both a transvaginal ultrasound and a pelvic ultrasound if they’re both performed in the same session.

A transvaginal ultrasound (CPT code *76830) is a diagnostic test providing a look at the female reproductive organs. A pelvic ultrasound (CPT code *76856 or *76857) typically evaluates the same organs and represents a redundancy in services.

In extenuating circumstances, a provider may submit medical records on the clinical editing appeal form supporting the medical need for both procedures. Indications that may result in payment of both ultrasounds may include the inability to visualize all the structures or a finding of some pathology extending outside the pelvis. These should be clearly documented in the medical record and should be unique to the individual member.

Sign up for additional training webinars

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

Here’s information on the upcoming training webinars:

The Blue Cross 201 webinar series provides an in-depth learning opportunity and builds on information shared in our Blue Cross 101: Understanding the Basics webinar. This new webinar reviews the processes and tools available when submitting claims.

The Autism Overview webinar reviews current processes related to providing services to members with autism.

Recordings of previous webinars are available on web-DENIS via the Blue Cross Provider Publications and Resources or BCN Provider Publications and Resources pages as follows.

Blue Cross Provider Publications and Resources

1. Log in to Provider Secured Services.
2. Click on BCBSM Provider Publications and Resources.
3. Click on BCBSM Newsletters and Resources.
4. Click on Provider Training.
5. In the Featured Links section of the page, check out 2020 Provider Training Webinars.

You can also get more information about online training, presentations and videos by clicking on the E‑Learning icon at the top of the page.

BCN Provider Publications and Resources

1. Log in to Provider Secured Services.
2. Go to BCN Provider Publications and Resources.
3. Under Other Resources, click on Learning Opportunities.
4. Find the most recent webinars under 2020 Provider Training Webinars.

As additional training webinars become available, we’ll provide notices through
web-DENIS, The Record and BCN Provider News.

Here are 2021 FEP benefit changes

Blue Cross and Blue Shield Federal Employee Program^® 2021 benefit changes will take effect Jan. 1, 2021. Below is an overview of the benefit changes. Complete information on benefit changes for Standard Option, Basic Option and FEP Blue Focus plans are available at www.fepblue.org/brochure.

Catastrophic out-of-pocket maximum

• FEP Blue Focus
• Self only — $7,500
• Self Plus One and Self and Family — $15,000

Hearing aids

• Standard Option and Basic Option — $2,500 hearing aid coverage every five  calendar years for adults age 22 and older. Coverage will allow current three-year accumulation to run out. See table below.
  
  

  Purchase year	Eligible for new hearing aid
  2018	2021
  2019	2022
  2020	2023
  2021	2026

Hepatitis C screening

• Standard Option, Basic Option and FEP Blue Focus — Hepatitis C preventive screening coverage for members age 18 to 79

HIV screening

• FEP Blue Focus — HIV screening for pregnant women covered under preventive care benefits with no member cost share when billed by a Preferred facility

Hospice

• FEP Blue Focus — Continuous home hospice care received from Preferred providers covered at no member cost share

Nutritional counseling

• Standard Option, Basic Option and FEP Blue Focus
• Nutritional counseling expanded to include telemedicine services for individual nutritional counseling therapy and group nutritional counseling therapy
• Group nutritional counseling removed from preventive nutritional counseling cost share applies
• Individual nutritional counseling will continue to be covered under preventive nutritional counseling with no member cost share
  

Outpatient emergency room facility

• Basic Option — Emergency room care for accidental injury and medical emergency, $175 copayment per day, per facility

Pharmacy

• Standard Option, Basic Option and FEP Blue Focus
• Formulary adjustments
• Standard Option — Expanded the list of excluded drugs
• Basic option — Expanded the list of managed formulary exclusions
• FEP Blue Focus — Expanded the list of non-covered medications (closed formulary)
• Certain bowel preparation medication associated with colon cancer screenings no longer have a member cost share for the first prescription filled from a Preferred retail pharmacy.
• Note: Standard Option and Basic Option with Medicare Part B includes the Mail Service Prescription Drug Program.
• For those at risk of HIV but don’t have HIV, Emtricitabine/tenofovir disoproxil fumarate (generic for Truvada) is covered with no member cost share when obtained from a Preferred retail pharmacy.
• Note: Standard Option and Basic Option with Medicare Part B includes the Mail Service Prescription Drug Program.

• Standard Option
• Pharmacy formulary for tiers 2, 3, 4 and 5 no longer apply a reduced copay after 30 prescriptions.

• Standard and Basic Option
• Copayment changes for Tier 4 and Tier 5
  
  

  Tier prescription supply	Standard Option	Basic Option without Medicare Part B	Basic Option with Medicare Part B
  Tier 4: 30-day supply	$65 copay	$85 copay	$80 copay
  Tier 4: 31-day to 90-day supply	$185 copay	$235 copay	$210 copay
  Tier 5: 30-day supply	$85 copay	$110 copay	$100 copay
  Tier 5: 31-day to 90-day supply	$250 copay	$300 copay	$255 copay

Telemedicine

• Standard Option, Basic Option and FEP Blue Focus — Phone consultations and online medical evaluations and management services coverage
• Standard Option
• $25 copayment (no deductible) for a Preferred primary care provider or other health care professional
• $35 copayment (no deductible) for a Preferred specialist
• 35% of the plan allowance (deductible applies) for a participating provider
• 35% of the plan allowance (deductible applies) plus any difference between our allowance and the billed amount for a non-participating provider
• Basic Option
• $30 copayment for a Preferred primary care provider
• $40 copayment for a Preferred specialist
• FEP Blue Focus
• $10 copayment (no deductible) for a Preferred provider per visit up to a combined total of 10 visits per calendar year

X-rays

• Standard Option, Basic Option and FEP Blue Focus — Chest X-ray coverage is being moved from preventive to medical coverage.

If you have any questions about benefit changes, contact Customer Service at 1-800-482-3600.

Reminder: Peer-to-peer review request process to change for inpatient medical hospital admissions

As you may have read in a web-DENIS message posted Nov. 23 and a December Record article, the process for requesting peer-to-peer reviews for inpatient medical hospital admissions is changing. Please use the following information as your reference on this matter.

Effective Jan. 4, 2021, the process for requesting peer-to-peer reviews for inpatient medical hospital admissions will change. Here are the changes that go into effect on that date:

• For Medicare Plus Blue℠ members, Blue Cross Blue Shield of Michigan will no longer accept peer‑to‑peer requests related to inpatient medical hospital admission denials. Instead, facilities are encouraged to follow the two-level provider appeal process for Medicare Plus Blue to reevaluate the denial decision on an inpatient admission request. See the "Contracted MI Provider Acute Inpatient Admission Appeals" section in the Medicare Plus Blue PPO Manual.
• For our Blue Care Network commercial, BCN Advantage℠ and Blue Cross commercial members, we’ll still accept peer-to-peer review requests. However, facilities must submit these requests within seven days of the date the initial authorization request was denied.

We're updating documents

We're updating the document titled How to request a peer-to-peer review with a Blue Cross or BCN medical director to reflect the changes in the process for all lines of business.

The updated document will be available starting Jan. 4 on our ereferrals.bcbsm.com website on these webpages:

• BCN Authorization Requirements & Criteria webpage — Look under the Referral and authorization information heading.
• Blue Cross Authorization Requirements & Criteria webpage — Located in both the Blue Cross PPO and Medicare Plus Blue PPO sections of the page.

We’re also updating the provider manuals to reflect the changes related to peer-to-peer-review request.

Guidelines for submitting clinical information

Follow these guidelines when submitting prior authorization requests for inpatient hospital admissions:

• Submit the request once the clinical documentation meets InterQual^® criteria.
• If InterQual criteria isn’t met, submit all the clinical documentation needed to support the medical necessity of the admission.

If a request is pended for clinical review, our clinicians will use the clinical information you’ve submitted to support a medical necessity determination.

How to expedite review of the authorization request

Here are some things you can do to expedite review of the authorization request and possibly avoid the need to request a peer-to-peer review:

• Attach all pertinent clinical information from the medical record to the authorization request to validate that an inpatient setting is appropriate.
• Submit only requests that have a complete set of clinical information.
• Clinical documentation must include:
• The InterQual^® criteria subset you used to support the decision for inpatient admission
• The pertinent clinical information that validates the InterQual criteria points that are met
• The procedure code from the Centers for Medicare & Medicaid Services inpatient surgical list you used to support the decision for an inpatient admission

Facilities required to prorate respiratory therapy services

Blue Cross Blue Shield of Michigan and Blue Care Network will require facilities to prorate daily respiratory therapy services by hours used, not to exceed 24 hours in a single day. This billing rule is effective Jan. 1, 2021, for Blue Cross commercial, Medicare Plus Blue℠, BCN commercial and BCN Advantage℠ members. It applies to an inpatient setting only.

The following is a list of general respiratory therapy services applicable to this billing policy:

• All types of ventilators
• Continuous positive airway pressure, or CPAP
• Bilevel positive airway pressure, or BiPAP
• All types of oxygen

Billing example

On a single day of service, a patient is on the ventilator for five hours and then weaned to CPAP for the remaining 19 hours of the day. Previously, services were billed at a daily rate, regardless of hours used. New billing should reflect only those hours used for each modality.

Background

Respiratory therapy services are prescribed by a physician or non-physician practitioner for the assessment and diagnostic evaluation, treatment, management and monitoring of patients with deficiencies and abnormalities of cardiopulmonary function. This billing policy isn’t intended to affect physician decision-making; providers are expected to apply medical judgment when caring for all members.

Facilities can’t bill for separate labs when using point-of-care testing for blood gas analysis

When blood analysis is completed by point-of-care testing in an inpatient hospital setting, Blue Cross Blue Shield of Michigan and Blue Care Network will only pay for the primary charge (per time and date of service) that the blood was analyzed — not for  other associated or separately billed labs. Separate labs should be zero-priced when billed and will be considered a provider write-off.

This policy is effective Jan. 1, 2021, for Blue Cross commercial, Medicare Plus Blue℠, BCN commercial and BCN Advantage℠ members.

Background

Blood gas analysis performed by point-of-care testing, or utilization of a blood gas analyzer, is prescribed by a physician, or a non-physician practitioner, to provide quick laboratory testing using one sample of blood to achieve multiple test results within minutes. It can affect the treatment and management of the patient. This billing policy isn’t intended to affect provider decision-making or patient care. Providers are expected to apply medical judgment when caring for all members.

The following is a list of common point-of-care testing or blood gas analyzer devices that are covered by this billing policy:

• Abbott handheld I-Stat Machine
• epoc^® blood analysis system
• Radiometer

The following is a list of commonly associated, but separately billed labs. These include, but aren’t limited to:

• Electrolytes (for example, sodium, potassium, chloride)
• Lactate/lactic acid
• Ionized calcium
• Creatinine and urea nitrogen
• Hemoglobin and hematocrit
• Glucose

We’re expanding access to diabetes monitoring products for commercial members, starting in January

Starting Jan. 1, 2021, diabetes monitoring products, such as glucometers and test strips, lancets, continuous glucose monitors and insulin delivery devices, will be added to the pharmacy benefit for Blue Cross Blue Shield of Michigan commercial and Blue Care Network commercial members.

Members will be able to obtain diabetes monitoring products or supplies through participating pharmacies or through durable medical equipment providers, as outlined below.

Participating pharmacies

Select glucometers and continuous glucose monitors will be available through members’ pharmacy benefit with no cost sharing.

Other diabetes supplies will be covered according to the drug list for the member’s plan. The appropriate pharmacy cost sharing or copayment will apply.

Glucometers and continuous glucose monitoring products that are available with no cost sharing include:

• OneTouch Verio Reflect^®
• OneTouch Verio Flex^®
• OneTouch Ultra^® 2
• Contour^®
• Contour Next
• Contour Next One
• Contour Next EZ
• Dexcom G5™ receivers and transmitters
• Dexcom G6™ receivers and transmitters

Durable medical equipment providers

Members can also obtain diabetes monitoring products through a DME provider. The process to locate DME providers varies depending on a member’s plan:

• Blue Cross commercial fully insured groups: These members must obtain their diabetes monitoring products through a Northwood Inc. network provider starting Jan. 1. To find a Northwood network provider, members can do one of the following:
• Log in to their Blue Cross member account through bcbsm.com or our mobile app and click on Find a Doctor.
• Go to bcbsm.com/dmesupplies and click on Find a Northwood provider.

A Northwood icon appears next to each Northwood network provider.

• Blue Cross commercial self-funded groups: To find a network provider, members can log in to their secure member account through bcbsm.com or our mobile app and click on Find a Doctor.
• BCN commercial members: To find a J&B Medical Supply network provider, members can do one of the following:
• Log in to their secure member account through bcbsm.com or our mobile app and click on Doctors & Hospitals. They can then click on the durable medical equipment link.
• Call J&B Medical Supply at 1-888-896-6233.

What this change means

This change effects members as follows:

• Blue Cross commercial fully insured groups: For these groups and members, we’re  moving to the Northwood network, beginning Jan. 1, 2021.
  
  Starting Jan. 1, if members use a provider in the Northwood network, their medical copayment, cost sharing, coinsurance or deductible won’t change. However, if members use a provider outside the Northwood network on or after Jan. 1, they may pay a higher copay, cost share, coinsurance or deductible. Members can obtain diabetes supplies and prescriptions from a participating network pharmacy or from a provider through the Northwood network.

• Blue Cross commercial self-funded groups: There’s no change to how members obtain DME. Members can continue to get diabetes supplies from the DME provider they’re using now under the pharmacy benefit.
• BCN commercial members: J&B Medical Supply is the diabetic supplies DME provider for BCN commercial members. There won’t be a negative effect on members who currently receive diabetes monitoring supplies under the medical benefit. This change simply expands access by allowing members to get diabetes supplies and prescriptions from participating network pharmacies, in addition to the DME providers they’re using now.

Reminder: We’re expanding our cardiology services authorization program with AIM for some members

Starting Jan. 1, 2021, we’re adding some cardiology services that will require authorization by AIM Specialty Health^® for Medicare Plus Blue℠, Blue Care Network commercial and BCN Advantage℠ members.

The services include cardiac implantable devices and arterial ultrasound for dates of service on or after Jan. 1, 2021. Please refer to the November 2020 Record article for more information.

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

Blue Cross Blue Shield of Michigan recognizes that for certain procedures, additional effort is required and additional costs are incurred when performed outside of a hospital setting. Starting Feb. 1, 2021, the PPO physician reimbursement policy will increase allowed amounts by 15% for select procedures when done in an ambulatory surgical facility. For a preliminary list of the CPT codes for these procedures, click here.

Note: This is in addition to the procedures identified in the May 2020 Record article, with payment policy that was adjusted in July 2020.

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

Starting March 1, changes coming to site-of-care requirements for Blue Cross commercial and BCN commercial pediatric members

Beginning March 1, 2021, site-of-care exemptions will no longer apply to pediatric Blue Cross Blue Shield of Michigan commercial members and pediatric Blue Care Network commercial members for some drugs covered under the medical benefit.

This means all drugs that have site-of-care requirements for adult commercial members will have the same site-of-care requirements for pediatric commercial members.

For these drugs:

• Pediatric members who begin therapy at a hospital outpatient location before March 1 are authorized to continue treatment at the current location through Aug. 31, 2021. This will provide continuity of care and give members time to work with their providers during the transition period.
• Pediatric members who begin therapy on or after March 1 must have an authorization that includes a site-of-care approval. Members should talk to their doctors before March 1 to arrange to receive infusion services at one of the following locations:

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

Notes

• Pediatric members who begin therapy on or after March 1 will be authorized to receive the first dose at a hospital outpatient facility.
• If a member requires treatment in a hospital outpatient setting, the provider must submit clinical documentation to establish medical necessity; the plan will review the documentation and make a determination.

Definition of pediatric members

Pediatric members are defined as one of the following:

• 15 years old or younger, regardless of weight
• 16 through 18 years old who weigh 50 kilograms or less

More about the authorization requirements

• These authorization requirements apply only to groups that currently participate in the commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit.
• Authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

How to submit authorization requests

Submit authorization requests through the NovoLogix^® online tool. It offers real-time status checks and immediate approvals for certain medications.

To learn how to submit requests through NovoLogix, go to ereferrals.bcbsm.com and do the following:

• For BCN commercial members: Click on BCN and then click on Medical Benefit Drugs. In the BCN HMO (commercial) column, see “How to submit authorization requests electronically using NovoLogix.”
• For Blue Cross commercial members: Click on Blue Cross and then click on Medical Benefit Drugs. In the Blue Cross PPO (commercial) column, see “How to submit authorization requests electronically using NovoLogix.”

Lists of requirements
To view requirements for these drugs, see the following drug lists:

• Standard commercial medical drug program: Blue Cross and BCN utilization management medical drug list for Blue Cross PPO (commercial) and BCN HMO (commercial) members
• UAW Retiree Medical Benefits Trust non-Medicare members: Medical Drug Management with Blue Cross for UAW Retiree Medical Benefit Trust PPO non-Medicare members
• Blue Cross and Blue Shield Federal Employee Program^® non-Medicare members: Utilization management medical drug list for Blue Cross and Blue Shield Federal Employee Program^® non-Medicare members

Update: Oncology management program for Blue Cross fully insured commercial members doesn’t include codes S0353, S0354

We wrote in the September edition of The Record that Blue Cross Blue Shield of Michigan expanded its medical oncology management program to include all fully insured commercial members starting Dec. 1, 2020. The program is administered by AIM Specialty Health^®. However, because of an update to the program, providers can’t bill or receive the enhanced reimbursement for codes S0353 or S0354 for Blue Cross commercial fully insured members.

This change doesn’t apply to Medicare Plus Blue℠, Blue Care Network commercial and BCN Advantage℠ members or to UAW Retiree Medical Benefits Trust non-Medicare members. For those members, providers can bill and be reimbursed for codes S0353 and S0354.

The Oncology management program: Frequently asked questions for providers document has been updated to reflect this change. Look in the section titled “About enhanced reimbursement.” Find the FAQ at ereferrals.bcbsm.com on the Blue Cross AIM-Managed Procedures page.

Authorization for IOP treatment no longer required for State of Michigan enrollees starting in January

Providers will no longer need to obtain authorization for intensive outpatient services from New Directions Behavioral Health for State of Michigan enrollees (group number 007000562), starting Jan. 1, 2021. Previously, the State of Michigan was one of the few groups that required authorization for IOP services.

Authorization will continue to be required for all higher level of behavioral health care admissions for which State of Michigan enrollees have a benefit, including acute inpatient psychiatric, substance use disorder acute detox and residential care, psychiatric and SUD partial hospitalization, and outpatient applied behavioral analysis treatment for autism.

Providers and office staff can log in to WebPass** to request prior authorizations for State of Michigan members. Providers who’ve never utilized WebPass before can visit the website** to review a training tutorial on how WebPass works.

Reminder

• Medical necessity criteria for New Directions is available on web-DENIS.
• Log in to web-DENIS.
• Click on BCBSM Provider Publications and Resources on the left side of the page.
• Click on Newsletters and Resources.
• Click on Clinical Criteria & Resources under Popular Links.
• Scroll down to Behavioral Health Information and Current Behavioral Health Clinical Criteria — Use for admissions on or after Jan. 1, 2020.
• Be sure to check your patients’ member ID cards and web-DENIS for eligibility and prior authorization information. 

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

Reminder: Providers must submit authorization requests to TurningPoint for musculoskeletal procedures for most members

As we reported in the November issue of The Record and the November-December issue of BCN Provider News (Page 46), TurningPoint Healthcare Solutions LLC has expanded its surgical quality and safety management program for dates of service on or after Jan. 1, 2021.

You now need to submit authorization requests for orthopedic, pain management and spinal procedures to TurningPoint for the following groups and members:

• Blue Cross commercial — All fully insured groups and select self-funded groups
• Medicare Plus Blue℠ members
• BCN commercial members
• BCN Advantage℠ members

Some important reminders

• Facilities should have an authorization number before scheduling surgery. The ordering physician or provider office must secure the authorization and provide the authorization number to the facility.
• For inpatient professional claims, include only the procedure codes authorized by TurningPoint on claims for musculoskeletal procedures.
• For procedures affected by the Jan. 1 program expansion, TurningPoint began accepting authorization requests on Dec. 1, 2020.
• You have until April 30, 2021, to submit retroactive authorization requests to eviCore healthcare^® for:
• Spinal procedures for Blue Cross’ commercial fully insured groups and Medicare Plus Blue members for dates of service prior to Jan. 1
• Pain management procedures for all Blue Cross commercial fully insured groups, select Blue Cross commercial self-funded groups, all Medicare Plus Blue members, all BCN commercial members and all BCN Advantage members for dates of service prior to Jan. 1

Webinar training
We’ll continue to offer webinar training for providers, facilities and clinical staff. Use the links below to register.

Professional provider training includes information about TurningPoint’s clinical model, operational changes and provider portal.

Facility training includes information about TurningPoint’s clinical model and operational changes and the facility verification process.

Portal training includes information about using the TurningPoint provider portal.

Where to find more information
For more information about TurningPoint, see the following pages on the ereferrals.bcbsm.com website:

• Blue Cross Musculoskeletal Services
• BCN Musculoskeletal Services

To view the lists of codes for which TurningPoint manages authorizations, see Musculoskeletal procedure codes that require authorization by TurningPoint.

For detailed information, see Musculoskeletal procedure authorizations: Frequently asked questions for providers.

Medical specialty drug prior authorization list will change in January for Blue Cross commercial fully insured groups

For dates of service on or after Jan. 18, 2021, we’re adding prior authorization requirements for the following specialty drugs covered under the medical benefit for Blue Cross Blue Shield of Michigan commercial fully insured groups, with the exception of the Michigan Education Special Services Association and the Blue Cross and Blue Shield Federal Employee Program^®:

• Blenrep (belantamab mafodotin-blmf), HCPCS codes J3490, J3590, J9999, C9399
• Monjuvi™ (tafasitamab-cxix), HCPCS codes J3490, J3590, J9999, C9399

Providers must request prior authorization for these drugs through AIM Specialty Health^®.

How to submit authorization requests

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

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

For information about registering for and accessing the AIM ProviderPortal℠, see the Frequently asked questions page** on the AIM website.

More about authorization requirements

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

For additional information on requirements related to drugs covered under the medical benefit, see the Blue Cross and BCN utilization management medical drug list and the Medical oncology prior authorization list.

We’ll update these lists to reflect these changes prior to the effective dates.

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

Expansion of drug waste avoidance program starts March 1

To minimize drug waste, reduce unnecessary drug exposure and decrease the risk of adverse events, we’re expanding our waste avoidance program to include additional drugs, effective March 1, 2021.

This change affects Blue Cross Blue Shield of Michigan commercial and Blue Care Network commercial members who receive these drugs:

• Onpattro^®, HCPCS code J0222
• Orencia^®,** HCPCS code J0129
• Stelara^®, HCPCS code J3357
• Stelara IV^®,** HCPCS code J3358
• Soliris^®, HCPCS code J1300
• Ultomiris^®, HCPCS code J1303

When this change takes effect, dosing for these therapies will be based on weight and will be specific to:

• The dosing guidelines of the U.S. Food and Drug Administration and the manufacturer
• Current medical best practices

This change will apply to members who start therapy and members whose authorizations are renewed on or after March 1. Members whose current authorizations for these drugs extend past March 1, 2021, can continue at their current dose until their authorization expires.

Members not affected by this change

This change doesn’t apply to:

• Blue Cross and Blue Shield Federal Employee Program^® members
• BCN Advantage℠ members
• Medicare Plus Blue℠ members

Lists of requirements

To view the requirements for these drugs, see the following drug lists:

• Standard commercial medical drug program
• UAW Retiree Medical Benefits Trust non-Medicare members
• Blue Cross and Blue Shield FEP non-Medicare members

We’ll update these drug lists with this information about the change in dosing strategy before March 1.

**In addition to Blue Cross commercial and BCN commercial members, the dosing strategy change for this drug applies to UAW Retiree Medical Benefits Trust non-Medicare members.

Sign up for additional training webinars

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

Here’s information on the upcoming training webinars:

The Blue Cross 201 webinar series provides an in-depth learning opportunity and builds on information shared in our Blue Cross 101: Understanding the Basics webinar. This new webinar reviews the processes and tools available when submitting claims.

The Autism Overview webinar reviews current processes related to providing services to members with autism.

Recordings of previous webinars are available on web-DENIS via the Blue Cross Provider Publications and Resources or BCN Provider Publications and Resources pages as follows.

Blue Cross Provider Publications and Resources

1. Log in to Provider Secured Services.
2. Click on BCBSM Provider Publications and Resources.
3. Click on BCBSM Newsletters and Resources.
4. Click on Provider Training.
5. In the Featured Links section of the page, check out 2020 Provider Training Webinars.

You can also get more information about online training, presentations and videos by clicking on the E‑Learning icon at the top of the page.

BCN Provider Publications and Resources

1. Log in to Provider Secured Services.
2. Go to BCN Provider Publications and Resources.
3. Under Other Resources, click on Learning Opportunities.
4. Find the most recent webinars under 2020 Provider Training Webinars.

As additional training webinars become available, we’ll provide notices through
web-DENIS, The Record and BCN Provider News.

Here are billing guidelines for home health care services

Blue Cross Blue Shield of Michigan requires home health care services to be billed using the number of visits (rather than hours or incremental hours) as a unit of service.

Visits should be reported individually on separate lines to correctly reflect if multiple visits were performed on the same date of service. Note: Some services, such as therapy services (revenue codes 0421, 0431 and 0441), are only payable once per day. Only the required and appropriate number of visits should be billed for reimbursement for home health care services.

Private duty nursing shouldn’t be billed as a home health care visit. For accurate processing and reimbursement, it should be billed according to billing guidelines for private duty nursing.

Additional guidelines for reference:

• Initial assessment and subsequent evaluations

• To bill a home health care initial assessment, report “revenue code 0583, assessment.”
  Note: The initial home health assessment is the only service that can be billed during this visit.
• To bill subsequent evaluations, report “revenue code 0551, skilled nursing visit charge.”
•  Nutritionist services
•  To bill for nutritionist service, use “revenue code 0589, other home health visit.”
•  Phlebotomy
• Phlebotomy can’t be billed as a visit without the inclusion of other services.
•  Physical therapy/medicine, occupational therapy, speech therapy

• To receive full payment for physical therapy/medicine, occupational therapy or speech therapy performed in the home, report a home health care diagnosis and a physical therapy/medicine, occupational therapy or speech therapy diagnosis, along with the appropriate revenue code, on the claim.
• Report the home health care diagnosis code as the principal diagnosis and the PT/medicine, OT or ST diagnosis code as the secondary diagnosis.
• If you bill with a non-home health care revenue code or a nonpayable home health care revenue code, those lines will be rejected and deemed a provider liability as they’re "bundled" with other payable services.
• Bill line item dates of service. 
• The reported units for revenue codes 0421, 0431, 0441, 0551, 0561, 0571 and 0589 must only be reported as one per visit. Claims will be rejected if units aren’t billed with the payable home health care revenue codes and if there’s an invalid or missing revenue line date of service.

Claims not billed according to these guidelines will be denied or reimbursed at the rate for one visit.

None of the information included herein 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 implements post-pay audits related to inpatient readmissions

In 2019, Blue Cross Blue Shield of Michigan implemented post-pay audits related to inpatient readmissions for all Medicare Plus Blue℠ members.

Blue Cross contracted with HMS^® to conduct audits for readmissions to the same facility occurring up to 30 days from the date the patient was released from the hospital if the readmission is related to the prior medical condition. This applies to both contracted and non-contracted hospitals that are reimbursed at a diagnosis-related group case rate. Hospitals can no longer rebill Medicare Part B services from the denied admission.

HMS’ initial letter will contain findings that medical conditions causing the readmission appear to be related to the prior medical condition. If the hospitals disagree with HMS’ decision, hospitals can submit a reconsideration request and submit medical records on appeal for all listed claims on the HMS letter (including the reference claim). If no medical records are submitted, we will recoup payment on the readmitted claim on the HMS letter.

How to request a reconsideration review:

• Gather the full medical record documentation requested for all listed claims in the letter (include reference claim records).
• Make sure all pages are complete, legible and include both sides and page edges where applicable.
• Attach a copy of the claim list to the medical records and highlight the claim numbers.

Hospitals are responsible for all costs pertaining to readmissions denied under the Medicare Plus Blue Readmissions Reimbursement Policy. They aren’t allowed to charge or balance bill Medicare Plus Blue members for the denied stay.

The following are exclusions to this policy:

• Professional services related to the readmission
• Admissions for chemotherapy or immunotherapy treatment
• Admissions to a substance abuse unit or facility
• Admissions to an inpatient rehabilitation unit
• Readmission after a patient is discharged from the hospital against medical advice
• Admissions for covered transplant services during the global case rate period for the transplant

Questions?

If you need to speak to an HMS representative during an audit, call 1-866-875-1749 from 9 a.m. to 7:30 p.m. Eastern time Monday through Friday.

We’re expanding access to diabetes monitoring products for commercial members, starting in January

Starting Jan. 1, 2021, diabetes monitoring products, such as glucometers and test strips, lancets, continuous glucose monitors and insulin delivery devices, will be added to the pharmacy benefit for Blue Cross Blue Shield of Michigan commercial and Blue Care Network commercial members.

Members will be able to obtain diabetes monitoring products or supplies through participating pharmacies or through durable medical equipment providers, as outlined below.

Participating pharmacies

Select glucometers and continuous glucose monitors will be available through members’ pharmacy benefit with no cost sharing.

Other diabetes supplies will be covered according to the drug list for the member’s plan. The appropriate pharmacy cost sharing or copayment will apply.

Glucometers and continuous glucose monitoring products that are available with no cost sharing include:

• OneTouch Verio Reflect^®
• OneTouch Verio Flex^®
• OneTouch Ultra^® 2
• Contour^®
• Contour Next
• Contour Next One
• Contour Next EZ
• Dexcom G5™ receivers and transmitters
• Dexcom G6™ receivers and transmitters

Durable medical equipment providers

Members can also obtain diabetes monitoring products through a DME provider. The process to locate DME providers varies depending on a member’s plan:

• Blue Cross commercial fully insured groups: These members must obtain their diabetes monitoring products through a Northwood Inc. network provider starting Jan. 1. To find a Northwood network provider, members can do one of the following:
• Log in to their Blue Cross member account through bcbsm.com or our mobile app and click on Find a Doctor.
• Go to bcbsm.com/dmesupplies and click on Find a Northwood provider.

A Northwood icon appears next to each Northwood network provider.

• Blue Cross commercial self-funded groups: To find a network provider, members can log in to their secure member account through bcbsm.com or our mobile app and click on Find a Doctor.
• BCN commercial members: To find a J&B Medical Supply network provider, members can do one of the following:
• Log in to their secure member account through bcbsm.com or our mobile app and click on Doctors & Hospitals. They can then click on the durable medical equipment link.
• Call J&B Medical Supply at 1-888-896-6233.

What this change means

This change effects members as follows:

• Blue Cross commercial fully insured groups: For these groups and members, we’re  moving to the Northwood network, beginning Jan. 1, 2021.
  
  Starting Jan. 1, if members use a provider in the Northwood network, their medical copayment, cost sharing, coinsurance or deductible won’t change. However, if members use a provider outside the Northwood network on or after Jan. 1, they may pay a higher copay, cost share, coinsurance or deductible. Members can obtain diabetes supplies and prescriptions from a participating network pharmacy or from a provider through the Northwood network.

• Blue Cross commercial self-funded groups: There’s no change to how members obtain DME. Members can continue to get diabetes supplies from the DME provider they’re using now under the pharmacy benefit.
• BCN commercial members: J&B Medical Supply is the diabetic supplies DME provider for BCN commercial members. There won’t be a negative effect on members who currently receive diabetes monitoring supplies under the medical benefit. This change simply expands access by allowing members to get diabetes supplies and prescriptions from participating network pharmacies, in addition to the DME providers they’re using now.

Starting March 1, changes coming to site-of-care requirements for Blue Cross commercial and BCN commercial pediatric members

Beginning March 1, 2021, site-of-care exemptions will no longer apply to pediatric Blue Cross Blue Shield of Michigan commercial members and pediatric Blue Care Network commercial members for some drugs covered under the medical benefit.

This means all drugs that have site-of-care requirements for adult commercial members will have the same site-of-care requirements for pediatric commercial members.

For these drugs:

• Pediatric members who begin therapy at a hospital outpatient location before March 1 are authorized to continue treatment at the current location through Aug. 31, 2021. This will provide continuity of care and give members time to work with their providers during the transition period.
• Pediatric members who begin therapy on or after March 1 must have an authorization that includes a site-of-care approval. Members should talk to their doctors before March 1 to arrange to receive infusion services at one of the following locations:

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

Notes

• Pediatric members who begin therapy on or after March 1 will be authorized to receive the first dose at a hospital outpatient facility.
• If a member requires treatment in a hospital outpatient setting, the provider must submit clinical documentation to establish medical necessity; the plan will review the documentation and make a determination.

Definition of pediatric members

Pediatric members are defined as one of the following:

• 15 years old or younger, regardless of weight
• 16 through 18 years old who weigh 50 kilograms or less

More about the authorization requirements

• These authorization requirements apply only to groups that currently participate in the commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit.
• Authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

How to submit authorization requests

Submit authorization requests through the NovoLogix^® online tool. It offers real-time status checks and immediate approvals for certain medications.

To learn how to submit requests through NovoLogix, go to ereferrals.bcbsm.com and do the following:

• For BCN commercial members: Click on BCN and then click on Medical Benefit Drugs. In the BCN HMO (commercial) column, see “How to submit authorization requests electronically using NovoLogix.”
• For Blue Cross commercial members: Click on Blue Cross and then click on Medical Benefit Drugs. In the Blue Cross PPO (commercial) column, see “How to submit authorization requests electronically using NovoLogix.”

Lists of requirements
To view requirements for these drugs, see the following drug lists:

• Standard commercial medical drug program: Blue Cross and BCN utilization management medical drug list for Blue Cross PPO (commercial) and BCN HMO (commercial) members
• UAW Retiree Medical Benefits Trust non-Medicare members: Medical Drug Management with Blue Cross for UAW Retiree Medical Benefit Trust PPO non-Medicare members
• Blue Cross and Blue Shield Federal Employee Program^® non-Medicare members: Utilization management medical drug list for Blue Cross and Blue Shield Federal Employee Program^® non-Medicare members

Update: Oncology management program for Blue Cross fully insured commercial members doesn’t include codes S0353, S0354

We wrote in the September edition of The Record that Blue Cross Blue Shield of Michigan expanded its medical oncology management program to include all fully insured commercial members starting Dec. 1, 2020. The program is administered by AIM Specialty Health^®. However, because of an update to the program, providers can’t bill or receive the enhanced reimbursement for codes S0353 or S0354 for Blue Cross commercial fully insured members.

This change doesn’t apply to Medicare Plus Blue℠, Blue Care Network commercial and BCN Advantage℠ members or to UAW Retiree Medical Benefits Trust non-Medicare members. For those members, providers can bill and be reimbursed for codes S0353 and S0354.

The Oncology management program: Frequently asked questions for providers document has been updated to reflect this change. Look in the section titled “About enhanced reimbursement.” Find the FAQ at ereferrals.bcbsm.com on the Blue Cross AIM-Managed Procedures page.

Medical specialty drug prior authorization list will change in January for Blue Cross commercial fully insured groups

For dates of service on or after Jan. 18, 2021, we’re adding prior authorization requirements for the following specialty drugs covered under the medical benefit for Blue Cross Blue Shield of Michigan commercial fully insured groups, with the exception of the Michigan Education Special Services Association and the Blue Cross and Blue Shield Federal Employee Program^®:

• Blenrep (belantamab mafodotin-blmf), HCPCS codes J3490, J3590, J9999, C9399
• Monjuvi™ (tafasitamab-cxix), HCPCS codes J3490, J3590, J9999, C9399

Providers must request prior authorization for these drugs through AIM Specialty Health^®.

How to submit authorization requests

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

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

For information about registering for and accessing the AIM ProviderPortal℠, see the Frequently asked questions page** on the AIM website.

More about authorization requirements

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

For additional information on requirements related to drugs covered under the medical benefit, see the Blue Cross and BCN utilization management medical drug list and the Medical oncology prior authorization list.

We’ll update these lists to reflect these changes prior to the effective dates.

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

Changes coming Jan. 1 for preferred, clinical, custom and custom select drug lists

We recently published an article that detailed changes to the Preferred Drug List, starting Jan. 1, 2021. We’re making an update to the exclusion information: Cimzia^® and Kevzara^® will remain on the Preferred Drug List. These drugs won’t be excluded.

Preferred Drug List changes
The following tables show the Preferred Drug List changes that are effective Jan. 1, 2021.

Drugs no longer covered – Preferred Drug List
We’ll no longer cover the following brand-name and generic drugs. If a member fills a prescription for one of these drugs on or after Jan. 1, 2021, he or she will be responsible for the full cost. The list below shows preferred alternatives that have similar effectiveness, quality and safety. Unless noted, we won’t cover both the brand-name and available generic equivalents. The example brand names of preferred alternatives are for your reference. When a prescription is filled, the generic equivalent is dispensed, if available.

Drugs with a higher copayment – Preferred Drug List
The brand-name drugs with a higher copayment are listed below along with the preferred alternatives with similar effectiveness, quality and safety. The example brand names of preferred alternatives are for your reference. When a prescription is filled, the generic equivalent is dispensed, if available.

Drugs with quantity limits – Preferred Drug List
These drugs have changes to the amount that can be filled.

Clinical, Custom and Custom Select Drug List changes
The following tables show the changes that are effective starting Jan. 1, 2021, for the Clinical, Custom or Custom Select Drug lists.

Drugs no longer covered – Clinical and Custom Drug lists
We’ll no longer cover the following brand-name and generic drugs. If a member fills a prescription for one of these drugs on or after Jan. 1, 2021, he or she will be responsible for the full cost. The list shows preferred alternatives that have similar effectiveness, quality and safety. Unless noted, we won’t cover both the brand-name and available generic equivalents. The example brand names of preferred alternatives are for your reference. When a prescription is filled, the generic equivalent is dispensed, if available.

Drugs with a higher copayment – Custom Drug List
The brand-name drugs with a higher copayment are listed below along with the preferred alternatives that have similar effectiveness, quality and safety. The example brand names of preferred alternatives are for your reference. When a prescription is filled, the generic equivalent is dispensed, if available.

Drugs no longer covered – Custom Select Drug List
We’ll no longer cover the following brand-name and generic drugs. If a member fills a prescription for one of these drugs on or after Jan. 1, 2021, he or she will be responsible for the full cost. The list shows preferred alternatives with similar effectiveness, quality and safety. Unless noted, we won’t cover both the brand-name and available generic equivalents. The example brand names of preferred alternatives are for your reference. When a prescription is filled, the generic equivalent is dispensed, if available.

Drugs with quantity limits – Clinical, Custom and Custom Select Drug lists
These drugs have changes to the amount that can be filled:

**Represents drugs that have brand names without generic equivalents. These may be considered “authorized generics,” which are the same as brand-name drugs but aren’t true generic drugs.

***Doesn’t apply to members whose plans use the Custom Select Drug List.

Manufacturer discontinues Zostavax shingles vaccine

Pharmaceutical company Merck announced it has discontinued the Zostavax^® vaccine, a vaccine for the prevention of shingles in adults age 60 and older. All remaining product had an expiration date of November 2020, and Zostavax is no longer available for use in the United States.

On Dec. 1, 2020, Blue Cross Blue Shield of Michigan and Blue Care Network commercial pharmacy stopped covering the Zostavax vaccine. Pharmacy claims for Zostavax will reject at the point of sale as of Dec. 1, 2020.

Blue Cross and BCN will continue to offer the Shingrix^® shingles prevention vaccine for adults age 50 and older.

Expansion of drug waste avoidance program starts March 1

To minimize drug waste, reduce unnecessary drug exposure and decrease the risk of adverse events, we’re expanding our waste avoidance program to include additional drugs, effective March 1, 2021.

This change affects Blue Cross Blue Shield of Michigan commercial and Blue Care Network commercial members who receive these drugs:

• Onpattro^®, HCPCS code J0222
• Orencia^®,** HCPCS code J0129
• Stelara^®, HCPCS code J3357
• Stelara IV^®,** HCPCS code J3358
• Soliris^®, HCPCS code J1300
• Ultomiris^®, HCPCS code J1303

When this change takes effect, dosing for these therapies will be based on weight and will be specific to:

• The dosing guidelines of the U.S. Food and Drug Administration and the manufacturer
• Current medical best practices

This change will apply to members who start therapy and members whose authorizations are renewed on or after March 1. Members whose current authorizations for these drugs extend past March 1, 2021, can continue at their current dose until their authorization expires.

Members not affected by this change

This change doesn’t apply to:

• Blue Cross and Blue Shield Federal Employee Program^® members
• BCN Advantage℠ members
• Medicare Plus Blue℠ members

Lists of requirements

To view the requirements for these drugs, see the following drug lists:

• Standard commercial medical drug program
• UAW Retiree Medical Benefits Trust non-Medicare members
• Blue Cross and Blue Shield FEP non-Medicare members

We’ll update these drug lists with this information about the change in dosing strategy before March 1.

**In addition to Blue Cross commercial and BCN commercial members, the dosing strategy change for this drug applies to UAW Retiree Medical Benefits Trust non-Medicare members.

Starting Jan. 1, Northwood is Blue Cross’ DME/POS program benefits manager

Starting Jan. 1, 2021, Northwood Inc. will administer and manage all aspects of durable medical equipment, prosthetics, orthotics and medical supply benefits for Blue Cross Blue Shield of Michigan commercial fully insured and individual members who reside in the state of Michigan.

Only members in groups enrolled in the program are required to participate. Blue Care Network, BCN Advantage℠, and Medicare Plus Blue℠ are already part of the tailored network arrangement with Northwood.

Northwood will administer:

• Prior authorizations
• Member services
• Claims payments
• Provider appeals, contracting, management and training
  

DME/POS program categories and examples of services include:

Standard equipment

• Requires little or no servicing by the member or provider
• CPAP, walkers, canes, crutches and commodes

Labor-intensive equipment

• Requires frequent servicing by trained professionals
• Oxygen or respiratory equipment, custom rehabilitation

Body supports and limbs

• Specifically fitted for the member’s needs
• Cervical collars, braces and limb replacement (prosthetics), orthotics

Medical or surgical supplies

• Essential for use with covered equipment
• Diabetic supplies, dressings, ostomy and urological

Prior authorization

• Out-of-state claims will go through NASCO and don’t require Northwood prior authorization.
• Northwood will be handling DME/POS prior authorization decisions.
• Northwood’s benefit coordinators will be your initial contact for requesting a prior  authorization.
• If product or service can’t be authorized by a benefit coordinator because it doesn’t immediately meet criteria, it’ll go to Northwood’s Case Review department.
• If Northwood’s medical director determines that the requested equipment or service doesn’t meet medical criteria, Northwood will issue a denial to the provider and member.

Participation
Blue Cross' DME/POS providers can contract with Northwood to provide these services to our commercial PPO membership. This includes providers already in the Northwood network.

If you’re interested in applying to the Northwood network, contact Northwood Provider Relations at 1‑800‑447‑9599 between 8:30 a.m. and 5 p.m. Eastern time Monday through Friday. Or email provideraffairs@northwoodinc.com.

You may also fill out an application online at northwoodinc.com.**

Additional information
For more information about the DME/POS program and how it works, refer to the following documents at bcbsm.com/providers:

• Northwood DMEPOS Management Program FAQ
• Northwood DMEPOS Management Program: Procedure Codes Requiring Prior Authorization

If you have additional questions about the 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.

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