June is Pride Month: A time to focus on needs of the LGBTQ+ community

June is LGBTQ+ Pride Month, a month that commemorates the Stonewall Uprising — considered the tipping point for what was then called the Gay Liberation Movement. During the uprising, which took place in Manhattan in June 1969, police clashed with LGBTQ+ protesters over a six‑day period.

The month of June provides an opportunity to recognize and increase awareness of issues faced by the LGBTQ+ community. In the May — June issue of Hospital and Physician Update, we wrote about the disparities that exist for the estimated 4% of Michigan adults identified as LGBTQ+.

The LGBTQ+ community has been identified as a "health disparity population" by the National Institute on Minority Health and Health Disparities.** Mental health conditions, higher rates of alcohol, tobacco and other substance use, as well as higher odds of obesity and eating disorders, are common conditions within the community. We’ve found that some members of the community don’t seek needed health services because they don’t feel comfortable or safe sharing gender or sexual identity with health care providers. 

What’s more, members of the LGBTQ+ community face other barriers to care, including exclusion from a partner's health insurance, provider‑related discrimination, psychosocial barriers (such as fear of disclosing possible illegal behaviors or sexual orientation) and poor matches between the needs of LGBTQ+ people and the kinds of services that are available. 

But there are many steps we can take to support LGBTQ+ members and help ensure they receive the best possible health outcomes. This includes providing appropriate training to doctors and office staff about the challenges this community faces:

Here are links to two training modules we recently shared with practices that have been designated as Patient‑Centered Medical Homes:

• Creating an LGBT-Friendly Practice**
• Quality Health Care for Lesbian, Gay, Bisexual and Transgender People**

Note: These are not Blue Cross Blue Shield of Michigan‑sponsored training sessions.

Following are some of the steps you can take to help promote more inclusive practices:

• Review policies, procedures, documents and forms to ensure they are inclusive. 
• Allow patients the opportunity to indicate the pronouns and names they wish to use.
• When you call patients from the waiting room, address them in a way that’s not specific to a particular gender.
• Understand the distinction between biological sex and gender identity. 
• Share community resources that can help patients with their concerns.
• Ensure that forms and policies don’t assume a patient's gender or their marital or partner status.
• Make sure the equal opportunity statement on forms addresses gender identity and sexual orientation.

For more information about this issue, see the article that ran in the May — June issue of Hospital and Physician Update.

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

Here are answers to some questions about Blue HPN

We’ve received some questions about our Blue High Performance Network℠, also called Blue HPN℠, which we wrote about in a November 2020 Record article. As you may have read, members who have Blue HPN in Southeast Michigan only pay the plan’s out‑of‑pocket expenses if they receive services from a Blue HPN health care provider.

Here are answers to some questions we recently received:

Q: Can a specialist treat a member with Blue HPN?

A: Yes. While referring a patient with Blue HPN to an Ascension provider is recommended, there are some specialty types and ancillary providers who aren’t affiliated with Ascension who patients can still see without being responsible for the full cost of treatment. These include chiropractors, skilled nursing home providers, behavioral health specialists, home health care providers and limited medical specialists who are in Blue Cross Blue Shield of Michigan’s PPO network. We want to be sure that providers in those specialty areas know they can treat Blue HPN members. Here’s a complete list of specialties that can treat Blue HPN members if they are within our PPO.

Referring providers should advise their patients to check our online directory, Find a Doctor, to ensure that a provider is in the Blue HPN or call the number on the back of their member ID card.

Q: What about facility services?

A: While specialists may be included in Blue HPN — and their claims processed as Professional in-network claims — related facility claims may be processed as out of network if a patient with Blue HPN goes to a non‑network facility. If you’re affiliated with a non-Ascension hospital, you’ll want to encourage your patient to get any necessary facility services at a Blue HPN facility. As a reminder, emergency services are covered benefits at Blue HPN facilities and non‑Blue HPN facilities within the broader PPO network.

Q: How will I know if a member has Blue HPN?

A: You can check the bottom left-hand corner of their member ID card. It features a suitcase logo with the initials “HPN” inside. Also, you can determine if a member has Blue HPN in web‑DENIS when checking eligibility.

Q: How do I know if a specialist or ancillary provider participates with Blue HPN?
If they participate with Blue HPN, their listing in the network directory will indicate that. You can check out the Find a Doctor search feature to see what plans a specific provider accepts.

For more information, see the November 2020 Record article or watch this video.

HCPCS replacement codes established

J1427 replaces J3490, J3590 and C9071 when billing for Viltepso (viltolarsen)

The Centers for Medicare & Medicaid Services has established a permanent procedure code for specialty medical drug Viltepso (viltolarsen).

All services through March 31, 2021, will continue to be reported with code J3490, J3590 and C9071. All services performed on and after April 1, 2021, must be reported with J1427.

Prior authorization is required for all groups unless they are opted out of the prior authorization program.

For groups that have opted out of the prior authorization program, this code is covered for the FDA‑approved indications.

J1554 replaces J1599 and C9072 when billing for Asceniv (immune globulin intravenous, human ‑ slra)

CMS has established a permanent procedure code for specialty medical drug Asceniv (immune globulin intravenous, human ‑ slra).

All services through March 31, 2021, will continue to be reported with code J1599 and C9072. All services performed on and after April 1, 2021, must be reported with J1554.

Prior authorization is required for all groups unless they are opted out of the prior authorization program.

For groups that have opted out of the prior authorization program, this code is covered for the FDA‑approved indications.

Site of care prior authorization is required through the Medical Benefit Drug Program for J1554 for all groups unless they are opted out of the program.

J9037 replaces J9999 and C9069 when billing for BLENREP (belantamab mafodontin‑blmf)

CMS has established a permanent procedure code for specialty medical drug BLENREP (belantamab mafodontin‑blmf).

All services through March 31, 2021, will continue to be reported with code J9999 and C9069. All services performed on and after April 1, 2021, must be reported with J9037.

AIM Specialty Health^® prior authorization is required for all groups unless they are opted out of the prior authorization program.

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

J9349 replaces J3590 and C9070 when billing for Monjuvi tafasitamab‑cxix.

CMS has established a permanent procedure code for specialty medical drug Monjuvi (tafasitamab‑cxix).

All services through March 31, 2021, will continue to be reported with code J3590 and C9070. All services performed on and after April 1, 2021, must be reported with J9349.

AIM Specialty Health^® prior authorization is required for all groups unless they are opted out of the prior authorization program.

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

J7402 replaces C9122 when billing for Sinuva (mometasone furoate) sinus implant

CMS has established a permanent procedure code for specialty medical drug Sinuva (mometasone furoate) sinus implant.

All services through March 31, 2021, will continue to be reported with code C9122. All services performed on and after April 1, 2021, must be reported with J7402.

Q2053 replaces J3590, J9999 and C9073 when billing for brexucabtagene autoleucel

CMS has established a permanent procedure code for specialty medical drug brexucabtagene autoleucel.

All services through March 31, 2021, will continue to be reported with code J3590, J9999 and C9073. All services performed on and after April 1, 2021, must be reported with Q2053.

Prior authorization is required for all groups unless they are opted out of the prior authorization program.

For groups that have opted out of the prior authorization program, this code is covered for the FDA‑approved indications.

HCPCS first‑quarter update: New and updated codes

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

Injections and Drugs Administered Other Than Oral Method

Injections/chemotherapy

Radiopharmaceuticals

Outpatient PPS

Medicine/Professional Miscellaneous/Data Gathering

Temporary Codes DME/P&O

Temporary National Codes

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

Second‑quarter 2021 CPT code update

Medicine

Vaccines and Toxoids

Category III codes

Radiology

Surgery

Medicine

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

Billing chart: Blues highlight medical, benefit policy changes

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

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

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

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

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

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

You can help Michigan reach COVID‑19 vaccination benchmarks

You can help the state of Michigan reach the benchmark of vaccinating 70% or more of Michiganders, age 16 and older, in the fight against COVID‑19.

How can you help?

• Reach out to your patients to encourage them to get a COVID‑19 vaccine. You can answer their questions to relieve any concerns about the vaccine. Overcoming vaccine hesitancy can help us reach herd immunity.

• Help patients who were vaccinated outside Michigan get their vaccines counted. Some Michiganders may have received their vaccines outside Michigan, either while visiting another state or purposefully going to a state bordering Michigan in early 2021, where they could more easily get it. Please ask your patients if they were vaccinated in Michigan. If not, do one of the following:
• If you have access to the Michigan Care Improvement Registry, ask the patient for their COVID‑19 vaccination record card and upload this information in MCIR as historical information.
• If you don’t have access to MCIR, ask the patient to visit their local health department with their COVID‑19 vaccination record card and their driver’s license or State of Michigan identification card so their vaccination can be counted.

Here’s how Blue Cross and BCN are helping
Blue Cross Blue Shield of Michigan and Blue Care Network have been sending communications since early 2021 to encourage our members to get a COVID‑19 vaccine. You can view these communications here:

• Log in as a provider at bcbsm.com.
• Click on Coronavirus (COVID‑19) at the top of the page.
• Look under Vaccines.

To make vaccine access easier, we waived member out‑of‑pocket cost and network requirements.

Thank you for the ongoing care you provide to your patients and our members. Together, we can help defeat COVID‑19.

Here are resources for TurningPoint musculoskeletal surgical quality and safety management program

We have resources to help you navigate the TurningPoint musculoskeletal surgical quality and safety management program.

You can find them on the following pages of the ereferrals.bcbsm.com website:

• Blue Cross Musculoskeletal services
• BCN Musculoskeletal services

The most comprehensive resource is the Frequently asked questions for providers document. Here are a few things you’ll find in the FAQ:

• How to submit authorization requests to TurningPoint through its portal, by fax and by phone
• How the peer‑to‑peer conversation process works
• Information related to submitting claims

Some of the other resources you’ll find on these pages are:

• The list of orthopedic, pain management and spinal procedure codes that require prior authorization by TurningPoint
• The list of orthopedic and spinal procedure codes for which we allow code substitutions
• A document that walks through the steps to determine whether prior authorization is required for Blue Cross commercial members. (This document is accessible only from the Blue Cross Musculoskeletal services page.)
• Clinical documentation requirements for musculoskeletal procedures
• The TurningPoint Provider Training Manual
• Fax forms for requesting authorization for musculoskeletal procedures
• Recordings and presentations from the TurningPoint provider training sessions

We encourage you to take advantage of these resources.

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

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

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

We’re enhancing TurningPoint surgical quality and safety management program to improve your experience

The Blue Cross Blue Shield of Michigan and Blue Care Network Utilization Management department is committed to enhancing your experience with the TurningPoint Healthcare Solutions, LLC surgical quality and safety management program. Since we implemented the program, we’ve made changes to several areas based on provider feedback.

We’ve recently made the following enhancements:

• Published the code substitutions that are available for musculoskeletal procedures
• Detailed the steps required to determine whether prior authorization is required for Blue Cross commercial members
• Simplified the process for requesting peer‑to‑peer conversations
• Clarified clinical documentation requirements
• Updated and added informational resources for the TurningPoint program

Keep reading to learn more…

Code substitutions for musculoskeletal procedures
In some situations, you may not know which orthopedic or spinal procedure will be required in advance of a surgery or the surgical plan may change intraoperatively. As a result, the procedure code TurningPoint authorized may not represent the procedure that was actually performed.

Prior to submitting claims for these procedures, you’ll need to determine whether you can substitute the code for the procedure that was performed for the code TurningPoint authorized. If you can substitute the code, you won’t need to contact TurningPoint to update the procedure coding.

To learn how to determine if the approved code allows substitutions and to view all codes that allow substitutions, see the Musculoskeletal procedure code substitutions for orthopedic and spinal surgeries document.

This document is available on the Musculoskeletal services pages of our ereferrals.bcbsm.com website.

Determining whether prior authorization is required for Blue Cross commercial members
We created a document that walks through the steps required to determine whether Blue Cross commercial members require prior authorization. The document is titled Determining whether Blue Cross commercial members require prior authorization for musculoskeletal surgeries and related procedures. It’s available on the Blue Cross Musculoskeletal services page of our ereferrals.bcbsm.com website.

Process for requesting peer-to-peer conversations
The steps that lead up to peer-to-peer conversations with TurningPoint vary depending on whether the member has coverage through a commercial product or through a Medicare Advantage product.

Commercial members (Blue Cross commercial or BCN commercial)
If TurningPoint denies an authorization request for a commercial member, you have two options for requesting a reconsideration of the denial:

• You can ask TurningPoint to review additional clinical documentation, you can provide clarifying details that are pertinent to the request or both. Submit the documentation, details or both in one of these ways:
• Through the TurningPoint Provider Portal
• By fax. Include a cover sheet that identifies the patient and send the fax to 313‑879‑5509 for joint and spine procedures or to 313‑483‑7323 for pain management procedures.
• You can request a peer‑to‑peer conversation to review the case with a physician. To do this, call 1‑833‑217‑9670. You’ll need to provide three dates when you’re available to meet. TurningPoint will schedule the conversation based on the dates you request.

You can request a reconsideration or a peer-to-peer conversation any time before providing services or filing an appeal with the health plan.

If you completed a reconsideration or peer-to-peer conversation and are dissatisfied with the decision, you may appeal.

Medicare Advantage members (Medicare Plus Blue℠ or BCN Advantage℠)
Before denying an authorization request, TurningPoint will make three attempts to notify you of its intent to deny any request that doesn’t meet medical necessity criteria. As part of this notification, TurningPoint will offer to schedule a peer‑to‑peer conversation. You’ll need to give TurningPoint three dates when you’re available to meet. TurningPoint will schedule the conversation based on the dates you requested.

If TurningPoint is unable to contact you, it’ll proceed with the authorization decision based on the information you provided with the authorization request.

Alternately, you can request a peer-to-peer conversation any time before providing services or filing an appeal.

For TurningPoint to consider information obtained during a peer‑to‑peer conversation when making an authorization determination, the peer‑to‑peer conversation must take place prior to the denial of an authorization request.

Note: If the peer‑to‑peer conversation takes place after TurningPoint denies the authorization request, TurningPoint can’t reverse the denial. In such cases, the peer‑to‑peer conversation is for informational purposes only.

Clinical documentation requirements
We recently published updated information about the clinical documentation you must include when submitting prior authorization requests to TurningPoint.

We updated or added information related to the specific clinical documentation requirements for:

• Conservative therapies
• Body mass index
• Smoking status
• Surgical plan

To view the updated requirements, see the Clinical documentation requirements for musculoskeletal procedures document. This document is available on the Musculoskeletal services pages of our ereferrals.bcbsm.com website.

Resources for the TurningPoint program
Resources are available to help you navigate the TurningPoint musculoskeletal surgical quality and safety management program.

We update these resources on a regular basis to provide you with the most current information.

To learn more, see Here are resources for TurningPoint musculoskeletal surgical quality and safety management program, also in this issue.

Answers to FAQs about Blue Cross and BCN patient experience survey now available

Blue Cross Blue Shield of Michigan and Blue Care Network are launching a new Medicare Advantage member survey in June 2021 to assess patient experience. Answers to frequently asked questions are now available, and include information about the survey process, sampling and reporting.

Our research shows positive member experiences at the point of care drive strong provider relationships and affect health outcome perceptions. And member perceptions are a crucial component of Centers for Medicare & Medicaid Services Star Ratings of health plans. Strong Star performance allows us to deliver affordable Medicare Advantage benefits to your patients.

The nationally recognized Clinician and Group Consumer Assessment of Healthcare Providers and Systems, or CG-CAHPS, survey protocol will be administered to gather patient feedback about specific care experiences with providers and their office staff. Key survey topics include provider communication, care coordination and access to care.

Approximately 7% of Medicare Plus Blue℠ and BCN Advantage℠ members will be randomly invited to take the survey annually. These members are eligible for the survey if our claims data indicates they’ve had a care experience within the past 45 days with a primary care provider or one of five coordinated care specialists:

• Cardiologists
• Endocrinologists
• Nephrologists
• Oncologists
• Pulmonologists

Results will allow Blue Cross to monitor patient experience ratings across provider organizations as one of many elements that inform overall performance measurement. We’ll also share the results with provider organizations, including comparisons to national benchmarks.

A CMS-certified vendor will began administering the mailed survey in June 2021, with online and phone completion options. Monthly mailings will be ongoing.

Medical coverage expanding under some Ford salaried plans for members who are transgender

Ford will soon begin covering additional medical services under salaried plans for members who are transgender with a clinical diagnosis of gender dysphoria.  

The following additional gender-affirming services for members will be covered starting June 1, 2021:

• Face and neck laser hair removal
• Facial feminization surgery
• Blepharoplasty
• Genioplasty
• Mandibular augmentation
• Forehead reduction/contouring
• Rhinoplasty
• Chondrolaryngoplasty (Adam’s apple reduction)

Currently, all Ford plans cover genital surgery, mastectomy in female-to-male transition, hormone therapy and counseling when medically necessary to treat gender dysphoria. Gender dysphoria involves a conflict between a person's gender identity and their gender assigned at birth, causing significant distress.

Coverage for the new services will require that members meet medical necessity criteria and use network providers. Coverage has up to a $30,000 lifetime limit. Plan cost share will apply.

The group numbers are 87241, 87252, 87254, 87262, 87264 and 87292. The number will be on the front of the member ID card. As always, be sure to check web-DENIS for benefits and eligibility.

Starting July 1, we’ll change how we cover some drugs on the Preferred Drug List

Blue Cross Blue Shield of Michigan and Blue Care Network are committed to ensuring members receive safe, high-quality care that meets their needs. To accomplish this, we’re making some changes to how we cover some drugs on the Preferred Drug List, starting July 1, 2021:

• We’ll no longer cover the brand-name and generic drugs list in the table below.
• If a member fills a prescription for one of the drugs listed in the table below on or after July 1, they’ll be responsible for the full cost.
• The list below shows suggested 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.

Quarterly update: Requirements changed for some commercial medical benefit drugs

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

During January, February and March 2021, there were changes to prior authorization requirements, site-of-care requirements or both for Blue Cross and BCN commercial members for the following medical benefit drugs:

• Amondys 45^® (casimersen), HCPCS code J3490
• Oxlumo™ (lumasiran), HCPCS code J3490
• Breyanzi^® (lisocabtagene-maraleucel), HCPCS code J9999

Note: The codes shown above will become unique codes.

For Blue Cross commercial members, these authorization requirements apply only to groups that currently participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To view the list of Blue Cross commercial groups that don’t require members to participate in the program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List. A link to this list is also available on the Blue Cross Medical Benefit Drugs page of the ereferrals.bcbsm.com website.

For a detailed list of requirements, see the Blue Cross and BCN utilization management medical drug list. Links to this list are also available on the Blue Cross Medical Benefit Drugs and BCN Medical Benefit Drugs pages of the ereferrals.bcbsm.com website.

Approval of an authorization request isn’t a guarantee of payment. As always, health care providers should verify eligibility and benefits for members.

Pharmacy Opportunities Focus updated for Spring 2021

The Pharmacy Opportunities Focus document, updated for spring 2021, has incorporated suggestions based on recent significant manufacturer drug price increases. This resource can serve as a quick reference guide for a variety of situations, such as when considering multiple drug options at the point of care or performing an evaluation of pharmacy claims data to identify high-cost drugs and their lower-cost preferred alternatives.

Below are additional suggestions when looking through pharmacy data to identify potential cost-saving opportunities:

• Moving from brand-name medications to generics. Compare pharmacy claims data with the drug lists.**

• Leveraging the preferred alternatives of a member’s respective drug list at the point of care. Download the free ScriptVision™ Physician app through the App Store^® for your iPhone or iPad. In real time, see the member’s out-of-pocket costs, any plan requirements (for example, prior authorization, step therapy and quantity limit) and lower-cost alternatives.
  
  If real-time prescription benefit check is enabled in your electronic health record or electronic medical record system, use this function to see the member’s out-of-pocket costs and specific plan requirements.

• Improving the generic prescribing rates of primary care provider. Use the physician profile report for details on certain drugs or members.

• Monitoring specialists who prescribe brand-name drugs when a generic is available or nonpreferred drugs when preferred alternatives are available. Identify the specialists and then reach out to them for discussion.

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

For a step-by-step guide on how to navigate Health e-Blue℠ to obtain pharmacy claims data, as well as how to generate the pharmacy profile report of a primary care provider, refer to the Pharmacy Opportunities Focus: Health e-Blue Pharmacy Guide on the Health e-Blue website.

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

**The drug lists are updated monthly to reflect new drug approvals, new safety or efficacy data and clinical guideline updates. Refer to the online documents for the most up-to-date versions.

Post-discharge medication reconciliation crucial to patient safety and care coordination efforts

Medication reconciliation helps reduce the chance of adverse drug events by comparing a patient’s current and discharge medication list. It’s especially important for patients taking multiple medications.

The Medication Reconciliation Post-Discharge, or MRP, Medicare Star Ratings measure (also a HEDIS^® measure) assesses patients age 18 and older in the measurement year who have Medicare coverage and whose medications were reconciled on the date of discharge through 30 days after discharge (a total of 31 days).

Changes in the medication list should be reviewed and documented during medication reconciliation. This provides documentation of the most accurate list of patient medications, allergies and adverse drug reactions.

View the Medication Reconciliation Post-Discharge tip sheet to learn more about this measure when reconciliation should be completed, information to include in medical records, CPT codes to use in claims and tips for talking with patients about this important topic.

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

Medicare Star Ratings: More ICD-10 codes added to exclusion list for SUPD measure

The Centers for Medicare & Medicaid Services has revised its Medicare Star Ratings measure known as Statin Use in Persons with Diabetes, or SUPD.

In the past, only patients in hospice or on dialysis could be excluded from the measure. Now, in addition to those two conditions, several other ICD-10 codes have been added to the exclusion list. These codes must be billed every year.

About the SUPD measure
The SUPD measure is defined as the percent of Medicare Part D patients age 40 to 75 who:

• Received at least two diabetes medication fills during the calendar year
• Also received a statin medication fill during the calendar year

Only statin claims billed through a patient’s Part D plan count toward closing gaps in the measure. The following types of statin claims won’t close a gap in the SUPD measure:

• Claims filled through drug discount cards or store pharmacy discount programs
• Cash claims
• Medication samples
• Fills from Veterans Affairs facilities
• Fills billed to a non-Medicare insurance plan

To satisfy the SUPD measure requirements, a statin claim must be filled no later than the month before the patient turns 76. Patients born in 1945 are turning 76 years old this year.

If statin therapy isn’t medically appropriate for your patients who have diabetes, make sure the proper ICD-10 code is billed to exclude them from the SUPD measure.

Diagnosis codes added
Here are the diagnoses codes added to the SUPD exclusion list:

The role of statin therapy in patients with cardiovascular disease

The American College of Cardiology and the American Heart Association both recommend statins of moderate or high intensity for adults with atherosclerotic cardiovascular disease. Statin therapy has been shown to lower the risk of future heart attack, stroke and related deaths.

The Centers for Medicare & Medicaid Services has established a Star Ratings measure to support the use of statin therapy for patients with ASCVD. To learn more about the measure, see the Statin Therapy for Patients with Cardiovascular Disease tip sheet.

Spravato and Panzyga to require prior authorization starting July 12 for Blue Cross URMBT non-Medicare members

We’re expanding the prior authorization requirements for drugs covered under the medical benefit for UAW Retiree Medical Benefits Trust, or URMBT, commercial (non-Medicare) members with Blue Cross Blue Shield of Michigan coverage.

For dates of service on or after July 12, 2021, the following drugs will require prior authorization:

• Spravato^® (esketamine), HCPCS code S0013  
• Panzyga^® (immune globulin, human-ifas), HCPCS code J1599

How to submit authorization requests

Submit prior 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, do the following:

1. Visit ereferrals.bcbsm.com.
2. Click on Blue Cross.
3. Click on Medical Benefit Drugs.
4. Scroll down to the Blue Cross’ PPO (commercial) column.
5. Review the information in the How to submit requests electronically using NovoLogix section.

More about the authorization requirements

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

For additional information on requirements related to drugs covered under the medical benefit, refer to the document Medical Drug Management with Blue Cross for UAW Retiree Medical Benefit Trust PPO non-Medicare members.

We’ll update this list with the new information about these drugs prior to the effective date.

Medicare 2% sequestration moratorium extended to Dec. 31, 2021

President Biden signed legislation on April 14, 2021, that extends the suspension of the Medicare 2% sequestration reduction until the end of 2021. We’ve aligned with the Centers for Medicare & Medicaid Services and will extend the suspension of the 2% sequestration applied to Medicare Plus Blue℠ and BCN Advantage℠ claims through Dec. 31, 2021. Providers don’t need to take any action.

Background

Since 2013, 2% sequestration reimbursement reductions have been in place for our Medicare Advantage professional and facility providers. This is in accordance with the terms of our Medicare Advantage provider agreements that pay according to Original Medicare methodologies. The 2% reimbursement adjustment is applied after determining any applicable member deductible, copayment or other required member cost sharing.

Timeline

The timeline of the suspensions is as follows:

• May 1, 2020, through Dec. 31, 2020
  The Coronavirus Aid, Relief, and Economic Security (also known as CARES) Act suspended the 2% sequestration payment adjustment percentage applied to all Medicare Fee-for-Service claims to offer financial relief to providers during the COVID-19 pandemic.
• Jan. 1, 2021, through March 31, 2021
  The Consolidated Appropriations Act of 2021 extended the suspension period to March 31, 2021.
• April 1, 2021, through Dec. 31, 2021
  On April 14, 2021, H.R. 1868 was signed into law, extending the suspension period to Dec. 31, 2021.

Reimbursement to providers who haven’t been affected by sequestration previously, such as durable medical equipment, end-stage renal disease and lab providers, won’t be affected by this change.

We expect that CMS will reinstate the 2% sequestration reimbursement reduction on Jan. 1, 2022, but will alert you of any changes prior to that date.

Reminder: Concierge practices must comply with their Blue Cross affiliation agreements

As a reminder, health care providers must comply with their affiliation agreements. Blue Cross Blue Shield of Michigan affiliation agreements require providers to:

• Submit claims for covered services directly to Blue Cross.
• Accept our payment for covered services as payment in full.
• Only charge the member the applicable copayment or deductible (or both) for the covered service.
• Not discriminate against members based on payment level, benefit or reimbursement policies.

About concierge medicine

In a concierge practice, patients pay membership fees to a health care provider or third-party vender for enhanced services or amenities. As a benefit of paying this fee, members typically receive:

• Easy appointment access
• Extended office visits
• Enhanced email and telephone communication with doctors
• Care coordination (including referrals) between the concierge practice and specialists
• Wellness programs and plans, genetic and nutritional counseling, risk appraisals

Policy information
Blue Cross’ concierge medicine policy states:

Health care providers who wish to use this model in their practice won’t be eligible for any value-based reimbursement through Blue Cross and Blue Care Network programs such as, but not limited to, Physician Group Incentive Program-related value-based reimbursement opportunities through the Patient-Centered Medical Home designation program or other programs.

Also, practitioners must ensure that the requirements of the concierge model are permitted by their affiliation agreements with Blue Cross.

Providers may charge a concierge fee if:

• Patients aren’t required to pay the concierge fee to become or continue to be a patient in the practice.
• Patients aren’t required to pay the concierge fee to obtain access to the provider and are only permitted access to ancillary providers, such as physician assistants or nurse practitioners, if they don’t pay the concierge fee.
• The services or products being offered as part of the concierge fee aren’t considered “covered services” under our affiliation agreements, but instead aren’t covered under a member’s benefit plan. Because benefit structures vary significantly among our members, providers are expected to understand each member’s benefit structure to ensure that covered services aren’t included in the concierge fee.
• Patients who don’t pay the concierge fee continue to receive the same level of access and services as they previously received.
• Providers continue to meet Blue Cross and BCN performance standards regarding access and service.
• The concierge level of service is clearly over and above usual practice in Michigan. Complaints from members who experience a decline in service level may result in Blue Cross concluding that the practice is noncompliant with the nondiscrimination clause of our affiliation agreements.

Provider Experience transitioning to new provider training site June 1

In previous issues of The Record, we’ve let you know that Provider Experience will be launching a new provider training site, which will enhance the training experience for health care providers and staff. We’re pleased to let you know that beginning June 1, users will be able access recorded webinars, videos, e-Learning modules and other training resources through this new site.

Active training courses and materials from 2019 to 2021 have moved from BCBSM Provider Training and BCN Learning Opportunities to the new site.

To request access, complete the following steps:

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

To learn more about the provider training site, watch this video that guides you through the experience.

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

Virtual provider symposiums to focus on patient experience, HEDIS, documentation and coding

We’ve scheduled this year’s provider symposiums virtually for physicians, office staff and coders. The dates are listed below. You may register by clicking on the registration links, and you may register for more than one topic.

Physicians, physician assistants, nurse practitioners, nurses and coders can receive up to four continuing education credits for attending the sessions.

These sessions are for physicians and office staff responsible for closing gaps in care related to quality measures and creating a positive patient experience:

The following sessions are for physicians, coders, billers and administrative staff:

HEDIS^® is a registered trademark of the National Committee for Quality Assurance.

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

Starting in April, we began offering webinars that provide updated information on risk adjustment documentation and coding of common challenging diagnoses.

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

Click on a link below to sign up for a webinar.

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

Here are resources to help FEP members with cancer screenings, low back pain

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

The Blue Cross and Blue Shield Federal Employee Program^® offers resources to help members with a variety of health-related issues.

Cancer screenings: the when and why

According to the American Cancer Society, 1 in 3 people will be diagnosed with cancer in their lifetime. It estimates an increase of more than 91,000 new cancer cases — and 2,000 more deaths in 2021 versus 2020.

The links below provide patient information on breast, cervical, colorectal and prostate cancer screening:

FEP provides coverage for colorectal, cervical, breast and prostate cancer screenings with no out-of-pocket cost when performed by a Preferred provider. FEP members and providers can call Customer Service for benefit information at 1-800-482-3600 or go to www.fepblue.org/brochure.

Managing low back pain in adults

Approximately 90% of low back pain cases are resolved within six weeks, regardless of treatment, according to the Michigan Quality Improvement Consortium.** Imaging, such as X-ray, CT scan or MRI, isn’t typically needed unless certain “red flags” are present. Red flags include:

• Unexplained weight loss
• Fever
• Sudden bladder or bowel problems
• Weakness in the legs
• History of cancer
• Infection

To view the MQIC guidelines on low back pain, click here.**

The FEP Lower Back Pain Remedies flyer provides information for patients on common back pain myths, how to treat back pain at home and when to see a doctor. FEP members and providers can call Customer Service for benefit information about low back pain at 1-800-482-3600 or go to www.fepblue.org/brochure.

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

Blue Cross now accepts electronic signatures on provider enrollment and contracting documents

As of March 15, 2021, Blue Cross Blue Shield of Michigan accepts electronic signatures on provider enrollment and contracting documents. Blue Cross currently doesn’t require the use of a specific signature software (Adobe, DocuSign, etc.) for these documents to be processed.

This change is specific to Blue Cross plans. Blue Care Network will continue to use electronic signatures on its provider contracting documents through DocuSign.

eviCore to post category updates online for outpatient physical therapy providers

On Aug. 2, 2021, eviCore will post on its provider portal the July 2021 utilization category updates for outpatient physical therapy service providers.

Review our March Record article for more details about eviCore’s change from paper mailings to online postings of the Practice Profile Summary, which includes the category update, and steps for accessing the information on the portal.

Alacura Medical Transport Management updates phone number

The telephone number for Alacura Medical Transport Management has changed to 1-844-425-2287.
We’ve updated the Air ambulance flight information (non-emergency) form to reflect the change. The fax number for Alacura is also on the form; the fax number hasn’t changed.

We’re also updating other documents to reflect this change.

Providers should no longer call Alacura at its previous number, which was 1-844-608-3676.

As a reminder, prior authorization by Alacura is required for non-emergency air transport of Blue Cross Blue Shield of Michigan and Blue Care Network commercial members. You’ll find more details about the authorization requirements on the form mentioned above.

Revised Participating Hospital Agreement takes effect July 1, 2021

Blue Cross Blue Shield of Michigan, with input from hospitals and the Michigan Health & Hospital Association, has been working over the past three years to update the Participating Hospital Agreement.

The Health Care Delivery Committee, a committee of the Blue Cross Blue Shield of Michigan Board of Directors, approved the Third Amended and Restated Participating Hospital Agreement earlier this year. A copy of the new PHA was sent to all participating hospitals, serving as the requisite notice of board approval by the committee and Blue Cross.  

It becomes effective on the first day of the participating hospitals’ fiscal year, beginning on or after July 1, 2021, or as otherwise set forth in an applicable Letter of Understanding.

The revisions to the PHA address the ever‑changing financial landscape of health care. The Third Amended and Restated PHA was designed to reduce the administrative burden on health care providers and foster more effective relationships between the hospitals and Blue Cross.

PHA revisions include, but are not limited to:

• Eliminating Blue Cross Interim Payments, or BIP, for all hospitals
• Eliminating the annual settlement process
• Streamlining the appeals process
• Updating the Contract Administration Process
• Simplifying Peer Group 5 administration
• Eliminating Exhibit B and references to reimbursement for Peer Group 1 through 4 hospitals

How do I learn more about the PHA changes?
Refer to the Frequently Asked Questions document for additional information or contact your contracting team:

• Mike Andreshak, director, at 313‑448‑3905 or MAndreshak@bcbsm.com   
• Lynda Cerutti, director, at 269‑321‑7680 or LCerutti@bcbsm.com
• Fred Schaal, director, at 810‑720‑8555 or FSchaal@bcbsm.com
• Kurt Prettenhofer, manager, at 313‑448‑5815 or KPrettenhofer@bcbsm.com
• Lauren Rossi, manager, at 313‑448‑6090 or LRossi2@bcbsm.com

Here are resources for TurningPoint musculoskeletal surgical quality and safety management program

We have resources to help you navigate the TurningPoint musculoskeletal surgical quality and safety management program.

You can find them on the following pages of the ereferrals.bcbsm.com website:

• Blue Cross Musculoskeletal services
• BCN Musculoskeletal services

The most comprehensive resource is the Frequently asked questions for providers document. Here are a few things you’ll find in the FAQ:

• How to submit authorization requests to TurningPoint through its portal, by fax and by phone
• How the peer‑to‑peer conversation process works
• Information related to submitting claims

Some of the other resources you’ll find on these pages are:

• The list of orthopedic, pain management and spinal procedure codes that require prior authorization by TurningPoint
• The list of orthopedic and spinal procedure codes for which we allow code substitutions
• A document that walks through the steps to determine whether prior authorization is required for Blue Cross commercial members. (This document is accessible only from the Blue Cross Musculoskeletal services page.)
• Clinical documentation requirements for musculoskeletal procedures
• The TurningPoint Provider Training Manual
• Fax forms for requesting authorization for musculoskeletal procedures
• Recordings and presentations from the TurningPoint provider training sessions

We encourage you to take advantage of these resources.

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

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

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

We’re enhancing TurningPoint surgical quality and safety management program to improve your experience

The Blue Cross Blue Shield of Michigan and Blue Care Network Utilization Management department is committed to enhancing your experience with the TurningPoint Healthcare Solutions, LLC surgical quality and safety management program. Since we implemented the program, we’ve made changes to several areas based on provider feedback.

We’ve recently made the following enhancements:

• Published the code substitutions that are available for musculoskeletal procedures
• Detailed the steps required to determine whether prior authorization is required for Blue Cross commercial members
• Simplified the process for requesting peer‑to‑peer conversations
• Clarified clinical documentation requirements
• Updated and added informational resources for the TurningPoint program

Keep reading to learn more…

Code substitutions for musculoskeletal procedures
In some situations, you may not know which orthopedic or spinal procedure will be required in advance of a surgery or the surgical plan may change intraoperatively. As a result, the procedure code TurningPoint authorized may not represent the procedure that was actually performed.

Prior to submitting claims for these procedures, you’ll need to determine whether you can substitute the code for the procedure that was performed for the code TurningPoint authorized. If you can substitute the code, you won’t need to contact TurningPoint to update the procedure coding.

To learn how to determine if the approved code allows substitutions and to view all codes that allow substitutions, see the Musculoskeletal procedure code substitutions for orthopedic and spinal surgeries document.

This document is available on the Musculoskeletal services pages of our ereferrals.bcbsm.com website.

Determining whether prior authorization is required for Blue Cross commercial members
We created a document that walks through the steps required to determine whether Blue Cross commercial members require prior authorization. The document is titled Determining whether Blue Cross commercial members require prior authorization for musculoskeletal surgeries and related procedures. It’s available on the Blue Cross Musculoskeletal services page of our ereferrals.bcbsm.com website.

Process for requesting peer-to-peer conversations
The steps that lead up to peer-to-peer conversations with TurningPoint vary depending on whether the member has coverage through a commercial product or through a Medicare Advantage product.

Commercial members (Blue Cross commercial or BCN commercial)
If TurningPoint denies an authorization request for a commercial member, you have two options for requesting a reconsideration of the denial:

• You can ask TurningPoint to review additional clinical documentation, you can provide clarifying details that are pertinent to the request or both. Submit the documentation, details or both in one of these ways:
• Through the TurningPoint Provider Portal
• By fax. Include a cover sheet that identifies the patient and send the fax to 313‑879‑5509 for joint and spine procedures or to 313‑483‑7323 for pain management procedures.
• You can request a peer‑to‑peer conversation to review the case with a physician. To do this, call 1‑833‑217‑9670. You’ll need to provide three dates when you’re available to meet. TurningPoint will schedule the conversation based on the dates you request.

You can request a reconsideration or a peer-to-peer conversation any time before providing services or filing an appeal with the health plan.

If you completed a reconsideration or peer-to-peer conversation and are dissatisfied with the decision, you may appeal.

Medicare Advantage members (Medicare Plus Blue℠ or BCN Advantage℠)
Before denying an authorization request, TurningPoint will make three attempts to notify you of its intent to deny any request that doesn’t meet medical necessity criteria. As part of this notification, TurningPoint will offer to schedule a peer‑to‑peer conversation. You’ll need to give TurningPoint three dates when you’re available to meet. TurningPoint will schedule the conversation based on the dates you requested.

If TurningPoint is unable to contact you, it’ll proceed with the authorization decision based on the information you provided with the authorization request.

Alternately, you can request a peer-to-peer conversation any time before providing services or filing an appeal.

For TurningPoint to consider information obtained during a peer‑to‑peer conversation when making an authorization determination, the peer‑to‑peer conversation must take place prior to the denial of an authorization request.

Note: If the peer‑to‑peer conversation takes place after TurningPoint denies the authorization request, TurningPoint can’t reverse the denial. In such cases, the peer‑to‑peer conversation is for informational purposes only.

Clinical documentation requirements
We recently published updated information about the clinical documentation you must include when submitting prior authorization requests to TurningPoint.

We updated or added information related to the specific clinical documentation requirements for:

• Conservative therapies
• Body mass index
• Smoking status
• Surgical plan

To view the updated requirements, see the Clinical documentation requirements for musculoskeletal procedures document. This document is available on the Musculoskeletal services pages of our ereferrals.bcbsm.com website.

Resources for the TurningPoint program
Resources are available to help you navigate the TurningPoint musculoskeletal surgical quality and safety management program.

We update these resources on a regular basis to provide you with the most current information.

To learn more, see Here are resources for TurningPoint musculoskeletal surgical quality and safety management program, also in this issue.

Medical coverage expanding under some Ford salaried plans for members who are transgender

Ford will soon begin covering additional medical services under salaried plans for members who are transgender with a clinical diagnosis of gender dysphoria.  

The following additional gender-affirming services for members will be covered starting June 1, 2021:

• Face and neck laser hair removal
• Facial feminization surgery
• Blepharoplasty
• Genioplasty
• Mandibular augmentation
• Forehead reduction/contouring
• Rhinoplasty
• Chondrolaryngoplasty (Adam’s apple reduction)

Currently, all Ford plans cover genital surgery, mastectomy in female-to-male transition, hormone therapy and counseling when medically necessary to treat gender dysphoria. Gender dysphoria involves a conflict between a person's gender identity and their gender assigned at birth, causing significant distress.

Coverage for the new services will require that members meet medical necessity criteria and use network providers. Coverage has up to a $30,000 lifetime limit. Plan cost share will apply.

The group numbers are 87241, 87252, 87254, 87262, 87264 and 87292. The number will be on the front of the member ID card. As always, be sure to check web-DENIS for benefits and eligibility.

Quarterly update: Requirements changed for some commercial medical benefit drugs

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

During January, February and March 2021, there were changes to prior authorization requirements, site-of-care requirements or both for Blue Cross and BCN commercial members for the following medical benefit drugs:

• Amondys 45^® (casimersen), HCPCS code J3490
• Oxlumo™ (lumasiran), HCPCS code J3490
• Breyanzi^® (lisocabtagene-maraleucel), HCPCS code J9999

Note: The codes shown above will become unique codes.

For Blue Cross commercial members, these authorization requirements apply only to groups that currently participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To view the list of Blue Cross commercial groups that don’t require members to participate in the program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List. A link to this list is also available on the Blue Cross Medical Benefit Drugs page of the ereferrals.bcbsm.com website.

For a detailed list of requirements, see the Blue Cross and BCN utilization management medical drug list. Links to this list are also available on the Blue Cross Medical Benefit Drugs and BCN Medical Benefit Drugs pages of the ereferrals.bcbsm.com website.

Approval of an authorization request isn’t a guarantee of payment. As always, health care providers should verify eligibility and benefits for members.

Spravato and Panzyga to require prior authorization starting July 12 for Blue Cross URMBT non-Medicare members

We’re expanding the prior authorization requirements for drugs covered under the medical benefit for UAW Retiree Medical Benefits Trust, or URMBT, commercial (non-Medicare) members with Blue Cross Blue Shield of Michigan coverage.

For dates of service on or after July 12, 2021, the following drugs will require prior authorization:

• Spravato^® (esketamine), HCPCS code S0013  
• Panzyga^® (immune globulin, human-ifas), HCPCS code J1599

How to submit authorization requests

Submit prior 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, do the following:

1. Visit ereferrals.bcbsm.com.
2. Click on Blue Cross.
3. Click on Medical Benefit Drugs.
4. Scroll down to the Blue Cross’ PPO (commercial) column.
5. Review the information in the How to submit requests electronically using NovoLogix section.

More about the authorization requirements

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

For additional information on requirements related to drugs covered under the medical benefit, refer to the document Medical Drug Management with Blue Cross for UAW Retiree Medical Benefit Trust PPO non-Medicare members.

We’ll update this list with the new information about these drugs prior to the effective date.

Medicare 2% sequestration moratorium extended to Dec. 31, 2021

President Biden signed legislation on April 14, 2021, that extends the suspension of the Medicare 2% sequestration reduction until the end of 2021. We’ve aligned with the Centers for Medicare & Medicaid Services and will extend the suspension of the 2% sequestration applied to Medicare Plus Blue℠ and BCN Advantage℠ claims through Dec. 31, 2021. Providers don’t need to take any action.

Background

Since 2013, 2% sequestration reimbursement reductions have been in place for our Medicare Advantage professional and facility providers. This is in accordance with the terms of our Medicare Advantage provider agreements that pay according to Original Medicare methodologies. The 2% reimbursement adjustment is applied after determining any applicable member deductible, copayment or other required member cost sharing.

Timeline

The timeline of the suspensions is as follows:

• May 1, 2020, through Dec. 31, 2020
  The Coronavirus Aid, Relief, and Economic Security (also known as CARES) Act suspended the 2% sequestration payment adjustment percentage applied to all Medicare Fee-for-Service claims to offer financial relief to providers during the COVID-19 pandemic.
• Jan. 1, 2021, through March 31, 2021
  The Consolidated Appropriations Act of 2021 extended the suspension period to March 31, 2021.
• April 1, 2021, through Dec. 31, 2021
  On April 14, 2021, H.R. 1868 was signed into law, extending the suspension period to Dec. 31, 2021.

Reimbursement to providers who haven’t been affected by sequestration previously, such as durable medical equipment, end-stage renal disease and lab providers, won’t be affected by this change.

We expect that CMS will reinstate the 2% sequestration reimbursement reduction on Jan. 1, 2022, but will alert you of any changes prior to that date.

Provider Experience transitioning to new provider training site June 1

In previous issues of The Record, we’ve let you know that Provider Experience will be launching a new provider training site, which will enhance the training experience for health care providers and staff. We’re pleased to let you know that beginning June 1, users will be able access recorded webinars, videos, e-Learning modules and other training resources through this new site.

Active training courses and materials from 2019 to 2021 have moved from BCBSM Provider Training and BCN Learning Opportunities to the new site.

To request access, complete the following steps:

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

To learn more about the provider training site, watch this video that guides you through the experience.

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

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

Starting in April, we began offering webinars that provide updated information on risk adjustment documentation and coding of common challenging diagnoses.

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

Click on a link below to sign up for a webinar.

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

Here are requirements for submitting Flexible Benefit Option and SNF admission requests for FEP members

Before we can process Flexible Benefit Option requests for Blue Cross and Blue Shield Federal Employee Program^® Service Benefit Plan members, including those for skilled nursing facility admissions or extensions, Blue Cross must receive a member-signed Alternative Benefit Agreement and a verbal or signed consent for Blue Cross Coordinated Care℠.

Flexible Benefit Option

This option is used to approve services outside the defined plan benefits, including:

• Skilled nursing home benefit for Basic Option members
• Skilled nursing home benefit extension for FEP Blue Focus members (14-day maximum allowed per year)
• Skilled nursing facility benefit extension for Standard Option members
• Extension of exhausted benefits, such as home health care or for physical, occupational or speech therapy for all members

Before we can process Flexible Benefit Option requests, the following must be completed for Standard Option, Basic Option and FEP Blue Focus members:

• An Alternative Benefit Agreement (also known as the Member Agreement Letter), signed by the member is required before services can be approved.
• The member’s verbal or signed consent for Blue Cross Coordinated Care is required before services can be approved. A signed consent must be returned by case closure.

Providers can submit all required documents in one of the following ways:

• Fax them to the Utilization Management department at 1-866-411-2573.
• Attach them to the authorization request in the e-referral system in the Case Communication field. For instructions, refer to the e-referral User Guide, under the Create New (communication) section.

Skilled Nursing Facility

Standard Option Benefit

• The member’s verbal or signed consent for the Blue Cross Blue Shield of Michigan care management program, Blue Cross Coordinated Care, is required prior to a SNF admission. A signed consent must be returned by the closure of the case.

Basic Option Benefit

• The member’s verbal or signed consent for Blue Cross Coordinated Care is required prior to a SNF admission. A signed consent must be returned by case closure.
• The Flexible Benefit Option is required for SNF benefits for Basic Option members. The Flexible Benefit Option must include a signed Alternative Benefit Agreement before services can be approved.
• The Flexible Benefit Option must also include a signed Provider Agreement letter by case closure.

FEP Blue Focus benefit — 14-day maximum allowed per year

• This plan follows the Basic Option Benefit process.

Note: No retrospective reviews are accepted.

eviCore to post category updates online for outpatient physical therapy providers

On Aug. 2, 2021, eviCore will post on its provider portal the July 2021 utilization category updates for outpatient physical therapy service providers.

Review our March Record article for more details about eviCore’s change from paper mailings to online postings of the Practice Profile Summary, which includes the category update, and steps for accessing the information on the portal.

Alacura Medical Transport Management updates phone number

The telephone number for Alacura Medical Transport Management has changed to 1-844-425-2287.
We’ve updated the Air ambulance flight information (non-emergency) form to reflect the change. The fax number for Alacura is also on the form; the fax number hasn’t changed.

We’re also updating other documents to reflect this change.

Providers should no longer call Alacura at its previous number, which was 1-844-608-3676.

As a reminder, prior authorization by Alacura is required for non-emergency air transport of Blue Cross Blue Shield of Michigan and Blue Care Network commercial members. You’ll find more details about the authorization requirements on the form mentioned above.

Starting July 1, we’ll change how we cover some drugs on the Preferred Drug List

Blue Cross Blue Shield of Michigan and Blue Care Network are committed to ensuring members receive safe, high-quality care that meets their needs. To accomplish this, we’re making some changes to how we cover some drugs on the Preferred Drug List, starting July 1, 2021:

• We’ll no longer cover the brand-name and generic drugs list in the table below.
• If a member fills a prescription for one of the drugs listed in the table below on or after July 1, they’ll be responsible for the full cost.
• The list below shows suggested 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.

Quarterly update: Requirements changed for some commercial medical benefit drugs

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

During January, February and March 2021, there were changes to prior authorization requirements, site-of-care requirements or both for Blue Cross and BCN commercial members for the following medical benefit drugs:

• Amondys 45^® (casimersen), HCPCS code J3490
• Oxlumo™ (lumasiran), HCPCS code J3490
• Breyanzi^® (lisocabtagene-maraleucel), HCPCS code J9999

Note: The codes shown above will become unique codes.

For Blue Cross commercial members, these authorization requirements apply only to groups that currently participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To view the list of Blue Cross commercial groups that don’t require members to participate in the program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List. A link to this list is also available on the Blue Cross Medical Benefit Drugs page of the ereferrals.bcbsm.com website.

For a detailed list of requirements, see the Blue Cross and BCN utilization management medical drug list. Links to this list are also available on the Blue Cross Medical Benefit Drugs and BCN Medical Benefit Drugs pages of the ereferrals.bcbsm.com website.

Approval of an authorization request isn’t a guarantee of payment. As always, health care providers should verify eligibility and benefits for members.

Pharmacy Opportunities Focus updated for Spring 2021

The Pharmacy Opportunities Focus document, updated for spring 2021, has incorporated suggestions based on recent significant manufacturer drug price increases. This resource can serve as a quick reference guide for a variety of situations, such as when considering multiple drug options at the point of care or performing an evaluation of pharmacy claims data to identify high-cost drugs and their lower-cost preferred alternatives.

Below are additional suggestions when looking through pharmacy data to identify potential cost-saving opportunities:

• Moving from brand-name medications to generics. Compare pharmacy claims data with the drug lists.**

• Leveraging the preferred alternatives of a member’s respective drug list at the point of care. Download the free ScriptVision™ Physician app through the App Store^® for your iPhone or iPad. In real time, see the member’s out-of-pocket costs, any plan requirements (for example, prior authorization, step therapy and quantity limit) and lower-cost alternatives.
  
  If real-time prescription benefit check is enabled in your electronic health record or electronic medical record system, use this function to see the member’s out-of-pocket costs and specific plan requirements.

• Improving the generic prescribing rates of primary care provider. Use the physician profile report for details on certain drugs or members.

• Monitoring specialists who prescribe brand-name drugs when a generic is available or nonpreferred drugs when preferred alternatives are available. Identify the specialists and then reach out to them for discussion.

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

For a step-by-step guide on how to navigate Health e-Blue℠ to obtain pharmacy claims data, as well as how to generate the pharmacy profile report of a primary care provider, refer to the Pharmacy Opportunities Focus: Health e-Blue Pharmacy Guide on the Health e-Blue website.

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

**The drug lists are updated monthly to reflect new drug approvals, new safety or efficacy data and clinical guideline updates. Refer to the online documents for the most up-to-date versions.

Medicare Star Ratings: More ICD-10 codes added to exclusion list for SUPD measure

The Centers for Medicare & Medicaid Services has revised its Medicare Star Ratings measure known as Statin Use in Persons with Diabetes, or SUPD.

In the past, only patients in hospice or on dialysis could be excluded from the measure. Now, in addition to those two conditions, several other ICD-10 codes have been added to the exclusion list. These codes must be billed every year.

About the SUPD measure
The SUPD measure is defined as the percent of Medicare Part D patients age 40 to 75 who:

• Received at least two diabetes medication fills during the calendar year
• Also received a statin medication fill during the calendar year

Only statin claims billed through a patient’s Part D plan count toward closing gaps in the measure. The following types of statin claims won’t close a gap in the SUPD measure:

• Claims filled through drug discount cards or store pharmacy discount programs
• Cash claims
• Medication samples
• Fills from Veterans Affairs facilities
• Fills billed to a non-Medicare insurance plan

To satisfy the SUPD measure requirements, a statin claim must be filled no later than the month before the patient turns 76. Patients born in 1945 are turning 76 years old this year.

If statin therapy isn’t medically appropriate for your patients who have diabetes, make sure the proper ICD-10 code is billed to exclude them from the SUPD measure.

Diagnosis codes added
Here are the diagnoses codes added to the SUPD exclusion list:

Spravato and Panzyga to require prior authorization starting July 12 for Blue Cross URMBT non-Medicare members

We’re expanding the prior authorization requirements for drugs covered under the medical benefit for UAW Retiree Medical Benefits Trust, or URMBT, commercial (non-Medicare) members with Blue Cross Blue Shield of Michigan coverage.

For dates of service on or after July 12, 2021, the following drugs will require prior authorization:

• Spravato^® (esketamine), HCPCS code S0013  
• Panzyga^® (immune globulin, human-ifas), HCPCS code J1599

How to submit authorization requests

Submit prior 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, do the following:

1. Visit ereferrals.bcbsm.com.
2. Click on Blue Cross.
3. Click on Medical Benefit Drugs.
4. Scroll down to the Blue Cross’ PPO (commercial) column.
5. Review the information in the How to submit requests electronically using NovoLogix section.

More about the authorization requirements

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

For additional information on requirements related to drugs covered under the medical benefit, refer to the document Medical Drug Management with Blue Cross for UAW Retiree Medical Benefit Trust PPO non-Medicare members.

We’ll update this list with the new information about these drugs prior to the effective date.