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May 2021
Clarification: We’ve simplified your appeal processWhat you need to know
An article on this topic in the September 2020 Record elicited some questions from providers. This new article is intended to clarify the changes in the appeal process. Effective Oct. 1, 2020, the level 1 provider appeals process transitioned to Provider Relations & Servicing. Your claim appeal requests can now be accepted verbally at the time you inquire about the status of a claim. Also, the fax number that was used to submit documentation regarding appeals prior to Oct. 1, 2020, has changed. The changes implemented on Oct. 1, 2020, only apply to Blue Cross Blue Shield of Michigan post-service commercial appeals. As always, your first step if you want to appeal an adverse benefit or claim determination is to call Provider Inquiry. You may contact a Customer Service representative at one of the phone numbers below.
Refer to the “Appeals and Problem Resolution” chapter of the PPO Provider Manual on web‑DENIS for a detailed explanation of appeal filing criteria and guidelines. Submitting documentation for review Once you gather your documentation, return it to Blue Cross Blue Shield of Michigan Provider Relations & Servicing by fax at 1‑866‑434‑6911, ensuring that the fax cover sheet from the Customer Service representative is the first page of your fax. This fax cover sheet will replace the cover sheet previously used by your office. Note: All faxes must include the Provider Level 1 Appeals Fax Cover Sheet provided by the Customer Service representative. Appeals not affected by this process For more information, see the September Record article.
We’ve updated our timeline for transition to Availity provider portal
We’re still working to have Blue Cross Blue Shield of Michigan and Blue Care Network content available in Availity in 2021, but a full transition is likely to move into 2022. We’ll share more on that timing later this year. To help support this change, we plan to have both our current portal (Provider Secured Services on bcbsm.com, including web‑DENIS) and Availity functioning with Blue Cross and BCN information for a period of time. We’ve been so excited about the advantages of moving to the Availity provider portal that we couldn’t wait to share them with you. That’s why we announced the decision to move to Availity in September 2020, and we began sharing some of the positive changes with you each issue of The Record, starting in November 2020. We’re still excited about what the future holds with our move to Availity, but we’re going to take a small break in telling you about it for the next few issues. We’ll bring you more tips as we get closer to the implementation date. We appreciate your patience as we work to improve our online services for you. Questions? Previous articles about Availity
Addressing health care disparities: Social determinants of healthThis article first ran in the March — April issue of Hospital and Physician Update as part of an ongoing series on how we’re addressing health care disparities in Michigan. If you’d like to read additional articles on the topic of health care disparities, subscribe to Hospital and Physician Update, a newsletter published every other month. According to the National Academy of Medicine,** medical care determines 10% to 20% of a person’s overall health. The other 80% to 90% is determined by circumstances in which people are born, live and age. Called the social determinants of health, these influences have a significant influence on a person’s health. They include:
When it comes to where people live, a person’s ZIP code can actually predict their longevity. For example, according to the National Center for Health Statistics,** residents of Grosse Pointe have a life expectancy of 82, while in the Dexter/Linwood area of Detroit, the life expectancy is just 62. The life expectancy in the state averages 78. These statistics illustrate that health starts long before an illness — or even birth. It starts in our schools, workplaces and communities. Within some communities, access to high-quality health care is limited. “The research is clear: Social determinants influence health disparities and burden certain population groups with higher rates of illness, injury, disability and mortality,” said Daniel J. Loepp, president and CEO of Blue Cross Blue Shield of Michigan, in a blog on mibluesperspectives.com. “To eliminate these disadvantages, communities must have equal access to the resources that improve quality of life.” As we wrote in the first article in this series, “Blue Cross launches Office of Health and Health Care Disparities,” one of the challenges to delivering health care in an equitable way is understanding the role that implicit bias plays in health care disparities. That’s why Blue Cross’ implicit bias education for participating health care providers is so important. Exploring socioeconomic factors To help address social needs, Blue Cross is focusing on food insecurity, housing, access to telehealth, health literacy and mental health. Along the way, we’ll continue to partner with and invest in community organizations across Michigan. One such community group is the Baxter Community Center in the Baxter neighborhood of southeast Grand Rapids where 42% of families live on less than $25,000 per year. Executive Director Sonja Forte works closely with residents who access services at Baxter’s health center. When residents access services at Baxter’s health center, they fill out a questionnaire that relates to various aspects of the social determinants of health. Forte said it helps guide resources and programming to address barriers such as transportation and child care that make it harder to get to appointments. “Missed visits aren’t always because people don’t care or just choose not to go,” Forte said. Blue Cross’ social mission Blue Cross’ longstanding mission is to improve the health of all Michigan residents. “We’re proud to be the largest private donor to Michigan’s free clinics, providing low‑cost medical, dental and mental health care for safety net programs for the uninsured and underinsured,” said Loepp. “Additionally, our organization has introduced policies that emphasize health equity, cultural competency and the quality of health care delivery. We’re connecting members to physicians, raising awareness of implicit bias through education, supporting organizations to address food insecurity and partnering with foundations to expand access to telehealth services for everyone.” If you have a patient who is struggling to afford basic household needs, the United Way’s 2‑1‑1 service can help. This free and confidential service helps people find the local resources they need 24 hours a day, 7 days a week and can be accessed by dialing 2‑1‑1 or visiting 211.org.** Previous articles in this series
**Blue Cross Blue Shield of Michigan doesn’t own or control this website.
Blue Cross committed to coordination of care and exchange of information among practitionersBlue Cross Blue Shield of Michigan collects and analyzes data each year to facilitate the coordination of care and exchange of information among specialists, behavioral health providers and primary care physicians following inpatient and outpatient visits. Good two‑way information exchange is especially important as we work to improve continuity and coordination of care within our network. For example, we not only need primary care providers to share information with specialists (including behavioral health specialists), but we need specialists to share patient information with the primary care providers as well. Patient care that isn’t coordinated across care settings results in confusion for members, increased risks to patient safety and unnecessary costs due to duplicate testing or procedures. Collaboration among health care providers can also greatly improve member satisfaction. We can work together to accomplish our goal of 100% coordination of care among all providers by:
We encourage all health care providers to continue to take steps to enhance the coordination of care and information exchange across the continuum of care to improve member satisfaction and care quality.
May is Mental Health Month: Check out resources available to youMay is Mental Health Month, a good time to remind your patients of the important role that good mental health plays in overall wellness. Blue Cross Blue Shield of Michigan has developed a wide range of materials and resources focused on mental and behavioral health — many of them suitable for sharing with patients. “We know it’s important to address mental and behavioral health issues as part of a patient’s overall well‑being — and to address them early before they escalate,” said Dr. Amy McKenzie, associate chief medical officer. “That’s why we’ve created an array of materials for members and health care providers to help connect patients to treatment and provide educational materials to help patients better manage their conditions.” We encourage you to check out the following:
In addition, members can follow Blue Cross on Facebook and Twitter for regularly updated mental health information. We’re also launching the second phase of our Behavioral Health Campaign this month. It will include a refreshed Behavioral and Mental Health site and an array of communications targeted to our members. The focus will be on removing mental health stigmas and other barriers to care.
Patient experience survey launches in JuneBlue Cross Blue Shield of Michigan and Blue Care Network are launching a new Medicare Advantage member survey in June 2021 to assess patient experience. Our research shows that 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 the Centers for Medicare & Medicaid Services Star Ratings of health plans. Strong Star Ratings performance allows us to deliver affordable Medicare Advantage benefits to your patients. The nationally recognized Clinician & Group Consumer Assessment of Healthcare Providers and Systems, or CG‑CAHPS, survey protocol will be used 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 BlueSM and BCN AdvantageSM members will be randomly invited to take the survey annually. These members will be eligible for the survey if our claims data shows they’ve had a care experience within the past 45 days with a primary care provider or one of five coordinated care specialists:
Results will allow Blue Cross to monitor patient experience ratings across physician organizations as one of many elements that inform overall performance measurement. We’ll also share results with provider organizations, including comparisons to national benchmarks. A CMS‑certified vendor will mail the survey beginning in June 2021, with online and phone completion options. Monthly mailings will then be ongoing.
Reminder: Using HCPCS code G2212We posted a web‑DENIS message in January to let you know the following:
For more information on HCPCS and CPT codes, refer to our 2021 CPT and HCPCS Update document, which was posted on the Clinical Criteria & Resources page of web‑DENIS early this year. It provided information on the new and deleted codes as of Jan. 1, 2021. Billing chart: Blues highlight medical, benefit policy changesYou’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:
We’re applying value‑based reimbursement to procedure codes for COVID‑19 vaccine, other immunizationsEffective July 1, 2021, value-based reimbursement will be applied to the new COVID‑19 vaccine administration codes billed by primary care providers and specialists who are receiving value‑based reimbursement. The relevant procedure codes to which value-based reimbursement will be applied are:
Value‑based reimbursement for primary care providers is currently applied to select evaluation and management, preventive health, telehealth and care management procedure codes. In addition to the codes listed above, value‑based reimbursement for primary care providers will be applied to six additional vaccine administration procedure codes, effective July 1, 2021. The additional procedure codes are:
If you have any questions, ask your physician organization to submit them to Value Partnerships through the PGIP Collaboration site.
Prepayment Utilization Review can affect physicians’ value‑based reimbursementPrimary care providers and specialists participating in Value Partnerships programs are eligible to receive value‑based reimbursement in accordance with the Value‑Based Reimbursement Fee Schedule. Value‑based reimbursement is available to practitioners who meet the criteria for quality improvement programs developed as part of Value Partnerships and the Physician Group Incentive Program. Keep in mind that practitioners become ineligible for value‑based reimbursement if Blue Cross Blue Shield of Michigan places them on Prepayment Utilization Review, or PPUR. Providers on PPUR are reviewed on a six‑month basis. Practitioners will remain ineligible for value-based reimbursement until the value‑based program designation cycle following the discontinuation of the PPUR. PPUR is a process we use to determine appropriate liability for covered health care services before paying claims. Providers on PPUR have a medical record review before claims are paid. Additional information about the PPUR process and reasons for review can be found in the provider manual. A link to the provider manual is on the homepage of web‑DENIS. Practitioners receive a written notification when placed on PPUR. In addition to the letters sent to the practitioner, a copy will be sent to the practitioner’s physician organization if the practitioner participates in PGIP. If you have questions about PPUR, call provider clinical consultant Tom Rybarcyzk at 248‑446‑3836.
RC Claim Assist available through Provider Secured ServicesStarting May 1, 2021, you’ll have to go through Provider Secured Services to access RC Claim Assist. To do this, log in to bcbsm.com as a provider, click on the RC Claim Assist link in the Provider Secured Services welcome page and follow the prompts. As a reminder, RC Claim Assist is a web‑based resource available to Blue Cross Blue Shield of Michigan and Blue Care Network contracted providers who bill for drugs covered under the medical benefit. RC Claim Assist provides an overview of medical drug products and a calculation tool to identify the correct National Drug Code and CPT codes to bill, along with the correct NDC quantity, unit of measure and HCPCS billable units, according to the package information.
CareCentrix to manage authorizations for home health care for Medicare Advantage membersAction item Referring providers and home health care agencies should sign up for training webinars on the home health care program for services managed by CareCentrix. Blue Cross Blue Shield of Michigan and Blue Care Network have contracted with CareCentrix® to manage the authorization of home health care for Medicare Advantage members. For episodes of care starting on or after June 1, 2021, providers will need to request prior authorization from CareCentrix for Medicare Plus BlueSM and BCN AdvantageSM members. For episodes starting prior to June 1, 2021, providers will need to request prior authorization in the following situations:
CareCentrix will authorize and support the coordination of home health care services, such as skilled nursing and physical, occupational and speech therapies. The CareCentrix program will:
Submitting prior authorization requests Home health care agencies will be able to submit prior authorization requests starting May 28, 2021. They can submit these requests online through the CareCentrix HomeBridge® portal, by phone or by fax. CareCentrix will provide detailed information to home health agencies about the steps required to submit prior authorization requests during the upcoming webinar training sessions. Registering for webinar training We’re offering training webinars on the home health care program for services managed by CareCentrix. There are training sessions for referring providers and for home health care agencies. Webinar for referring providers — This session will cover the CareCentrix home health care program and details about members’ transitions from hospital to home.
Webinars for home health care agencies — These sessions will cover the CareCentrix home health care program: the steps required to obtain prior authorizations for home health care services, intent to deny, peer-to-peer and appeal processes, and provider support and resources.
Learning more about the CareCentrix home health care program
Pilot program with naviHealth supports Medicare Advantage members after hospital dischargeBlue Cross Blue Shield of Michigan and Blue Care Network have started working with naviHealth, an independent company, to pilot the company’s Patient Navigation Program. This pilot program provides non‑clinical support to Medicare Plus BlueSM and BCN AdvantageSM members to assist with their discharge needs after an acute hospital stay through their transition to home. It will be offered to select members admitted to select hospitals in the Detroit area in an effort to reduce readmissions. The pilot, which started in April, will run through July, at which time an evaluation will be completed to determine whether the program should continue after the pilot stage. Members have no out‑of‑pocket costs when using this program, which is a component of our existing clinical partnership with naviHealth. NaviHealth’s patient navigation team won’t provide medical care or make clinical recommendations and doesn’t replace any existing case management program the member may be participating in. Patient navigators support members by:
Starting in June, we’ll use clinical information to validate providers’ answers to some questionnaires in the e-referral systemBeginning in June 2021, we’ll pend some authorization requests that would usually be auto‑approved based on your responses to questionnaires in the e‑referral system. This applies to authorization requests submitted for BCN commercial, Medicare Plus BlueSM and BCN AdvantageSM members. When we pend a request, you’ll get this message in the e‑referral system: “Case requires validation. Medical records required. Please attach clinical information from the patient’s medical record applicable to this request in the Case Communication field.” For instructions on how to attach clinical information to the authorization request in the e‑referral system, refer to the e‑referral User Guide. Look in the section titled “Create New (communication).” We’ll review and verify that the clinical information you provide supports your responses to the questionnaire and make a determination on the request. If we don’t receive the clinical information or the information you send doesn’t support your answers in the questionnaire, we won’t be able to approve the request. As a reminder, on the preview questionnaires that we publish on our ereferrals.bcbsm.com website, we state that we’ll retrospectively monitor compliance with this authorization requirement. You can access the preview questionnaires:
Starting June 22, additional medications will require prior authorization for Medicare Advantage membersWhat you need to know For dates of service on or after June 22, 2021, you’ll need to submit prior authorization requests through NovoLogix® for Oxlumo™ (lumasiran), Evkeeza™ (evinacumab‑dgnb) and Nulibry™ (fosdenopterin) for Medicare Plus BlueSM and BCN AdvantageSM members. For dates of service on or after June 22, 2021, the following medications will require prior authorization through the NovoLogix® online tool:
This affects Medicare Plus BlueSM and BCN AdvantageSM members. Places of service that require authorizationFor Medicare Advantage members, we require authorization for these drugs when they’re administered by a health care professional in a provider office, at the member’s home, in an off‑campus or on-campus outpatient hospital or in an ambulatory surgical center (sites of care 11, 12, 19, 22 and 24) and billed as follows:
ReminderSubmit authorization requests for these drugs through NovoLogix. It offers real‑time status checks and immediate approvals for certain medications. If you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix. If you need to request access to Provider Secured Services, complete the Provider Secured Access Application form and fax it to the number on the form. List of requirementsFor a list of requirements related to drugs covered under the medical benefit, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members. We’ll update the list to reflect this change prior to June 22.
Additional medications will require prior authorization for most members, starting May 24What you need to know For dates of service on or after May 24, 2021, you’ll need to submit prior authorization requests to AIM Specialty Health® for Cosela™ (trilaciclib) and Pepaxto® (melphalan flufenamide) for most members. The following drugs covered under the medical benefit will require prior authorization for dates of service on or after May 24, 2021:
The prior authorization requirements apply when these drugs are administered in outpatient settings for:
These requirements don’t apply to Blue Cross commercial self-funded groups, including:
How to submit authorization requests Submit authorization requests to AIM using one of the following methods:
For information about registering for and accessing the AIM ProviderPortal, see the Frequently asked questions page** on the AIM website. More about the authorization requirements Authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members. See the following documents for additional information on requirements related to drugs covered under the medical benefit:
We’ll update the requirements lists with the new information prior to May 24, 2021. **Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.
Updates to preferred products for drugs covered under the medical benefitAction item Review the medications listed in this article to make sure you understand the prescribing guidelines. We’ve designated certain medications as preferred products for dates of service on or after April 1, 2021. This change affects most Blue Cross Blue Shield of Michigan commercial, all Medicare Plus BlueSM, all Blue Care Network commercial and all BCN AdvantageSM members. We originally announced this information in a previous edition of The Record. But since that time, we’ve updated some of the guidelines. To make sure you’re aware of the revisions, we’ve marked the updated information with two asterisks (**). Here’s what you need to know when prescribing these products for dates of service on or after April 1:
Information for Blue Cross commercial membersThe requirements outlined in this article apply as follows:
Preferred and nonpreferred products for most membersWe’re designating the following products as preferred and nonpreferred for:
1 Preferred rituximab products don’t require authorization through AIM Specialty Health. 2 Will become a unique code. 3 For BCN commercial, Medicare Plus Blue and BCN Advantage members: For courses of treatment that started Oct. 1, 2020, through March 31, 2021, submit these requests to AIM. For courses of treatment that started on or after April 1, 2021, submit these requests through NovoLogix. 4 For Blue Cross commercial fully insured members and Blue Cross commercial members with individual coverage: For courses of treatment that started on or after Oct. 1, 2020, you’re already submitting these requests through NovoLogix; your process won’t change. Additional preferred and nonpreferred products for most commercial membersWe’re designating the following products as preferred and nonpreferred for:
Additional preferred and nonpreferred products for Medicare Advantage membersWe’re designating the following products as preferred and nonpreferred for Medicare Plus Blue and BCN Advantage members.
Submitting requests for prior authorizationHere’s how to submit prior authorization requests for preferred products and nonpreferred products:
Exception:** Ruxience and Riabni don’t require authorization. Note: Previous communications incorrectly stated that Ruxience and Riabni require prior authorization. Disregard those communications, and use this information.
Authorization isn’t a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members. Lists of requirementsSee the following lists to view requirements for these products.
**This information has been updated since it originally appeared in a previous edition of The Record. ***Blue Cross Blue Shield of Michigan doesn’t own or control this website.
Abecma requires prior authorization for Medicare Advantage membersFor dates of service on or after April 5, 2021, the following CAR‑T medication requires prior authorization through the NovoLogix® online tool:
This applies to Medicare Plus BlueSM and BCN AdvantageSM members. Places of service that require authorization For Medicare Advantage members, we require authorization for all outpatient places of service when you bill these medications as either a professional or a facility service:
Reminder For this drug, submit authorization requests through NovoLogix. It offers real‑time status checks and immediate approvals for certain medications. If you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix. If you need to request access to Provider Secured Services, complete and fax the Provider Secured Access Application form to 1‑800‑495‑0812. List of requirements For a list of requirements related to drugs covered under the medical benefit, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members.
Reminder: Zulresso only payable for inpatient facility claimsIn the May 2020 Record, we notified you that Zulresso™ (brexanolone) is only payable for inpatient facility claims for Blue Cross Blue Shield of Michigan commercial members. However, we want to let you know the HCPCS code for providing this medication is now J1632. We’ll deny Blue Cross commercial claims for Zulresso that indicate the place of service as being other than an inpatient facility. This applies only to in‑state providers.
Updated profiling information now available for Blue Cross commercial chiropractorsWe’ve successfully completed making enhancements to the data exchange process between Optum® and Blue Cross Blue Shield of Michigan. Chiropractors within the Blue Cross commercial network can now visit the Optum provider website** to review their profiling data. If providers have questions, contact an Optum support clinician at 952‑205‑3121 or a Blue Cross profiling analyst at 313‑448‑7371. **Blue Cross Blue Shield of Michigan doesn’t own or control this website.
Qualified providers invited to apply for designation in BDC Substance Use Treatment program
This is the newest BDC designation, as we wrote in an October 2020 Record article. Currently, we have three Michigan providers who applied for and received this designation. Achieving this national designation recognizes that providers have demonstrated expertise in delivering quality specialty care in this area safely, effectively and cost efficiently. All providers who apply for this designation must offer programs for opioid use disorder, including medication-assisted treatment as needed. Providers can obtain detailed information about the Substance Use Treatment and Recovery BDC program selection criteria and eligibility here. Additional information on Blue Distinction Specialty Care can be found on the Blue Cross and Blue Shield Association website. Achieving this designation provides value to health care providers in various ways, including:
Whether a provider meets program selection criteria or not, every provider evaluated receives a customized report that provides useful insights into their performance. Finding a BDC provider Consumers and referring physicians alike can locate designated providers through the Blue Distinction Center Finder. Designations are also identified on the Find a Doctor search tool, which can be accessed from the homepage of bcbsm.com. To apply for designation If you’re interested in applying for Blue Distinction Center for Substance Use Treatment and Recovery designation, send an email to Michelle Williams at MWilliams3@bcbsm.com. Did you know?
Reminder: Lunch and learn webinars for physicians and coders focus on risk adjustment, codingAction item Sign up now for our live, monthly, lunchtime webinars. In April, we began offering webinars that provide updated information on documentation and coding of common, challenging diagnoses. These live, lunchtime educational sessions include an opportunity to ask any questions you may have. The May through September webinars are led by physicians. The last three sessions of the year focus on coding guideline updates and are led by coders. Here’s our current schedule and the tentative topics for the remaining sessions. All sessions start at 12:15 p.m. Eastern time and generally run for 15 to 30 minutes. Click on a Register here link below to sign up for a session.
If you have any questions about the sessions, contact April Boyce at aboyce@bcbsm.com. If you have questions regarding registration, email Patricia Scarlett at pscarlett@bcbsm.com.
New webinars and on-demand training availableAction item Check out what’s new on our provider training websites, including an e‑learning overview of HCPCS and revenue code combinations and a webinar recording from our Claims Basics presentation for professional providers. Provider Experience is continuing its series of training webinars for health care providers and staff to promote collaboration with Blue Cross Blue Shield of Michigan and Blue Care Network. Upcoming training webinars:
Provider Experience also offers training resources for health care providers and staff that includes previously recorded webinars, plus specific topic videos and e‑Learning modules. These on-demand courses are designed to help you work efficiently with Blue Cross and BCN. The following are the newest available resources:
Access to 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
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
As additional training webinars become available, we’ll provide notices through web‑DENIS, The Record and BCN Provider News.
Reminder: Virtual provider symposiums to focus on patient experience, HEDIS, documentation and codingAction item Register for one or more of the upcoming provider symposiums, using the links included in this article. We’ve scheduled this year’s provider symposiums virtually throughout May and June 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 continuing education credits for attending the sessions. You can get a total of four credits if you attend all three 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:
HEDIS® is a registered trademark of the National Committee for Quality Assurance.
We’re preparing for new provider training websiteLast month we announced that Provider Experience is launching a new provider training site to enhance the training experience for health care providers and staff. The new site is expected to be introduced in June. Once the system is available, we’ll share instructions on how to register for access using your email address and a unique password. As we transition from BCBSM Provider Training and BCN Learning Opportunities on web‑DENIS to the new training site, we’ll offer guidance on how to log in and navigate through the site to locate training courses and track progress. Watch for more details in the June Record.
Starting June 1, we’ll only cover preferred hyaluronic acid products for GM, FCA and Ford commercial groupsBlue Cross Blue Shield of Michigan and Blue Care Network will cover select hyaluronic acid products under the medical benefit for General Motors, Fiat Chrysler Automobiles and Ford commercial groups, starting June 1, 2021. There are currently 16 hyaluronic acid products on the market that have been approved by the U.S. Food and Drug Administration. To date, no study has shown one hyaluronic acid product to be superior to another. Starting June 1, we’ll cover the following preferred hyaluronic acid products, which are listed on the left side of the table, for GM, FCA and Ford commercial groups. Nonpreferred hyaluronic acid products, which will no longer be covered starting June 1, are listed on the right side of the table.
Here are some other things you need to know:
Note: We started covering select hyaluronic acid products for other Blue Cross commercial and BCN commercial members on Jan. 1, 2020.
Providers must submit musculoskeletal authorization requests to TurningPoint for URMBT non‑Medicare membersLast year, we announced that health care providers needed to submit prior authorization requests for all orthopedic, pain management and spinal procedures to TurningPoint as part of Blue Cross Blue Shield of Michigan’s Musculoskeletal Surgical Quality & Safety Management Program. This originally affected most Blue Cross and all Blue Care Network members. UAW Retiree Medical Benefits Trust, or URMBT, non‑Medicare members will need prior authorization requests for these procedures that are scheduled on or after May 31, 2021. Health care providers will be able to submit prior authorization requests to TurningPoint starting May 3, 2021. Where to find more information For more details about the program, see this article in the January 2021 issue of The Record and this article from the July 2020 issue of The Record. For more information about TurningPoint, see the following pages on the ereferrals.bcbsm.com website: 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.
Additional medical benefit drugs to require prior authorization for some Blue Cross commercial membersStarting in June 2021, we’re adding prior authorization requirements for additional drugs covered under the medical benefit for UAW Retiree Medical Benefits Trust non‑Medicare members. For dates of service on or after June 24, 2021, submit prior authorization requests to AIM Specialty Health® for these drugs:
How to submit requests For information about registering for and accessing the AIM ProviderPortal, see the Frequently Asked Questions page** on the AIM website. More about the authorization requirements Authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members. For more information on requirements related to drugs covered under the medical benefit for these members, refer to the Medical oncology prior authorization list for UAW Retiree Medical Benefits Trust PPO non‑Medicare members. We’ll update this list to reflect these changes prior to the effective date. **Blue Cross Blue Shield of Michigan doesn’t own or control this website.
Federal Employee Program offers prenatal care, well‑child resources for FEP membersThis is part of an ongoing series of articles focusing on the tools and resources available to help FEP members manage their health. Since prenatal care is so important for women during the first trimester, the Blue Cross and Blue Shield Federal Employee Program® offers resources and programs to its members who are expectant mothers. Resources for FEP members include:
Well‑child resources FEP also encourages members to schedule regular well‑child visits and routine vaccinations for their children. The following are additional resources for FEP members with babies and growing children:
To help FEP members save out‑of‑pocket costs, refer them to a Blue Cross and Blue Shield Preferred provider. If members need assistance finding a Preferred provider or information about benefit coverage, tell them to visit fepblue.org or call Customer Service at 1‑800‑482‑3600.
RC Claim Assist available through Provider Secured ServicesStarting May 1, 2021, you’ll have to go through Provider Secured Services to access RC Claim Assist. To do this, log in to bcbsm.com as a provider, click on the RC Claim Assist link in the Provider Secured Services welcome page and follow the prompts. As a reminder, RC Claim Assist is a web‑based resource available to Blue Cross Blue Shield of Michigan and Blue Care Network contracted providers who bill for drugs covered under the medical benefit. RC Claim Assist provides an overview of medical drug products and a calculation tool to identify the correct National Drug Code and CPT codes to bill, along with the correct NDC quantity, unit of measure and HCPCS billable units, according to the package information.
Save time: Don’t fax unnecessary information about inpatient staysWe’re receiving faxes related to inpatient stays from hospital utilization review departments. Most of these faxes aren’t required, and you can save time by not sending them. The table below shows how to save time and get the information to the right place.
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.
Starting in August, Michigan outpatient facilities must bill NDCs with NOCs or commercial claims will rejectWhat you need to know When outpatient facilities bill for drugs on an outpatient claim with a HCPCS code that has a not‑otherwise‑classified code, they must also include the NDC. This change begins on Aug. 1, 2021, and affects claims for commercial members. Starting Aug. 1, 2021, we’re making changes to the way Michigan outpatient facilities bill some drugs. Drugs billed for a Blue Cross Blue Shield of Michigan commercial member on an outpatient claim with a HCPCS code that has a description indicating “miscellaneous ‑ not otherwise classified,” unlisted or non‑specified must also include the National Drug Code, or NDC. HCPCS codes for not otherwise classified, or NOC, drugs billed without this information will be rejected and must be resubmitted with the missing information included. Submitting NDCs on claims The following is information on outpatient facility claims and general guidelines to assist you with proper submission of valid NDCs: The NDC must be submitted along with the applicable drug NOC HCPCS codes. Many NDCs are displayed on drug packaging in a 10‑digit format. Proper billing of an NDC requires an 11‑digit number in a 5‑4‑2 format (11 numeric digits with no spaces or special characters). If the NDC on the package label has fewer than 11 digits, you must add a strategically placed zero. The following table shows common 10-digit NDC formats indicated on packaging and the appropriate conversion to an 11‑digit format. The correctly formatted additional "0" is in bold and underlined in the following examples. Hyphens below are used only to illustrate the various formatting examples for NDCs. Don’t use hyphens when entering the NDC in your claim.
The NDC must be active on the date of service. To submit electronic claims (ANSI 837I), report the following information:
Do’s and don’ts when submitting commercial SNF requests using the e‑referral systemStarting Dec. 1, 2020, skilled nursing facilities were required to submit authorization requests for Blue Cross Blue Shield of Michigan commercial and Blue Care Network commercial members through the e‑referral system and not by fax. You should fax the form only when the e-referral system isn’t available.
Training resources for SNFs It’s important to use the available training resources to familiarize yourself with the e‑referral system, especially:
You can access a recorded webinar for SNFs and the webinar slides at ereferrals.bcbsm.com. Click on Training Tools and scroll down to find the e‑referral Overview for Skilled Nursing Facilities presentation section of the page and check out: Next steps If you haven’t done so already, there are two important things you should do right away.
Clarification: Don’t use F codes when requesting prior authorization for inpatient medical admissionsWe’re clarifying an article published in the March 2021 issue of The Record to indicate that this information applies to prior authorization requests for BCN commercial members in addition to Medicare Advantage members. When requesting authorization for acute care inpatient medical (non-behavioral health) admissions, select a medical ICD‑10 diagnosis code in the e‑referral system — one that doesn’t begin with F. If you select an ICD‑10 diagnosis code that begins with F, the processing of your request will be delayed because:
Background We’ve noticed that for members admitted to a medical unit for acute detoxification (such as withdrawal from alcohol or other drugs), providers are sometimes submitting authorization requests with diagnosis codes that begin with F. However, these are considered medical admissions — even if the member’s condition involves the use of alcohol or other substances. Members this applies to This applies to:
CareCentrix to manage authorizations for home health care for Medicare Advantage membersAction item Referring providers and home health care agencies should sign up for training webinars on the home health care program for services managed by CareCentrix. Blue Cross Blue Shield of Michigan and Blue Care Network have contracted with CareCentrix® to manage the authorization of home health care for Medicare Advantage members. For episodes of care starting on or after June 1, 2021, providers will need to request prior authorization from CareCentrix for Medicare Plus BlueSM and BCN AdvantageSM members. For episodes starting prior to June 1, 2021, providers will need to request prior authorization in the following situations:
CareCentrix will authorize and support the coordination of home health care services, such as skilled nursing and physical, occupational and speech therapies. The CareCentrix program will:
Submitting prior authorization requests Home health care agencies will be able to submit prior authorization requests starting May 28, 2021. They can submit these requests online through the CareCentrix HomeBridge® portal, by phone or by fax. CareCentrix will provide detailed information to home health agencies about the steps required to submit prior authorization requests during the upcoming webinar training sessions. Registering for webinar training We’re offering training webinars on the home health care program for services managed by CareCentrix. There are training sessions for referring providers and for home health care agencies. Webinar for referring providers — This session will cover the CareCentrix home health care program and details about members’ transitions from hospital to home.
Webinars for home health care agencies — These sessions will cover the CareCentrix home health care program: the steps required to obtain prior authorizations for home health care services, intent to deny, peer-to-peer and appeal processes, and provider support and resources.
Learning more about the CareCentrix home health care program
Pilot program with naviHealth supports Medicare Advantage members after hospital dischargeBlue Cross Blue Shield of Michigan and Blue Care Network have started working with naviHealth, an independent company, to pilot the company’s Patient Navigation Program. This pilot program provides non‑clinical support to Medicare Plus BlueSM and BCN AdvantageSM members to assist with their discharge needs after an acute hospital stay through their transition to home. It will be offered to select members admitted to select hospitals in the Detroit area in an effort to reduce readmissions. The pilot, which started in April, will run through July, at which time an evaluation will be completed to determine whether the program should continue after the pilot stage. Members have no out‑of‑pocket costs when using this program, which is a component of our existing clinical partnership with naviHealth. NaviHealth’s patient navigation team won’t provide medical care or make clinical recommendations and doesn’t replace any existing case management program the member may be participating in. Patient navigators support members by:
Starting in June, we’ll use clinical information to validate providers’ answers to some questionnaires in the e-referral systemBeginning in June 2021, we’ll pend some authorization requests that would usually be auto‑approved based on your responses to questionnaires in the e‑referral system. This applies to authorization requests submitted for BCN commercial, Medicare Plus BlueSM and BCN AdvantageSM members. When we pend a request, you’ll get this message in the e‑referral system: “Case requires validation. Medical records required. Please attach clinical information from the patient’s medical record applicable to this request in the Case Communication field.” For instructions on how to attach clinical information to the authorization request in the e‑referral system, refer to the e‑referral User Guide. Look in the section titled “Create New (communication).” We’ll review and verify that the clinical information you provide supports your responses to the questionnaire and make a determination on the request. If we don’t receive the clinical information or the information you send doesn’t support your answers in the questionnaire, we won’t be able to approve the request. As a reminder, on the preview questionnaires that we publish on our ereferrals.bcbsm.com website, we state that we’ll retrospectively monitor compliance with this authorization requirement. You can access the preview questionnaires:
Starting June 22, additional medications will require prior authorization for Medicare Advantage membersWhat you need to know For dates of service on or after June 22, 2021, you’ll need to submit prior authorization requests through NovoLogix® for Oxlumo™ (lumasiran), Evkeeza™ (evinacumab‑dgnb) and Nulibry™ (fosdenopterin) for Medicare Plus BlueSM and BCN AdvantageSM members. For dates of service on or after June 22, 2021, the following medications will require prior authorization through the NovoLogix® online tool:
This affects Medicare Plus BlueSM and BCN AdvantageSM members. Places of service that require authorizationFor Medicare Advantage members, we require authorization for these drugs when they’re administered by a health care professional in a provider office, at the member’s home, in an off‑campus or on-campus outpatient hospital or in an ambulatory surgical center (sites of care 11, 12, 19, 22 and 24) and billed as follows:
ReminderSubmit authorization requests for these drugs through NovoLogix. It offers real‑time status checks and immediate approvals for certain medications. If you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix. If you need to request access to Provider Secured Services, complete the Provider Secured Access Application form and fax it to the number on the form. List of requirementsFor a list of requirements related to drugs covered under the medical benefit, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members. We’ll update the list to reflect this change prior to June 22.
Additional medications will require prior authorization for most members, starting May 24What you need to know For dates of service on or after May 24, 2021, you’ll need to submit prior authorization requests to AIM Specialty Health® for Cosela™ (trilaciclib) and Pepaxto® (melphalan flufenamide) for most members. The following drugs covered under the medical benefit will require prior authorization for dates of service on or after May 24, 2021:
The prior authorization requirements apply when these drugs are administered in outpatient settings for:
These requirements don’t apply to Blue Cross commercial self-funded groups, including:
How to submit authorization requests Submit authorization requests to AIM using one of the following methods:
For information about registering for and accessing the AIM ProviderPortal, see the Frequently asked questions page** on the AIM website. More about the authorization requirements Authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members. See the following documents for additional information on requirements related to drugs covered under the medical benefit:
We’ll update the requirements lists with the new information prior to May 24, 2021. **Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.
Updates to preferred products for drugs covered under the medical benefitAction item Review the medications listed in this article to make sure you understand the prescribing guidelines. We’ve designated certain medications as preferred products for dates of service on or after April 1, 2021. This change affects most Blue Cross Blue Shield of Michigan commercial, all Medicare Plus BlueSM, all Blue Care Network commercial and all BCN AdvantageSM members. We originally announced this information in a previous edition of The Record. But since that time, we’ve updated some of the guidelines. To make sure you’re aware of the revisions, we’ve marked the updated information with two asterisks (**). Here’s what you need to know when prescribing these products for dates of service on or after April 1:
Information for Blue Cross commercial membersThe requirements outlined in this article apply as follows:
Preferred and nonpreferred products for most membersWe’re designating the following products as preferred and nonpreferred for:
1 Preferred rituximab products don’t require authorization through AIM Specialty Health. 2 Will become a unique code. 3 For BCN commercial, Medicare Plus Blue and BCN Advantage members: For courses of treatment that started Oct. 1, 2020, through March 31, 2021, submit these requests to AIM. For courses of treatment that started on or after April 1, 2021, submit these requests through NovoLogix. 4 For Blue Cross commercial fully insured members and Blue Cross commercial members with individual coverage: For courses of treatment that started on or after Oct. 1, 2020, you’re already submitting these requests through NovoLogix; your process won’t change. Additional preferred and nonpreferred products for most commercial membersWe’re designating the following products as preferred and nonpreferred for:
Additional preferred and nonpreferred products for Medicare Advantage membersWe’re designating the following products as preferred and nonpreferred for Medicare Plus Blue and BCN Advantage members.
Submitting requests for prior authorizationHere’s how to submit prior authorization requests for preferred products and nonpreferred products:
Exception:** Ruxience and Riabni don’t require authorization. Note: Previous communications incorrectly stated that Ruxience and Riabni require prior authorization. Disregard those communications, and use this information.
Authorization isn’t a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members. Lists of requirementsSee the following lists to view requirements for these products.
**This information has been updated since it originally appeared in a previous edition of The Record. ***Blue Cross Blue Shield of Michigan doesn’t own or control this website.
Abecma requires prior authorization for Medicare Advantage membersFor dates of service on or after April 5, 2021, the following CAR‑T medication requires prior authorization through the NovoLogix® online tool:
This applies to Medicare Plus BlueSM and BCN AdvantageSM members. Places of service that require authorization For Medicare Advantage members, we require authorization for all outpatient places of service when you bill these medications as either a professional or a facility service:
Reminder For this drug, submit authorization requests through NovoLogix. It offers real‑time status checks and immediate approvals for certain medications. If you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix. If you need to request access to Provider Secured Services, complete and fax the Provider Secured Access Application form to 1‑800‑495‑0812. List of requirements For a list of requirements related to drugs covered under the medical benefit, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members.
Reminder: Zulresso only payable for inpatient facility claimsIn the May 2020 Record, we notified you that Zulresso™ (brexanolone) is only payable for inpatient facility claims for Blue Cross Blue Shield of Michigan commercial members. However, we want to let you know the HCPCS code for providing this medication is now J1632. We’ll deny Blue Cross commercial claims for Zulresso that indicate the place of service as being other than an inpatient facility. This applies only to in‑state providers.
Qualified providers invited to apply for designation in BDC Substance Use Treatment program
This is the newest BDC designation, as we wrote in an October 2020 Record article. Currently, we have three Michigan providers who applied for and received this designation. Achieving this national designation recognizes that providers have demonstrated expertise in delivering quality specialty care in this area safely, effectively and cost efficiently. All providers who apply for this designation must offer programs for opioid use disorder, including medication-assisted treatment as needed. Providers can obtain detailed information about the Substance Use Treatment and Recovery BDC program selection criteria and eligibility here. Additional information on Blue Distinction Specialty Care can be found on the Blue Cross and Blue Shield Association website. Achieving this designation provides value to health care providers in various ways, including:
Whether a provider meets program selection criteria or not, every provider evaluated receives a customized report that provides useful insights into their performance. Finding a BDC provider Consumers and referring physicians alike can locate designated providers through the Blue Distinction Center Finder. Designations are also identified on the Find a Doctor search tool, which can be accessed from the homepage of bcbsm.com. To apply for designation If you’re interested in applying for Blue Distinction Center for Substance Use Treatment and Recovery designation, send an email to Michelle Williams at MWilliams3@bcbsm.com. Did you know?
Reminder: Lunch and learn webinars for physicians and coders focus on risk adjustment, codingAction item Sign up now for our live, monthly, lunchtime webinars. In April, we began offering webinars that provide updated information on documentation and coding of common, challenging diagnoses. These live, lunchtime educational sessions include an opportunity to ask any questions you may have. The May through September webinars are led by physicians. The last three sessions of the year focus on coding guideline updates and are led by coders. Here’s our current schedule and the tentative topics for the remaining sessions. All sessions start at 12:15 p.m. Eastern time and generally run for 15 to 30 minutes. Click on a Register here link below to sign up for a session.
If you have any questions about the sessions, contact April Boyce at aboyce@bcbsm.com. If you have questions regarding registration, email Patricia Scarlett at pscarlett@bcbsm.com.
New webinars and on-demand training availableAction item Check out what’s new on our provider training websites, including an e‑learning overview of HCPCS and revenue code combinations and a webinar recording from our Claims Basics presentation for professional providers. Provider Experience is continuing its series of training webinars for health care providers and staff to promote collaboration with Blue Cross Blue Shield of Michigan and Blue Care Network. Upcoming training webinars:
Provider Experience also offers training resources for health care providers and staff that includes previously recorded webinars, plus specific topic videos and e‑Learning modules. These on-demand courses are designed to help you work efficiently with Blue Cross and BCN. The following are the newest available resources:
Access to 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
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
As additional training webinars become available, we’ll provide notices through web‑DENIS, The Record and BCN Provider News.
We’re preparing for new provider training websiteLast month we announced that Provider Experience is launching a new provider training site to enhance the training experience for health care providers and staff. The new site is expected to be introduced in June. Once the system is available, we’ll share instructions on how to register for access using your email address and a unique password. As we transition from BCBSM Provider Training and BCN Learning Opportunities on web‑DENIS to the new training site, we’ll offer guidance on how to log in and navigate through the site to locate training courses and track progress. Watch for more details in the June Record.
Starting June 1, we’ll only cover preferred hyaluronic acid products for GM, FCA and Ford commercial groupsBlue Cross Blue Shield of Michigan and Blue Care Network will cover select hyaluronic acid products under the medical benefit for General Motors, Fiat Chrysler Automobiles and Ford commercial groups, starting June 1, 2021. There are currently 16 hyaluronic acid products on the market that have been approved by the U.S. Food and Drug Administration. To date, no study has shown one hyaluronic acid product to be superior to another. Starting June 1, we’ll cover the following preferred hyaluronic acid products, which are listed on the left side of the table, for GM, FCA and Ford commercial groups. Nonpreferred hyaluronic acid products, which will no longer be covered starting June 1, are listed on the right side of the table.
Here are some other things you need to know:
Note: We started covering select hyaluronic acid products for other Blue Cross commercial and BCN commercial members on Jan. 1, 2020.
Providers must submit musculoskeletal authorization requests to TurningPoint for URMBT non‑Medicare membersLast year, we announced that health care providers needed to submit prior authorization requests for all orthopedic, pain management and spinal procedures to TurningPoint as part of Blue Cross Blue Shield of Michigan’s Musculoskeletal Surgical Quality & Safety Management Program. This originally affected most Blue Cross and all Blue Care Network members. UAW Retiree Medical Benefits Trust, or URMBT, non‑Medicare members will need prior authorization requests for these procedures that are scheduled on or after May 31, 2021. Health care providers will be able to submit prior authorization requests to TurningPoint starting May 3, 2021. Where to find more information For more details about the program, see this article in the January 2021 issue of The Record and this article from the July 2020 issue of The Record. For more information about TurningPoint, see the following pages on the ereferrals.bcbsm.com website: 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.
Additional medical benefit drugs to require prior authorization for some Blue Cross commercial membersStarting in June 2021, we’re adding prior authorization requirements for additional drugs covered under the medical benefit for UAW Retiree Medical Benefits Trust non‑Medicare members. For dates of service on or after June 24, 2021, submit prior authorization requests to AIM Specialty Health® for these drugs:
How to submit requests For information about registering for and accessing the AIM ProviderPortal, see the Frequently Asked Questions page** on the AIM website. More about the authorization requirements Authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members. For more information on requirements related to drugs covered under the medical benefit for these members, refer to the Medical oncology prior authorization list for UAW Retiree Medical Benefits Trust PPO non‑Medicare members. We’ll update this list to reflect these changes prior to the effective date. **Blue Cross Blue Shield of Michigan doesn’t own or control this website.
RC Claim Assist available through Provider Secured ServicesStarting May 1, 2021, you’ll have to go through Provider Secured Services to access RC Claim Assist. To do this, log in to bcbsm.com as a provider, click on the RC Claim Assist link in the Provider Secured Services welcome page and follow the prompts. As a reminder, RC Claim Assist is a web‑based resource available to Blue Cross Blue Shield of Michigan and Blue Care Network contracted providers who bill for drugs covered under the medical benefit. RC Claim Assist provides an overview of medical drug products and a calculation tool to identify the correct National Drug Code and CPT codes to bill, along with the correct NDC quantity, unit of measure and HCPCS billable units, according to the package information.
Starting June 22, additional medications will require prior authorization for Medicare Advantage membersWhat you need to know For dates of service on or after June 22, 2021, you’ll need to submit prior authorization requests through NovoLogix® for Oxlumo™ (lumasiran), Evkeeza™ (evinacumab‑dgnb) and Nulibry™ (fosdenopterin) for Medicare Plus BlueSM and BCN AdvantageSM members. For dates of service on or after June 22, 2021, the following medications will require prior authorization through the NovoLogix® online tool:
This affects Medicare Plus BlueSM and BCN AdvantageSM members. Places of service that require authorizationFor Medicare Advantage members, we require authorization for these drugs when they’re administered by a health care professional in a provider office, at the member’s home, in an off‑campus or on-campus outpatient hospital or in an ambulatory surgical center (sites of care 11, 12, 19, 22 and 24) and billed as follows:
ReminderSubmit authorization requests for these drugs through NovoLogix. It offers real‑time status checks and immediate approvals for certain medications. If you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix. If you need to request access to Provider Secured Services, complete the Provider Secured Access Application form and fax it to the number on the form. List of requirementsFor a list of requirements related to drugs covered under the medical benefit, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members. We’ll update the list to reflect this change prior to June 22.
Additional medications will require prior authorization for most members, starting May 24What you need to know For dates of service on or after May 24, 2021, you’ll need to submit prior authorization requests to AIM Specialty Health® for Cosela™ (trilaciclib) and Pepaxto® (melphalan flufenamide) for most members. The following drugs covered under the medical benefit will require prior authorization for dates of service on or after May 24, 2021:
The prior authorization requirements apply when these drugs are administered in outpatient settings for:
These requirements don’t apply to Blue Cross commercial self-funded groups, including:
How to submit authorization requests Submit authorization requests to AIM using one of the following methods:
For information about registering for and accessing the AIM ProviderPortal, see the Frequently asked questions page** on the AIM website. More about the authorization requirements Authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members. See the following documents for additional information on requirements related to drugs covered under the medical benefit:
We’ll update the requirements lists with the new information prior to May 24, 2021. **Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.
Updates to preferred products for drugs covered under the medical benefitAction item Review the medications listed in this article to make sure you understand the prescribing guidelines. We’ve designated certain medications as preferred products for dates of service on or after April 1, 2021. This change affects most Blue Cross Blue Shield of Michigan commercial, all Medicare Plus BlueSM, all Blue Care Network commercial and all BCN AdvantageSM members. We originally announced this information in a previous edition of The Record. But since that time, we’ve updated some of the guidelines. To make sure you’re aware of the revisions, we’ve marked the updated information with two asterisks (**). Here’s what you need to know when prescribing these products for dates of service on or after April 1:
Information for Blue Cross commercial membersThe requirements outlined in this article apply as follows:
Preferred and nonpreferred products for most membersWe’re designating the following products as preferred and nonpreferred for:
1 Preferred rituximab products don’t require authorization through AIM Specialty Health. 2 Will become a unique code. 3 For BCN commercial, Medicare Plus Blue and BCN Advantage members: For courses of treatment that started Oct. 1, 2020, through March 31, 2021, submit these requests to AIM. For courses of treatment that started on or after April 1, 2021, submit these requests through NovoLogix. 4 For Blue Cross commercial fully insured members and Blue Cross commercial members with individual coverage: For courses of treatment that started on or after Oct. 1, 2020, you’re already submitting these requests through NovoLogix; your process won’t change. Additional preferred and nonpreferred products for most commercial membersWe’re designating the following products as preferred and nonpreferred for:
Additional preferred and nonpreferred products for Medicare Advantage membersWe’re designating the following products as preferred and nonpreferred for Medicare Plus Blue and BCN Advantage members.
Submitting requests for prior authorizationHere’s how to submit prior authorization requests for preferred products and nonpreferred products:
Exception:** Ruxience and Riabni don’t require authorization. Note: Previous communications incorrectly stated that Ruxience and Riabni require prior authorization. Disregard those communications, and use this information.
Authorization isn’t a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members. Lists of requirementsSee the following lists to view requirements for these products.
**This information has been updated since it originally appeared in a previous edition of The Record. ***Blue Cross Blue Shield of Michigan doesn’t own or control this website.
Abecma requires prior authorization for Medicare Advantage membersFor dates of service on or after April 5, 2021, the following CAR‑T medication requires prior authorization through the NovoLogix® online tool:
This applies to Medicare Plus BlueSM and BCN AdvantageSM members. Places of service that require authorization For Medicare Advantage members, we require authorization for all outpatient places of service when you bill these medications as either a professional or a facility service:
Reminder For this drug, submit authorization requests through NovoLogix. It offers real‑time status checks and immediate approvals for certain medications. If you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix. If you need to request access to Provider Secured Services, complete and fax the Provider Secured Access Application form to 1‑800‑495‑0812. List of requirements For a list of requirements related to drugs covered under the medical benefit, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members.
Starting June 1, we’ll only cover preferred hyaluronic acid products for GM, FCA and Ford commercial groupsBlue Cross Blue Shield of Michigan and Blue Care Network will cover select hyaluronic acid products under the medical benefit for General Motors, Fiat Chrysler Automobiles and Ford commercial groups, starting June 1, 2021. There are currently 16 hyaluronic acid products on the market that have been approved by the U.S. Food and Drug Administration. To date, no study has shown one hyaluronic acid product to be superior to another. Starting June 1, we’ll cover the following preferred hyaluronic acid products, which are listed on the left side of the table, for GM, FCA and Ford commercial groups. Nonpreferred hyaluronic acid products, which will no longer be covered starting June 1, are listed on the right side of the table.
Here are some other things you need to know:
Note: We started covering select hyaluronic acid products for other Blue Cross commercial and BCN commercial members on Jan. 1, 2020.
Additional medical benefit drugs to require prior authorization for some Blue Cross commercial membersStarting in June 2021, we’re adding prior authorization requirements for additional drugs covered under the medical benefit for UAW Retiree Medical Benefits Trust non‑Medicare members. For dates of service on or after June 24, 2021, submit prior authorization requests to AIM Specialty Health® for these drugs:
How to submit requests For information about registering for and accessing the AIM ProviderPortal, see the Frequently Asked Questions page** on the AIM website. More about the authorization requirements Authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members. For more information on requirements related to drugs covered under the medical benefit for these members, refer to the Medical oncology prior authorization list for UAW Retiree Medical Benefits Trust PPO non‑Medicare members. We’ll update this list to reflect these changes prior to the effective date. **Blue Cross Blue Shield of Michigan doesn’t own or control this website. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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We’re moving our estimated timeline for the move to the Availity® provider portal back a bit. This change will ensure our transition to Availity provides you with the features you want and the accuracy and dependability you’ve come to expect. 
Qualified facility providers are urged to apply for national designation as a Blue Distinction® Center for Substance Use Treatment and Recovery. 
