What you need to know about doing business with Blue Cross

We publish an article on this topic annually to help ensure our providers have the information they need to do business with us.

There’s certain information our participating providers need to know about doing business with Blue Cross Blue Shield of Michigan. This article provides a summary of key information.

Online provider manuals — Important information you need to do business with Blue Cross is included in our online provider manuals. To access them, click on Provider Manuals in the left-hand column of the homepage of web-DENIS.

Access and availability guidelines — When a member requests an appointment, Blue Cross providers are required to comply with the following standards.

For more detailed information, see the “PPO Policies” chapter in the provider manual.

Affirmative statement about incentives — Medical decisions are based only on appropriateness of care and service and existence of coverage. See the affirmation statement in the “Participation” chapter of the provider manual. It’s located in the section titled Requirements and Guidelines.

Clinical practice guidelines — For medical and behavioral health care, Blue Cross follows Michigan Quality Improvement Consortium guidelines, which can be found on the mqic.org** website.

Comprehensive care management — To learn about Blue Cross’ comprehensive care management program and how to refer our members to the program, check out the “Case management” section of the Blue Pages Directory in your online provider manual. To find the information on bcbsm.com, click on the Providers tab and type Blue Cross Coordinated Care in the search field. Scroll down to For Providers: Blue Cross Coordinated Care.

Criteria used for level of care utilization management decisions

For hospitals and facilities, Blue Cross uses InterQual criteria to assess medical necessity and the appropriate level of care. Criteria encompasses acute care (adult and pediatric), rehabilitation (adult and pediatric), long-term acute care, skilled nursing facility and home health care.

Blue Cross modifications of the InterQual criteria (local rules) can be accessed online by following these steps:

• Log in to web-DENIS.
• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters & Resources.
• Click on Clinical Criteria & Resources.

If you have questions about InterQual, send an email to CESupport@mckesson.com. Provide your name and address and reference that the question pertains to InterQual.

Note: Criteria for Blue Cross and Blue Shield Federal Employee Program^® utilization management decision-making can be found at fepblue.org.

Medical policies

To review additional Blue Cross medical policies, go to bcbsm.com/providers.

• Click on Quick Links.
• Click on Preauthorization and precertification.
• Click on Medical policy, precertification and preauthorization router.
• Use the button to select Medical Policy, then follow online prompts.

FEP policies can be found at fepblue.org.

Member rights and responsibilities

Blue Cross outlines the rights and responsibilities of our members, including how members can file a complaint or grievance. Go to the Important Information page on our website and click on Learn More under Rights and responsibilities for more information.

Pharmacy management

It’s important for you to be familiar with our drug lists and our pharmacy management programs, such as step therapy, quantity limits, dose optimization, use of generics and specialty pharmacy. You also need to know how to request prior authorization and the information needed to support your request.

Note: Generic substitution may be required for Blue Cross members. If both the generic and brand name are listed on our drug list, members are encouraged to receive the generic equivalent when available. Some members may be required to pay the difference between the brand-name and generic drug, as well as applicable copay, depending on the member’s plan.

See the Pharmacy Services page on our website for more details. We recommend that you visit this page at least quarterly to access our drug lists and view updates. Go to bcbsm.com/providers. You can also call 1-800-437-3803 for the most up-to-date pharmaceutical information.

Translation services

Members who need language assistance can call the Customer Service number on the back of their member ID card. TTY users should call 711.

Utilization management staff availability

Department telephone numbers and hours are shown in the “Preapproval Decisions/Utilization Management Decisions” section of the “Appeals and problem resolution chapter” of the provider manuals.

Behavioral health care — New Directions

New Directions Behavioral Health is an independent company administering behavioral health benefits on behalf of Blue Cross. For information on the New Directions Behavioral Health Quality Improvement Program, click here.**

Contact information:

• Commercial (PPO and Traditional) programs: 1-800-762-2382
• Federal Employee Program: 1-800-342-5891
• United Auto Workers Retiree Medical Benefits Trust, or URMBT: 1-877-228-3912
• MESSA: 1-877-866-2395
• GM salaried: 1-877-240-0705
• State of Michigan: 1-866-503-3158

For more information

• Information about our programs and additional resources are available on the Important Information page of our website.
• To request a printed copy of any of the information contained in this article, call HCV Quality Management at 248-455-2808.

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

Contact Provider Inquiry if you have claims issues

This article was updated Oct. 11, 2021.

Contact Provider Inquiry if you’re experiencing claims (or complex claims) issues. If you call your provider consultant, you’ll first need a reference number from Provider Inquiry.

To speak with a Provider Inquiry representative, call one of the following phone numbers from 8:30 a.m. to noon and 1 to 5 p.m. Monday through Friday:

• Professional providers  ̶  1‑800‑344‑8525
• Facility providers  ̶  1‑800‑249‑5103
• Dental, hearing and vision providers  ̶  1‑800‑482‑4047
• Medicare Advantage providers  ̶  1‑866‑309‑1719

If you don’t think your issue has been satisfactorily resolved, ask the representative to escalate your inquiry to our help desk in Provider Inquiry.

Other questions?

• If you have enrollment questions, contact Provider Enrollment and Data Management at 1‑800‑822‑2761 from 8 a.m. to 4 p.m. Monday through Friday.
• Online tutorials about our e-referral system are available on the Training Tools page at ereferrals.bcbsm.com.

You’ll also find job aids, FAQs, brochures, flyers and user guides on the BCBSM Newsletters and Resources and BCN Provider Publications and Resources pages on Provider Secured Services.

2021 COVID‑19 HCPCS update: New code added

The Centers for Medicare & Medicaid Services has added a new COVID‑19 code as part of its quarterly Health Care Procedure Coding System update. The code, effective date and Blue Cross Blue Shield of Michigan’s coverage decision are below.

Injection

None of the information included above 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.

Benefit changes retroactive to Jan. 1, 2021, for UAW Retiree Medical Benefits Trust members

Earlier this year, the UAW Retiree Medical Benefits Trust requested Blue Cross Blue Shield of Michigan make the benefit changes outlined below for its members in the Enhanced Care Plan, or ECP, and the Traditional Care Network, or TCN. All current benefits identified below are effective retroactive to Jan. 1, 2021, for these members.

• Ambulatory infusion centers:
• Previously, medical drugs and related services administered at an ambulatory infusion center weren’t covered.
• Medical drugs and related services administered at an ambulatory infusion center will be a covered benefit.  
• This benefit will now align with the Blue Cross standard payment and reimbursement policy.
• Member cost share will apply.

• Occupational therapy and speech therapy services:
• Previously, OT and ST services applied in‑network cost share.
• In‑network OT and ST services will be covered at 100%.

• Outpatient behavioral health and substance use disorder:
• The 35‑visit limit for outpatient visits will be removed. This change allows for unlimited outpatient behavioral health and substance use disorder visits but doesn’t apply to partial hospitalization services.
• Behavioral health services rendered by a physician assistant will also be covered. 
• No change to current member cost share.

• Medical injections:
• Previously, the Trust had group-specific coverage for medical injections and was limited to specific types (considered surgical in nature or related to a malignancy). 
• All medical injection types will be covered provided the medical drug itself is a covered benefit.  
• No change to current member cost share.
• This benefit will now align with the Blue Cross standard payment and reimbursement policy.

• Medical emergency criteria:
• Previously, the Trust had group-specific medical emergency qualification criteria.
• The Trust will align with Blue Cross’ standard medical emergency diagnoses and qualification standards for professional and facility services.
• The “72-hour rule” is no longer applicable for emergency room claims. This will eliminate the claims rejecting for treatment not being sought within 72 hours from the onset of symptoms.

• Tobacco cessation:
• Trust members are no longer required to participate in any tobacco cessation program as a pre‑requisite to receive prescription tobacco cessation medications.
• Questions about these claims should be directed to Express Scripts.

Claims for members with the affected services will be reprocessed and restored starting at the end of September to pay correctly to the health care provider.

About 30 days after the claims are restored, members will receive letters letting them know that their claims have been reprocessed and if they paid their health care provider for one of the services, then they could be entitled to a refund or a credit to the members’ account. We’re instructing members to contact their health care providers about these services.

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

Billing chart: Blue Cross highlights medical, benefit policy changes

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

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

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

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

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

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

Next Drug Take Back Day scheduled for Oct. 23

Let your patients know that the U.S. Drug Enforcement Agency’s next National Prescription Drug Take Back Day is Saturday, Oct. 23, from 10 a.m. to 2 p.m.

These twice-yearly events provide a safe, convenient and responsible means of disposing of prescription drugs, while also educating people about the potential for abuse of medications, including opioids. At the most recent Drug Take Back Day in April, 839,543 pounds of drugs were collected nationwide.

People can find a drug disposal facility near them that’s participating in Drug Take Back Day by checking out the DEA’s search tool.** And our Opioids 101 site provides a variety of resources, including flyers and brochures, that you can use to help educate your patients about opioids.

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

We’d like your input on your virtual experiences during the pandemic

In a recent column in Hospital and Physician Update, Dr. S. George Kipa, deputy chief medical officer, wrote about the challenges medical directors have faced in working remotely during the COVID‑19 pandemic. He invited readers to share their own experiences and tips for how they coped with the challenges.

He’d like to invite readers of The Record to share their experiences, as well. What worked well? What didn’t? What else did you learn from your experiences during the pandemic that can lead us to a better future?   

Send an email to PBerry@bcbsm.com with any ideas or tips you’d like to share, and we’ll publish a selection of your comments in a future publication. Please provide your name, title and department.

Updated edits for Medicare Plus Blue claims are coming in October 2021

As communicated in a March 2021 Record article, we’ll begin updating edits applied to Medicare Plus Blue℠ claims in October 2021. We’re enhancing our claim editing to promote correct coding and improve claim payment accuracy.

In the past, modifiers (including, but not limited to, modifiers 25, 59, 79 and 24) have been used to override bundling edits inappropriately. Due to the prevalence of incorrect modifier use, the Centers for Medicare & Medicaid Services:

• Adopted the Office of the Inspector General’s recommendations
• Implemented a prepayment review of modifiers using claim details and patient history for support of the modifier override

Registered nurses with coding credentials will utilize nationally sourced guidelines documented within the Current Procedural Terminology manual, the American Medical Association’s Coding with Modifiers manual, the CMS Correct Coding Initiatives manual, and the CMS claims processing manuals to review information on the claim and the patient’s claim history.

The additional review will ensure claims have been coded correctly for more complex situations where an overriding modifier has been appended. Providers should code claims to the level of specificity for the services rendered and appropriately append diagnosis codes and modifiers following the guidelines published by the AMA and CMS. The reported services should be supported in the patient’s medical record.

Modifier 25 guidelines

Append modifier 25 to evaluation and management services when they’re significant, separately identifiable, and performed by the same physician on the day of a procedure.

All E/M services provided on the same day as a procedure are part of the procedure, and Medicare only makes a separate payment if an exception applies. CPT guidelines define this significant and separate service as being above and beyond the usual preoperative and postoperative care associated with the procedure or service performed.

The E/M service must meet the key components (history, examination, medical decision making) of that service, including medical record documentation.

To use modifier 25 correctly, the chosen level of E/M service needs to be supported by adequate documentation for the appropriate level of service and referenced by a diagnosis code.

The CPT codes for procedures do include the evaluation services necessary before the performance of the procedure. (For example: The evaluation services could include assessing the site and condition of the problem area, explaining the procedure and obtaining informed consent.)

However, when significant and identifiable E/M services are performed, these services aren’t included in the descriptor for the procedure or service performed. (Examples of significant and identifiable E/M services could include medical decision-making and another key component.)

Appropriate usage

• Modifier 25 indicates that on the day of a procedure, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre- and post-operative care associated with the procedure or service performed. 
• Use modifier 25 with the appropriate level of E/M service. 
• The procedure performed has a global period listed on the Medicare Fee Schedule Relative Value File. This global period could be 000, 010 or 090 days. 
• An E/M service may occur on the same day as a procedure and within the post-operative period of a previous procedure. Medicare allows payment when the documentation supports modifier 25 and modifier 24 (unrelated E/M service during a post-operative period). 
• Use modifier 25 in the rare circumstance of an E/M service the day before a major surgery that isn’t the decision for surgery and represents a significant, separately identifiable service.

Inappropriate usage

• Submitted by a physician other than the physician performing the procedure
• Documentation shows the amount of work performed is consistent with that normally performed with the procedure

Modifiers 59, XE, XP, XS and XU guidelines

Modifiers 59, XE, XP, XS and XU should be used when the physician needs to indicate that a procedure or service was distinct or independent from other services performed on the same day.

Modifier 59 is used to identify procedures or services that aren’t normally reported together but are appropriate under certain circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician.

CMS established the National Correct Coding Initiative program to ensure the correct coding of services. NCCI procedure to procedure edits prevent inappropriate payment of services that shouldn’t be reported together.

Each edit has a Column 1 and Column 2 HCPCS/CPT code. If a provider reports the two codes of an edit pair for the same patient on the same date of service, the Column 2 code is denied, and the Column 1 code is eligible for payment. When we update the claims editing, only select codes will allow modifier 59 to automatically bypass the NCCI code pair edits. Refer to the September 2021 Record article on modifier 59 for examples of appropriate usage.

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

Coming soon: New edits for Blue Cross commercial claims

At Blue Cross Blue Shield of Michigan, we remain committed to payment integrity solutions that support payment accuracy and encourage correct coding. In support of that commitment, you’ll begin to see new claim edits in the coming weeks and months.

In the July 2021 issue of The Record, we let  you know we would begin enhancing our current claim editing with the addition of new ClaimsXten™ edits. In the August 2021 issue of The Record, we also informed you of edits that will occur through our new partnership with Optum.

ClaimsXten edits will occur in prepayment processing. Optum edits are also prepayment.

Continue to follow the clinical editing appeals process that you currently follow. You’ll be able to recognize these new edits as “clinical editing.” based on the unique provider message codes that will appear on the provider voucher:

• The new Optum message codes are K500‑K544. 
• The new ClaimsXten message codes are K211‑K221.

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

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

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

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

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

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

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

Notice: Health care providers must attest in CAQH every 90 days

Have you attested in CAQH within the past 90 days? CAQH is a nonprofit alliance of health plans and trade associations focused on simplifying health care administration. If health care providers don’t re-attest with CAQH every 90 days, they won’t be included in Blue Cross Blue Shield of Michigan provider directories. That includes our Find a Doctor search tool. That’s why it’s so important to perform this task.

Here are some other reasons to re-attest with CAQH:

• Ensure that your affiliation with Blue Cross isn’t interrupted.
• Keep your contact information up to date.
• Make sure that claims payment isn’t interrupted.

Regardless of whether  providers are practicing at an office location or practicing exclusively in an inpatient hospital setting, they need to perform this attestation.

If you’re practicing exclusively in an inpatient hospital setting, you must indicate it on your CAQH application. This information is used to determine whether full credentialing is required.

Blue Cross uses CAQH to gather and coordinate our practitioner credentialing information. All health care practitioners, including hospital-based providers and nurse practitioners, need to be registered with CAQH.

If you have questions about CAQH, call the help desk at 1-888-599-1771, or go to CAQH.org.**

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

We’re expanding laboratory claims editing for Medicare Plus Blue

Starting January 2022, Blue Cross Blue Shield of Michigan will expand its laboratory claim editing process to promote correct coding and assist with payment accuracy for Medicare Plus Blue℠ claims.

These enhancements will help ensure that our claim payment policies are easy to understand and align with nationally recognized sources of information. They’ll also help us better meet the needs of a changing health care industry while maintaining alignment with national coding guidelines.

Additional information and updates will be included in future communications over the coming months.

Multitarget genetic testing procedure code *81443 became payable Aug. 1, 2021

Blue Cross Blue Shield of Michigan approved multitarget genetic testing procedure code *81443. The code is payable for patients seeking the following medical care:

• Testing for carrier status for severe, lethal or developmentally impactful genetic diseases and disorders
• Patients seeking evaluation or clinical interventions related to infertility
• Patients receiving prenatal services with encounters for routine prenatal care or non-procreative and procreative counseling where the number of targets tested is fifteen or above

For the above services, CPT code *81443 should be billed as opposed to individual, incremental gene testing codes. This change is effective Aug. 1, 2021.

Note: Blue Cross doesn’t provide separate reimbursement for individual gene codes when the gene tests performed can be collectively represented by a single CPT multitarget molecular genetic testing code.

Lab codes
Proprietary laboratory panel tests may be represented by proprietary laboratory analyses codes. Most of these panels consist of a combination of mutations found to be clinically useful as well as many mutations of uncertain or unknown clinical utility. Some of these proprietary tests are not covered by Blue Cross and coverage should not be assumed unless there is a specific Blue Cross medical policy identifying the test as established and therefore reimbursable.

When a selection of individual gene tests (15 or more) that may be included in a large proprietary lab panel are conducted, *81443 should be used. If both a multitarget CPT code (*81443) and the individual gene codes that may be included in a panel are billed — a process called unbundling — only the CPT multitarget code will be reimbursed.

Blue Cross uses data analytics to identify improper and unbundled claims. Keep in mind that unbundling claims to obtain payment or increased payment is a crime.

Clarification: ClaimsXten Modifier 59 requirements

A July 2021 Record article about appending modifier 59 to multiple claim lines stated that you must submit medical records when using modifier 59 on four or more claim lines. It should have stated that if modifier 59 is appended to more than four services, the claim will suspend to allow manual review of lines appended with modifier 59 when attachments are included. Otherwise, each service appended with modifier 59 will be denied for lack of supporting documentation. 

TurningPoint updated its medical policies for musculoskeletal procedures and related services

TurningPoint Healthcare Solutions LLC updated various medical policies for musculoskeletal procedures and related services based on feedback from the provider community. The updated policies went into effect on July 26, 2021.

To view the updated policies, access the TurningPoint Provider Portal** and click on Help in the menu at the top of the screen.

Criteria used to make determinations on authorization requests
As a reminder, TurningPoint uses the following criteria to make determinations on authorization requests for musculoskeletal and pain management procedures.

• For Blue Cross Blue Shield of Michigan commercial and Blue Care Network commercial members: TurningPoint applies medical policy guidelines for musculoskeletal and pain management procedures that Blue Cross, BCN and TurningPoint agreed on.
• For Medicare Plus Blue℠ and BCN Advantage℠ members: TurningPoint applies the Medicare national coverage determinations and Medicare local coverage determinations.

If there is no Medicare NCD and LCD, TurningPoint applies medical policy guidelines for musculoskeletal and pain management procedures that Blue Cross, BCN and TurningPoint agreed on.

Additional information
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

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

***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 developing a provider satisfaction survey with TurningPoint

Blue Cross Blue Shield of Michigan and Blue Care Network are working with TurningPoint Healthcare Solutions, LLC to develop a health care provider satisfaction survey.

TurningPoint will send the survey to providers who have submitted authorization requests for musculoskeletal procedures and related services. The survey will give these providers the opportunity to provide feedback on the TurningPoint musculoskeletal surgical quality and safety management program.

TurningPoint will send the survey via email by the end of the year.

We’ll communicate the distribution timeline for the surveys in future provider communications.

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.

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

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

This applies to members with the following coverage:

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

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

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

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

• BCN Musculoskeletal Services
• Blue Cross Musculoskeletal Services

Updated questionnaires in the e‑referral system

We updated questionnaires in the e-referral system in July and August. We also added and updated the corresponding preview questionnaires on the ereferrals.bcbsm.com website.

Updated questionnaires
We updated the following questionnaires:

• On July 11, 2021, we updated the Enteral nutrition questionnaire for pediatric and adult BCN commercial and BCN Advantage℠ members.
  
  For questionnaires submitted on or after July 11, 2021, approved authorization requests for this service are valid for six months. (For questionnaires submitted on or before July 10, approved authorization requests were valid for three months.)

• On July 25, 2021, we updated the following questionnaires for adult and pediatric BCN commercial and BCN Advantage members:
• Out-of-network providers
• Sleep studies

• On Aug. 29, 2021, we updated the following questionnaires:
• Orthognathic surgery — For adult and pediatric BCN commercial and BCN Advantage members
• Vascular embolization or occlusion of hepatic tumors (TACE/RFA) — For adult Medicare Plus Blue℠, BCN commercial and BCN Advantage members. This questionnaire now opens for procedure code *75894, and it continues to open for procedure codes *37242 and *37243.

As a reminder, we use our authorization criteria, our medical policies and your answers to the questionnaires in the e-referral system when making utilization management determinations on your authorization requests.

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

To find the preview questionnaires:

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

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

Direct reimbursement available to genetic counselors, effective Jan. 1

Genetic counselors have the opportunity to participate in Blue Cross Blue Shield of Michigan’s Traditional and TRUST PPO (commercial) networks and Blue Care Network commercial, effective Jan. 1, 2022.

Participating genetic counselors can bill their professional services using codes *96040 and S0265. They can receive direct reimbursement for covered services within the scope of their licensure at 85% of the applicable fee schedule, minus any member deductibles and copayments. 

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

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

Enrollment forms
Genetic counselors can find enrollment forms and practitioner agreements at bcbsm.com/providers. To find enrollment information, click on Enroll to become a provider. Specific qualification requirements are identified within each agreement.

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

Background
Genetic counselors obtain and evaluate individual, family and medical histories to determine the risk for genetic or medical conditions or diseases in a client, the client’s descendants or other family members of the client. Genetic counselors explain to the client the clinical implications of genetic laboratory tests and other diagnostic studies, as well as their results.

Medical policy
Refer to the Blue Cross and BCN medical policy titled “Genetic Testing and Counseling” for more information.

Here are highlights of our policy regarding sleep studies

Some providers have told us they have questions about Blue Cross Blue Shield of Michigan’s policy regarding sleep studies. We haven’t communicated about our policy in The Record for a few years, so we’d like to provide an overview of our policy for our Blue Cross commercial members and our Medicare Plus Blue℠ members.

Physician board-certification requirement

• To perform and get reimbursed for in-center or out-of-center sleep testing, a doctor must be board-certified in sleep medicine by the American Board of Medical Specialties or the American Board of Sleep Medicine.

• Any physician may order the initial evaluation of patients suspected of having a sleep disorder (e.g., physical exam, medical and sleep history, etc.), but they must refer their patients to board-certified sleep specialists in the network for all diagnostic sleep studies.

• Any M.D. or D.O. may prescribe a sleep test, however, the performing physician must be board-certified in sleep medicine.

Facility accreditation requirement

• All in-lab sleep testing services for Blue Cross commercial members and Medicare Plus Blue members must be performed by an accredited sleep laboratory.
• Facilities performing polysomnography must be accredited by a Blue Cross Blue Shield of Michigan-designated accrediting body. 
• For nonhospital-based sleep laboratories, Blue Cross requires accreditation by the American Academy of Sleep Medicine. Hospital-based sleep testing facilities must be accredited by AASM or an accreditation organization accepted under the Participating Hospital Agreement.

Prior authorization process

For Blue Cross commercial and Medicare Plus Blue members, prior authorization requests for sleep studies must be submitted to AIM Specialty Health®. Here’s more information about that:

• All physician specialties can submit a prior authorization request. Requests can be submitted online 24/7 through AIM’s ProviderPortal℠ at aimspecialtyhealth.com.** Alternatively, providers may submit a request via phone at 1-800-728-8008, 8 a.m. to 5 p.m. Eastern time Monday through Friday. 
• AIM will perform a clinical evaluation of the request and provide a determination to the provider. The clinical criteria used by AIM are available on AIM’s website. 
• Providers are expected to obtain an authorization before administering the service. However, retroactive authorization requests are permitted, but only up to 90 days past the date of service. Such requests must be requested by phone or through the portal, and there is no guarantee that an already administered test will be authorized. This is a provider liability authorization program.
• Providers can request a prior authorization up to 30 days before the scheduled date of service.
• Prior authorization must be obtained for the following CPT codes: *95805, *95807, *95808, *95810 and *95811.
• Currently, the AIM Specialty Health Sleep program doesn’t require prior authorization for the following services:
• CPT codes *95782 and *95783 (polysomnography, younger than 6 years)
• CPT code *95806 (home testing)
• Home sleep testing services don’t require prior authorization from AIM Specialty Health^®.

Notes:

• Authorizations are only valid for a time frame of up to 30 days after the anticipated date of service identified in the authorization request. Should an authorized sleep study get rescheduled outside the valid time frame from the initial anticipated date of service, the provider must request a new authorization.
• These prior authorization rules regarding AIM don’t apply to sleep studies for Blue Care Network commercial or BCN Advantage℠ members. For information on prior authorization requirements for those members, see the BCN Sleep Management Program webpage on the ereferrals.bcbsm.com website.)

For more information, see the “Polysomnography and other sleep testing” section of the Blue Cross PPO Provider Manual and the “Preauthorization of advanced imaging, cardiology and in-lab sleep study services — AIM Specialty Health” section of the Medicare Plus Blue PPO provider manual You can also reference the medical policy using the Medical Policy & Pre-Cert/Pre-Auth Router.

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

Reminder: e‑learning lesson on E/M guidelines available on provider training website

We encourage you to check out an e-learning lesson about the evaluation and management guidelines and scenarios. You can follow the new E/M guidelines outlined in the lesson as you prepare to submit claims.

The course, available on our new provider training site, includes a video summary of the important points, with links to supporting documents from Blue Cross Blue Shield of Michigan.

Access to the site will differ slightly for new and existing users.

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

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

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

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

How to submit prior authorization requests for drugs managed by AIM when the drugs are prescribed for non‑oncology diagnoses

AIM Specialty Health^® manages authorizations for medical oncology drugs for most members. They don’t manage those drugs when prescribed for non-oncology diagnoses.

When prescribing these drugs for non-oncology diagnoses, don’t submit the prior authorization to AIM. Instead:

• For Blue Cross fully insured commercial members and UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans: Fax all clinical documentation to the Blue Cross Pharmacy Help Desk at 1-866-915-9187.

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

• For BCN commercial members: Fax all clinical documentation to the Blue Cross Pharmacy Help Desk at 1-877-402-7695.
• For Medicare Plus Blue℠ and BCN Advantage℠ members: Call the Blue Cross Blue Shield of Michigan and Blue Care Network Pharmacy Clinical Help Desk at
  1-800-437-3803.

To determine which drugs this applies to, see the following drug lists:

• Medical oncology prior authorization list for Blue Cross commercial fully insured and BCN commercial members
• Medical oncology prior authorization list for UAW Retiree Medical Benefits Trust PPO non-Medicare members
• Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members

We’re updating these drug lists and other documents to reflect this requirement.

Saphnelo and Nexviazyme require prior authorization for Medicare Advantage members

The following drugs require prior authorization through the NovoLogix^® online tool for dates of service on or after Sept. 1, 2021:

• Saphnelo™ (anifrolumab-fnia), HCPCS code J3590
• Nexviazyme™ (avalglucosidase alfa-ngpt), HCPCS code J3490

This requirement applies to Medicare Plus Blue℠ and BCN Advantage℠ members.

When prior authorization is required

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

• Electronically through an 837P transaction or on a professional CMS-1500 claim form
• Electronically through an 837I transaction or by using the UB04 claim form for a hospital outpatient type of bill 013x

Reminder

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

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

If you need to request access to Provider Secured Services, complete the Provider Secured Access Application form and fax it to the number on the form.

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.

Medicare Advantage claims now using G codes for Spravato

When billing Spravato^® (esketamine) for dates of service on or after Aug. 23, 2021, use one of the following HCPCS codes for Medicare Plus Blue℠ and BCN Advantage℠ members: 

• G2082: Office or other outpatient visit for the evaluation and management of an established patient who requires the supervision of a physician or other qualified health care professional and provision of up to 56 mg of esketamine nasal self-administration; includes two hours post-administration observation
• G2083: Office or other outpatient visit for the evaluation and management of an established patient who requires the supervision of a physician or other qualified health care professional and provision of greater than 56 mg of esketamine nasal self-administration; includes two hours post-administration observation

This change is based on Centers for Medicare & Medicaid Services coding guidelines and applies only to Medicare Plus Blue and BCN Advantage members.

What’s not changing
Don’t use these G codes when billing Spravato claims for Blue Cross Blue Shield of Michigan commercial or Blue Care Network commercial members. Instead, when billing for those members, continue to do the following:

• Use S0013 for dates of service on or after Jan. 1, 2021.
• Use J3490 or J3590 for dates of service prior to Jan. 1, 2021.

Prior authorization information
As a reminder, you must request prior authorization for Spravato using the NovoLogix^® online tool when it’s administered in outpatient settings for members with the following coverage:

• Blue Cross commercial
  Note: Blue Cross and Blue Shield Federal Employee Program^® members and UAW Retiree Medical Benefits Trust non-Medicare members don’t participate in the standard prior authorization program. Refer to the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List to determine whether other Blue Cross groups participate in the standard prior authorization program.
• Medicare Plus Blue
• BCN commercial
• BCN Advantage

Using NovoLogix
NovoLogix 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. 

Additional information
For more information on requirements related to drugs covered under the medical benefit, see the following documents:

• For commercial members, see the Blue Cross and BCN utilization management medical drug list for Blue Cross PPO (commercial) and BCN HMO (commercial) members document.
• For Medicare Advantage members, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members document.

Oncology management program to include MESSA group members, starting Jan. 1, 2022

Beginning Jan. 1, 2022, MESSA will opt in to the Blue Cross Blue Shield of Michigan utilization management program for medical oncology medications.

This means that for dates of service on or after Jan. 1, 2022, providers will need to request prior authorization from AIM Specialty Health^® for certain medical oncology and supportive care medications for MESSA group members.

To ensure continuity of care, MESSA members already receiving these medications as of Dec. 31, 2021, will be automatically authorized through June 30, 2022.

Note: AIM, an independent company, manages authorizations for medical oncology drugs. It doesn’t manage those drugs when prescribed for non-oncology diagnoses. When prescribing these drugs for non-oncology diagnoses for dates of service on or after Jan. 1, don’t submit the prior authorization request to AIM. Instead, fax all clinical documentation to the Blue Cross Pharmacy Help Desk at 1-866-915-9187.

How to submit authorization requests to AIM

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

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

More about 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 Blue Cross medical benefit, see:

• Medical oncology prior authorization list for Blue Cross commercial fully insured and BCN commercial members
• Blue Cross and BCN utilization management medical drug list

We’ll update these lists before the effective date for MESSA members.

More about AIM medical oncology management program

For more information about the AIM medical oncology program, see:

• aimproviders.com**
• Blue Cross AIM Managed Procedures page on ereferrals.bcbsm.com
• Frequently asked questions document about the oncology management program

The AIM oncology management program is already in effect for:

• Blue Cross commercial fully insured members
• UAW Retiree Medical Benefits Trust members with a Blue Cross non-Medicare plan (This doesn’t include UAW Retiree Healthcare Trust, group 70605, and UAW International Union, group 71714, both of which are separate from URMBT.)
• Medicare Plus Blue℠ members
• BCN commercial members
• BCN Advantage℠ members

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

Encourage eligible Medicare Advantage patients to get screened for colorectal cancer

Colorectal cancer is the third leading cause of cancer death for both men and women in the United States, according to the American Cancer Society. Screening, early detection and treatments are effective in reducing deaths from this cancer.

The Colorectal Cancer Screening, or COL, HEDIS^® measure (also a Medicare Star Ratings measure) assesses patients ages 50 to 75 who had appropriate screenings for colorectal cancer.

Colonoscopy is considered the “gold standard” for colorectal cancer screening. There are alternative options for patients who are hesitant to have one.

Read the Colorectal Cancer Screening tip sheet to learn about this measure, including what information to include in medical records, codes for patient claims and tips for talking with patients.

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

Help improve health of patients with diabetes while reducing medical record review requests

The Comprehensive Diabetes Care, or CDC, HEDIS^® measure (also a Medicare Star Ratings measure) supports the consistent medical care and monitoring needed by patients with diabetes to reduce the risk of severe complications and improve outcomes.

Interventions to improve outcomes go beyond glycemic control. That’s why the measure assesses HbA1c control, screening for diabetic retinopathy, screening for nephropathy and blood pressure control.

View the Comprehensive Diabetes Care tip sheet to learn more about what’s included in the measure, exclusions such as advanced illness and frailty, and ways you can close gaps in care for patients with diabetes.

The tip sheet also covers medical record documentation and claims coding that can reduce the need for medical record reviews.

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

Breast cancer screening rates drop in 2021

Many patients deferred breast cancer screening in 2020 because of the COVID-19 pandemic. A study recently published in the Journal of the National Cancer Institute showed that breast cancer screening rates aren’t catching up to rates prior to the pandemic.

This is primarily due to two factors:

• Many screening sites were closed for a time during the pandemic.
• Many patients chose to defer preventive care during the pandemic.

“We continue to see breast cancer screening rates lagging this year,” said Martha Walsh, medical director, Provider Engagement. “It’s important that patients continue to receive this important preventive care.”

What you need to know about mammograms and COVID-19 vaccine boosters

In August, the U.S. Department of Health and Human Services announced plans to begin offering COVID-19 vaccine booster shots this fall. As patients prepare to receive either a COVID-19 vaccine or the COVID-19 booster, it’s important that they have their screening mammogram done prior to their vaccine or booster, or at least four weeks after.

The COVID-19 vaccine can cause a temporary enlargement of lymph nodes, making the mammogram to appear abnormal and resulting in a false positive, as we wrote in an August Record article. The Society of Breast Imaging** recommends scheduling screening mammograms either prior to the COVID-19 vaccine or four weeks after the vaccine to give the lymph nodes time to return to their normal size. 

What some health care providers are doing to promote breast cancer screening

Here are some tips from other providers who are working to boost their breast cancer screening rates:

• Send requisitions directly to patients with gaps in care to remind them to schedule their mammogram.
• Schedule the patient for their mammogram when they are in the office for another reason. 
• Send a requisition for a mammogram directly to an associated radiology department and have the department call the patient to schedule.
• Call members who are past due for their breast cancer screening and connect them directly to a breast imaging center for scheduling.
• Have specialists help close breast cancer screening gaps by encouraging them to look at the “Gaps in Care” section of the patient’s electronic health record. 
• Reach out to patients during specific months of the year to highlight the importance of breast cancer screening. For example, in May for Mother’s Day or October for Breast Cancer Screening Awareness Month. 
• Create a contest for practices within a physician organization to close the most gaps in care, with a special lunch or some other reward provided to the practice that wins. 

Breast Cancer Screening tip sheet 

As you read in an August Record article, breast cancer screening is a key HEDIS^® measure*** for our commercial members, as well as a Star Ratings measure for Medicare Advantage members. In the article, we linked to a Breast Cancer Screening tip sheet that has information to include in medical records, codes to include on patient claims to exclude patients who had a mastectomy and tips for talking with patients about this measure.

The Breast Cancer Screening tip sheet is one of a series of HEDIS and Medicare Star Ratings tip sheets that have been posted in the Clinical Quality Corner section of web-DENIS. To access them, follow these steps:

1. From the homepage of web-DENIS, click on BCBSM Provider Publications and Resources.
2. Click on Newsletters & Resources.
3. Click on Clinical Quality Corner.

We encourage you to check them out.

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

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

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

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

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

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

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

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

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

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

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

More information

• If you need assistance creating your login ID or navigating the site, email ProviderTraining@bcbsm.com.
• If you have any questions about the sessions, contact April Boyce at aboyce@bcbsm.com.
• If you have questions regarding registration, email Patricia Scarlett at pscarlett@bcbsm.com.

Reminder: New e‑learning training videos focus on Medicare Star Ratings

The Quality and Provider Education team continues to offer important training resources for health care providers and staff. New e-learning videos designed for physician office staff responsible for closing gaps related to Medicare Star measures launched Aug. 15. The video series discusses the importance of creating positive patient experiences as part of your efforts to close gaps in care.

Topics include:

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

The video series has been approved for AMA PRA Category 1 Credit™. It’s available on our provider training site.

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

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

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

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

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

Reminder: On‑demand training available

Provider Experience continues to offer resources for health care providers and staff on our provider training website. We’ve posted recordings of webinars previously delivered this year, along with video and e-learning modules on specific topics. The on-demand courses are designed to help you work more efficiently with us.

Our newest resources include:

• AIM Preauthorization Program Overview — This updated video gives an overview of the Blue Cross Blue Shield of Michigan and Blue Care Network preauthorization program managed by AIM Specialty Health^® .
• Blue Cross Physician Choice PPO — This video was previously on the BCBSM Provider Training page in Provider Secured Services and gives an overview of the plan.
• Medicare Advantage risk adjustment program — These training modules focus on topics that include clinical criteria, medical documentation and coding guidelines. The first three modules are Commercial CDI alert, Major depressive disorder and Telehealth and telemedicine visits.
• CMS Star Measures Overview — This video course discusses closing gaps and the importance of creating positive patient experiences. This activity has been approved for AMA PRA Category 1 Credit™. Licensed doctors and nurses interested in earning credit must complete all 13 lesson modules and submit a course evaluation.
• 2021 lunch and learn webinar recordings — Chronic Kidney Disease is the newest topic added to the series that focuses on risk adjustment documentation and coding of common challenging diagnoses.

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

1. Open the registration page.
2. Complete the registration. We recommend using the same email you use to communicate with Blue Cross 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 experience, watch this video. If you need assistance creating your login ID or navigating the site, contact ProviderTraining@bcbsm.com.

Share prenatal, well‑child resources with patients

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

A healthy pregnancy and baby start with patient education. For pregnant women, learning about expectations during pregnancy, nutrition, weight and fitness can help keep them healthy. For parents, learning about the importance of regular well-child visits, monitoring developmental milestones and receiving timely immunizations can help keep their baby on a healthy path.

March of Dimes,** a nonprofit focused on improving the health of mothers and babies, has resources for patients and health care providers. The following links may help you  educate patients on the importance of prenatal care and well-child visits.

• Prenatal care checkups:** Information on frequency and what patients can expect during these visits
• Nutrition, weight and fitness:** Resources on healthy eating, exercise, vitamins and nutrients, and information on weight gain during pregnancy.
• Caring for your baby:** Information on developmental milestones, newborn screenings, safe sleeping, vaccinations and checkups
• Your baby’s checkups:** Information on why checkups are important, when to get well-baby checkups and what to expect during the checkup

For Blue Cross and Blue Shield Federal Employee Program^® members, prenatal care visits and well-child visits are covered with no out-of-pocket costs when seen by a Preferred provider. Members can call Customer Service at 1-800-482-3600 or go to www.fepblue.org for help locating a Preferred provider and for benefit information.

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

We’re aligning local rules for acute inpatient medical admissions for Blue Cross commercial plans and requesting your input

This article focuses on the alignment of local rules for acute inpatient medical admissions for Blue Cross Blue Shield of Michigan commercial plans. There’s a separate article in this issue on aligning local rules for Blue Care Network commercial, Medicare Plus Blue℠ and BCN Advantage℠ plans.

Blue Cross Blue Shield of Michigan is working to align local rules across all plans for acute inpatient medical admissions. We’re implementing a local rule for specific conditions that could appropriately be managed in an observation setting for at least 48 hours.

The following conditions should be submitted for clinical review once the 48-hour observation stay is met:

For patients with a Blue Cross commercial plan, the program will begin with admissions on or after March 1, 2022.

This program will decrease provider burden by decreasing receipt of multiple communications and the need to submit multiple requests for clinical documentation. It will also have an impact on authorizations denied for lack of clinical information as all clinical documentation to support the admission would be received after 48 hours of observation care.

Observation requirement

For patients diagnosed with conditions listed in the local rule, the patient must be observed for 48 hours before a facility can request prior authorization for an inpatient acute care admission. For admissions where patient is receiving intensive care services requiring an ICU setting, authorizations will be accepted prior to the 48-hour observation period.

Once the 48-hour observation stay requirement is met or patient is receiving intensive care services, a medical necessity review will be conducted based on the supporting clinical documentation submitted by the provider. InterQual criteria will be applied based on the patient’s condition when the patient transitions from 48-hour observation stay to an inpatient admission or is receiving intensive care services.

• If InterQual criteria is met, the prior authorization request will be approved.
• If InterQual criteria isn’t met, the prior authorization request will be sent to the plan medical director for review.
• If the patient hasn’t met the 48-hour observation requirement, the prior authorization request will be sent to the plan medical director for review.

Applicable peer-to-peer review requests and appeals will remain available for those cases in which a facility disputes the severity of illness and intensity of services provided were higher than an observation.

Requesting input

We’re requesting your input on the alignment of local rules for inpatient acute care admissions detailed in this article. Please submit your input to Liz Bowman at ebowman@bcbsm.com by Oct. 31, 2021.

Per the Participating Hospital Agreement, effective July 1, 2021, the Contract Administration Process >was revised to allow for non-binding input from all participating hospitals. After input is received, Blue Cross Blue Shield of Michigan has 30 calendar days to respond to facility input.

We’re aligning local rules for acute inpatient medical admissions for BCN, Medicare Plus Blue and BCN Advantage plans

This article focuses on thealignment of local rules for acute inpatient medical admissions for Blue Care Network commercial, Medicare Plus Blue℠ and BCN Advantage℠ plans. There’s a separate article in this issue on aligning local rules for Blue Cross Blue Shield of Michigan commercial plans.

Blue Cross Blue Shield of Michigan and Blue Care Network are working to align local rules across all plans for acute inpatient medical admissions. We’re implementing a local rule for specific conditions that could appropriately be managed in an observation setting for at least 48 hours.

The following conditions should be submitted for clinical review once the 48-hour observation stay is met:

For patients with BCN commercial, Medicare Plus Blue and BCN Advantage plans, the program will begin with admissions on or after Jan. 3, 2022.

This program will decrease receipt of multiple communications and the need to submit multiple requests for clinical documentation. It will also have an impact on authorizations denied for lack of clinical information as all clinical documentation to support the admission would be received after 48 hours of observation care.

Observation requirement

For patients diagnosed with conditions listed in the local rule, the patient must be observed for 48 hours before a facility can request prior authorization for an inpatient acute care admission. For admissions where a patient is receiving intensive care services requiring an ICU setting, authorizations will be accepted prior to the 48-hour observation period.

Once the 48-hour observation stay requirement is met or the patient is receiving intensive care services, a medical necessity review will be conducted based on the supporting clinical documentation submitted by the provider. InterQual criteria will be applied based on the patient’s condition when the patient transitions from 48-hour observation stay to an inpatient admission or is receiving intensive care services.

• If InterQual criteria is met, the prior authorization request will be approved.
• If InterQual criteria isn’t met, the prior authorization request will be sent to the plan medical director for review.
• If the patient hasn’t met the 48-hour observation requirement, the prior authorization request will be sent to the plan medical director for review.

Applicable peer-to-peer review requests and appeals will remain available for those cases in which a facility disputes the severity of illness and intensity of services provided were higher than an observation.

We’re requesting input from facilities by Oct. 31

Per our Participating Hospital Agreement, effective July 1, 2021, the Contract Administration Process was revised to allow for nonbinding input from all participating hospitals. As outlined in the PHA, hospitals are invited to provide input on various programs and initiatives within CAP.

We’re requesting that facilities submit their input to Liz Bowman at ebowman@bcbsm.com by Oct. 31, 2021.

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

Transparency requirement
In a related development, Blue Cross Blue Shield of Michigan will be posting its allowed amounts publicly in 2022, as required by law. Blue Cross will also share similar financial information with entities that have entered into risk contracts for attributed member populations.

In addition, the following information will be shared with those entities: 

• Volume of admissions at each facility for members attributed to such entities  
• Readmission rates at a facility level to include the new HEDIS “All Cause Readmission” definition that now includes both admissions and observations.
• Other quality and utilization data, as necessary

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

Coming soon: New edits for Blue Cross commercial claims

At Blue Cross Blue Shield of Michigan, we remain committed to payment integrity solutions that support payment accuracy and encourage correct coding. In support of that commitment, you’ll begin to see new claim edits in the coming weeks and months.

In the July 2021 issue of The Record, we let  you know we would begin enhancing our current claim editing with the addition of new ClaimsXten™ edits. In the August 2021 issue of The Record, we also informed you of edits that will occur through our new partnership with Optum.

ClaimsXten edits will occur in prepayment processing. Optum edits are also prepayment.

Continue to follow the clinical editing appeals process that you currently follow. You’ll be able to recognize these new edits as “clinical editing.” based on the unique provider message codes that will appear on the provider voucher:

• The new Optum message codes are K500‑K544. 
• The new ClaimsXten message codes are K211‑K221.

We’re expanding laboratory claims editing for Medicare Plus Blue

Starting January 2022, Blue Cross Blue Shield of Michigan will expand its laboratory claim editing process to promote correct coding and assist with payment accuracy for Medicare Plus Blue℠ claims.

These enhancements will help ensure that our claim payment policies are easy to understand and align with nationally recognized sources of information. They’ll also help us better meet the needs of a changing health care industry while maintaining alignment with national coding guidelines.

Additional information and updates will be included in future communications over the coming months.

Multitarget genetic testing procedure code *81443 became payable Aug. 1, 2021

Blue Cross Blue Shield of Michigan approved multitarget genetic testing procedure code *81443. The code is payable for patients seeking the following medical care:

• Testing for carrier status for severe, lethal or developmentally impactful genetic diseases and disorders
• Patients seeking evaluation or clinical interventions related to infertility
• Patients receiving prenatal services with encounters for routine prenatal care or non-procreative and procreative counseling where the number of targets tested is fifteen or above

For the above services, CPT code *81443 should be billed as opposed to individual, incremental gene testing codes. This change is effective Aug. 1, 2021.

Note: Blue Cross doesn’t provide separate reimbursement for individual gene codes when the gene tests performed can be collectively represented by a single CPT multitarget molecular genetic testing code.

Lab codes
Proprietary laboratory panel tests may be represented by proprietary laboratory analyses codes. Most of these panels consist of a combination of mutations found to be clinically useful as well as many mutations of uncertain or unknown clinical utility. Some of these proprietary tests are not covered by Blue Cross and coverage should not be assumed unless there is a specific Blue Cross medical policy identifying the test as established and therefore reimbursable.

When a selection of individual gene tests (15 or more) that may be included in a large proprietary lab panel are conducted, *81443 should be used. If both a multitarget CPT code (*81443) and the individual gene codes that may be included in a panel are billed — a process called unbundling — only the CPT multitarget code will be reimbursed.

Blue Cross uses data analytics to identify improper and unbundled claims. Keep in mind that unbundling claims to obtain payment or increased payment is a crime.

TurningPoint updated its medical policies for musculoskeletal procedures and related services

TurningPoint Healthcare Solutions LLC updated various medical policies for musculoskeletal procedures and related services based on feedback from the provider community. The updated policies went into effect on July 26, 2021.

To view the updated policies, access the TurningPoint Provider Portal** and click on Help in the menu at the top of the screen.

Criteria used to make determinations on authorization requests
As a reminder, TurningPoint uses the following criteria to make determinations on authorization requests for musculoskeletal and pain management procedures.

• For Blue Cross Blue Shield of Michigan commercial and Blue Care Network commercial members: TurningPoint applies medical policy guidelines for musculoskeletal and pain management procedures that Blue Cross, BCN and TurningPoint agreed on.
• For Medicare Plus Blue℠ and BCN Advantage℠ members: TurningPoint applies the Medicare national coverage determinations and Medicare local coverage determinations.

If there is no Medicare NCD and LCD, TurningPoint applies medical policy guidelines for musculoskeletal and pain management procedures that Blue Cross, BCN and TurningPoint agreed on.

Additional information
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

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

***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 developing a provider satisfaction survey with TurningPoint

Blue Cross Blue Shield of Michigan and Blue Care Network are working with TurningPoint Healthcare Solutions, LLC to develop a health care provider satisfaction survey.

TurningPoint will send the survey to providers who have submitted authorization requests for musculoskeletal procedures and related services. The survey will give these providers the opportunity to provide feedback on the TurningPoint musculoskeletal surgical quality and safety management program.

TurningPoint will send the survey via email by the end of the year.

We’ll communicate the distribution timeline for the surveys in future provider communications.

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.

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

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

This applies to members with the following coverage:

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

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

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

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

• BCN Musculoskeletal Services
• Blue Cross Musculoskeletal Services

Updated questionnaires in the e‑referral system

We updated questionnaires in the e-referral system in July and August. We also added and updated the corresponding preview questionnaires on the ereferrals.bcbsm.com website.

Updated questionnaires
We updated the following questionnaires:

• On July 11, 2021, we updated the Enteral nutrition questionnaire for pediatric and adult BCN commercial and BCN Advantage℠ members.
  
  For questionnaires submitted on or after July 11, 2021, approved authorization requests for this service are valid for six months. (For questionnaires submitted on or before July 10, approved authorization requests were valid for three months.)

• On July 25, 2021, we updated the following questionnaires for adult and pediatric BCN commercial and BCN Advantage members:
• Out-of-network providers
• Sleep studies

• On Aug. 29, 2021, we updated the following questionnaires:
• Orthognathic surgery — For adult and pediatric BCN commercial and BCN Advantage members
• Vascular embolization or occlusion of hepatic tumors (TACE/RFA) — For adult Medicare Plus Blue℠, BCN commercial and BCN Advantage members. This questionnaire now opens for procedure code *75894, and it continues to open for procedure codes *37242 and *37243.

As a reminder, we use our authorization criteria, our medical policies and your answers to the questionnaires in the e-referral system when making utilization management determinations on your authorization requests.

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

To find the preview questionnaires:

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

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

Here are highlights of our policy regarding sleep studies

Some providers have told us they have questions about Blue Cross Blue Shield of Michigan’s policy regarding sleep studies. We haven’t communicated about our policy in The Record for a few years, so we’d like to provide an overview of our policy for our Blue Cross commercial members and our Medicare Plus Blue℠ members.

Physician board-certification requirement

• To perform and get reimbursed for in-center or out-of-center sleep testing, a doctor must be board-certified in sleep medicine by the American Board of Medical Specialties or the American Board of Sleep Medicine.

• Any physician may order the initial evaluation of patients suspected of having a sleep disorder (e.g., physical exam, medical and sleep history, etc.), but they must refer their patients to board-certified sleep specialists in the network for all diagnostic sleep studies.

• Any M.D. or D.O. may prescribe a sleep test, however, the performing physician must be board-certified in sleep medicine.

Facility accreditation requirement

• All in-lab sleep testing services for Blue Cross commercial members and Medicare Plus Blue members must be performed by an accredited sleep laboratory.
• Facilities performing polysomnography must be accredited by a Blue Cross Blue Shield of Michigan-designated accrediting body. 
• For nonhospital-based sleep laboratories, Blue Cross requires accreditation by the American Academy of Sleep Medicine. Hospital-based sleep testing facilities must be accredited by AASM or an accreditation organization accepted under the Participating Hospital Agreement.

Prior authorization process

For Blue Cross commercial and Medicare Plus Blue members, prior authorization requests for sleep studies must be submitted to AIM Specialty Health®. Here’s more information about that:

• All physician specialties can submit a prior authorization request. Requests can be submitted online 24/7 through AIM’s ProviderPortal℠ at aimspecialtyhealth.com.** Alternatively, providers may submit a request via phone at 1-800-728-8008, 8 a.m. to 5 p.m. Eastern time Monday through Friday. 
• AIM will perform a clinical evaluation of the request and provide a determination to the provider. The clinical criteria used by AIM are available on AIM’s website. 
• Providers are expected to obtain an authorization before administering the service. However, retroactive authorization requests are permitted, but only up to 90 days past the date of service. Such requests must be requested by phone or through the portal, and there is no guarantee that an already administered test will be authorized. This is a provider liability authorization program.
• Providers can request a prior authorization up to 30 days before the scheduled date of service.
• Prior authorization must be obtained for the following CPT codes: *95805, *95807, *95808, *95810 and *95811.
• Currently, the AIM Specialty Health Sleep program doesn’t require prior authorization for the following services:
• CPT codes *95782 and *95783 (polysomnography, younger than 6 years)
• CPT code *95806 (home testing)
• Home sleep testing services don’t require prior authorization from AIM Specialty Health^®.

Notes:

• Authorizations are only valid for a time frame of up to 30 days after the anticipated date of service identified in the authorization request. Should an authorized sleep study get rescheduled outside the valid time frame from the initial anticipated date of service, the provider must request a new authorization.
• These prior authorization rules regarding AIM don’t apply to sleep studies for Blue Care Network commercial or BCN Advantage℠ members. For information on prior authorization requirements for those members, see the BCN Sleep Management Program webpage on the ereferrals.bcbsm.com website.)

For more information, see the “Polysomnography and other sleep testing” section of the Blue Cross PPO Provider Manual and the “Preauthorization of advanced imaging, cardiology and in-lab sleep study services — AIM Specialty Health” section of the Medicare Plus Blue PPO provider manual You can also reference the medical policy using the Medical Policy & Pre-Cert/Pre-Auth Router.

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

How to submit prior authorization requests for drugs managed by AIM when the drugs are prescribed for non‑oncology diagnoses

AIM Specialty Health^® manages authorizations for medical oncology drugs for most members. They don’t manage those drugs when prescribed for non-oncology diagnoses.

When prescribing these drugs for non-oncology diagnoses, don’t submit the prior authorization to AIM. Instead:

• For Blue Cross fully insured commercial members and UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans: Fax all clinical documentation to the Blue Cross Pharmacy Help Desk at 1-866-915-9187.

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

• For BCN commercial members: Fax all clinical documentation to the Blue Cross Pharmacy Help Desk at 1-877-402-7695.
• For Medicare Plus Blue℠ and BCN Advantage℠ members: Call the Blue Cross Blue Shield of Michigan and Blue Care Network Pharmacy Clinical Help Desk at
  1-800-437-3803.

To determine which drugs this applies to, see the following drug lists:

• Medical oncology prior authorization list for Blue Cross commercial fully insured and BCN commercial members
• Medical oncology prior authorization list for UAW Retiree Medical Benefits Trust PPO non-Medicare members
• Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members

We’re updating these drug lists and other documents to reflect this requirement.

Saphnelo and Nexviazyme require prior authorization for Medicare Advantage members

The following drugs require prior authorization through the NovoLogix^® online tool for dates of service on or after Sept. 1, 2021:

• Saphnelo™ (anifrolumab-fnia), HCPCS code J3590
• Nexviazyme™ (avalglucosidase alfa-ngpt), HCPCS code J3490

This requirement applies to Medicare Plus Blue℠ and BCN Advantage℠ members.

When prior authorization is required

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

• Electronically through an 837P transaction or on a professional CMS-1500 claim form
• Electronically through an 837I transaction or by using the UB04 claim form for a hospital outpatient type of bill 013x

Reminder

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

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

If you need to request access to Provider Secured Services, complete the Provider Secured Access Application form and fax it to the number on the form.

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.

Medicare Advantage claims now using G codes for Spravato

When billing Spravato^® (esketamine) for dates of service on or after Aug. 23, 2021, use one of the following HCPCS codes for Medicare Plus Blue℠ and BCN Advantage℠ members: 

• G2082: Office or other outpatient visit for the evaluation and management of an established patient who requires the supervision of a physician or other qualified health care professional and provision of up to 56 mg of esketamine nasal self-administration; includes two hours post-administration observation
• G2083: Office or other outpatient visit for the evaluation and management of an established patient who requires the supervision of a physician or other qualified health care professional and provision of greater than 56 mg of esketamine nasal self-administration; includes two hours post-administration observation

This change is based on Centers for Medicare & Medicaid Services coding guidelines and applies only to Medicare Plus Blue and BCN Advantage members.

What’s not changing
Don’t use these G codes when billing Spravato claims for Blue Cross Blue Shield of Michigan commercial or Blue Care Network commercial members. Instead, when billing for those members, continue to do the following:

• Use S0013 for dates of service on or after Jan. 1, 2021.
• Use J3490 or J3590 for dates of service prior to Jan. 1, 2021.

Prior authorization information
As a reminder, you must request prior authorization for Spravato using the NovoLogix^® online tool when it’s administered in outpatient settings for members with the following coverage:

• Blue Cross commercial
  Note: Blue Cross and Blue Shield Federal Employee Program^® members and UAW Retiree Medical Benefits Trust non-Medicare members don’t participate in the standard prior authorization program. Refer to the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List to determine whether other Blue Cross groups participate in the standard prior authorization program.
• Medicare Plus Blue
• BCN commercial
• BCN Advantage

Using NovoLogix
NovoLogix 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. 

Additional information
For more information on requirements related to drugs covered under the medical benefit, see the following documents:

• For commercial members, see the Blue Cross and BCN utilization management medical drug list for Blue Cross PPO (commercial) and BCN HMO (commercial) members document.
• For Medicare Advantage members, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members document.

Oncology management program to include MESSA group members, starting Jan. 1, 2022

Beginning Jan. 1, 2022, MESSA will opt in to the Blue Cross Blue Shield of Michigan utilization management program for medical oncology medications.

This means that for dates of service on or after Jan. 1, 2022, providers will need to request prior authorization from AIM Specialty Health^® for certain medical oncology and supportive care medications for MESSA group members.

To ensure continuity of care, MESSA members already receiving these medications as of Dec. 31, 2021, will be automatically authorized through June 30, 2022.

Note: AIM, an independent company, manages authorizations for medical oncology drugs. It doesn’t manage those drugs when prescribed for non-oncology diagnoses. When prescribing these drugs for non-oncology diagnoses for dates of service on or after Jan. 1, don’t submit the prior authorization request to AIM. Instead, fax all clinical documentation to the Blue Cross Pharmacy Help Desk at 1-866-915-9187.

How to submit authorization requests to AIM

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

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

More about 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 Blue Cross medical benefit, see:

• Medical oncology prior authorization list for Blue Cross commercial fully insured and BCN commercial members
• Blue Cross and BCN utilization management medical drug list

We’ll update these lists before the effective date for MESSA members.

More about AIM medical oncology management program

For more information about the AIM medical oncology program, see:

• aimproviders.com**
• Blue Cross AIM Managed Procedures page on ereferrals.bcbsm.com
• Frequently asked questions document about the oncology management program

The AIM oncology management program is already in effect for:

• Blue Cross commercial fully insured members
• UAW Retiree Medical Benefits Trust members with a Blue Cross non-Medicare plan (This doesn’t include UAW Retiree Healthcare Trust, group 70605, and UAW International Union, group 71714, both of which are separate from URMBT.)
• Medicare Plus Blue℠ members
• BCN commercial members
• BCN Advantage℠ members

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

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

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

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

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

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

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

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

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

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

More information

• If you need assistance creating your login ID or navigating the site, email ProviderTraining@bcbsm.com.
• If you have any questions about the sessions, contact April Boyce at aboyce@bcbsm.com.
• If you have questions regarding registration, email Patricia Scarlett at pscarlett@bcbsm.com.

Reminder: On‑demand training available

Provider Experience continues to offer resources for health care providers and staff on our provider training website. We’ve posted recordings of webinars previously delivered this year, along with video and e-learning modules on specific topics. The on-demand courses are designed to help you work more efficiently with us.

Our newest resources include:

• AIM Preauthorization Program Overview — This updated video gives an overview of the Blue Cross Blue Shield of Michigan and Blue Care Network preauthorization program managed by AIM Specialty Health^® .
• Blue Cross Physician Choice PPO — This video was previously on the BCBSM Provider Training page in Provider Secured Services and gives an overview of the plan.
• Medicare Advantage risk adjustment program — These training modules focus on topics that include clinical criteria, medical documentation and coding guidelines. The first three modules are Commercial CDI alert, Major depressive disorder and Telehealth and telemedicine visits.
• CMS Star Measures Overview — This video course discusses closing gaps and the importance of creating positive patient experiences. This activity has been approved for AMA PRA Category 1 Credit™. Licensed doctors and nurses interested in earning credit must complete all 13 lesson modules and submit a course evaluation.
• 2021 lunch and learn webinar recordings — Chronic Kidney Disease is the newest topic added to the series that focuses on risk adjustment documentation and coding of common challenging diagnoses.

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

1. Open the registration page.
2. Complete the registration. We recommend using the same email you use to communicate with Blue Cross 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 experience, watch this video. If you need assistance creating your login ID or navigating the site, contact ProviderTraining@bcbsm.com.

How to submit prior authorization requests for drugs managed by AIM when the drugs are prescribed for non‑oncology diagnoses

AIM Specialty Health^® manages authorizations for medical oncology drugs for most members. They don’t manage those drugs when prescribed for non-oncology diagnoses.

When prescribing these drugs for non-oncology diagnoses, don’t submit the prior authorization to AIM. Instead:

• For Blue Cross fully insured commercial members and UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans: Fax all clinical documentation to the Blue Cross Pharmacy Help Desk at 1-866-915-9187.

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

• For BCN commercial members: Fax all clinical documentation to the Blue Cross Pharmacy Help Desk at 1-877-402-7695.
• For Medicare Plus Blue℠ and BCN Advantage℠ members: Call the Blue Cross Blue Shield of Michigan and Blue Care Network Pharmacy Clinical Help Desk at
  1-800-437-3803.

To determine which drugs this applies to, see the following drug lists:

• Medical oncology prior authorization list for Blue Cross commercial fully insured and BCN commercial members
• Medical oncology prior authorization list for UAW Retiree Medical Benefits Trust PPO non-Medicare members
• Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members

We’re updating these drug lists and other documents to reflect this requirement.

Saphnelo and Nexviazyme require prior authorization for Medicare Advantage members

The following drugs require prior authorization through the NovoLogix^® online tool for dates of service on or after Sept. 1, 2021:

• Saphnelo™ (anifrolumab-fnia), HCPCS code J3590
• Nexviazyme™ (avalglucosidase alfa-ngpt), HCPCS code J3490

This requirement applies to Medicare Plus Blue℠ and BCN Advantage℠ members.

When prior authorization is required

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

• Electronically through an 837P transaction or on a professional CMS-1500 claim form
• Electronically through an 837I transaction or by using the UB04 claim form for a hospital outpatient type of bill 013x

Reminder

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

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

If you need to request access to Provider Secured Services, complete the Provider Secured Access Application form and fax it to the number on the form.

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.

Medicare Advantage claims now using G codes for Spravato

When billing Spravato^® (esketamine) for dates of service on or after Aug. 23, 2021, use one of the following HCPCS codes for Medicare Plus Blue℠ and BCN Advantage℠ members: 

• G2082: Office or other outpatient visit for the evaluation and management of an established patient who requires the supervision of a physician or other qualified health care professional and provision of up to 56 mg of esketamine nasal self-administration; includes two hours post-administration observation
• G2083: Office or other outpatient visit for the evaluation and management of an established patient who requires the supervision of a physician or other qualified health care professional and provision of greater than 56 mg of esketamine nasal self-administration; includes two hours post-administration observation

This change is based on Centers for Medicare & Medicaid Services coding guidelines and applies only to Medicare Plus Blue and BCN Advantage members.

What’s not changing
Don’t use these G codes when billing Spravato claims for Blue Cross Blue Shield of Michigan commercial or Blue Care Network commercial members. Instead, when billing for those members, continue to do the following:

• Use S0013 for dates of service on or after Jan. 1, 2021.
• Use J3490 or J3590 for dates of service prior to Jan. 1, 2021.

Prior authorization information
As a reminder, you must request prior authorization for Spravato using the NovoLogix^® online tool when it’s administered in outpatient settings for members with the following coverage:

• Blue Cross commercial
  Note: Blue Cross and Blue Shield Federal Employee Program^® members and UAW Retiree Medical Benefits Trust non-Medicare members don’t participate in the standard prior authorization program. Refer to the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List to determine whether other Blue Cross groups participate in the standard prior authorization program.
• Medicare Plus Blue
• BCN commercial
• BCN Advantage

Using NovoLogix
NovoLogix 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. 

Additional information
For more information on requirements related to drugs covered under the medical benefit, see the following documents:

• For commercial members, see the Blue Cross and BCN utilization management medical drug list for Blue Cross PPO (commercial) and BCN HMO (commercial) members document.
• For Medicare Advantage members, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members document.

Oncology management program to include MESSA group members, starting Jan. 1, 2022

Beginning Jan. 1, 2022, MESSA will opt in to the Blue Cross Blue Shield of Michigan utilization management program for medical oncology medications.

This means that for dates of service on or after Jan. 1, 2022, providers will need to request prior authorization from AIM Specialty Health^® for certain medical oncology and supportive care medications for MESSA group members.

To ensure continuity of care, MESSA members already receiving these medications as of Dec. 31, 2021, will be automatically authorized through June 30, 2022.

Note: AIM, an independent company, manages authorizations for medical oncology drugs. It doesn’t manage those drugs when prescribed for non-oncology diagnoses. When prescribing these drugs for non-oncology diagnoses for dates of service on or after Jan. 1, don’t submit the prior authorization request to AIM. Instead, fax all clinical documentation to the Blue Cross Pharmacy Help Desk at 1-866-915-9187.

How to submit authorization requests to AIM

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

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

More about 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 Blue Cross medical benefit, see:

• Medical oncology prior authorization list for Blue Cross commercial fully insured and BCN commercial members
• Blue Cross and BCN utilization management medical drug list

We’ll update these lists before the effective date for MESSA members.

More about AIM medical oncology management program

For more information about the AIM medical oncology program, see:

• aimproviders.com**
• Blue Cross AIM Managed Procedures page on ereferrals.bcbsm.com
• Frequently asked questions document about the oncology management program

The AIM oncology management program is already in effect for:

• Blue Cross commercial fully insured members
• UAW Retiree Medical Benefits Trust members with a Blue Cross non-Medicare plan (This doesn’t include UAW Retiree Healthcare Trust, group 70605, and UAW International Union, group 71714, both of which are separate from URMBT.)
• Medicare Plus Blue℠ members
• BCN commercial members
• BCN Advantage℠ members

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