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September 2021
September is Suicide Prevention Awareness MonthMore than 47,500 people in the U.S. die by suicide each year, according to the Centers for Disease Control and Prevention. In Michigan, provisional data showed there were 1,282 deaths by suicide in 2020, but that number is expected to increase as more reports are finalized. The primary reason for suicide is depression, according to the Hope for Depression Research Foundation.** It affects 1 in 10 adults in any given year. Blue Cross Blue Shield of Michigan is committed to helping its members cope with mental health issues, such as depression, as part of their overall health. “We want them to address mental and behavioral health issues early before they escalate, and potentially lead to suicide,” said Dr. Amy McKenzie, associate chief medical officer for Blue Cross. That’s why we recently developed a Behavioral Health Campaign for members, including member emails, a behavioral and mental health website, advertising and more. We encourage health care providers to let patients know about the website and other resources about behavioral health and suicide prevention. Here are several good resources:
**Blue Cross Blue Shield of Michigan doesn’t own or control this website.
Our care management program offers support for patients, health care providersLast year, we launched our reimagined care management program to help support your patients who may need assistance with care coordination or health care support in other areas. Blue Cross Coordinated Care, now called Blue Cross Coordinated Care Core℠, is part of a broader portfolio of health care solutions. It’s been deployed across all lines of business, including:
“The purpose of this program is threefold,” said Lisa Zmijewski, manager, Coordinated Care Advocate. “First, we want to help our members — particularly high‑risk members with chronic or complex conditions — navigate the increasingly complex health care system. Second, we want to assist health care providers in their efforts to improve the health of their patient population, and last, but not least, it’s a program that can help to better manage health care costs.” Poorly coordinated care, she pointed out, can result in higher health care costs, less satisfactory patient outcomes, inappropriate emergency room use and more frequent inpatient admissions. As part of this program, specially designated nurse care managers lead multidisciplinary care teams to:
Participation in the program is completely voluntary for members. We use enhanced analytics to identify members with chronic or complex conditions who can benefit from the program, as well as those who may be at increased risk due to a recent diagnosis and related gaps in care. When necessary to support patient care, we notify the primary care provider or specialist if one of his or her patients is in our care management program. “It isn’t intended to replace the doctor-patient relationship in any way,” Zmijewski said. “Instead, the program has been designed to support health care providers in their efforts to provide the best possible care for their patients.”
No‑cost COVID‑19 treatment ending Sept. 30As we reported in The Record previously, we’re ending our $0 member cost share for COVID‑19 treatment Sept. 30. We’ll still pay for medically necessary treatment, but it will now be subject to member cost sharing. This change applies to Blue Cross Blue Shield of Michigan, Blue Care Network, Medicare Plus Blue℠, BCN Advantage℠ and Medigap plans. Effective Oct. 1, member cost sharing will apply for COVID‑19 treatment.** Throughout the pandemic, we’ve implemented many short-term changes to help our providers and members during this difficult time. This included waiving authorization requirements and member cost sharing for COVID‑19 testing and treatments. Many of our policies had end dates that were revised throughout the health emergency. We’re continuing to revise the end dates for temporary changes to our policies. For additional information, refer to this document. We’ll continue to cover physician‑approved testing for the duration of the public health emergency, as required by federal guidelines. **Some commercial self-funded groups may end the temporary waiver of member cost sharing on a different date. For example, MESSA is extending the waiver of member cost sharing through the end of 2021. Providers are encouraged to submit claims to Blue Cross and BCN, and wait for the voucher before charging member cost sharing, if applicable.
Reminder: Participating providers may only bill members for applicable deductibles and copaymentsWe want to remind participating providers that they must bill Blue Cross Blue Shield of Michigan and Blue Care Network for all covered services and may only bill members for applicable deductibles and copayments. In keeping with provider contracts, you may not collect deposits or bill members upfront for unpaid balances of covered services. The following guidance comes from the “Patient Copayment and Deductibles” chapter of the Blue Cross Provider Manual.
Blue Cross retires modifier 22 payment policy for pain control optimization pathway programBlue Cross Blue Shield of Michigan’s pain-control optimization pathway, or POP — and an associated modifier 22 payment mechanism — will end Dec. 31, 2021. Part of a pilot program, it’s being retired due to the success of the initiative. Blue Cross’ pilot program was introduced nearly three years ago to assist providers with appropriate pain management following certain surgical procedures, including limited post-operative opioid dispensing to help reduce risks associated with dependence and diversion. The initiative covered 20 surgical procedures aimed at promoting effective pain control through care processes that limit opioid dispensing. The pain-control optimization process is an evidence-based prescribing pathway created by surgeons in partnership with Michigan Opioid Prescribing Engagement Network, or Michigan-OPEN, to address opioid overprescribing following surgery. The POP program and use of modifier 22 were both instrumental in reducing opioid prescribing patterns over the course of the initiative while still providing appropriate pain management. Modifier 22 will continue to be used for other purposes.
Fiscal year 2022 ICD‑10‑CM and PCS code updates now availableThe fiscal year 2022 ICD‑10‑CM and ICD‑10‑PCS code updates, which will be effective with dates of service on and after Oct. 1, 2021, are available on the Centers for Medicare & Medicaid Services website. This year’s updates include 350 new CM and PCS (diagnosis and inpatient procedure) codes, 83 CM and PCS code revisions and 139 CM and PCS deletions. To view the code updates, visit the CMS website.** **Blue Cross Blue Shield of Michigan doesn’t own or control this website. Billing chart: Blue Cross highlights medical, benefit policy changesYou’ll find the latest information about procedure codes and Blue Cross Blue Shield of Michigan billing guidelines in the following chart. This billing chart is organized numerically by procedure code. Newly approved procedures will appear under the New Payable Procedures heading. Procedures for which we have changed a billing guideline or added a new payable group will appear under Updates to Payable Procedures. Procedures for which we are clarifying our guidelines will appear under Policy Clarifications. New procedures that are not covered will appear under Experimental Procedures. You will also see that descriptions for the codes are no longer included. This is a result of recent negotiations with the AMA on use of the codes. We will publish information about new BCBS groups or changes to group benefits under the Group Benefit Changes heading. For more detailed descriptions of the BCBSM policies for these procedures, please check under the Medical/Payment Policy tab in Explainer on web-DENIS. To access this online information:
New method of obtaining emergency crisis assessment for psychiatric issues, treatment comingStarting Oct. 1, 2021, Blue Cross Blue Shield of Michigan and Blue Care Network will begin covering mobile crisis and crisis stabilization services. Both urgent care and crisis residential services are already covered. Note: Medicare Plus Blue℠ members won’t be included in this new program at this time. Mobile crisis services include:
The mobile crisis team may stay involved for two to four weeks after the initial encounter to ensure members are connected to the right level of care for mental health or substance use disorder treatment and to provide treatment, as necessary. Crisis stabilization services (formerly psychiatric observation) include:
“The goal of such services is to make sure our members get treated at the right place at the right time,” said Dr. William Beecroft, medical director of behavioral health. Facilities to be used for physical site-based services would be open 24/7 and use the services of a multidisciplinary staff, including physicians, registered nurses, licensed master social workers, psychologists, clinical supervisors and additional support staff. Members may be referred to a facility from a mobile crisis team, law enforcement or other community-based services, or they may walk in on their own. Blue Care Network recently conducted a pilot program with two providers in Southeast Michigan — Hegira Health's COPE** and Common Ground Resource and Crisis Center.** COPE, which stands for Community Outreach for Psychiatric Emergencies, is a program created by Hegira Health, Inc. As the State of Michigan further develops the certification process for crisis stabilization units in freestanding and hospital‑affiliated locations across the state, Blue Cross and BCN will expand their efforts to include additional providers within the state. Here’s some additional information about the Common Ground and COPE centers: Common Ground Resource and Crisis Center Hegira Health’s COPE BCN has had two years of experience working with these two centers, with positive results. Some of the benefits for members receiving treatment at one of these two locations include:
As part of the evaluation and treatment process at these centers, some members may still need psychiatric hospitalization. Beecroft pointed out that the Substance Abuse and Mental Health Services Administration, or SAMHSA, published a paper suggesting that a significant number of individuals presenting for crisis services don’t require hospital admission and can be treated in another, more appropriate care setting. “Centers that offer mobile crisis and crisis stabilization services make it more likely that people will get treated quickly and at the right level of care,” he said. We’ll be publishing additional details about our coverage of crisis services as they become available and let you know of additional providers that join us in this transformative program of care. We’ll also be including program criteria in our provider manuals. Watch for further updates and information on how you can become involved on web-DENIS and in The Record and BCN Provider News.
CareCentrix to manage network for independent home infusion therapy and ambulatory infusion suite providers, starting Jan. 1What you need to know The information in this article applies to independent home infusion therapy and ambulatory infusion suite providers who:
It doesn’t apply to hospital-owned home infusion therapy and ambulatory infusion suite providers. We’ll notify all nonhospital-owned home infusion therapy and ambulatory infusion suite providers of this change by mail. We’ll also send letters to members who may be affected by this change, and we’ll work with CareCentrix® to ensure that there are no gaps in care. Effective Jan. 1, 2022, Blue Cross Blue Shield of Michigan and Blue Care Network will delegate management of the in-state independent home infusion therapy and ambulatory infusion suite provider network to CareCentrix for commercial members. This change won’t affect:
CareCentrix is a leader in managing infusion therapy services. It manages a national network of more than 800 home infusion therapy and ambulatory infusion suite providers. We expect the transition to CareCentrix to improve member care through better management of home infusion therapy and ambulatory infusion suite services. Note: Ambulatory infusion suites are a subset of ambulatory infusion centers. Here’s what affected providers need to do
Note: Independent home infusion therapy and ambulatory infusion suite providers can continue to bill Blue Cross and BCN for services provided to Medicare Advantage members and for other services, such as providing durable medical equipment and supplies. These services aren’t affected by this change. We’ll end-date all Blue Cross and BCN independent home infusion therapy and ambulatory infusion suite contracts for commercial coverage, effective Dec. 31, 2021. Who this change applies to This change applies to independent HIT and AIS providers who:
This change doesn’t apply to hospital-owned HIT and AIS providers. We’ll notify all non-hospital-owned HIT and AIS providers of this change by mail. We’ll also send letters to members who may be affected by this change, and we’ll work with CareCentrix to ensure that there are no gaps in care. Questions? To learn more, see this document. If you have questions about provider contracting, email CareCentrix at homeinfusion@carecentrix.com.
Learn more about submitting authorizations for our new Medicare Advantage home health care programWhat you need to know CareCentrix® began managing authorizations for home health care services for Medicare Plus Blue℠ and BCN Advantage℠ members as of June 1, 2021. We’d like to provide additional information and clarification on several key aspects of this new program:
Note: You also don’t need to update authorizations for Medicare Plus Blue members when services are provided by clinicians with lower-level credentials. See the following table to determine which HCPCS codes are associated with revenue codes by discipline:
We’re updating the Home health care: Frequently asked questions for providers document to reflect these clarifications. As a reminder, CareCentrix manages prior authorizations for home health care services for Medicare Plus Blue and BCN Advantage members as follows:
CareCentrix monitoring home health authorizations for missing HIPPS codes for Medicare Plus Blue membersWhen submitting claims for home health care services for Medicare Plus Blue℠ members who receive services in Michigan, you must include the Care‑Centrix®‑assigned health insurance prospective payment system, or HIPPS, code. This is required because Blue Cross Blue Shield of Michigan will reject claims that don’t include the HIPPS code. To ensure that you have a HIPPS code when you submit claims for these members, CareCentrix monitors home health authorizations for missing HIPPS codes. What we communicated previously The preferred methods for obtaining the HIPPS code are:
For detailed information about the preferred methods, see Home health care: Frequently asked questions for providers. As a reminder, CareCentrix manages prior authorizations for home health care services for Medicare Plus Blue and BCN Advantage members for:
Here’s what’s new If you don’t obtain the HIPPS code using one of the preferred methods by Day 25 of the episode of care, CareCentrix will make two attempts to call you. When CareCentrix contacts you and you supply the information needed to assign the HIPPS code, CareCentrix will update the authorization with the code.
In either case, you’ll be able to find the CareCentrix‑assigned HIPPS code on the Authorization Status screen in the CareCentrix HomeBridge® portal. Additional information
For more information about the CareCentrix home health care program, see the following pages on ereferrals.bcbsm.com:
We’ve updated our Choices for Care and Blue Cross Online Visits toolkitsWe’ve refreshed our Choices for Care and Blue Cross Online Visits℠ employer toolkits to continue supporting member education about the care that’s always there with Blue Cross Blue Shield of Michigan and Blue Care Network health plans. These toolkits, which contain print, digital and video resources, are part of our continuing efforts to make sure members know they have 24-hour access to care that’s always there. You’re welcome to use these materials in your office. Choices for Care In the Choices for Care campaign, we remind members to check with their primary care providers first when they need care and let them know that many primary care providers have the following options available:
We also stress that members should follow up with their primary care provider when they receive care elsewhere. The other choices for care available to members when their primary care provider isn’t available are:
To download materials from the Choices for Care toolkit, click here. Blue Cross Online Visits We know that many primary care providers offer virtual care. If your office doesn’t offer virtual care or your Blue Cross and BCN patients need virtual care after hours, you can let them know about Blue Cross Online Visits. To download materials from the Blue Cross Online Visits toolkit, click here.
Quarterly update: Requirements changed for some commercial medical benefit drugsBlue Cross Blue Shield of Michigan and Blue Care Network encourage proper utilization of high-cost medications that are covered under the medical benefit. As part of this effort, we maintain a comprehensive list of requirements for both Blue Cross commercial and BCN commercial members. During April, May and June 2021, there were changes to prior authorization requirements, site-of-care requirements or both for the following medical benefit drugs:
**Will become a unique code For a detailed list of requirements, see the Blue Cross and BCN utilization management medical drug list.This list is available on the following pages of the ereferrals.bcbsm.com website: Additional notes These authorization requirements apply only to groups that currently participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To view the list of PPO groups that don’t require members to participate in the program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List. This list is also available on the Blue Cross Medical Benefit Drugs page of the ereferrals.bcbsm.com website. As a reminder, an authorization approval isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.
We’re transitioning to new pharmacy benefit managerWhat you need to know
Blue Cross Blue Shield of Michigan and Blue Care Network’s transition to a new pharmacy benefit manager, which we reported in a March Record article, will result in certain changes we want to alert you to. As you may have read, we’re moving from Express Scripts, Inc. to OptumRx on Jan. 1, 2022, for commercial and individual group members, and Jan. 1, 2023, for Medicare Advantage individual and group members. The change is expected to improve the pharmacy experience for members and customers, better manage drug costs and drive better health outcomes. While we anticipate that the bulk of the transition will be seamless for our members and health care providers, members who use home delivery pharmacy services may be affected. Most of these members’ current prescriptions with Express Scripts will automatically transfer to OptumRx if they have refills remaining, but prescriptions for controlled substances won’t transfer automatically. Members with a prescription for a controlled substance will need to see their doctor to request a new prescription for our new home delivery pharmacy. Examples include medications for ADHD and seizures, as well as opioid pain medications like oxycodone, methadone and other drugs that put a person at high risk for developing substance use disorder. We’re sending letters to members in mid-September to explain what they need to do. A second letter from OptumRx will follow in November. After receiving these letters, some members may schedule appointments with their health care providers, including primary care providers and specialists, to request new prescriptions for medications they want delivered to their homes. New ID cards Due to the transition to OptumRx, we’ll mail about 1.8 million new ID cards to members this fall, beginning Oct. 3. Members must show their new cards at the pharmacy starting Jan. 1 for their prescriptions to be covered correctly under their benefits. Electronic tools for providers We’ll provide more information in The Record later this year about electronic tools for prior authorization requests and member benefits information related to this transition.
We’re changing how we pay for certain drugs that should be administered by health care providerStarting Oct. 1, 2021, Blue Cross Blue Shield of Michigan and Blue Care Network will no longer pay for the following drugs under a patient’s drug benefits. These medications should only be administered by a health care provider, and we’ll only pay for them under a patient’s medical benefits. Our drug plans only pay for drugs that can be self-administered by the patient, as per prescription labeling approved by the Food and Drug Administration. If members fill a prescription for one of these drugs at a pharmacy on or after Oct. 1, 2021, they’ll be responsible for the full cost.
We’ll notify affected members of these changes and advise them to talk with their provider about continuing to receive their treatment.
Additional drugs to require prior authorization for URMBT members with Blue Cross non‑Medicare planFor dates of service on or after Nov. 1, 2021, we’re adding prior authorization requirements for the following drugs covered under the medical benefit:
Submit prior authorization requests through the NovoLogix® online tool. Prior authorization requirements apply when these drugs are administered in an outpatient setting for UAW Retiree Medical Benefits Trust, or URMBT, members with a non-Medicare plan. How to submit authorization requests Submit prior authorization requests through NovoLogix. It offers real-time status checks and immediate approvals for certain medications. To learn how to submit requests through NovoLogix, do the following:
More about the authorization requirements Authorization isn’t a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members. For additional information on requirements related to drugs covered under the medical benefit for URMBT members with a Blue Cross non-Medicare plan, see:
Note: Accredo manages prior authorization requests for the URMBT for select medical benefit drugs that aren’t included on these two lists. We’ll update the appropriate drug lists to reflect the information in this message before the effective date.
Clarification: Services requiring AIM prior authorizationIn an August Record article, we wrote that services associated with certain radiology codes required prior authorization from AIM Specialty Health® for Blue Cross Blue Shield of Michigan commercial members, including UAW Retiree Medical Benefits Trust members with a Blue Cross Blue Shield of Michigan non‑Medicare plan. We want to clarify that this requirement doesn’t apply to the following:
These two groups don’t require prior authorization from AIM.
Policy update coming for nonchemotherapy drug administration codingBlue Cross Blue Shield of Michigan and Blue Care Network will be updating their policy for nonchemotherapy drug administration later this year to align with a Centers for Medicare & Medicaid Services local coverage determination for our commercial and Medicare Advantage lines of business. Nonchemotherapy drugs should be reported with administration CPT code *96372, not chemotherapy administration code *96401. Here are the descriptions of these codes:
If the following drugs are billed with a chemotherapy administration code, the administration code will be denied.
We’ll provide the effective date of this new policy and additional information in future communications. Appeal process If you need to appeal a denial, follow the clinical editing appeal process. Fax one appeal at a time to avoid processing delays. Before filing an appeal, validate that you’re using the correct administration code for billing nonchemotherapy drugs. Find examples of correct coding in this CMS article: Billing and Coding: Complex Drug Administration Coding (A58544).** **Blue Cross Blue Shield of Michigan doesn’t own or control this website.
Claim editing update coming later this year to Medicare Plus Blue actinotherapy and photochemotherapy claimsTo promote correct coding and assist with payment accuracy, Blue Cross Blue Shield of Michigan will enhance its claim editing process later this year for Medicare Plus Blue℠ claims to align with American Academy of Dermatology guidelines for actinotherapy and photochemotherapy services. According to the AAD, there are specific diagnoses that are appropriate indications for CPT codes *96910-*96912 (photochemotherapy; PUVA), including atopic dermatitis, lichen planus, psoriasis and vitiligo. The photochemotherapy codes aren’t considered billable services unless an appropriate diagnosis is reported. Following are appropriate ICD-10 codes that can be used: C84.0-C84.09, C84.1-C84.19, C84.A-C84.A9, C96.2-C96.29, D45, D89.81-D89.813, L11.1, L20-L20.9, L28.1, L29.8, L29.9, L30.0, L30.1, L40-L40.9, L41-L41.9, L42, L43-L43.9, L44.8, L44.9, L45, L50.3, L50.8, L53.8, L56.4, L57.1, L57.8, L63-L63.9, L66.1, L80, L81.7, L90.0, L90.9, L91.9, L92.0, L94.0, L94.1, L94.3, L94.9, L98.5, Q82 We’ll provide updates on other pertinent information about these claims, including when this edit will be effective, in future communications. Note: The appeal process won’t change. Continue to submit appeals on the Clinical Editing Appeal Form with the necessary supporting documentation. Fax one appeal at a time to avoid processing delays.
HMS launches new provider portal for auditsWhat you need to know HMS, an independent company that works with us on audits, updated its provider portal in August with some new features. Providers won’t need to register for the new portal. On Aug. 27, 2021, Health Management Systems, or HMS, launched an updated provider portal called HMS Portal. It replaces the portal our health care providers have been using for their audit activity. Providers, hospitals and facilities with provider portal accounts won’t have to register for the new portal. Their access will migrate to HMS Portal automatically. They can use the same user ID and password to access the new portal. Not registered for the provider portal? Providers, hospitals and facilities involved in HMS audits who don’t have a provider portal account can register for an HMS Portal account now. Here’s how:
All communication with HMS regarding audits will go through the new portal, but providers will still receive audit information through the mail as a secondary form of reporting notification. HMS Portal features:
Training Click here** to download a user guide on the new portal. Questions? HMS is available for you during any step of the process. If you have trouble or questions when using the portal, contact the HMS Provider Relations team at 1-866-875-1749. **Blue Cross Blue Shield of Michigan doesn’t own or control this website.
Claim editing update for modifier 59 coming later this year to Medicare Plus Blue claimsAs we communicated in an August Record article, we’ll begin editing claim lines when modifier 59 is appended on Medicare Plus Blue℠ claims. Following are additional details. Background This list indicates whether modifier 59 can be used to allow two codes to be billed together that would otherwise be denied. When we update the claims editing process, only select codes will allow modifier 59 to automatically bypass the NCCI code pair edits. While the editing enhancements won’t take place until later this year, we encourage you to follow the guidelines provided in this article now. Examples of billing scenarios If you bill modifier 59 and receive a claim line denial, following are some examples of circumstances when it would be appropriate to appeal the denial by submitting medical records that demonstrate the services are separate and distinct: Example 1:
Modifier 59 may be reported with CPT code *11102 if the procedures are performed at different anatomic sites. For example, a lesion is biopsied by shave removal on the left forearm and a benign lesion was destructed on the cheek. Modifier 59 shouldn’t be used if the procedures were performed on the same lesion. Modifier 59 is used appropriately for different anatomic sites during the same encounter only when procedures that aren’t ordinarily performed or encountered on the same day are performed on different organs, different anatomic regions or in limited situations on different, noncontiguous lesions in different anatomic regions of the same organ. Example 2:
Modifier 59 may be reported with CPT code *45380 if the procedures are performed at separate sites. For example, a polyp was removed in the transverse and descending colon by cold snare technique and a biopsy of a lesion was performed in the ascending colon by cold forceps. Modifier 59 shouldn’t be used if both techniques are used to remove the same polyp, tumor or lesion. Example 3:
Modifier 59 may be reported with CPT code *88342 if each procedure is for a different antibody. For example: A needle biopsy is performed on the left breast and an immunohistochemistry antibody stain procedure is performed using GATA3 and a morphometric analysis antibody stain procedure is performed using HER2. Modifier 59 shouldn’t be used if the same antibody is used for each procedure. Modifier 59 is used appropriately when two timed procedures are performed in different blocks of time on the same day. Example 4:
Modifier 59 may be reported with CPT code *97110 if the two procedures are performed in distinctly different time blocks. For example, provider performs 15 minutes of therapeutic exercises from 11:30 to 11:45 and the provider performs 15 minutes of aquatic therapy with the patient from noon to 12:15 p.m. Modifier 59 shouldn’t be used if both procedures were performed during the same time block. Modifier 59 is used appropriately when two services describe nonoverlapping services even though they may occur during the same encounter. Example 5:
Modifier 59 may be reported with HCPCS code G0444 as it’s a time-based procedure and is separate and significant from the E/M. For example, an E/M is conducted due to an ear infection and sore throat. The provider indicates a depression screening was performed for 15 minutes using the PHQ-9. Modifier 59 shouldn’t be used if the documentation doesn’t indicate the time spent doing the depression screening. Example 6:
Modifier 59 may be reported with CPT code *64447 if the procedure is performed for post-operative pain management. For example, surgeon requests an injection for post-op pain management and the anesthesia is administered for the procedure. These two services are separate and distinct as they are being administered at separate times for separate reasons. Modifier 59 shouldn’t be used if the injection wasn’t administered for post-operative pain management. Modifier 59 is used appropriately for a diagnostic procedure that precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure. Example 7:
Modifier 59 may be reported with CPT code *93458 if the diagnostic angiography hasn’t been previously performed and the decision to perform the angioplasty is based on the result of the diagnostic angiography. Modifier 59 shouldn’t be used if the angiography isn’t performed diagnostically and is included or performed during the angioplasty. Example 8:
Modifier 59 may be reported with CPT code *75710 if the diagnostic angiography hasn’t been previously performed and the decision to perform the revascularization is based on the result of the diagnostic angiography. Modifier 59 shouldn’t be used if the angiography isn’t performed diagnostically and is included or performed during the revascularization. Modifier 59 is always appended to the Column II Code on the NCCI list. This enhancement also applies to modifiers:
Note: The appeal process won’t change. Continue to submit appeals on the Clinical Editing Appeal Form with the necessary documentation that supports the procedures are separate and distinct. Also, continue to fax one appeal at a time to avoid processing delays. None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.
Claim editing enhancements coming to Blue Cross commercial claimsIn an August 2021 Record article, we let you know that Blue Cross Blue Shield of Michigan will be working with Optum to enhance our claim editing process to promote correct coding starting in November 2021. Anatomical modifiers for surgical procedures One of the enhancements we’ll be making is to require anatomical modifiers for surgical procedures. Anatomical modifiers identify the specific area of the body where a procedure is performed. Requiring these modifiers aligns with AMA CPT guidelines and supports our commitment to implementing payment integrity solutions that enhance payment accuracy. Surgical procedures requiring anatomical modifiers include CPT codes in the range *10000-*69999 that have a Medicare Physician Fee Schedule bilateral indicator “1,” denoting that the surgical code is eligible to be billed on both sides of the body. We’ll edit the surgical code when anatomical modifiers (50, LT, RT, E1, E2, E3, E4, F1, F2, F3, F4, F5, F6, F7, F8, F9, FA, T1, T2, T3, T4, T5, T6, T7, T8, T9, TA, LC, LD, RC, LM, RI) are appropriate, but haven’t been appended to the claim line. Although the requirement begins later this year, we encourage you to follow the new process now. If you have questions about the Blue Cross claim editing process, contact Provider Inquiry. Professional providers should call 1-800-344-8525, while facility providers should call 1-800-249-5103.
Asparlas will require prior authorization for URMBT members with a Blue Cross non‑Medicare planFor dates of service on or after Nov. 1, 2021, Asparlas™ (calasparagase pegol-mknl), HCPCS code J9118, will require prior authorization through AIM Specialty Health®. This drug is covered under the medical benefit. Prior authorization requirements apply when this drug is administered in an outpatient setting for UAW Retiree Medical Benefits Trust members who have a Blue Cross Blue Shield of Michigan non-Medicare plan. How to submit authorization requests Submit prior authorization requests to AIM using one of the following methods:
More about the authorization requirements Authorization isn’t a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members. For additional information on requirements related to drugs covered under the medical benefit for URMBT members with a Blue Cross non-Medicare plan, see:
We’ll update the appropriate drug lists to reflect the information in this message prior to the effective date. Notes:
**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.
Cosela and Libtayo to require prior authorization for URMBT members with a Blue Cross non‑Medicare planFor dates of service on or after Nov. 1, 2021, the following drugs will require prior authorization through AIM Specialty Health®:
These drugs are covered under the medical benefit. Prior authorization requirements apply when these drugs are administered in an outpatient setting for UAW Retiree Medical Benefits Trust members with a Blue Cross Blue Shield of Michigan non-Medicare plan. How to submit authorization requests Submit prior authorization requests to AIM using one of the following methods:
More about the authorization requirements Authorization isn’t a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members. For additional information on requirements related to drugs covered under the medical benefit for URMBT members with a Blue Cross non-Medicare plan, see:
Notes:
We’ll update the appropriate drug lists to reflect the information in this message prior to the effective date. **Blue Cross Blue Shield of Michigan doesn’t own or control this website.
Rybrevant requires prior authorization for most membersFor dates of service on or after Sept. 27, 2021, Rybrevant™ (amivantamab-vmjw), HCPCS codes J9999, J3490, J3590 and C9399, will require prior authorization through AIM Specialty Health®. This drug is covered under the medical benefit. Prior authorization requirements apply when this drug is administered in outpatient settings for:
Exceptions: This requirement doesn’t apply to Michigan Education Special Services Association members or members who have coverage through the Blue Cross and Blue Shield Federal Employee Program®. This requirement also doesn’t apply to UAW Retiree Medical Benefits Trust members with a Blue Cross non-Medicare plan and other members with coverage through self-funded groups.
How to submit authorization requests Submit authorization requests to AIM using one of the following methods:
More about the authorization requirements Authorization isn’t a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members. For additional information on requirements related to drugs covered under the medical benefit, see:
We’ll update the appropriate drug lists to reflect the information in this message prior to the effective date. **Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.
Data shows higher flu vaccine rate leads to lower illnesses, hospitalizations and deathsThis is part of an ongoing series of articles focusing on the tools and resources available to help FEP members manage their health. Nearly 52% of the U.S. population received a flu vaccine during the 2019-2020 flu season, up from 49% during the 2018-2019 flu season, according to the Centers for Disease Control and Prevention. See a two-year comparison from the CDC of the flu vaccination rate and how it affected the health of those who received it below:
The CDC encourages individuals to get annual flu vaccinations. We encourage you to share the 2019-2020 Flu Season: Burden and Burden Averted by Vaccination*** infographic with patients to help them understand the importance of the vaccine. Flu vaccines have no out-of-pocket cost for Blue Cross and Blue Shield Federal Employee Program® members when received from a Preferred provider. Also, medical professionals are available anytime through the 24/7 Nurse Line (1-888-258-3432), where FEP members can get their questions about the flu and vaccine answered. For more benefit information, providers and FEP members can call Customer Service at 1-800-482-3600 or visit www.fepblue.org. **Estimates ***Blue Cross and Blue Shield of Michigan doesn’t own or control this website.
Lunch and learn webinars for physicians and coders focus on risk adjustment, codingAction item 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:
Once logged in, users can access the modules in two ways:
If you need assistance creating your login ID or navigating the site, email ProviderTraining@bcbsm.com.
Reminder: e‑learning lesson on E/M guidelines available on provider training websiteWe encourage you to view an e-learning lesson about the evaluation and management guidelines and scenarios for 2020 and beyond. 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 website, 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.
Once logged in, users have two options for accessing the module:
If you need assistance creating your login ID or navigating the site, email ProviderTraining@bcbsm.com.
Reminder: On‑demand training availableAction item Provider Experience continues to offer training resources for health care providers and staff. We’ve posted recordings of webinars previously delivered this year, along with video and e-learning modules on specific topics, on our provider training site. Our on-demand courses are designed to help you work more efficiently with us. As previously communicated in The Record, we launched our new provider training site to enhance your training experience. Watch this video for an overview of the site’s features.
As you may have read previously, training courses and materials from 2019 through 2021 have moved from BCBSM Provider Training and BCN Learning Opportunities to the new training site. To request access, follow these steps:
If you need assistance creating your login ID or navigating the site, contact ProviderTraining@bcbsm.com.
Reminder: New e‑learning training videos focus on Medicare Star RatingsThe 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:
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:
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.
Clarification: Pending authorization requestsIn a May Record article, we reported that we would begin pending some authorization requests in June but the effective date subsequently changed to July 25. On that date, we started pending some authorization requests that would usually be auto-approved based on your answers to the questionnaires in the e-referral system. This allows us to validate the answers you provided on the questionnaire.
New method of obtaining emergency crisis assessment for psychiatric issues, treatment comingStarting Oct. 1, 2021, Blue Cross Blue Shield of Michigan and Blue Care Network will begin covering mobile crisis and crisis stabilization services. Both urgent care and crisis residential services are already covered. Note: Medicare Plus Blue℠ members won’t be included in this new program at this time. Mobile crisis services include:
The mobile crisis team may stay involved for two to four weeks after the initial encounter to ensure members are connected to the right level of care for mental health or substance use disorder treatment and to provide treatment, as necessary. Crisis stabilization services (formerly psychiatric observation) include:
“The goal of such services is to make sure our members get treated at the right place at the right time,” said Dr. William Beecroft, medical director of behavioral health. Facilities to be used for physical site-based services would be open 24/7 and use the services of a multidisciplinary staff, including physicians, registered nurses, licensed master social workers, psychologists, clinical supervisors and additional support staff. Members may be referred to a facility from a mobile crisis team, law enforcement or other community-based services, or they may walk in on their own. Blue Care Network recently conducted a pilot program with two providers in Southeast Michigan — Hegira Health's COPE** and Common Ground Resource and Crisis Center.** COPE, which stands for Community Outreach for Psychiatric Emergencies, is a program created by Hegira Health, Inc. As the State of Michigan further develops the certification process for crisis stabilization units in freestanding and hospital‑affiliated locations across the state, Blue Cross and BCN will expand their efforts to include additional providers within the state. Here’s some additional information about the Common Ground and COPE centers: Common Ground Resource and Crisis Center Hegira Health’s COPE BCN has had two years of experience working with these two centers, with positive results. Some of the benefits for members receiving treatment at one of these two locations include:
As part of the evaluation and treatment process at these centers, some members may still need psychiatric hospitalization. Beecroft pointed out that the Substance Abuse and Mental Health Services Administration, or SAMHSA, published a paper suggesting that a significant number of individuals presenting for crisis services don’t require hospital admission and can be treated in another, more appropriate care setting. “Centers that offer mobile crisis and crisis stabilization services make it more likely that people will get treated quickly and at the right level of care,” he said. We’ll be publishing additional details about our coverage of crisis services as they become available and let you know of additional providers that join us in this transformative program of care. We’ll also be including program criteria in our provider manuals. Watch for further updates and information on how you can become involved on web-DENIS and in The Record and BCN Provider News.
CareCentrix to manage network for independent home infusion therapy and ambulatory infusion suite providers, starting Jan. 1What you need to know The information in this article applies to independent home infusion therapy and ambulatory infusion suite providers who:
It doesn’t apply to hospital-owned home infusion therapy and ambulatory infusion suite providers. We’ll notify all nonhospital-owned home infusion therapy and ambulatory infusion suite providers of this change by mail. We’ll also send letters to members who may be affected by this change, and we’ll work with CareCentrix® to ensure that there are no gaps in care. Effective Jan. 1, 2022, Blue Cross Blue Shield of Michigan and Blue Care Network will delegate management of the in-state independent home infusion therapy and ambulatory infusion suite provider network to CareCentrix for commercial members. This change won’t affect:
CareCentrix is a leader in managing infusion therapy services. It manages a national network of more than 800 home infusion therapy and ambulatory infusion suite providers. We expect the transition to CareCentrix to improve member care through better management of home infusion therapy and ambulatory infusion suite services. Note: Ambulatory infusion suites are a subset of ambulatory infusion centers. Here’s what affected providers need to do
Note: Independent home infusion therapy and ambulatory infusion suite providers can continue to bill Blue Cross and BCN for services provided to Medicare Advantage members and for other services, such as providing durable medical equipment and supplies. These services aren’t affected by this change. We’ll end-date all Blue Cross and BCN independent home infusion therapy and ambulatory infusion suite contracts for commercial coverage, effective Dec. 31, 2021. Who this change applies to This change applies to independent HIT and AIS providers who:
This change doesn’t apply to hospital-owned HIT and AIS providers. We’ll notify all non-hospital-owned HIT and AIS providers of this change by mail. We’ll also send letters to members who may be affected by this change, and we’ll work with CareCentrix to ensure that there are no gaps in care. Questions? To learn more, see this document. If you have questions about provider contracting, email CareCentrix at homeinfusion@carecentrix.com.
Learn more about submitting authorizations for our new Medicare Advantage home health care programWhat you need to know CareCentrix® began managing authorizations for home health care services for Medicare Plus Blue℠ and BCN Advantage℠ members as of June 1, 2021. We’d like to provide additional information and clarification on several key aspects of this new program:
Note: You also don’t need to update authorizations for Medicare Plus Blue members when services are provided by clinicians with lower-level credentials. See the following table to determine which HCPCS codes are associated with revenue codes by discipline:
We’re updating the Home health care: Frequently asked questions for providers document to reflect these clarifications. As a reminder, CareCentrix manages prior authorizations for home health care services for Medicare Plus Blue and BCN Advantage members as follows:
CareCentrix monitoring home health authorizations for missing HIPPS codes for Medicare Plus Blue membersWhen submitting claims for home health care services for Medicare Plus Blue℠ members who receive services in Michigan, you must include the Care‑Centrix®‑assigned health insurance prospective payment system, or HIPPS, code. This is required because Blue Cross Blue Shield of Michigan will reject claims that don’t include the HIPPS code. To ensure that you have a HIPPS code when you submit claims for these members, CareCentrix monitors home health authorizations for missing HIPPS codes. What we communicated previously The preferred methods for obtaining the HIPPS code are:
For detailed information about the preferred methods, see Home health care: Frequently asked questions for providers. As a reminder, CareCentrix manages prior authorizations for home health care services for Medicare Plus Blue and BCN Advantage members for:
Here’s what’s new If you don’t obtain the HIPPS code using one of the preferred methods by Day 25 of the episode of care, CareCentrix will make two attempts to call you. When CareCentrix contacts you and you supply the information needed to assign the HIPPS code, CareCentrix will update the authorization with the code.
In either case, you’ll be able to find the CareCentrix‑assigned HIPPS code on the Authorization Status screen in the CareCentrix HomeBridge® portal. Additional information
For more information about the CareCentrix home health care program, see the following pages on ereferrals.bcbsm.com:
Additional drugs to require prior authorization for URMBT members with Blue Cross non‑Medicare planFor dates of service on or after Nov. 1, 2021, we’re adding prior authorization requirements for the following drugs covered under the medical benefit:
Submit prior authorization requests through the NovoLogix® online tool. Prior authorization requirements apply when these drugs are administered in an outpatient setting for UAW Retiree Medical Benefits Trust, or URMBT, members with a non-Medicare plan. How to submit authorization requests Submit prior authorization requests through NovoLogix. It offers real-time status checks and immediate approvals for certain medications. To learn how to submit requests through NovoLogix, do the following:
More about the authorization requirements Authorization isn’t a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members. For additional information on requirements related to drugs covered under the medical benefit for URMBT members with a Blue Cross non-Medicare plan, see:
Note: Accredo manages prior authorization requests for the URMBT for select medical benefit drugs that aren’t included on these two lists. We’ll update the appropriate drug lists to reflect the information in this message before the effective date.
Clarification: Services requiring AIM prior authorizationIn an August Record article, we wrote that services associated with certain radiology codes required prior authorization from AIM Specialty Health® for Blue Cross Blue Shield of Michigan commercial members, including UAW Retiree Medical Benefits Trust members with a Blue Cross Blue Shield of Michigan non‑Medicare plan. We want to clarify that this requirement doesn’t apply to the following:
These two groups don’t require prior authorization from AIM.
Claim editing update coming later this year to Medicare Plus Blue actinotherapy and photochemotherapy claimsTo promote correct coding and assist with payment accuracy, Blue Cross Blue Shield of Michigan will enhance its claim editing process later this year for Medicare Plus Blue℠ claims to align with American Academy of Dermatology guidelines for actinotherapy and photochemotherapy services. According to the AAD, there are specific diagnoses that are appropriate indications for CPT codes *96910-*96912 (photochemotherapy; PUVA), including atopic dermatitis, lichen planus, psoriasis and vitiligo. The photochemotherapy codes aren’t considered billable services unless an appropriate diagnosis is reported. Following are appropriate ICD-10 codes that can be used: C84.0-C84.09, C84.1-C84.19, C84.A-C84.A9, C96.2-C96.29, D45, D89.81-D89.813, L11.1, L20-L20.9, L28.1, L29.8, L29.9, L30.0, L30.1, L40-L40.9, L41-L41.9, L42, L43-L43.9, L44.8, L44.9, L45, L50.3, L50.8, L53.8, L56.4, L57.1, L57.8, L63-L63.9, L66.1, L80, L81.7, L90.0, L90.9, L91.9, L92.0, L94.0, L94.1, L94.3, L94.9, L98.5, Q82 We’ll provide updates on other pertinent information about these claims, including when this edit will be effective, in future communications. Note: The appeal process won’t change. Continue to submit appeals on the Clinical Editing Appeal Form with the necessary supporting documentation. Fax one appeal at a time to avoid processing delays.
Facility charges for daily respiratory therapy services will be proratedBlue Cross Blue Shield of Michigan and Blue Care Network are prorating daily respiratory therapy services by hours used, not to exceed 24 hours in a single day. We communicated this in a January 2021 Record article titled “Facilities required to prorate respiratory therapy services.” Providers have told us that they’re unable to bill respiratory therapy on an hourly basis. Therefore, we’ll manually prorate the service and won’t reimburse the full charge. This reimbursement policy is effective Jan. 1, 2021, for Blue Cross commercial, Medicare Plus Blue℠, BCN commercial and BCN Advantage℠ members. It applies to an inpatient setting only. The following is a list of general respiratory therapy services applicable to this billing policy:
Billing guidance If, on a single day of service, a patient is on the ventilator for five hours and then weaned to CPAP for the remaining 19 hours of the day, Blue Cross and BCN will only provide reimbursement for those hours used for each modality. Currently, services are billed at a daily rate, regardless of hours used. Background Respiratory therapy services are services prescribed by a physician or a non-physician practitioner for the assessment and diagnostic evaluation, treatment, management and monitoring of patients with deficiencies and abnormalities of cardiopulmonary function. This reimbursement policy isn’t intended to affect physician decision-making; providers are expected to apply medical judgment when caring for all members.
HMS launches new provider portal for auditsWhat you need to know HMS, an independent company that works with us on audits, updated its provider portal in August with some new features. Providers won’t need to register for the new portal. On Aug. 27, 2021, Health Management Systems, or HMS, launched an updated provider portal called HMS Portal. It replaces the portal our health care providers have been using for their audit activity. Providers, hospitals and facilities with provider portal accounts won’t have to register for the new portal. Their access will migrate to HMS Portal automatically. They can use the same user ID and password to access the new portal. Not registered for the provider portal? Providers, hospitals and facilities involved in HMS audits who don’t have a provider portal account can register for an HMS Portal account now. Here’s how:
All communication with HMS regarding audits will go through the new portal, but providers will still receive audit information through the mail as a secondary form of reporting notification. HMS Portal features:
Training Click here** to download a user guide on the new portal. Questions? HMS is available for you during any step of the process. If you have trouble or questions when using the portal, contact the HMS Provider Relations team at 1-866-875-1749. **Blue Cross Blue Shield of Michigan doesn’t own or control this website.
Asparlas will require prior authorization for URMBT members with a Blue Cross non‑Medicare planFor dates of service on or after Nov. 1, 2021, Asparlas™ (calasparagase pegol-mknl), HCPCS code J9118, will require prior authorization through AIM Specialty Health®. This drug is covered under the medical benefit. Prior authorization requirements apply when this drug is administered in an outpatient setting for UAW Retiree Medical Benefits Trust members who have a Blue Cross Blue Shield of Michigan non-Medicare plan. How to submit authorization requests Submit prior authorization requests to AIM using one of the following methods:
More about the authorization requirements Authorization isn’t a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members. For additional information on requirements related to drugs covered under the medical benefit for URMBT members with a Blue Cross non-Medicare plan, see:
We’ll update the appropriate drug lists to reflect the information in this message prior to the effective date. Notes:
**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.
Cosela and Libtayo to require prior authorization for URMBT members with a Blue Cross non‑Medicare planFor dates of service on or after Nov. 1, 2021, the following drugs will require prior authorization through AIM Specialty Health®:
These drugs are covered under the medical benefit. Prior authorization requirements apply when these drugs are administered in an outpatient setting for UAW Retiree Medical Benefits Trust members with a Blue Cross Blue Shield of Michigan non-Medicare plan. How to submit authorization requests Submit prior authorization requests to AIM using one of the following methods:
More about the authorization requirements Authorization isn’t a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members. For additional information on requirements related to drugs covered under the medical benefit for URMBT members with a Blue Cross non-Medicare plan, see:
Notes:
We’ll update the appropriate drug lists to reflect the information in this message prior to the effective date. **Blue Cross Blue Shield of Michigan doesn’t own or control this website.
Rybrevant requires prior authorization for most membersFor dates of service on or after Sept. 27, 2021, Rybrevant™ (amivantamab-vmjw), HCPCS codes J9999, J3490, J3590 and C9399, will require prior authorization through AIM Specialty Health®. This drug is covered under the medical benefit. Prior authorization requirements apply when this drug is administered in outpatient settings for:
Exceptions: This requirement doesn’t apply to Michigan Education Special Services Association members or members who have coverage through the Blue Cross and Blue Shield Federal Employee Program®. This requirement also doesn’t apply to UAW Retiree Medical Benefits Trust members with a Blue Cross non-Medicare plan and other members with coverage through self-funded groups.
How to submit authorization requests Submit authorization requests to AIM using one of the following methods:
More about the authorization requirements Authorization isn’t a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members. For additional information on requirements related to drugs covered under the medical benefit, see:
We’ll update the appropriate drug lists to reflect the information in this message prior to the effective date. **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, codingAction item 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:
Once logged in, users can access the modules in two ways:
If you need assistance creating your login ID or navigating the site, email ProviderTraining@bcbsm.com.
Reminder: On‑demand training availableAction item Provider Experience continues to offer training resources for health care providers and staff. We’ve posted recordings of webinars previously delivered this year, along with video and e-learning modules on specific topics, on our provider training site. Our on-demand courses are designed to help you work more efficiently with us. As previously communicated in The Record, we launched our new provider training site to enhance your training experience. Watch this video for an overview of the site’s features.
As you may have read previously, training courses and materials from 2019 through 2021 have moved from BCBSM Provider Training and BCN Learning Opportunities to the new training site. To request access, follow these steps:
If you need assistance creating your login ID or navigating the site, contact ProviderTraining@bcbsm.com.
Clarification: Pending authorization requestsIn a May Record article, we reported that we would begin pending some authorization requests in June but the effective date subsequently changed to July 25. On that date, we started pending some authorization requests that would usually be auto-approved based on your answers to the questionnaires in the e-referral system. This allows us to validate the answers you provided on the questionnaire.
We’re changing how we pay for certain drugs that should be administered by health care providerStarting Oct. 1, 2021, Blue Cross Blue Shield of Michigan and Blue Care Network will no longer pay for the following drugs under a patient’s drug benefits. These medications should only be administered by a health care provider, and we’ll only pay for them under a patient’s medical benefits. Our drug plans only pay for drugs that can be self-administered by the patient, as per prescription labeling approved by the Food and Drug Administration. If members fill a prescription for one of these drugs at a pharmacy on or after Oct. 1, 2021, they’ll be responsible for the full cost.
We’ll notify affected members of these changes and advise them to talk with their provider about continuing to receive their treatment.
Additional drugs to require prior authorization for URMBT members with Blue Cross non‑Medicare planFor dates of service on or after Nov. 1, 2021, we’re adding prior authorization requirements for the following drugs covered under the medical benefit:
Submit prior authorization requests through the NovoLogix® online tool. Prior authorization requirements apply when these drugs are administered in an outpatient setting for UAW Retiree Medical Benefits Trust, or URMBT, members with a non-Medicare plan. How to submit authorization requests Submit prior authorization requests through NovoLogix. It offers real-time status checks and immediate approvals for certain medications. To learn how to submit requests through NovoLogix, do the following:
More about the authorization requirements Authorization isn’t a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members. For additional information on requirements related to drugs covered under the medical benefit for URMBT members with a Blue Cross non-Medicare plan, see:
Note: Accredo manages prior authorization requests for the URMBT for select medical benefit drugs that aren’t included on these two lists. We’ll update the appropriate drug lists to reflect the information in this message before the effective date.
Asparlas will require prior authorization for URMBT members with a Blue Cross non‑Medicare planFor dates of service on or after Nov. 1, 2021, Asparlas™ (calasparagase pegol-mknl), HCPCS code J9118, will require prior authorization through AIM Specialty Health®. This drug is covered under the medical benefit. Prior authorization requirements apply when this drug is administered in an outpatient setting for UAW Retiree Medical Benefits Trust members who have a Blue Cross Blue Shield of Michigan non-Medicare plan. How to submit authorization requests Submit prior authorization requests to AIM using one of the following methods:
More about the authorization requirements Authorization isn’t a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members. For additional information on requirements related to drugs covered under the medical benefit for URMBT members with a Blue Cross non-Medicare plan, see:
We’ll update the appropriate drug lists to reflect the information in this message prior to the effective date. Notes:
**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.
Cosela and Libtayo to require prior authorization for URMBT members with a Blue Cross non‑Medicare planFor dates of service on or after Nov. 1, 2021, the following drugs will require prior authorization through AIM Specialty Health®:
These drugs are covered under the medical benefit. Prior authorization requirements apply when these drugs are administered in an outpatient setting for UAW Retiree Medical Benefits Trust members with a Blue Cross Blue Shield of Michigan non-Medicare plan. How to submit authorization requests Submit prior authorization requests to AIM using one of the following methods:
More about the authorization requirements Authorization isn’t a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members. For additional information on requirements related to drugs covered under the medical benefit for URMBT members with a Blue Cross non-Medicare plan, see:
Notes:
We’ll update the appropriate drug lists to reflect the information in this message prior to the effective date. **Blue Cross Blue Shield of Michigan doesn’t own or control this website.
Rybrevant requires prior authorization for most membersFor dates of service on or after Sept. 27, 2021, Rybrevant™ (amivantamab-vmjw), HCPCS codes J9999, J3490, J3590 and C9399, will require prior authorization through AIM Specialty Health®. This drug is covered under the medical benefit. Prior authorization requirements apply when this drug is administered in outpatient settings for:
Exceptions: This requirement doesn’t apply to Michigan Education Special Services Association members or members who have coverage through the Blue Cross and Blue Shield Federal Employee Program®. This requirement also doesn’t apply to UAW Retiree Medical Benefits Trust members with a Blue Cross non-Medicare plan and other members with coverage through self-funded groups.
How to submit authorization requests Submit authorization requests to AIM using one of the following methods:
More about the authorization requirements Authorization isn’t a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members. For additional information on requirements related to drugs covered under the medical benefit, see:
We’ll update the appropriate drug lists to reflect the information in this message prior to the effective date. **Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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