Enrollment open for private duty nursing agencies

As we communicated in the June 2022 Record, Blue Cross Blue Shield of Michigan is expanding its network to include private duty nursing agencies. In addition, private duty nursing services require prior authorization before providing care to the member.

On July 15, 2022, Blue Cross opened the Traditional and TRUST PPO (commercial) network to private duty nursing agencies for enrollment. As a Blue Cross provider, you’ll be paid directly for approved services, have access to member eligibility information and your contact information will be accessible to millions of our members.

To be selected for the networks, the providers must meet a list of selection standards that include:

• Have an accreditation certificate from one of the following:
• Accreditation Commission for Health Care, or ACHC
• Commission on Accreditation of Rehabilitations Facilities, or CARF
• Community Health Accreditation Program Inc., or CHAP
• The Joint Commission, or TJC
• The Substantial Compliant Medicare Site Survey
• Primary practice location in Michigan
• If applicable, verification must include the record of any disciplinary action taken or pending against the applicant.
• Absence of inappropriate utilization practices as identified through proven subscriber complaints, medical necessity audits and peer reviews.
• Absence of fraud and illegal activities.

To obtain a full list of selection standards and a copy of the proposed agreement, email PDN@bcbsm.com. This email address will only be valid through Sept. 30, 2022.

Training
Our dedicated provider training site gives you easy access to recorded webinars, videos, eLearning modules and other training resources. Click here for instructions to register and log in. We recommend using the same email you use to communicate with Blue Cross for provider-related needs. This will become your user ID.

Prior authorization
As a reminder, private duty nursing services will require prior authorization, effective for dates of service beginning Oct. 1, 2022. We’ll begin accepting requests for prior authorization starting Sept. 1, 2022. Prior authorizations will be submitted through e-referral.

For billing and authorization requests, agencies should use S9123 for RN or S9124 for LPN and indicate total hours as units (1 unit = 1 hour).

New emergency line for behavioral health goes live

People struggling with a mental health or substance use crisis — or who are having thoughts of suicide — now have a new number they can use: 988. The number, which went live July 16, 2022, connects to the existing National Suicide Prevention Lifeline.

The move to 988 doesn’t mean the National Suicide Prevention Lifeline number at 1-800-273-8255 goes away. Using either number will get callers to Lifeline’s network of more than 200 locally operated and funded crisis centers across the country. Text (English only) will also be available through 988.

When someone calls or texts 988, they will be responded to by a crisis counselor within a group of Lifeline crisis centers. The counselor will listen, work to understand the problem, provide support and share resources that may be helpful.

“We were pleased to learn that there will be another lifesaving resource to help people in emotional distress who are coping with mental health and substance use issues,” said Dr. Amy McKenzie, Blue Cross Blue Shield of Michigan’s vice president for clinical partnerships and associate chief medical officer.

988 is a shorter, easier-to-remember way to connect to the National Suicide Prevention Lifeline, which has been operational since 2005. Congress and the Federal Communications Commission established the 988 number as part of an effort to strengthen and expand the existing Lifeline, which experienced a significant increase in calls following the onset of the COVID-19 pandemic.

“The COVID-19 pandemic and subsequent lockdowns led to an increase in the number of people struggling with mental health conditions and substance use disorder,” McKenzie explained. “At Blue Cross, we’ve put many new initiatives in place over the past two years to help our members get the support they need, and the federal government has also been focused on addressing the behavioral health crisis, which amplifies the impact across the country.”

She pointed specifically to our behavioral health website, which launched last year as part of our behavioral health member engagement campaign. It provides a wide range of information about mental health and substance use conditions, as well as resources that members can use to address behavioral health concerns.

For more information about 988, see this information** on the Substance Abuse and Mental Health Services Administration website.

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

New collections vendor for FEP claims

Effective July 1, 2022, Blue Cross Blue Shield of Michigan began contracting with a new collections company, GB Collects, for Blue Cross and Blue Shield Federal Employee Program^® claims.
GB Collects handles collections cases that were created on or after July 1. Collections cases that were created on or before June 30 will be handled by Windham Professionals.

As a reminder, we communicated in a provider alert and in a May Record article that GB Collects began handling collections for other Blue Cross commercial claims on April 1, 2022.

GB Collects and Windham Professionals are independent companies that provide collections services for Blue Cross commercial and BCN commercial claims.

HCPCS replacement codes, effective July 1, 2022, established

J0739 replaces C9399 J3490, J3590 and J9999 when billing Apretude (ciltacabtagene autoleucel)

Effective July 1, 2022, the Centers for Medicare and Medicaid Services has established a permanent procedure code for specialty medical drug Apretude (cabotegravir extended-release injectable suspension).

Services can continue to be reported with J3490, J3590, C9399 and J9999 through June 30, 2022. All services performed on and after July 1, 2022, must be reported with J0739.

J1306 replaces C9399 J3490, J3590 and J9999 when billing Leqvio (inclisiran)

Effective July 1, 2022, CMS has established a permanent procedure code for specialty medical drug Leqvio (inclisiran).

Services can continue to be reported with C9399, J3490, J3590 and J9999 through June 30, 2022. All services performed on and after July 1, 2022, must be reported with J1306.

Prior authorization is still required for all groups unless they are opted out of the Specialty Medical Drug Prior Authorization program.

For groups that have opted out of the Medical Benefit Drug Program, this code is covered for its FDA-approved indications.

J1551 replaces J1599, C9399, J3490, J3590 and J9999 when billing Cutaquig (immune globulin subcutaneous [human]-hipp)

Effective July 1, 2022, CMS has established a permanent procedure code for specialty medical drug Cutaquig (immune globulin subcutaneous [human]-hipp).

All services through June 30, 2022, will continue to be reported with code J1599, C9399, J3490, J3590 and J9999.  All services performed on and after July 1, 2022, must be reported with J1551.

Prior authorization is required through the Medical Benefit Drug Program for J1551 for all groups unless they are opted out of the program.

Site-of-care prior authorization is required through the Medical Benefit Drug Program for J1551 for all groups unless they are opted out of the program.

For groups that have opted out of the Medical Benefit Drug Program, this code is covered for its FDA-approved indications.

J2356 replaces C9399, J3490, J3590 and J9999 when billing Tezspire (tezepelumab-ekko)

Effective July 1, 2022, CMS has established a permanent procedure code for specialty medical drug Tezspire (tezepelumab-ekko).

All services through June 30, 2022, will continue to be reported with code C9399, J3490, J3590 and J9999.  All services performed on and after July 1, 2022, must be reported with J2356.

Prior authorization is required through the Medical Benefit Drug Program for J2356 for all groups unless they are opted out of the program.

For groups that have opted out of the Medical Benefit Drug Program, this code is covered for its FDA-approved indications.

J2779 replaces C9093, C9399, J3490, J3590, J9999 when billing Susvimo (ranibizumab injection)

Effective July 1, 2022, CMS has established a permanent procedure code for specialty medical drug Susvimo (ranibizumab injection).

All services through June 30, 2022, will continue to be reported with code C9093, C9399, J3490, J3590 and J9999. All services performed on and after July 1, 2022, must be reported with J2779.

Prior authorization is required through the Medical Benefit Drug Program for J2779 for all groups unless they are opted out of the program.

For groups that have opted out of the Medical Benefit Drug Program, this code is covered for its FDA-approved indications.

J2998 replaces C9090, C9399, J3490, J3590 and J9999 when billing Ryplazim (plasminogen, human-tvmh)

Effective July 1, 2022, CMS has established a permanent procedure code for specialty medical drug Ryplazim (plasminogen, human-tvmh).

All services through June 30, 2022, will continue to be reported with code C9090, C9399, J3490 J3590 and J9999. All services performed on and after July 1, 2022, must be reported with J2998.

Prior authorization is required through the Medical Benefit Drug Program for J2998 for all groups unless they are opted out of the rogram.

For groups that have opted out of the Medical Benefit Drug Program, this code is covered for its FDA-approved indications.

J3299 replaces C9092, C9399, J3490, J3590 and J9999 when billing Xipere (triamcinolone acetonide injectable suspension)

Effective July 1, 2022, CMS has established a permanent procedure code for specialty medical drug Xipere (triamcinolone acetonide injectable suspension).

All services through June 30, 2022, will continue to be reported with code C9092, C9399, J3490, J3590 and J9999. All services performed on and after July 1, 2022, must be reported with J3299.

J9331 replaces C9091, C9399, J3490, J3590 and J9999 when billing Fyarro (sirolimus protein-bound particles for injectable suspension) (albumin-bound)

Effective July 1, 2022, CMS has established a permanent procedure code for specialty medical drug Fyarro (sirolimus protein-bound particles for injectable suspension) (albumin-bound).

All services through June 30, 2022, will continue to be reported with code C9091, C9399, J3490, J3590 and J9999. All services performed on and after July 1, 2022, must be reported with J9331.

J9332 replaces C9399, J3490, J3590 and J9999 when billing Vyvgart (efgartigimod alfa-fcab)

Effective July 1, 2022, CMS has established a permanent procedure code for specialty medical drug Vyvgart (efgartigimod alfa-fcab).

All services through June 30, 2022, will continue to be reported with code C9399, J3490, J3590 and J9999. All services performed on and after July 1, 2022, must be reported with J9332.

Prior authorization is required through the Medical Benefit Drug Program for J9332 for all groups unless they are opted out of the program.

For groups that have opted out of the Medical Benefit Drug Program, this service requires manual review.

Site-of-care prior authorization is required through the Medical Benefit Drug Program for J9332 for all groups unless they are opted out of the program.

HCPCS 2nd-quarter update: New and updated codes

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

Injections

Injections/chemotherapy

Outpatient Prospective Payment System/Injections

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

Billing chart: 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.

None of the information included in this billing chart 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.

CS modifier limited to specific codes that result in COVID-19 testing for commercial plans, effective Sept. 1

To make provider billing practices more uniform, Blue Cross Blue Shield of Michigan and Blue Care Network commercial plans will limit the use of the CS modifier to a list of codes that is similar to the list published by the Centers for Medicare & Medicaid Services on Feb. 4, 2021. This change for our commercial plans will go into effect with dates of service on or after Sept. 1, 2022.

The CS modifier identifies that the services resulted in a COVID-19 test and are subject to the member cost-sharing waiver during the public health emergency.

Effective with dates of service on or after Sept. 1, 2022, for Blue Cross and BCN commercial plans, you should only bill the CS modifier with one of the procedure codes on the Services that result in a COVID-19 test and the CS modifier document. We will only waive member cost share when the CS modifier is billed with one of these codes.

As a reminder, the procedure code may not be eligible for the member cost-sharing waiver if you bill with a diagnosis code that indicates the service was administrative or routine, such as an examination for an employer, school, sports team or research study. Always check the member’s eligibility and benefits.

You should follow CMS guidance for our Medicare Advantage plans, Medicare Plus Blue℠ and BCN Advantage℠. If you submit a CS modifier with a procedure code that’s not allowed by CMS for one of our Medicare Advantage members, the claim will be denied. The latest CMS code list is available as part of this CMS guidance.**

Reminder: These claims are subject to a post-service review (audit).

We’ve updated the COVID-19 patient testing recommendations for physicians document, which can be found on our new provider portal or our public website as follows.

Our provider portal:

Log in to our provider portal (availity.com**) and follow these steps:

1. Click on Payer Spaces in the menu bar.
2. Click on the BCBSM and BCN logo.
3. Click on the Resources tab.
4. Click on Secure Provider Resources (Blue Cross and BCN).
5. Under Easy Access, click on Coronavirus information.

Our public website:

Visit our COVID-19 webpage for health care providers.

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

Reminder: Use modifier 59 and related X modifiers for Medicare Plus Blue claims appropriately

When appending modifier 59 and related X modifiers on Medicare Plus Blue℠ claims, continue to follow the guidelines communicated in the September 2021 Record article. We’ve begun editing claim lines when modifier 59 and related X modifiers are appended on Medicare Plus Blue claims.

Our edits align with the Centers for Medicare & Medicaid Services’ National Correct Coding Initiative, or NCCI, program, and help ensure the correct coding of services. Modifier 59 and related X modifiers are used to indicate that a procedure or service was distinct or independent from other services that aren’t normally reported together but are performed on the same day.

We no longer automatically allow payment for certain procedures billed with modifier 59 and related X modifiers when billed with a procedure code on CMS’ NCCI Procedure‑to‑Procedure coding edits list.** Only select codes allow modifier 59 and related X modifiers to automatically bypass the NCCI code pair edits.

CMS provides more information on the proper use of modifier 59 and  related X modifiers on this Medicare Learning Network Fact Sheet.**

The related X modifiers are defined below:

• XE – “Separate Encounter, a service that is distinct because it occurred during a separate encounter.” Only use XE to describe separate encounters on the same date of service.
• XS – “Separate Structure, a service that is distinct because it was performed on a separate organ/ structure.”
• XP – “Separate Practitioner, a service that is distinct because it was performed by a different practitioner.”
• XU – “Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service.”

The additional review assures 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 American Medical Association and CMS. The reported services should be supported in the patient’s medical record.

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

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

Submit clinical documentation in timely manner for faster Medicare Advantage DME authorizations

For durable medical equipment authorization requests, health care providers must submit all required clinical documentation that supports medical necessity and appropriateness for treatment of the member’s diagnosis. Blue Cross Blue Shield of Michigan and Blue Care Network, or our delegated entity, must receive this information with the request to respond within certain time frames required by the National Committee for Quality Assurance and the Centers for Medicare & Medicaid Services.

Blue Cross and BCN contract with Northwood, Inc. and J&B Medical Supply, independent companies, to manage DME authorizations and diabetic supplies for our Medicare Advantage (Medicare Plus Blue℠ and BCN Advantage℠) members.

Northwood, Inc.

Northwood manages authorizations for DME, prosthetics and orthotics, including diabetic shoes and inserts.

With the prior authorization request, include supporting documentation of medical necessity of the prescribed equipment, including prescriptions and letter or certificate of medical necessity in the medical record.

Contact Northwood at 1-800-393-6432 from 8:30 a.m. to 5 p.m. Eastern time Monday through Friday to submit the request. Northwood will identify a contracted DME supplier. Contracted providers can access the Northwood provider portal for authorization submission using our provider portal, Availity Essentials, by following these steps:

1. Log in to our provider portal (availity.com**).
2. Click on Payer Spaces from the Availity^® menu bar.
3. Click on the BCBSM and BCN logo.
4. Click on the Applications tab and scroll down to the Northwood Provider Portal.

J&B Medical Supply

J&B Medical Supply manages authorizations for continuous glucose monitors, insulin pumps and supplies, test strips (if quantity is over standard parameter).

When submitting requests for the supplies listed above, include the following criteria in the medical record:

• Evidence the member has diabetes
• A dated and signed standard written order containing the following:
• Prescribing physician's name, address and telephone number
• Patient's name, address and date of birth
• Diagnosis related to the services or items provided
• Detailed description of the patient's condition to substantiate the necessity for services or items
• Description and quantity of all items, accessories and options ordered
• Estimated duration of need and frequency of use
• Physician's written signature and date. (We don’t accept stamps. Electronic prescriptions are acceptable but must adhere to all privacy, security and electronic signature rules.)

Note: We can’t accept "PRN" (Latin for pro re nata, or as the situation demands) or "as needed" as estimates for supply replacement, use or consumption

• Supporting documentation that the member or caregiver has the necessary training on the diabetic supply or device, met by the standard written order
• Supporting evidence that the member meets Medicare’s Local Coverage Determination for continuous glucose monitoring and/or insulin pumps and supplies 

To request higher quantities of test strips and lancets, include the following documentation:

• Evidence of the member’s in-person practitioner visit to evaluate his or her diabetes control within six months before submitting the request
• Supporting evidence that the member needs a supply quantity that exceeds the usual amount
• Verification every six months that the member’s adherence to a high-use testing regimen requires prescribing quantities that exceed the usual amount

Submit information to J&B Medical Supply by one of the methods below:

• Email: ProviderServices@jandbmedical.com
• Fax: 1-248-255-0157
• Phone: 1-888-896-6233 Monday through Friday from 8 a.m. to 5 p.m. Eastern time

The J&B Medical Supply provider portal is currently in the process of development.

Out-of-state providers

Bill claims for Medicare Plus Blue and BCN Advantage members traveling or residing outside of Michigan through the nationwide network of Blue plan providers via the Blue Cross and Blue Shield Association.

For more information about utilization management, refer to our provider manuals:

• Medicare Plus Blue PPO Provider Manual
• “BCN Advantage” chapter in the BCN Provider Manual (accessed from our e-referral website)

Requirements changed for some commercial medical benefit drugs

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

From March through June 2022, we added prior authorization requirements, site-of-care requirements or both for Blue Cross commercial and BCN commercial members for the following medical benefit drugs:

For additional details, 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:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

As a reminder, an authorization approval isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.

Additional information
For Blue Cross commercial groups, this authorization requirement applies only to groups that currently participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list. A link to this list is also available on the Blue Cross Medical Benefit Drugs page of the ereferrals.bcbsm.com website.

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.

Oxlumo to have site-of-care requirement for commercial members beginning in October

Starting Oct. 1, 2022, Oxlumo^® (lumarisan), HCPCS code J0224, will have a site-of-care requirement for Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members.

When the site-of-care requirement goes into effect, this drug may be covered only when administered at the following sites of care:

• Doctor’s or other health care provider’s office
• Ambulatory infusion center
• The member's home, from a home infusion therapy provider

As a reminder, this drug already requires prior authorization; providers can submit prior authorization requests using the NovoLogix^® online tool. The new site-of-care requirement is in addition to the current prior authorization requirement.

Members who start treatment before Oct. 1, 2022, will be able to continue receiving the drug in their current location until their existing authorization expires. Providers should then transition members to one of the above sites of care.

Note: This drug is part of members’ medical benefits, not their pharmacy benefits.

Some Blue Cross commercial groups not subject to these requirements

For Blue Cross commercial groups, this authorization requirement applies only to groups that currently participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list.

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.

List of requirements

For a full list of requirements related to drugs covered under the medical benefit, see the Blue Cross and BCN utilization management medical drug list for Blue Cross commercial and BCN commercial members. We’ll update this list prior to Oct. 1.

You can access this list and other information about requesting prior authorization at ereferrals.bcbsm.com, at these locations:

• Blue Cross Medical Benefit Drugs page
• BCN Medical Benefit Drugs page

As always, authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

Blue Cross, BCN covering additional vaccine

To increase access to vaccines and decrease the risk of vaccine-preventable disease outbreaks, Blue Cross Blue Shield of Michigan and Blue Care Network will add the following vaccine to our list of vaccines covered under the pharmacy benefit:

The following table lists all the vaccines that are covered under eligible members’ prescription drug plans. Most Blue Cross and BCN commercial (non-Medicare) members with prescription drug coverage are eligible. If a member meets the coverage criteria, the vaccine is covered with no cost sharing.

If a member doesn’t meet the age requirement for a vaccine, Blue Cross and BCN won’t cover the vaccine under the prescription drug plan, and the claim will reject.

Vaccines must be administered by certified, trained and qualified registered pharmacists.

We’re updating our HEDIS and Star tip sheets for 2022

Each year, we update our HEDIS and Star measure tip sheets, which are then posted on the Clinical Quality area of our provider portal.

The Star tip sheets were updated and posted earlier this year on the Clinical Quality section of availity.com.** We recently made additional revisions to the following six:

• Advanced Illness and Frailty Guide
• Colorectal Cancer Screening (COL)
• Hemoglobin A1c Control for Patients with Diabetes (HBD)
• Statin Therapy for Patients with Cardiovascular Disease (SPC)
• Statin use in persons with diabetes (SUPD)
• Transitions of Care (TRC)

Virtual Care Summary
The Virtual Care Summary (previously known as the Telehealth Summary) has also been updated for 2022 and is available on the Clinical Quality section of availity.com.**

HEDIS tip sheets
Updates to our HEDIS^® tip sheets are currently in process, and we’ll let you know as soon as they’re finalized and posted.

More about our tip sheets

• HEDIS^® tip sheets are developed to assist health care providers and their staff in efforts to improve overall health care quality and prevent or control diseases and chronic conditions. HEDIS^® is one of the most widely used performance improvement tools in the U.S.
• Star tip sheetshighlight select measures in the Medicare Star Ratings program. Most of the measures featured in our Star tip sheetsare also HEDIS measures.

Accessing the tip sheets
Tip sheets are housed on the Clinical Quality page of Availity. You can get there by following these steps:

1. Log in to our provider portal (availity.com**).
2. Click on Payer Spaces on the Availity menu bar.
3. Click on the BCBSM and BCN logo.
4. Click on Secure Provider Resources (Blue Cross and BCN) on the Resources tab.
5. Click on Clinical Quality under the Member Care tab.

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

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

Lunch and learn webinars focus on risk adjustment, coding

Physicians and coders are invited to attend webinars that provide new information on documentation and coding of common and challenging diagnoses. These live lunchtime educational sessions will include an opportunity to ask questions.

Current schedule
All sessions start at noon Eastern time and generally run for 30 minutes. Click on a link below to sign up.

You can watch previously hosted sessions on our provider training website. Use the keyword “Lunch” to search for the courses. You’ll also find them listed in the Quality management section of the course catalog.

Click here if you are already registered for the site.

To request access to the provider training website:

1. Click here to register.   
2. Complete the registration. We recommend using the same email you use to communicate with Blue Cross Blue Shield of Michigan for other provider-related needs. This will become your login ID.

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

New on-demand training available

Provider Experience continues to offer training resources for health care providers and staff. On-demand courses are designed to help you work more efficiently with Blue Cross Blue Shield of Michigan and Blue Care Network.

We recently added the following new learning opportunities:

• NDC billing for medical drug benefits: The eLearning module will give an overview of National Drug Code for medical drug benefits, explain NDC billing requirements and how to fill out professional paper and electronic claims for NDC payment.
• Training and resources guide for private duty nursing: This document serves as a quick guide to training and resources available for private duty nurses who join our network.

Our provider training site is available to enhance the training experience for health care providers and staff.
To request access, follow these 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 this link to log in.

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

Here are resources to promote flu vaccination and educate patients about avoiding antibiotic use for acute bronchitis

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

To support health care providers in protecting their patients against influenza and educating them on why antibiotics aren’t used for acute bronchitis treatment, the Centers for Disease Control and Prevention provides these resources to share with patients:  

• HCP Fight Flu Toolkit**
• Preventing and Treating Bronchitis**

The CDC also provides health care professionals with:

• Educational resources, including handouts, videos and window clings**
• Continuing education and informational resources for providers**

For benefit information, providers and Federal Employee Program^® members can call Customer Service at 1-800-482-3600 or go online to fepblue.org.

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

Keep your Provider Authorization form updated

Blue Cross Blue Shield of Michigan is dedicated to safeguarding the protected health information of its members. These safeguards include completion of Trading Partner Agreement and Provider Authorization form as part of the electronic data interchange setup process. All EDI trading partners must complete the TPA and Provider Authorization form before they can exchange PHI with Blue Cross.

The terms of the TPA require you to notify Blue Cross of any changes in your trading partner information, so it’s important to keep your Provider Authorization form up to date. Updating the form also ensures information is routed to the proper destination.

Update the form when you:

• Change service bureaus or clearinghouses
• Change software vendors
• Change billing services
• Change submitter IDs
• Change 835-file recipients
• Change unique 835 receivers or Trading Partner IDs
• Decide you no longer want to receive 835 remittance files

Review the form when you:

• Join a new group practice
• Leave a group practice and start billing using your own NPI
• Hire a new billing service
• Start submitting claims through a clearinghouse or change clearinghouses
• Select a new destination for your 835

You don’t need to update the Provider Authorization form if your submitter and trading partner IDs don’t change.

How to change your EDI setup

To make changes to your EDI setup, log in to the Trading Partner Agreement webpage. 

Or follow the complete navigation steps to arrive at the TPA login page at bcbsm.com/providers/help/edi:

1. Visit bcbsm.com/providers.
2. Click on Help.
3. Scroll to the Provider online tools section and click on How do I sign up for Electronic Data Interchange?
4. Click on Trading Partner Agreements.
5. Click on Complete or Update a Provider Authorization.

If you have any questions about EDI enrollment, email the EDI Help Desk at EDISupport@bcbsm.com. Include your billing NPI and submitter ID with all correspondence.

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

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

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

About concierge medicine

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

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

Policy information

Blue Cross’ concierge medicine policy states:

“Health care practitioners who wish to use this model in their practice may not be eligible for any value-based reimbursement (VBR) opportunities through Blue Cross and Blue Care Network (BCN) programs such as, but not limited to, Physician Group Incentive Program-related VBR opportunities through the Patient-Centered Medical Home (PCMH) designation program or other programs.”

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

Providers may charge a concierge fee if:

• Blue Cross and BCN members aren’t required to pay the concierge fee to become or continue to be a patient in the practice.
• Blue Cross and BCN members aren’t required to pay the concierge fee to obtain access to the provider. Blue Cross members who don’t pay the concierge fee may not be restricted to access only to ancillary providers, such as physician assistants or nurse practitioners. 
• The services or products being offered as part of the concierge fee aren’t considered covered services as defined under our affiliation agreements or the member’s benefit plan. Because benefit structures vary significantly among our members, providers are expected to understand each member’s benefit structure to ensure that covered services are not included in the concierge fee.
• Blue Cross and BCN members who don’t pay the concierge fee continue to receive the same level of access and services as they previously received.
• Providers continue to meet Blue Cross and BCN performance standards regarding access and service.

The concierge level of service is clearly over and above usual practice in Michigan. Complaints from members who experience a decline in service level may result in Blue Cross concluding that the practice is noncompliant with the nondiscrimination clause of our affiliation agreements.

Blue Cross professional providers may get new messages regarding medical drug claims for commercial members

Starting in October, Blue Cross Blue Shield of Michigan professional providers may receive a new informational message when a medical drug claim line is billed incorrectly as it relates to the National Drug Code or the HCPCS code. For example, we may have determined that:

• Reimbursement should be at the HCPCS level.
• Reimbursement should be at the HCPCS level and the HCPCS units billed were over our daily quantity maximum.
• Reimbursement should be at the NDC level and the NDC units billed were over our daily quantity maximum.

Following is a look at the messages and when you may receive them.

When a National Drug Code is billed with an incorrect HCPCS combination or unit conversion, you’ll receive this new message on your provider voucher:

WE WERE NOT ABLE TO MATCH THE HCPCS AND NDC TO EACH OTHER OR CONVERT THE NDC UNITS TO THE HCPCS UNITS BILLED. WHEN BILLING MEDICAL DRUG CLAIMS, REPORT THE NDC AND NDC UNITS THAT ARE APPROPRIATE TO THE HCPCS AND HCPCS UNITS BILLED, OTHERWISE REIMBURSEMENT MAY NOT BE AT THE LEVEL YOU EXPECTED. (P660)

When a National Drug Code is billed with an incorrect HCPCS combination or unit conversion and the NDC unit reaches or exceeds its daily quantity maximum, you’ll receive a new message on your provider voucher:

THE NDC UNITS AND HCPCS UNITS SUPPLIED, BASED ON OUR CALCULATIONS, ARE NOT A MATCH. WHEN BILLING MEDICAL DRUG CLAIMS, REPORT THE NDC AND NDC UNITS THAT ARE APPROPRIATE TO THE HCPCS AND HCPCS UNITS BILLED, OTHERWISE REIMBURSEMENT MAY NOT BE AT THE LEVEL YOU EXPECTED. THIS DRUG CLAIM HAS A NDC QUANTITY THAT'S MORE THAN WE CAN PAY. WE BASED OUR PAYMENT, AND THE MEMBER'S LIABILITY, ON THE AMOUNT FOR THE ELIGIBLE LIMIT. A PARTICIPATING PROVIDER SHOULD NOT ASK THE MEMBER TO PAY MORE THAN THE AMOUNT WE ALLOWED. WHEN OTHER PROVIDERS PERFORM THIS SERVICE, THE MEMBER MIGHT OWE ANY AMOUNT NOT PAID BY THE HEALTH CARE PLAN.  (P667)

When a National Drug Code is billed with an incorrect HCPCS combination or unit conversion and the HCPCS unit reaches or exceeds its daily quantity maximum, you’ll receive a new message on your provider voucher:

WE WERE NOT ABLE TO MATCH THE HCPCS AND NDC TO EACH OTHER. PLEASE CHECK TO MAKE SURE THE NDC CODE IS APPROPRIATE FOR THE HCPCS BILLED AND THE UNITS FOR EACH ARE CORRECT, OTHERWISE REIMBURSEMENT MAY NOT BE AT THE LEVEL YOU EXPECTED. THIS DRUG CLAIM HAS A HCPCS QUANTITY THAT'S MORE THAN WE CAN PAY. WE BASED OUR PAYMENT, AND THE MEMBER'S LIABILITY, ON THE AMOUNT FOR THE ELIGIBLE LIMIT. A PARTICIPATING PROVIDER SHOULD NOT ASK THE MEMBER TO PAY MORE THAN THE AMOUNT WE ALLOWED. WHEN OTHER PROVIDERS PERFORM THIS SERVICE, THE MEMBER MIGHT OWE ANY AMOUNT NOT PAID BY THE HEALTH CARE PLAN.  (P668)

These messages don’t apply to outpatient hospital providers because these providers aren't required to submit claims at the NDC level unless they’re submitting a Not Otherwise Classified Code.

Post-acute care providers need direct access to naviHealth’s provider portal

The way post-acute care providers access naviHealth’s provider portal, nH Access, is changing with Blue Cross Blue Shield of Michigan and Blue Care Network’s transition to Availity Essentials. Post-acute care providers will need direct access to nH Access.

Current method of entering the nH Access portal

In Blue Cross and BCN’s Provider Secured Services, you can click on the Medicare Advantage Post-Acute Care Authorization link and type in your NPI to enter nH Access. This method of access ends when Provider Secured Services retires.

New method of entering the nH Access portal

Here are the steps you’ll use after logging in to Availity Essentials:

1. Click on Payer Spaces in the Availity^® menu bar.
2. Click on the BCBSM and BCN logo.
3. Click on naviHealth Provider Portal.

This will take you to a login screen where you’ll need to type in your email address and password. You can also access this login screen outside of Availity by going to access.navihealth.com.**

Either way, if you don’t already have a naviHealth nH Access account, you’ll need one. To register for direct access to naviHealth’s nH Access portal, go to partners.navihealth.com/partner/nh-access** and scroll to the nH Access – Setting Up Your Account section. Follow the instructions in the Account Creation Guide.

After naviHealth creates your account, you’ll receive an email from naviHealth with instructions on how to log in.

While you’re waiting to get direct access to naviHealth’s nH Access, you may submit authorization requests to naviHealth by faxing them to 1-844-899-3730 or calling 1-855-851-0843.

If you have any questions about nH Access, call naviHealth at 1-888-276-5777. Go to nH Access Fundamentals** for nH Access training.

Background information

Post-acute care admission authorizations for Blue Cross and BCN’s Medicare Advantage plans (Medicare Plus Blue℠ and BCN Advantage℠) are managed by naviHealth through nH Access™. Providers involved in post-acute care include skilled nursing, rehabilitation and long-term care facilities as well as acute care hospitals.

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

DRG clinical validation audits will begin in September for Medicare Plus Blue claims

EXL, an independent company that provides auditing support for Blue Cross Blue Shield of Michigan, will perform clinical validation and coding claim audits for Medicare Plus Blue℠ claims on inpatient hospital diagnosis‑related groups, or DRGs, beginning in September 2022.

The audits will review medical records to ensure claims were billed in accordance with coding guidelines and diagnoses were supported by documentation in the medical record. 

Be ready to share medical charts for review at the time of an audit. After an audit, EXL will send you a letter with the findings and information on how to request an appeal, if necessary.

The purpose of the clinical DRG audit is to:

• Confirm compliance with national coding guidelines.
• Ensure documentation supports diagnoses and procedures reported.
• Detect, prevent and correct waste and abuse.
• Facilitate accurate claim payment.

Questions?
Call EXL’s Customer Service number at 1-833-717-0378 if you have any questions.

CS modifier limited to specific codes that result in COVID-19 testing for commercial plans, effective Sept. 1

To make provider billing practices more uniform, Blue Cross Blue Shield of Michigan and Blue Care Network commercial plans will limit the use of the CS modifier to a list of codes that is similar to the list published by the Centers for Medicare & Medicaid Services on Feb. 4, 2021. This change for our commercial plans will go into effect with dates of service on or after Sept. 1, 2022.

The CS modifier identifies that the services resulted in a COVID-19 test and are subject to the member cost-sharing waiver during the public health emergency.

Effective with dates of service on or after Sept. 1, 2022, for Blue Cross and BCN commercial plans, you should only bill the CS modifier with one of the procedure codes on the Services that result in a COVID-19 test and the CS modifier document. We will only waive member cost share when the CS modifier is billed with one of these codes.

As a reminder, the procedure code may not be eligible for the member cost-sharing waiver if you bill with a diagnosis code that indicates the service was administrative or routine, such as an examination for an employer, school, sports team or research study. Always check the member’s eligibility and benefits.

You should follow CMS guidance for our Medicare Advantage plans, Medicare Plus Blue℠ and BCN Advantage℠. If you submit a CS modifier with a procedure code that’s not allowed by CMS for one of our Medicare Advantage members, the claim will be denied. The latest CMS code list is available as part of this CMS guidance.**

Reminder: These claims are subject to a post-service review (audit).

We’ve updated the COVID-19 patient testing recommendations for physicians document, which can be found on our new provider portal or our public website as follows.

Our provider portal:

Log in to our provider portal (availity.com**) and follow these steps:

1. Click on Payer Spaces in the menu bar.
2. Click on the BCBSM and BCN logo.
3. Click on the Resources tab.
4. Click on Secure Provider Resources (Blue Cross and BCN).
5. Under Easy Access, click on Coronavirus information.

Our public website:

Visit our COVID-19 webpage for health care providers.

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

Improved process for prior authorization requests for initial SNF stays for Medicare Advantage members

Effective Sept. 21, 2022, naviHealth Inc. will add a new tool — the nH Access authorization wizard — to the nH Access portal for Medicare Plus Blue℠ and BCN Advantage℠ members.

When submitting prior authorization requests for initial skilled nursing facility stays for Medicare Plus Blue and BCN Advantage members, health care providers will be able to submit additional clinical details about members’ current needs and abilities through the wizard. The additional information will expedite the review process, resulting in faster authorization determinations and more timely transitions to the next level of care.

To learn more about the nH Access authorization wizard, go to naviHealth’s Partner Resources page** where you’ll find a video tutorial, an FAQ document and a resource guide.

Note: If you haven’t already done so, you’ll have to register for access to naviHealth’s Partner Resources Page.**

If you have questions about this change, contact your local naviHealth provider relations manager. If you aren’t sure who your naviHealth provider relations manager is, send an email to umproviderconcerns@bcbsm.com.

naviHealth Inc. is an independent company that manages authorizations for post-acute care services for Blue Cross Blue Shield of Michigan and Blue Care Network members who have Medicare Advantage plans. To learn more, see Post-acute care services: Frequently asked questions for providers.

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

Requirements changed for some commercial medical benefit drugs

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

From March through June 2022, we added prior authorization requirements, site-of-care requirements or both for Blue Cross commercial and BCN commercial members for the following medical benefit drugs:

For additional details, 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:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

As a reminder, an authorization approval isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.

Additional information
For Blue Cross commercial groups, this authorization requirement applies only to groups that currently participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list. A link to this list is also available on the Blue Cross Medical Benefit Drugs page of the ereferrals.bcbsm.com website.

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.

Here are updated guidelines for billing self-administered medications provided in outpatient facilities

When a Medicare Advantage member is receiving services in an outpatient facility but hasn’t brought their self-administered medications with them, here are some guidelines for what to do and what not to do.

These guidelines include and expand on information we provided in earlier communications.

What to do

Here are steps to follow:

1. Obtain the medication through the onsite ambulatory pharmacy, not from the inpatient pharmacy.
2. Administer it to the member.
3. Have the onsite ambulatory pharmacy do the following:
• Deliver the medication to the patient’s bedside.
• Bill for the medication under the member’s Medicare Part D pharmacy benefits.

The member is responsible for the copayment amount.

What not to do

We ask that you avoid obtaining the medication through the inpatient pharmacy and billing for the medication on the facility bill under Medicare Part B. Here’s why: When outpatient facilities administer and bill self-administered medications through Medicare Part B, the claims will be denied as not payable. The member has to seek direct reimbursement for the expenses they incur during the outpatient stay.

Questions and answers

Here are the answers to some questions we received following an earlier communication on this topic.

Which drugs are considered self-administered?

The Centers for Medicare & Medicaid Services, not Blue Cross or BCN, determines which drugs are self-administered. Refer to CMS’ Self-Administered Drug Exclusion List (SAD List).**

Can outpatient facilities bill the self-administered drug on the facility bill?

• If the outpatient facility has an onsite ambulatory pharmacy, that pharmacy should bring the drug to the bedside and bill it to the member’s Part D benefits. The member pays the copayment.
• If the outpatient facility doesn’t have an onsite ambulatory pharmacy, the facility should obtain the drug from the inpatient pharmacy and bill it using revenue code 0637 (self-administered drugs). This claim will be denied for beneficiary responsibility under the member’s Part B medical benefits and the provider can bill the member for the item on that line. The member can use the bill they receive to seek reimbursement directly through their Part D plan.

Do Medicare Plus Blue℠ and BCN Advantage℠ handle facility claims submitted with revenue code 0637 differently?

Both Medicare Plus Blue and BCN Advantage handle these claims the same way:

• Medicare Plus Blue denies facility claims submitted with revenue code 0637 under the member’s Part B medical benefits. The member should seek reimbursement under their Part D benefits.
• Earlier this year, BCN Advantage updated its claims system to deny the service billed with revenue code 0637 and tell the member: “This service is not a payable Part B benefit; please consult your Part D benefits to seek any reimbursements. The patient is responsible.”

Which members the information in this article applies to

This information applies to our Medicare Advantage (Medicare Plus Blue and BCN Advantage) members during their outpatient stays. It doesn’t apply to Blue Cross Blue Shield of Michigan and Blue Care Network commercial members.

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

Oxlumo to have site-of-care requirement for commercial members beginning in October

Starting Oct. 1, 2022, Oxlumo^® (lumarisan), HCPCS code J0224, will have a site-of-care requirement for Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members.

When the site-of-care requirement goes into effect, this drug may be covered only when administered at the following sites of care:

• Doctor’s or other health care provider’s office
• Ambulatory infusion center
• The member's home, from a home infusion therapy provider

As a reminder, this drug already requires prior authorization; providers can submit prior authorization requests using the NovoLogix^® online tool. The new site-of-care requirement is in addition to the current prior authorization requirement.

Members who start treatment before Oct. 1, 2022, will be able to continue receiving the drug in their current location until their existing authorization expires. Providers should then transition members to one of the above sites of care.

Note: This drug is part of members’ medical benefits, not their pharmacy benefits.

Some Blue Cross commercial groups not subject to these requirements

For Blue Cross commercial groups, this authorization requirement applies only to groups that currently participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list.

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.

List of requirements

For a full list of requirements related to drugs covered under the medical benefit, see the Blue Cross and BCN utilization management medical drug list for Blue Cross commercial and BCN commercial members. We’ll update this list prior to Oct. 1.

You can access this list and other information about requesting prior authorization at ereferrals.bcbsm.com, at these locations:

• Blue Cross Medical Benefit Drugs page
• BCN Medical Benefit Drugs page

As always, authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

Lunch and learn webinars focus on risk adjustment, coding

Physicians and coders are invited to attend webinars that provide new information on documentation and coding of common and challenging diagnoses. These live lunchtime educational sessions will include an opportunity to ask questions.

Current schedule
All sessions start at noon Eastern time and generally run for 30 minutes. Click on a link below to sign up.

You can watch previously hosted sessions on our provider training website. Use the keyword “Lunch” to search for the courses. You’ll also find them listed in the Quality management section of the course catalog.

Click here if you are already registered for the site.

To request access to the provider training website:

1. Click here to register.   
2. Complete the registration. We recommend using the same email you use to communicate with Blue Cross Blue Shield of Michigan for other provider-related needs. This will become your login ID.

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

Keep your Provider Authorization form updated

Blue Cross Blue Shield of Michigan is dedicated to safeguarding the protected health information of its members. These safeguards include completion of Trading Partner Agreement and Provider Authorization form as part of the electronic data interchange setup process. All EDI trading partners must complete the TPA and Provider Authorization form before they can exchange PHI with Blue Cross.

The terms of the TPA require you to notify Blue Cross of any changes in your trading partner information, so it’s important to keep your Provider Authorization form up to date. Updating the form also ensures information is routed to the proper destination.

Update the form when you:

• Change service bureaus or clearinghouses
• Change software vendors
• Change billing services
• Change submitter IDs
• Change 835-file recipients
• Change unique 835 receivers or Trading Partner IDs
• Decide you no longer want to receive 835 remittance files

Review the form when you:

• Join a new group practice
• Leave a group practice and start billing using your own NPI
• Hire a new billing service
• Start submitting claims through a clearinghouse or change clearinghouses
• Select a new destination for your 835

You don’t need to update the Provider Authorization form if your submitter and trading partner IDs don’t change.

How to change your EDI setup

To make changes to your EDI setup, log in to the Trading Partner Agreement webpage. 

Or follow the complete navigation steps to arrive at the TPA login page at bcbsm.com/providers/help/edi:

1. Visit bcbsm.com/providers.
2. Click on Help.
3. Scroll to the Provider online tools section and click on How do I sign up for Electronic Data Interchange?
4. Click on Trading Partner Agreements.
5. Click on Complete or Update a Provider Authorization.

If you have any questions about EDI enrollment, email the EDI Help Desk at EDISupport@bcbsm.com. Include your billing NPI and submitter ID with all correspondence.

Requirements changed for some commercial medical benefit drugs

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

From March through June 2022, we added prior authorization requirements, site-of-care requirements or both for Blue Cross commercial and BCN commercial members for the following medical benefit drugs:

For additional details, 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:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

As a reminder, an authorization approval isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.

Additional information
For Blue Cross commercial groups, this authorization requirement applies only to groups that currently participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list. A link to this list is also available on the Blue Cross Medical Benefit Drugs page of the ereferrals.bcbsm.com website.

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.

Here are updated guidelines for billing self-administered medications provided in outpatient facilities

When a Medicare Advantage member is receiving services in an outpatient facility but hasn’t brought their self-administered medications with them, here are some guidelines for what to do and what not to do.

These guidelines include and expand on information we provided in earlier communications.

What to do

Here are steps to follow:

1. Obtain the medication through the onsite ambulatory pharmacy, not from the inpatient pharmacy.
2. Administer it to the member.
3. Have the onsite ambulatory pharmacy do the following:
• Deliver the medication to the patient’s bedside.
• Bill for the medication under the member’s Medicare Part D pharmacy benefits.

The member is responsible for the copayment amount.

What not to do

We ask that you avoid obtaining the medication through the inpatient pharmacy and billing for the medication on the facility bill under Medicare Part B. Here’s why: When outpatient facilities administer and bill self-administered medications through Medicare Part B, the claims will be denied as not payable. The member has to seek direct reimbursement for the expenses they incur during the outpatient stay.

Questions and answers

Here are the answers to some questions we received following an earlier communication on this topic.

Which drugs are considered self-administered?

The Centers for Medicare & Medicaid Services, not Blue Cross or BCN, determines which drugs are self-administered. Refer to CMS’ Self-Administered Drug Exclusion List (SAD List).**

Can outpatient facilities bill the self-administered drug on the facility bill?

• If the outpatient facility has an onsite ambulatory pharmacy, that pharmacy should bring the drug to the bedside and bill it to the member’s Part D benefits. The member pays the copayment.
• If the outpatient facility doesn’t have an onsite ambulatory pharmacy, the facility should obtain the drug from the inpatient pharmacy and bill it using revenue code 0637 (self-administered drugs). This claim will be denied for beneficiary responsibility under the member’s Part B medical benefits and the provider can bill the member for the item on that line. The member can use the bill they receive to seek reimbursement directly through their Part D plan.

Do Medicare Plus Blue℠ and BCN Advantage℠ handle facility claims submitted with revenue code 0637 differently?

Both Medicare Plus Blue and BCN Advantage handle these claims the same way:

• Medicare Plus Blue denies facility claims submitted with revenue code 0637 under the member’s Part B medical benefits. The member should seek reimbursement under their Part D benefits.
• Earlier this year, BCN Advantage updated its claims system to deny the service billed with revenue code 0637 and tell the member: “This service is not a payable Part B benefit; please consult your Part D benefits to seek any reimbursements. The patient is responsible.”

Which members the information in this article applies to

This information applies to our Medicare Advantage (Medicare Plus Blue and BCN Advantage) members during their outpatient stays. It doesn’t apply to Blue Cross Blue Shield of Michigan and Blue Care Network commercial members.

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

Oxlumo to have site-of-care requirement for commercial members beginning in October

Starting Oct. 1, 2022, Oxlumo^® (lumarisan), HCPCS code J0224, will have a site-of-care requirement for Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members.

When the site-of-care requirement goes into effect, this drug may be covered only when administered at the following sites of care:

• Doctor’s or other health care provider’s office
• Ambulatory infusion center
• The member's home, from a home infusion therapy provider

As a reminder, this drug already requires prior authorization; providers can submit prior authorization requests using the NovoLogix^® online tool. The new site-of-care requirement is in addition to the current prior authorization requirement.

Members who start treatment before Oct. 1, 2022, will be able to continue receiving the drug in their current location until their existing authorization expires. Providers should then transition members to one of the above sites of care.

Note: This drug is part of members’ medical benefits, not their pharmacy benefits.

Some Blue Cross commercial groups not subject to these requirements

For Blue Cross commercial groups, this authorization requirement applies only to groups that currently participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list.

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.

List of requirements

For a full list of requirements related to drugs covered under the medical benefit, see the Blue Cross and BCN utilization management medical drug list for Blue Cross commercial and BCN commercial members. We’ll update this list prior to Oct. 1.

You can access this list and other information about requesting prior authorization at ereferrals.bcbsm.com, at these locations:

• Blue Cross Medical Benefit Drugs page
• BCN Medical Benefit Drugs page

As always, authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

Blue Cross, BCN covering additional vaccine

To increase access to vaccines and decrease the risk of vaccine-preventable disease outbreaks, Blue Cross Blue Shield of Michigan and Blue Care Network will add the following vaccine to our list of vaccines covered under the pharmacy benefit:

The following table lists all the vaccines that are covered under eligible members’ prescription drug plans. Most Blue Cross and BCN commercial (non-Medicare) members with prescription drug coverage are eligible. If a member meets the coverage criteria, the vaccine is covered with no cost sharing.

If a member doesn’t meet the age requirement for a vaccine, Blue Cross and BCN won’t cover the vaccine under the prescription drug plan, and the claim will reject.

Vaccines must be administered by certified, trained and qualified registered pharmacists.

Submit clinical documentation in timely manner for faster Medicare Advantage DME authorizations

For durable medical equipment authorization requests, health care providers must submit all required clinical documentation that supports medical necessity and appropriateness for treatment of the member’s diagnosis. Blue Cross Blue Shield of Michigan and Blue Care Network, or our delegated entity, must receive this information with the request to respond within certain time frames required by the National Committee for Quality Assurance and the Centers for Medicare & Medicaid Services.

Blue Cross and BCN contract with Northwood, Inc. and J&B Medical Supply, independent companies, to manage DME authorizations and diabetic supplies for our Medicare Advantage (Medicare Plus Blue℠ and BCN Advantage℠) members.

Northwood, Inc.

Northwood manages authorizations for DME, prosthetics and orthotics, including diabetic shoes and inserts.

With the prior authorization request, include supporting documentation of medical necessity of the prescribed equipment, including prescriptions and letter or certificate of medical necessity in the medical record.

Contact Northwood at 1-800-393-6432 from 8:30 a.m. to 5 p.m. Eastern time Monday through Friday to submit the request. Northwood will identify a contracted DME supplier. Contracted providers can access the Northwood provider portal for authorization submission using our provider portal, Availity Essentials, by following these steps:

1. Log in to our provider portal (availity.com**).
2. Click on Payer Spaces from the Availity^® menu bar.
3. Click on the BCBSM and BCN logo.
4. Click on the Applications tab and scroll down to the Northwood Provider Portal.

J&B Medical Supply

J&B Medical Supply manages authorizations for continuous glucose monitors, insulin pumps and supplies, test strips (if quantity is over standard parameter).

When submitting requests for the supplies listed above, include the following criteria in the medical record:

• Evidence the member has diabetes
• A dated and signed standard written order containing the following:
• Prescribing physician's name, address and telephone number
• Patient's name, address and date of birth
• Diagnosis related to the services or items provided
• Detailed description of the patient's condition to substantiate the necessity for services or items
• Description and quantity of all items, accessories and options ordered
• Estimated duration of need and frequency of use
• Physician's written signature and date. (We don’t accept stamps. Electronic prescriptions are acceptable but must adhere to all privacy, security and electronic signature rules.)

Note: We can’t accept "PRN" (Latin for pro re nata, or as the situation demands) or "as needed" as estimates for supply replacement, use or consumption

• Supporting documentation that the member or caregiver has the necessary training on the diabetic supply or device, met by the standard written order
• Supporting evidence that the member meets Medicare’s Local Coverage Determination for continuous glucose monitoring and/or insulin pumps and supplies 

To request higher quantities of test strips and lancets, include the following documentation:

• Evidence of the member’s in-person practitioner visit to evaluate his or her diabetes control within six months before submitting the request
• Supporting evidence that the member needs a supply quantity that exceeds the usual amount
• Verification every six months that the member’s adherence to a high-use testing regimen requires prescribing quantities that exceed the usual amount

Submit information to J&B Medical Supply by one of the methods below:

• Email: ProviderServices@jandbmedical.com
• Fax: 1-248-255-0157
• Phone: 1-888-896-6233 Monday through Friday from 8 a.m. to 5 p.m. Eastern time

The J&B Medical Supply provider portal is currently in the process of development.

Out-of-state providers

Bill claims for Medicare Plus Blue and BCN Advantage members traveling or residing outside of Michigan through the nationwide network of Blue plan providers via the Blue Cross and Blue Shield Association.

For more information about utilization management, refer to our provider manuals:

• Medicare Plus Blue PPO Provider Manual
• “BCN Advantage” chapter in the BCN Provider Manual (accessed from our e-referral website)