Farewell, web-DENIS; hello, Availity Essentials

As we announced in the November issue, beginning Dec. 16, you’ll no longer be able to log in to Provider Secured Services or web-DENIS.

If you’re new to Availity^® Essentials or if you’d like to brush up on how to best use the tools in our new provider portal, you can register for webinars and view recordings of prior webinars on the Get Up to Speed with Training** website.

Tip: When you need help using our new provider portal, your first step should be to call 1-800-AVAILITY (282-4548). Help is available from 8 a.m. to 8 p.m. Eastern time, Monday through Friday (excluding holidays). When you call, ask for an Availity Client Services, or ACS, ticket number. This number is helpful if the call doesn’t resolve your problem and follow-up assistance is needed.

Want to know what’s new on our provider portal?

Check out the Provider Portal Change and Status Updates document for new provider portal improvements, features and functionality, and issues we’re working to address. Here’s how to find it:

1. Log in to our provider portal (availity.com**).
2. Click on Payer Spaces on the menu bar, and then click on the BCBSM and BCN logo.
3. Click on the News and Announcements tab.
4. Click on Provider Portal Change and Status Updates.

Watch for additional announcements

Continue to read our provider alerts within the Blue Cross and BCN Payer Space in Availity Essentials, for the latest information on the retirement of Provider Secured Services and web-DENIS. We’ll post an alert if there are any changes to the date listed in this article.

Here’s how to find provider alerts within Availity Essentials.

1. Click on Payer Spaces on 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. Click on Read Alerts.

You can make the Provider Resources site a favorite by clicking on the heart icon next to Secure Provider Resources (Blue Cross and BCN) in Step 4 above. Once you’ve done this, you’ll find a link to Provider Resources when you click on My Favorites in the top menu bar.

Here are recent notices about the retirement of Provider Secured Services and web-DENIS:

• Provider alert: Eligibility and benefits functionality retires from web-DENIS on Nov. 18
• November Record article: Final Provider Secured Services and web-DENIS retirement dates announced along with Availity enhancements

Read the November Record article for earlier retirement notices.

Resources

• Register for Availity Essentials.** Learn more at Get Started with Availity Essentials.**
• Learn how to use Availity Essentials on Get Up to Speed with Training.**
• Check out our frequently asked questions about transitioning to the Availity^® provider portal.
• Need help? Call Availity Client Services at 1-800-AVAILITY (282-4548), from 8 a.m. to 8 p.m. Eastern time, Monday through Friday (excluding holidays). Request an ACS ticket number for reference in case this call doesn’t resolve your problem and follow-up assistance is needed.

Availity is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal services.

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

Follow these tips for checking eligibility and benefits

To get started checking eligibility and benefits on our new provider portal, Availity^® Essentials, simply click on Patient Registration at the top of your Availity home screen. Then select Eligibility and Benefits Inquiry. Here are some tips.

• Select a patient — When you’re looking for a patient, click on the Patient Search Option drop-down menu for a choice of search options. One option is the patient’s first and last name, and date of birth.
• Active and inactive contracts — Active contracts have a green bar; inactive contracts have a red bar.
• If a patient’s plan is inactive — Here are two actions you can take if you find that a patient’s plan is inactive:
• A Patient ID in Availity is the patient’s enrollee ID on his or her member ID card. If you search based on Patient ID and receive a response indicating the patient’s plan is inactive, submit another inquiry that doesn’t include the patient’s enrollee ID. The patient may have changed plans and received a new enrollee ID number.
• After taking the above action, if the patient’s coverage is still displaying as inactive on the current date, change the “As of Date” to a date when coverage was active. Inactive coverage will display an end date. You can select a date prior to the end date for more information on the prior coverage. Information is available on coverage up to one year prior to the current date. 

• Narrow the benefit results — Before clicking on the patient box and selecting Submit, click on the Benefit / Service Type drop-down menu. You can select multiple benefits in this field to narrow down the benefits you want to view. Click on Search, and then click on the Coverage and Benefits tab to see details for the benefits you’ve selected.
• Find the result you need — A categorized list of frequently viewed benefits information is on the left side of the screen. You can click the links listed under each benefit or service type to navigate to the corresponding section of the Coverage and Benefits screen.
• Some health plans have a custom message — If a patient’s plan has a custom message, you’ll find it under the Blue Cross and BCN logo in the green bar.
• Networks — On the Coverage and Benefits tab, you may see some filters by network such as “All Networks,” “In Network” or “Out of Network.” These links provide the benefits but don’t indicate the network status of the health care provider. To determine the network status for a specific provider, look up the provider in our online provider search at bcbsm.com/find-a-doctor. For detailed steps, review Finding your plans and networks.
• Coordination of benefits — Coordination of benefits information is available on the Patient Information tab in the Payer Details section under Other or Additional Payers.
• Medicare and Medicaid contracts — Medicare and Medicaid are listed as separate payers. For more information, see pages 12 and 13 of Transitioning to the Availity provider portal frequently asked questions for providers.
• Non-Michigan Blue plan members — To check eligibility and benefits for an out-of-state Blue plan member, go to the Patient Information section, and select Click here to search for Federal Employee Program or Blue Exchange members.
• Get training — For more details on how to use eligibility and benefits, go to Get Up to Speed with Training,** and select Availity Overview, Payer Spaces, Eligibility & Benefits.

Direct your questions to Availity Client Services at 1-800-AVAILITY (282-4548), from 8 a.m. to 8 p.m. Eastern time, Monday through Friday (excluding holidays). Request an ACS ticket number for reference in case this call doesn’t resolve your problem and follow-up assistance is needed.

Availity is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal services.

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

Blue Cross and BCN receive high Medicare Star Ratings from CMS again this year

You may have seen this article previously in Hospital and Physician Update but we’re reprinting it here in case you missed it. To subscribe to the Update or any of our other provider publications, click here.

The Centers for Medicare & Medicaid Services recently announced its 2023 Medicare Star Ratings — and Blue Cross Blue Shield of Michigan achieved strong results.

Both our BCN Advantage℠ HMO plan and our Medicare Plus Blue℠ PPO plan captured 4.5-Star ratings, making our plans once again among the highest-rated in the country.

CMS publishes Star Ratings each year to measure the quality of health services received by beneficiaries enrolled in Medicare Advantage plans. They’re designed to evaluate how well plans that contract with Medicare perform, and to help consumers select a Medicare Advantage plan that works best for them.

“These phenomenal ratings reflect our dedication to provide our Medicare members with service that goes above and beyond,” said Daniel J. Loepp, Blue Cross president and CEO. “We are grateful to the care teams in our network who work closely with our members to meet their health care needs.” 

Medicare considers five categories when assigning Star Ratings:

• How the plan emphasizes staying healthy, including such benefits as screenings, tests and vaccines
• How the plan manages chronic conditions
• How responsive the plan is, as well as the quality of care that people with the plan receive
• Member complaint reports, which include problems in getting services and decisions on appeals
• How many members leave the plan each year

Blue Cross Blue Shield of Michigan’s high ratings for 2023 reflect sustained performance in several key areas, including HEDIS^® measures** and CAHPS^® surveys.*** The Consumer Assessment of Healthcare Providers and Systems surveys, developed by the Agency for Healthcare Research and Quality, evaluate a member’s experience with their plan, quality of care received and access to care.

The role of health care providers

Dr. James Grant, senior vice president and chief medical officer for Blue Cross, acknowledged the important role health care providers played in achieving the ratings. “We couldn’t have achieved this strong performance without our physician partners and the efforts of each patient care team. These professionals interact with our patients every day and are helping to provide quality care to everyone they touch,” he said.  

Going forward, Blue Cross and BCN will continue to work with health care providers to focus on quality, pursue operational excellence and provide a best-in-class experience for our members.

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

***CAHPS^®, which stands for Consumer Assessment of Healthcare Providers and Systems, is a registered trademark of the Agency for Healthcare Quality and Research.

Speed up review process for AIM prior authorization requests

To make the process of submitting prior authorization requests to AIM Specialty Health^® as speedy and efficient as possible, we’re offering some important tips to keep in mind. These tips apply to both initial requests and appeals.

What to do

• Gather all pertinent information about the procedure and the patient’s condition before submitting the request.

Example: For requests that involve oncology services, include information on tumor testing results, tumor staging and previous therapy.

• Submit the request with a complete set of clinical information that supports the rationale for the treatment of care you’re planning.

Here’s why: This will move the clinical review process along faster.

• Provide a phone number where the provider can be reached for a peer-to-peer discussion.

Here’s why: This will help AIM get answers to clinical questions so they can determine the medical necessity of the proposed services.

Note: AIM physicians are available for peer-to-peer discussions at any time during AIM’s business hours. 

Submit authorization requests electronically

We encourage you to submit authorization requests to AIM through our provider portal. To do this:

1. Log in to availity.com.**
2. On the Availity^® menu bar, click on Payer Spaces and then click on the BCBSM and BCN logo.
3. On the Applications tab, click on the AIM Provider Portal tile.

Note: If you need to request access to our provider portal, follow the instructions on the Register for web tools webpage on bcbsm.com/providers.

As an alternative, you can call the AIM Contact Center at 1-844-377-1278.

Where to find information about AIM requirements

For more information about the services that AIM manages for us, including procedure codes, and for more details on how to submit prior authorization requests to AIM, refer to these webpages at ereferrals.bcbsm.com:

• Blue Cross AIM-Managed Procedures
• BCN AIM-Managed Procedures
• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

AIM Specialty Health is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage authorizations for select services.

Availity is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal services.

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

Intensive services program for children, adults now available for Blue Cross commercial providers

A program that’s been successfully developed for Blue Care Network commercial and BCN Advantage℠ members over the past few years is now payable for Blue Cross Blue Shield of Michigan as well — for both our commercial and Medicare Plus Blue℠ members. Our Adult Intensive Services and Child Intensive Services program provides intensive case management services for members with chronic mental illness.

The program works especially well for members with a recently identified acute illness who aren’t yet responding to treatment after discharge from a hospital or other care facility, as well as those who haven’t achieved remission. It’s designed to offer face-to-face services, with telemedicine used when necessary, such as in rural areas or with homebound members.

It seeks to meet the needs of the following types of individuals:

• People recently discharged from a higher level of care who are still in the early stages of healing and need support
• People with a history of nonadherence to treatment and frequent hospitalizations
• People with severe chronic mental illness who need support and coordinated care to stay stable and out of the hospital
• People who have been seen by one of our crisis teams, as part of our crisis services program, and haven’t returned to their functional baseline.

Program services include the following:

• Identifies barriers to care
• Teaches problem-solving skills
• Arranges community services to address social determinants of health, food insecurity, adherence to medication and treatment program
• Continues alternative treatment protocols if determined to be clinically necessary 
• Allows services to be applied to families and individuals with autism, especially those with neurobehavioral symptoms that, if left untreated, can result in admission to a higher level of care 

Individual professional services, such as psychotherapy, psychiatric evaluation and management services, psychological testing and autism treatment services, if necessary, can also be provided.

Provider requirements

Health care providers who have the resources to provide all necessary care for these individuals, under the supervision of a psychiatrist, can participate in this program. Participants must be contracted with both Blue Cross and BCN to provide these services as outlined in the BCN contracting documents.

There is no special credentialling needed, and services can be provided by an M.D., D.O. or outpatient psychiatric clinic. Also, it’s not necessary to obtain prior authorization before performing these services.

Key to the program — and key and the successful treatment of our members — is coordination of care among all providers who are involved in treating the member, as well as the member’s support systems. If the member is receiving care management through Blue Cross, providers need to coordinate their efforts with the care manager provided by the member’s plan.

If you have any questions, email Dr. William Beecroft at WBeecroft@bcbsm.com or Bill Pompos at WPompos@bcbsm.com.

Learn more about patient experience resources

The Centers for Medicare & Medicaid Services continues to emphasize the importance of the patient experience in all their programs. Blue Cross Blue Shield of Michigan and Blue Care Network administer the Clinician and Group Consumer Assessment of Healthcare Providers and Systems^®, or CG-CAHPS, a nationally recognized survey that's widely used to collect data about patient experiences and monitor provider performance.

We’ve added a page on our Provider Resources site to provide more details about the CG-CAHPS survey and our patient experience resources, including our Provider Experience podcast series. (To read more about the podcasts, see this article in the current issue of The Record.)

You can find the Provider Experience page on the Member Care tab. To get there:

1. Log in to our provider portal at 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 Patient Experience on the Member Care tab.

CAHPS^® is a registered trademark of the Agency for Healthcare Quality and Research, or AHQR.

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal services.

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

Services rendered as result of telemarketing subject to post-service audit

Blue Cross Blue Shield of Michigan and Blue Care Network work with health care providers to facilitate the provision of optimal medical care for our members. To this end, we reserve the right to audit services provided to our members to ensure these services were medically necessary.

Blue Cross and BCN don’t condone telemarketing services, defined as provider solicitation or cold calling of our members, to prescribe items that may be medically unnecessary, including, but not limited to, durable medical equipment, genetic testing, wound care items or prescription medication. All services are subject to a post-service audit and possible payment recovery if it’s determined that the services were rendered as a result of providers soliciting members.

Blue Cross programs target lower costs and medication adherence

Every medication says it on the label: Take as directed. Yet many people don’t. Their health suffers as a result. The cost of prescription medication is often a barrier that prevents people from refilling and taking their medication as directed. Blue Cross Blue Shield of Michigan and Blue Care Network’s programs help members take their medications as prescribed and save money.

Drug Adherence Discount Program

It’s fairly common for patients not to take their medications as prescribed. But Blue Cross has been successful in increasing medication adherence among our members.

In 2020, the Drug Adherence Discount Program, powered by Sempre Health, was introduced as a coupon program that encourages timely prescription refills for select maintenance medications. The program uses digital technology, such as text messages, to remind enrollees to fill their medications on time. Those who adhere to their drug therapies, as prescribed by their physician, are rewarded with discounts on their prescriptions for select medications.

Since this program began:

• Members participating in the program have saved over $5.6 million.
• More than 118,000 prescriptions have been filled.

The longer members receive on-time refills, the greater their discounts become for covered medications.

“We really couldn’t be more pleased with the results of our great partnership with the Sempre Health team,” said Kim Foerster, director, Pharmacy Account Management. “They continue to go above and beyond to ensure a great experience for our members that has resulted in significant savings. This collaborative effort allowed us to expand the program in January to now also include home delivery prescriptions. They are also working diligently on expanding the list of drugs covered by the program.”

While this is a significant success, Foerster says Blue Cross is still working to increase the number of members taking advantage of this program.

High-Cost Drug Discount Optimization Program

Blue Cross’ High-Cost Drug Discount Optimization Program, powered by PillarRx, is expanding. The program, started in 2020, uses copay assistance to pay most or all of a member’s prescription copay. In July, almost all the groups with a health savings account or deductible were able to opt in.

“This is really exciting,” Foerster said. “More members will be able to reduce their out-of-pocket costs on more than 300 high-cost drugs. And they don’t have to jump through hoops. PillarRx calls them, explains the program and answers their questions.”

The program includes expensive medications obtained at retail and specialty pharmacies so it’s not limited to exclusive specialty pharmacy arrangements.

Blue Cross and BCN identify eligible members based on their claims history for drugs included in the program. After enrolling, the member can save a significant amount of money. They may even pay nothing for their medication refills. In addition to cost savings, the program improves medication adherence and patient health outcomes.

Blue Cross Blue Shield of Michigan and Blue Care Network have contracted with Sempre Health, an independent company, to provide a drug discount program.

PillarRx is an independent company providing Blue Cross Blue Shield of Michigan and Blue Care Network with a high-cost drug discount program.

HCPCS 3rd-quarter update: New and deleted 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

Skin substitutes

Radiopharmaceuticals

Other medical services

Medical/surgical supplies

Durable medical equipment

Therapeutic, preventive or other interventions

National T codes, Medicaid

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.

Coding Advisor outreach to educate providers about appropriate use of procedure codes

It can be challenging for health care providers and their office staff to select the CPT^® code that best reflects the complexity of a patient visit. That’s why Blue Cross Blue Shield of Michigan contracted with Change Healthcare, an independent company, to implement our Coding Advisor program in 2019.

Change Healthcare reviews evaluation and management codes billed and other scenarios — such as use of modifier 25, observation care and nursing facility care — on claims submitted to Blue Cross. While Change Healthcare won’t review E/M services for BCN and BCN Advantage℠ because they use a repricing program that’s already in place, the company will review other modules that include services provided by BCN and BCN Advantage. The program offers useful data insights to the provider community and maximizes coding efficiency and accuracy through upfront education, rather than through a traditional post-claim review process.

Effective Jan. 1, 2023, the Coding Advisor program will expand to include the review of home health services to help ensure the Domiciliary Rest Home or Custodial Care Services procedure codes *99324-*99337 and Home Services procedure codes *99341-*99350 are used and billed appropriately.

Throughout this program, Coding Advisor will continue to monitor billing practices and send updated reports periodically. Coding Advisor may contact your practice to discuss coding variances and offer one-on-one coding education. You’ll receive all correspondence from Change Healthcare.

If you have questions, call Coding Advisor Customer Support at 1-844-592-7009 and select option 3.

Here’s an example of a physician profile:

CareCentrix processes improved for Medicare Plus Blue prior authorization requests

We’re improving the prior authorization process for home health care services for Medicare Plus Blue℠ members who receive services in Michigan.

Clinical questionnaire available for Medicare Plus Blue

Starting Nov. 14, 2022, when submitting prior authorization requests for Medicare Plus Blue members who receive services in Michigan, a new clinical questionnaire opens in the CareCentrix HomeBridge^® portal.

Completing the clinical questionnaire expedites the review process and enables CareCentrix to make authorization determinations more quickly.

You can find reference materials about the clinical questionnaire in the HomeBridge portal. To access the portal:

1. Log in to our provider portal (availity.com**).
2. Click on Payer Spaces in the menu bar and then click on the BCBSM and BCN logo.
3. Click on the CareCentrix Provider Portal tile in the Applications tab.

In addition, CareCentrix has recorded trainings about the questionnaire. To access the trainings:

1. Go to carecentrixportal.com/providerportal.**
2. Click on the Review button under Provider Education and Documentation.
3. Click on BCBSM Home Health Reference Material under Education Center.

Individual training is available upon request.

The clinical questionnaire already opens for BCN Advantage℠ members.

HIPPS code optional when submitting prior authorization requests for Medicare Plus Blue

Currently, CareCentrix requires providers to enter the health insurance prospective payment system, or HIPPS, codes when submitting prior authorization requests for Medicare Plus Blue members who receive services in Michigan. Blue Cross Blue Shield of Michigan also requires that the HIPPS code on the prior authorization match the HIPPS code on the claim for home health services.

As of Nov. 14, 2022, CareCentrix and Blue Cross made the following changes based on feedback from and collaboration with home health agencies:

• CareCentrix no longer requires that you enter the HIPPS code when submitting prior authorization requests.
• You’ll still see the question, “Do you have the current HIPPS code for this requested period?” on the questionnaire. You can choose to enter the HIPPS code, or you’ll be able to select “No” as your response. 
• Blue Cross no longer requires that the HIPPS code on the claim match the HIPPS code on the prior authorization. We expect providers to bill according to Centers for Medicare & Medicaid Services billing guidelines.
• For more information about billing guidelines and audit protocols, see the “Utilization management” and “Medical records” sections of the Medicare Plus Blue PPO Provider Manual.

Additional information about home health care

For more information about the CareCentrix home health care program, see the following pages on our ereferrals.bcbsm.com website:

• Blue Cross Home Health Care
• BCN Home Health Care

CareCentrix is an independent company that manages the authorization of home health care services for Blue Cross Blue Shield of Michigan and Blue Care Network members who have Medicare Advantage plans.

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

We’re changing our payment policy for lab services billed by independent labs

Blue Cross Blue Shield of Michigan is updating our payment policy for laboratory services billed by an independent lab. We’re making this change to support correct coding and payment accuracy.

The following change to our payment policy is effective in January 2023.

For lab services provided to members during their inpatient stay at a hospital facility, follow these guidelines:

• Laboratory services performed by nonhospital labs should be billed through the hospital under existing arrangements. Independent laboratories shouldn’t submit claims to Blue Cross for those services.
• Only the hospital with the inpatient admission may bill for lab services provided to the inpatient member during his or her stay.

We may deny claims if they’re submitted by an independent laboratory for services members received during their inpatient stay.

How Landmark can support primary care providers as they care for our most vulnerable Medicare Advantage members

On Jan. 1, 2023, all Medicare Plus Blue℠ and BCN Advantage℠ members who have multiple chronic conditions and reside in Michigan’s Lower Peninsula will be eligible for Blue Cross Blue Shield of Michigan and Blue Care Network’s high-intensity in-home care program. This program uses the services of Landmark Health L.L.C., an independent company that provides Blue Cross and BCN with in-home care services.

The Landmark program

Using a physician-led, interdisciplinary team, the Landmark program complements office-based primary care by:

• Collaborating and coordinating with each member’s primary care provider, using the primary care provider’s preferred method of communication
• Supporting frail, elderly patients who want to manage their conditions through in-home care
• Meeting patients in the comfort of their homes
• Delivering geriatric care, including medical, behavioral, urgent care, medication management and 24/7 nurse triage

The program doesn’t replace members’ primary care providers or other health care providers. Instead, the Landmark team provides supplemental support between members’ regularly scheduled medical appointments, when it’s often needed most.

The Landmark program is a member benefit. Members who are eligible for the Landmark program decide whether they want to participate in the program.

Opportunities to discuss collaboration

Blue Cross, BCN and Landmark are available to meet with primary care practices, providers and care managers to answer questions about Landmark’s care model and coordination of care.

Discussion topics include:

• Coordination of care between Landmark and an identified person in the practice
• The best method of communication with the practice and how to coordinate on urgent patient needs
• How and when practices can call on Landmark for eligible or engaged patients when the patient has an urgent need or can’t come into the office
• Feedback on Landmark communication with primary care providers

If you want to participate in an open-forum discussion, email the Care Delivery Solutions team at CareDeliverySolutionsProgramMtg@bcbsm.com.

How patients are identified for the Landmark program\

Blue Cross and BCN identify eligible members through specific criteria related to level and number of qualifying chronic conditions, age, geographic location and other factors (for example, frailty).

You can refer patients to the Landmark program. To do this, send an encrypted email message to CareDeliverySolutionsProgramMtg@bcbsm.com with the patient’s:

• First and last name
• Contract ID
• Date of birth
• Any pertinent medical information, including chronic conditions.

For the patients you refer, we’ll review the information you provide and reply to your email to let you know whether the patient will be accepted into the Landmark program.

Additional information

To learn more about our program with Landmark, see the High-intensity in-home care program: Frequently asked questions for providers document.

Note: Health care providers who are in full-risk arrangements have separate provisions for this benefit.

Modifier 26 no longer used to support denial of new patient claim

On Oct. 10, 2022, a Blue Cross Blue Shield of Michigan payment policy was updated so that procedure codes previously submitted with a modifier 26 aren’t used to support the denial of a new patient visit. Providers are allowed to bill a new patient visit when the only previous patient encounters that they have billed were billed with a modifier 26, indicating that only the professional component of a procedure was performed.

If you have submitted a new patient office visit and received a denial based on a previous patient encounter billed with a modifier 26, you can resubmit your claim for consideration.

Modifier 54 identifies surgical care only

Blue Cross Blue Shield of Michigan is updating its payment policy for surgical services in March 2023.

When no follow-up care is provided, modifier 54 (surgical care only) should be added to the surgical procedure code with a global period of 10 or 90 days. Payment will be reduced when only the surgical procedure is rendered. The reduction will be based on the individual procedure code values in the Centers for Medicare & Medicaid Services’ physician fee schedule.

If modifier 54 isn’t on the claim in instances where surgery is performed in the emergency department by a trauma surgeon or an emergency medicine professional provider, it will be added.

Ordering transfers from noncontracted ambulance services costs members money

Health care providers must order transfers from contracted (participating) ambulance services when arranging for non-emergency ground transfers. This applies to transfers for Blue Cross Blue Shield of Michigan commercial, Medicare Plus Blue℠, Blue Care Network commercial and BCN Advantage℠ members.

Noncontracted (nonparticipating) ambulance services may balance bill members, which may result in members being charged large amounts for these services.

You can avoid this situation by using only contracted ground ambulance services for non-emergency transfers. To determine which ground ambulance services are contracted with or participate with a member’s health plan:

1. Go to bcbsm.com.
2. Click on Find a Doctor.
3. Click on the Search without logging in link.
4. If prompted, choose a location.
5. In the upper-right corner of the screen, do one of the following:
6. Click on the I don’t know my network button.
7. Click on the Change your location or plan link and then click on I don’t know my network.
8. Click on the Find a different plan button.
9. Select the appropriate plan.
10. Click on the Confirm selection button.
11. Click on Places by type.
12. Enter Land ambulance or the name of a specific ambulance provider and then press Enter.

The search results include the ground ambulance services that are contracted with or participate with the plan you selected.

See our Ground Ambulance Services medical policy for additional information. To view the policy:

1. Go to bcbsm.com/providers.
2. Click on Resources.
3. Scroll down the page and click on the Search Medical Policies button.
4. In the Medical Policy Router Search page, enter “ground ambulance services” in the Policy/Topic Keyword field and then press Enter.
5. Click on the Medical Policy – Ground Ambulance Services link.

We also published this information as a provider alert.

Starting Jan. 1, male condoms will be covered as a preventive care product

Starting Jan. 1, 2023, Blue Cross Blue Shield of Michigan and Blue Care Network will cover generic and select brand-name male condoms that comply with the Affordable Care Act’s preventive care benefits requirements.

The amount that can be filled will be limited to 12 units per 30 days. Generic condoms will be dispensed where available.

Keep in mind that members must obtain a prescription from a doctor for preventive care drugs and products, including over-the-counter drugs, in order for them to be covered at no cost.

Xenpozyme, Zynteglo require prior authorization for Medicare Advantage members

For dates of service on or after Nov. 1, 2022, we’ve added a prior authorization requirement for Medicare Plus Blue℠ and BCN Advantage℠ members for the following medications:

• Xenpozyme™ (olipudase alfa-rpcp), HCPCS code J3590
• Zynteglo^® (betibeglogene autotemcel), HCPCS code J3590

Submit prior authorization requests through the NovoLogix^® online tool.

These medications are part of members’ medical benefits, not their pharmacy benefits.

When prior authorization is required

These medications require prior authorization when they’re administered by a health care provider in an outpatient facility or a physician’s office and billed in one of the following ways:

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

Submit prior authorization requests through the NovoLogix tool

To access NovoLogix, log in to our provider portal (availity.com**), click on Payer Spaces in the menu bar and then click on the BCBSM and BCN logo. You’ll find links to the NovoLogix tools on the Applications tab.

Note: If you need to request access to our provider portal, follow the instructions on the Register for web tools webpage on bcbsm.com/providers.

List of requirements

For a list of requirements related to drugs covered under the medical benefit, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members.

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal services.

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

Medicare Plus Blue members will be able to select a primary care provider in Blue Cross’ member portal

Blue Cross Blue Shield of Michigan is enhancing the current claims-based attribution model by giving Medicare Plus Blue℠ members in Michigan the ability to choose a primary care provider in the member portal. Planned for early 2023, this optional tool will take priority over the current claims-based attribution model for members who choose to use it.

Feedback shows that the current attribution model, which is a retrospective model based on claims look-back, can sometimes cause a significant delay in attributing a member to a health care provider, depending on a member’s claims history. This member selection enhancement tool will allow for quick and current alignment between the primary care provider and the member in Blue Cross’ data systems and enable greater efficiency with data sharing and other operations.

This tool is optional and there’ll be no requirement or incentive for a member to use it to choose a primary care provider. Choosing a primary care provider in the portal won’t affect a member’s benefits or claims payments, nor will it limit which providers a member can see for care. Those who don’t select a primary care provider in the portal will be attributed based on claims, per the current model.

New microsite gives members access to maternity, family-building resources

Blue Cross Blue Shield of Michigan has developed a microsite that enhances the experience of Blue Cross and Blue Care Network members seeking to build families, and improves clinical outcomes for mothers and babies.

It’s part of a comprehensive maternal health strategy to improve member education about maternal health coverage and how to navigate maternity benefits. This strategy can help encourage members to get recommended care and increase their engagement in available Blue Cross programs.

Members on a journey to parenthood can find information on this new family building and maternity microsite at bcbsm.com. The site includes information for each stage of a family building journey, from fertility testing, counseling and treatments to prepregnancy, pregnancy and labor and delivery, including pregnancy loss, postpartum and pediatrics.

Each page on the microsite also includes a link to our behavioral health site where members can find information about mental health support throughout their family-building journey. Another link directs them to their Blue Cross member account where they can get information about their health plan coverage.
Additional webpage topics include:

Prepregnancy planning

• Fertility testing, counseling and treatments
• Egg freezing

Pregnancy, labor and delivery

• Prenatal vitamins
• Prenatal exam schedule
• Prenatal testing
• Pregnancy loss
• Self-care
• Birthing experience, traditional and nontraditional
• Midwives, doulas and birthing classes
• Preparing for baby’s arrival
• Breast pump coverage
• Hospital checklist
• Family medical leave
• Labor and delivery, epidural and cesarean section

Postpartum care pediatrics

• Lactation and breastfeeding
• Insurance for your newborn
• Baby’s first physical
• Postpartum physical
• Pregnancy prevention and pills, injection and IUDs, morning-after pill, condom and vasectomies, having your tubes tied, insurance coverage

You can direct Blue Cross members who are on a family planning journey to our family building and maternity microsite.

Podcasts give you quick, easy tools for improving the patient experience

As part of our ongoing efforts to help practices improve the patient experience, we’ve developed a podcast series called “Practice Up.” The four podcasts included in the series are short and engaging, allowing physicians and other health care providers to listen at their convenience.

Podcasts include the following:

• Episode 1: A Minute to Win It
• Episode 2: What Matters Most
• Episode 3: Finding Room for Feelings
• Episode 4: Rock the Wrap-up

“These podcasts give providers concrete tools they can implement that will improve the patient experience,” said Martha Walsh, M.D., senior medical director and associate chief medical officer for Provider Engagement. “Many of us think of the patient experience as very subjective, but the reality is there are very objective things that a provider can implement in their interactions with patients that will improve the patient experience. Our goal in creating these podcasts was not only to improve the patient experience, but also to help providers improve their own experience.”

CME credit

Listening to all four of the episodes — and scoring 100% on the quiz questions — will also allow you to apply for continuing medical education credit. To receive credit, you must access the podcasts through the provider training site.

Accessing the podcasts

To access the podcasts, follow these steps:

1. Open the registration page.
2. Complete the registration, which takes less than a minute. (We recommend using the same email you use to communicate with Blue Cross Blue Shield of Michigan for provider-related needs. This will become your login ID.)
3. Follow the link to log in.
4. Scroll down and click on the link that says Click here to locate the podcasts.

Note: If you already have access to the site, you can go directly to Step 3 to log in. Currently, nearly 1,200 providers have access to our provider training site.

For more information

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

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, educational lunchtime sessions 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.

Get ready for Welcome to Medicare, annual wellness visits for Medicare Plus Blue patients

The new year will bring new and existing Medicare Plus Blue℠ members to your medical practice for their annual wellness visits — which are at no cost to them. These visits play an important role in helping your patients maintain or improve their health.

Welcome to Medicare visit

New Medicare Plus Blue members should be scheduling their Welcome to Medicare preventive visit, also known as the initial preventive examination. This is a one-time appointment for new Medicare patients to be scheduled within their first 12 months of enrollment. Medicare pays for one Welcome to Medicare visit per member, per lifetime.

This visit is a great way to get up-to-date information on health screenings, shot records, family medical history and other preventive care services. For more information on the components of a Welcome to Medicare visit, see the Medicare Learning Network Educational Tool.**

Billing code

The billing code for a Welcome to Medicare visit, also called initial preventive physical examination, is G0402.

Annual wellness visit

Existing Medicare Plus Blue members should be scheduling their annual wellness visits. Medicare will cover an annual wellness visit every 12 months for patients who’ve been enrolled in Medicare for longer than one year.

The annual wellness visit is a chance for you to develop or update your patient’s personalized prevention plan based on his or her current health situation and risk factors. A health risk assessment is part of the annual wellness visit. It includes self-reported information from your patient to be completed before or during the visit. For more information on the components of an annual wellness visit, see the Medicare Learning Network Educational Tool.**

Billing codes for annual wellness visits

Here are the billing codes for annual wellness visits, which include a personalized prevention plan of service:

• G0438 — First visit AWV, can only be billed one time, 12 months after a G0402 (Welcome to Medicare Visit)
• G0439 — Annual wellness visit (subsequent)

Note: G0438 or G0439 must not be billed within 12 months of the previous billing of a G0402.

You can also offer to conduct telehealth visits depending on your office’s capabilities.

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

We’re sharing resources for management of acute low back pain

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

Low back pain is the fifth most common reason for all physician visits. Studies have shown that imaging, such as X-ray, MRI or CT scan, of the lower spine before six weeks from the onset of acute low back pain doesn’t improve outcomes but does increase costs, according to the American Academy of Family Physicians.

Here are some helpful resources for treating acute low back pain:

• MQIC Management of Acute Low Back Pain in Adults**
• 2022 HEDIS^® Measure Tips: Use of Imaging Studies for Low Back Pain (LBP)

If health care providers or members have questions about benefits, call Customer Service at 1-800-482-3600 or go online to fepblue.org.

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

**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 the Trading Partner Agreement and the Provider Authorization form as part of the electronic data interchange setup process. All EDI trading partners must complete the TPA and the Provider Authorization form before they can exchange PHI with Blue Cross.

It’s important to keep your Provider Authorization form updated. The terms of the TPA require you to notify Blue Cross of any changes in your trading partner information. 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 when you’ve changed 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.  

You can also 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, contact the EDI Help Desk at EDISupport@bcbsm.com. Include your billing NPI and submitter ID with all correspondence.

We’re updating review threshold for high-dollar prepayments

Since 2017, Blue Cross Blue Shield of Michigan and Blue Care Network have been partnering with Equian, an independent company, to review certain types of high-cost inpatient claims. This review helps us detect and resolve errors before payment to ensure that all claims will be paid right the first time.

As we previously communicated, Blue Cross and BCN intended to review high-cost claims greater than $25,000. But since beginning the review process in May 2017, we’ve only examined claims greater than $100,000. After five years of reviews at this higher amount, Blue Cross and BCN have decided to lower the review threshold.

Effective Jan. 1, 2023, high-cost claims greater than $75,000 are now eligible for high-dollar prepayment review by Blue Cross and BCN.

This change only affects the review threshold. It doesn’t affect any other aspect of the current high-dollar prepayment review process, including claim payments and reconsideration time frames.

For more information:

• A detailed look at the process is available in the Blue Cross provider manual under the “High-cost claims review process” section.
• You can also read the previously published articles in the April 2017 issue and August 2017 issue of The Record, and the March-April 2017 issue of Hospital and Physician Update.

If you have any questions, contact your provider consultant.

Prior authorization, billing reminders for SNF interrupted stays for Medicare Advantage members

Per Centers for Medicare & Medicaid Services guidance, a skilled nursing facility interrupted stay occurs when a patient is discharged from a SNF and is readmitted to the same SNF within three consecutive days. When this occurs:

• The readmission or subsequent stay is considered a continuation of the previous stay.
• One claim must be submitted for both stays.
• The completion of new patient assessments is optional.
• The variable per diem isn’t reset.

For more information, see the “Interrupted Stay Policy” section of the Medicare Learning Network^® document titled SNF PPS: Patient Driven Payment Model.**

How naviHealth issues authorizations for SNF interrupted stays

naviHealth’s authorization process is based on its medical necessity review process.

If a patient who’s receiving skilled services leaves a SNF for the emergency department, for an observation stay or for an acute-care hospital inpatient stay and:

• Returns to the same SNF before two midnights have passed, naviHealth will use the original prior authorization number.
• Returns to the same SNF after two or more midnights have passed, naviHealth will create a new authorization number.

How to submit claims for SNF interrupted stays

Here’s what you need to know about billing for SNF interrupted stays:

• You must submit only one claim for both stays.
• Submitting authorization numbers on Medicare Plus Blue℠ and BCN Advantage℠ claims for post-acute care stays is optional. If you choose to include an authorization number on the claim, include the prior authorization number for the initial SNF stay.
• If naviHealth assigns a different patient-driven payment model, or PDPM, code for the subsequent stay:
1. Include a claim line for the original dates of service and PDPM code.
2. Include a separate or new claim line for the subsequent dates of service and the second PDPM code.

Reminders

• naviHealth authorizes the first four digits of the PDPM code based on the associated case mix groups, or CMGs. The health care provider is responsible for assigning the appropriate fifth digit.
• Providers are responsible for billing appropriately.  
• Claims for unauthorized services and procedures are subject to denial.

Resources for CMS billing guidance

• Medicare Claims Processing Manual Chapter 6 - SNF Inpatient Part A Billing and SNF Consolidated Billing** — Section 120.2 - Interrupted Stay Policy
• Medicare Benefit Policy Manual Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance** — Section 30.1 - Administrative Level of Care Presumption

Additional information

For more information, see the document titled Post-acute care services: Frequently asked questions for providers.

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.

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

How to submit prior authorization requests for inpatient admissions involving elective surgeries

When submitting a prior authorization request for a Blue Cross Blue Shield of Michigan commercial member admitted for an inpatient elective surgical procedure, do the following:

• Enter only the primary procedure code for the surgery. If you enter additional procedure codes, the claim may not be paid.
• Include the supporting diagnosis code.

Blue Cross utilization management nurses who review the request only look at primary procedure and supporting diagnosis codes to determine whether the surgery meets the medical necessity criteria for an inpatient setting.

Be sure to check the member’s benefits and eligibility for the surgery and any other planned procedures.

Note: For inpatient medical admissions that don’t involve surgeries, enter procedure code *99222 for the admission.

Use Availity^® to check benefits and eligibility

To check the member’s eligibility and benefits:

1. Log in to our provider portal at availity.com.**
2. Click on Patient Registration on the menu bar and then click on Eligibility and Benefits Inquiry.
3. Follow the prompts to enter information, locate a patient and review their eligibility and benefits information.

Use the e-referral system to submit the prior authorization request

Once you’ve checked the member’s eligibility and benefits, submit the request through the e-referral system. Here’s how to access the e-referral system through availity.com.**

1. Click on Payer Spaces on the menu bar and then click on the BCBSM and BCN logo.
2. Click on the e-referral tile on the Applications tab.

Submit the prior authorization request as outlined in the “Submit an inpatient authorization” section of the e-referral User Guide.

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal services.

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

We’re enhancing our claim editing for Medicare Plus Blue

In 2023, Blue Cross Blue Shield of Michigan will enhance its Medicare Plus Blue℠ claim editing process for multiple type of bill 0131 claims, submitted for the same member and date of service.

All outpatient services performed on the same date of service, by the same health care provider, should be reported on the same claim. Any necessary correction or addition to the claim should be reported using a different type of bill. We’ll immediately begin retrospective claim adjustments to promote correct coding and assist with payment accuracy.

Subsequent claims submitted after an initial outpatient claim with TOB 0131 will be denied.

There should be only one claim with TOB 0131 per patient, per facility, per day. If a claim is submitted with TOB 0131 and additional charges or changes need to be submitted, a corrected claim should be submitted with either a 0137 or 0138 bill type. If a TOB 0137 claim is submitted, this indicates that the previous claim was incomplete and the current claim has all the information that should have been included from the first claim. 

According to Uniform Billing Editor:

• Hospitals are required to report all outpatient prospective payment system services that are provided on the same day of surgery, on the same claim, except claims containing condition codes 20, 21, or G0.
• Hospitals and community mental health centers can’t submit a late charge bill for TOB code 012X, 013X, 014X or 076X.  Instead, they must submit an adjustment claim using TOB code 0XX7 for any services required to be billed with a HCPCS code, units and line-item dates of service. A separate claim containing only late charges isn’t allowed by Medicare.

Exclusions

Claims with condition code 20, 21, G0 reported in any position and repetitive billing type of service revenue codes:

• DME rental 0290 to 0299
• Respiratory therapy 0410, 0412, 0419
• Physical therapy 0420 to 0429
• Occupational therapy 0430 to 0439
• Speech-language pathology 0440 to 0449
• Skilled nursing 0550 to 0559
• Kidney dialysis treatments 0820 to 0859
• Cardiac rehabilitation services 0482, 0943
• Pulmonary rehabilitation services 0948

Note: The best way to receive payment for these services is to submit a corrected claim. If necessary, you can use the appeal process, which won’t change. Continue to submit appeals on the Clinical Editing Appeal Form with the necessary documentation. Fax one appeal at a time, to avoid processing delays. If appealing a retrospective recovery, refer to your provider manual for appeal options or call 1-866-309-1719.

Reminder: Bill new, corrected original claim when reporting a modifier change on OPC facility claims

For Blue Cross Blue Shield of Michigan commercial members, you must bill a new, corrected claim when changing the modifier on an outpatient psychiatric care, or OPC, facility claim. A replacement claim (frequency code 7) can’t be reported in these instances.

The modifier on a claim identifies the level of therapist who rendered the service. Any change in the modifier may cause the claim to be denied.

Additionally, any change to the patient’s information or to the health care provider’s information — including NPI, PIN or taxonomy code — requires that you void or cancel your original paid claim and report the member or provider change in a new, corrected original claim.

You can avoid having to submit a new, corrected claim by including the correct information on the claim the first time you submit it. Here’s how to do that.

In the CMS-1500 claim:

• In field 24D – enter the appropriate modifier to identify the type of therapist who provided the service:

• In field 24J – RENDERING PROVIDER ID, leave both the shaded and unshaded areas blank.

For more information about billing for outpatient psychiatric care facilities, see the “Psychiatric Care Services” chapter of the Blue Cross Commercial Provider Manual.

Coding Advisor outreach to educate providers about appropriate use of procedure codes

It can be challenging for health care providers and their office staff to select the CPT^® code that best reflects the complexity of a patient visit. That’s why Blue Cross Blue Shield of Michigan contracted with Change Healthcare, an independent company, to implement our Coding Advisor program in 2019.

Change Healthcare reviews evaluation and management codes billed and other scenarios — such as use of modifier 25, observation care and nursing facility care — on claims submitted to Blue Cross. While Change Healthcare won’t review E/M services for BCN and BCN Advantage℠ because they use a repricing program that’s already in place, the company will review other modules that include services provided by BCN and BCN Advantage. The program offers useful data insights to the provider community and maximizes coding efficiency and accuracy through upfront education, rather than through a traditional post-claim review process.

Effective Jan. 1, 2023, the Coding Advisor program will expand to include the review of home health services to help ensure the Domiciliary Rest Home or Custodial Care Services procedure codes *99324-*99337 and Home Services procedure codes *99341-*99350 are used and billed appropriately.

Throughout this program, Coding Advisor will continue to monitor billing practices and send updated reports periodically. Coding Advisor may contact your practice to discuss coding variances and offer one-on-one coding education. You’ll receive all correspondence from Change Healthcare.

If you have questions, call Coding Advisor Customer Support at 1-844-592-7009 and select option 3.

Here’s an example of a physician profile:

CareCentrix processes improved for Medicare Plus Blue prior authorization requests

We’re improving the prior authorization process for home health care services for Medicare Plus Blue℠ members who receive services in Michigan.

Clinical questionnaire available for Medicare Plus Blue

Starting Nov. 14, 2022, when submitting prior authorization requests for Medicare Plus Blue members who receive services in Michigan, a new clinical questionnaire opens in the CareCentrix HomeBridge^® portal.

Completing the clinical questionnaire expedites the review process and enables CareCentrix to make authorization determinations more quickly.

You can find reference materials about the clinical questionnaire in the HomeBridge portal. To access the portal:

1. Log in to our provider portal (availity.com**).
2. Click on Payer Spaces in the menu bar and then click on the BCBSM and BCN logo.
3. Click on the CareCentrix Provider Portal tile in the Applications tab.

In addition, CareCentrix has recorded trainings about the questionnaire. To access the trainings:

1. Go to carecentrixportal.com/providerportal.**
2. Click on the Review button under Provider Education and Documentation.
3. Click on BCBSM Home Health Reference Material under Education Center.

Individual training is available upon request.

The clinical questionnaire already opens for BCN Advantage℠ members.

HIPPS code optional when submitting prior authorization requests for Medicare Plus Blue

Currently, CareCentrix requires providers to enter the health insurance prospective payment system, or HIPPS, codes when submitting prior authorization requests for Medicare Plus Blue members who receive services in Michigan. Blue Cross Blue Shield of Michigan also requires that the HIPPS code on the prior authorization match the HIPPS code on the claim for home health services.

As of Nov. 14, 2022, CareCentrix and Blue Cross made the following changes based on feedback from and collaboration with home health agencies:

• CareCentrix no longer requires that you enter the HIPPS code when submitting prior authorization requests.
• You’ll still see the question, “Do you have the current HIPPS code for this requested period?” on the questionnaire. You can choose to enter the HIPPS code, or you’ll be able to select “No” as your response. 
• Blue Cross no longer requires that the HIPPS code on the claim match the HIPPS code on the prior authorization. We expect providers to bill according to Centers for Medicare & Medicaid Services billing guidelines.
• For more information about billing guidelines and audit protocols, see the “Utilization management” and “Medical records” sections of the Medicare Plus Blue PPO Provider Manual.

Additional information about home health care

For more information about the CareCentrix home health care program, see the following pages on our ereferrals.bcbsm.com website:

• Blue Cross Home Health Care
• BCN Home Health Care

CareCentrix is an independent company that manages the authorization of home health care services for Blue Cross Blue Shield of Michigan and Blue Care Network members who have Medicare Advantage plans.

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

We’re changing our payment policy for lab services billed by independent labs

Blue Cross Blue Shield of Michigan is updating our payment policy for laboratory services billed by an independent lab. We’re making this change to support correct coding and payment accuracy.

The following change to our payment policy is effective in January 2023.

For lab services provided to members during their inpatient stay at a hospital facility, follow these guidelines:

• Laboratory services performed by nonhospital labs should be billed through the hospital under existing arrangements. Independent laboratories shouldn’t submit claims to Blue Cross for those services.
• Only the hospital with the inpatient admission may bill for lab services provided to the inpatient member during his or her stay.

We may deny claims if they’re submitted by an independent laboratory for services members received during their inpatient stay.

Ordering transfers from noncontracted ambulance services costs members money

Health care providers must order transfers from contracted (participating) ambulance services when arranging for non-emergency ground transfers. This applies to transfers for Blue Cross Blue Shield of Michigan commercial, Medicare Plus Blue℠, Blue Care Network commercial and BCN Advantage℠ members.

Noncontracted (nonparticipating) ambulance services may balance bill members, which may result in members being charged large amounts for these services.

You can avoid this situation by using only contracted ground ambulance services for non-emergency transfers. To determine which ground ambulance services are contracted with or participate with a member’s health plan:

1. Go to bcbsm.com.
2. Click on Find a Doctor.
3. Click on the Search without logging in link.
4. If prompted, choose a location.
5. In the upper-right corner of the screen, do one of the following:
6. Click on the I don’t know my network button.
7. Click on the Change your location or plan link and then click on I don’t know my network.
8. Click on the Find a different plan button.
9. Select the appropriate plan.
10. Click on the Confirm selection button.
11. Click on Places by type.
12. Enter Land ambulance or the name of a specific ambulance provider and then press Enter.

The search results include the ground ambulance services that are contracted with or participate with the plan you selected.

See our Ground Ambulance Services medical policy for additional information. To view the policy:

1. Go to bcbsm.com/providers.
2. Click on Resources.
3. Scroll down the page and click on the Search Medical Policies button.
4. In the Medical Policy Router Search page, enter “ground ambulance services” in the Policy/Topic Keyword field and then press Enter.
5. Click on the Medical Policy – Ground Ambulance Services link.

We also published this information as a provider alert.

Starting Feb. 1, 2023, we’re changing how we cover some drugs

Starting Feb. 1, 2023, we’re changing how we cover some medications on the drug lists associated with our prescription drug plans plans for Blue Cross Blue Shield of Michigan and Blue Care Network commerical members. These changes are listed below and apply to both the brand name and any available generic equivalents for drug lists where the drugs are currently covered. No changes will apply if a drug isn’t currently covered.

We’ll encourage members to discuss their treatment options with their health care provider if they have any concerns.

For a complete list of drugs and coverage requirements go to bcbsm.com/pharmacy.

Xenpozyme, Zynteglo require prior authorization for Medicare Advantage members

For dates of service on or after Nov. 1, 2022, we’ve added a prior authorization requirement for Medicare Plus Blue℠ and BCN Advantage℠ members for the following medications:

• Xenpozyme™ (olipudase alfa-rpcp), HCPCS code J3590
• Zynteglo^® (betibeglogene autotemcel), HCPCS code J3590

Submit prior authorization requests through the NovoLogix^® online tool.

These medications are part of members’ medical benefits, not their pharmacy benefits.

When prior authorization is required

These medications require prior authorization when they’re administered by a health care provider in an outpatient facility or a physician’s office and billed in one of the following ways:

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

Submit prior authorization requests through the NovoLogix tool

To access NovoLogix, log in to our provider portal (availity.com**), click on Payer Spaces in the menu bar and then click on the BCBSM and BCN logo. You’ll find links to the NovoLogix tools on the Applications tab.

Note: If you need to request access to our provider portal, follow the instructions on the Register for web tools webpage on bcbsm.com/providers.

List of requirements

For a list of requirements related to drugs covered under the medical benefit, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members.

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal services.

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

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, educational lunchtime sessions 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 the Trading Partner Agreement and the Provider Authorization form as part of the electronic data interchange setup process. All EDI trading partners must complete the TPA and the Provider Authorization form before they can exchange PHI with Blue Cross.

It’s important to keep your Provider Authorization form updated. The terms of the TPA require you to notify Blue Cross of any changes in your trading partner information. 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 when you’ve changed 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.  

You can also 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, contact the EDI Help Desk at EDISupport@bcbsm.com. Include your billing NPI and submitter ID with all correspondence.

Starting Feb. 1, 2023, we’re changing how we cover some drugs

Starting Feb. 1, 2023, we’re changing how we cover some medications on the drug lists associated with our prescription drug plans for Blue Cross Blue Shield of Michigan and Blue Care Network commerical members. These changes are listed below and apply to both the brand name and any available generic equivalents for drug lists where the drugs are currently covered. No changes will apply if a drug isn’t currently covered.

We’ll encourage members to discuss their treatment options with their health care provider if they have any concerns.

For a complete list of drugs and coverage requirements go to bcbsm.com/pharmacy.

Starting Jan. 1, male condoms will be covered as a preventive care product

Starting Jan. 1, 2023, Blue Cross Blue Shield of Michigan and Blue Care Network will cover generic and select brand-name male condoms that comply with the Affordable Care Act’s preventive care benefits requirements.

The amount that can be filled will be limited to 12 units per 30 days. Generic condoms will be dispensed where available.

Keep in mind that members must obtain a prescription from a doctor for preventive care drugs and products, including over-the-counter drugs, in order for them to be covered at no cost.

Xenpozyme, Zynteglo require prior authorization for Medicare Advantage members

For dates of service on or after Nov. 1, 2022, we’ve added a prior authorization requirement for Medicare Plus Blue℠ and BCN Advantage℠ members for the following medications:

• Xenpozyme™ (olipudase alfa-rpcp), HCPCS code J3590
• Zynteglo^® (betibeglogene autotemcel), HCPCS code J3590

Submit prior authorization requests through the NovoLogix^® online tool.

These medications are part of members’ medical benefits, not their pharmacy benefits.

When prior authorization is required

These medications require prior authorization when they’re administered by a health care provider in an outpatient facility or a physician’s office and billed in one of the following ways:

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

Submit prior authorization requests through the NovoLogix tool

To access NovoLogix, log in to our provider portal (availity.com**), click on Payer Spaces in the menu bar and then click on the BCBSM and BCN logo. You’ll find links to the NovoLogix tools on the Applications tab.

Note: If you need to request access to our provider portal, follow the instructions on the Register for web tools webpage on bcbsm.com/providers.

List of requirements

For a list of requirements related to drugs covered under the medical benefit, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members.

Availity^® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal services.

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