Federal No Surprises Act prohibits ‘surprise billing’

Blue Cross Blue Shield of Michigan and Blue Care Network have made changes to align with the federal No Surprises Act, effective Jan. 1, 2022. The law, part of the Consolidated Appropriations Act, or CAA, prohibits surprise billing nationwide for emergency, some non-emergency and air ambulance services.  

Surprise billing is when a member unknowingly receives care from a health care provider who doesn’t participate with the member’s health insurance plan. The member then receives an unexpected bill for the difference between the health plan’s payment and what the health care provider charges. 

Blue Cross and BCN already align with the state surprise billing law, which went into effect Oct. 22, 2020. The state law prohibits surprise billing by Michigan nonparticipating professional providers for emergency services and some non-emergency services.  

As of Jan, 1, 2022, Blue Cross is handling claims according to the federal law for self-funded ERISA plans, grandfathered plans and federal health plans. We’re also following the federal law for fully insured plans and self-funded state or local government plans. However, these plans will still follow the state law for professional provider payment rates and arbitration procedures.  

Blue Cross maintains the broadest network of providers in Michigan, and helps ensure access to high-quality, in-network care across the country through our relationship with the Blue Cross Blue Shield Association. 

If you have questions, contact Provider Inquiry at the appropriate number below:

• Blue Cross Blue Shield of Michigan
• Michigan physicians and other professional providers of care: 1-800-344-8525
• Providers outside of Michigan: 1-800-676-2583
• Michigan hospital and facility providers: 1-800-249-5103
• Hospital and facility providers outside of Michigan: 1-800-676-2583

• Blue Care Network
• Professional providers: 1-800-344-8525
• Ancillary and facility providers:1-800-249-5103

Our self‑service tools can help you find answers to your questions

We encourage our provider community to use our self-service tools to avoid long wait times to reach a representative.

Blue Cross Blue Shield of Michigan is committed to helping you become more knowledgeable about such topics as claims, benefits, authorizations, referrals and medical policy.

When you contact Provider Inquiry, you have an opportunity to interact with our automated system before speaking with a service representative. We urge you to take advantage of that useful option.

Additional self-service tools include web-DENIS, Provider Secured Services, online provider manuals and ereferrals.bcbsm.com.

Here’s an overview of key resources:

Need contact information?

Eligibility and benefits:
Eligibility precertification and preauthorization contacts

Claims:
Claims submission and status contacts

Main contact page:
Contact Us

Have a question about authorizations and referrals?

Visit ereferrals.bcbsm.com before contacting Provider Inquiry. Select the Blue Cross or BCN tab. You’re likely to find your questions answered at this comprehensive site.

Have a medical policy question?

Check out our online provider manuals in one of two ways:

• After logging in as a provider at bcbsm.com, click on Provider Manuals in the lower right section of the page, or
• From the homepage of web-DENIS, click on Provider Manuals at the left.

Other resources

• Click on BCBSM Provider Publications and Resources and then Newsletters & Resources while in web-DENIS or BCN Provider Publications and Resources for a wealth of information.
• Blue Cross and BCN Provider Systems and Web Resources flyer

Get ready for Availity: Learn more about alerts and provider resources

This is part of a series of articles on our move to Availity^® for our provider portal.

After we transition to the Availity provider portal, you’ll still be able to access important alerts, resources and publications for Blue Cross Blue Shield of Michigan and Blue Care Network. However, how you find this information will change, and you’ll also see a new and improved look.

Currently, you read broadcast messages when you click on web-DENIS. They’re listed in the center of the screen under Welcome to web-DENIS. In the left navigation of web-DENIS, you can click on one of the following to find the information you need to do business with us:

• BCBSM Provider Publications and Resources
• BCN Provider Publications and Resources
• Provider Manuals

New way to find alerts and provider resources

After the transition to Availity, what you see now as web-DENIS broadcast messages will simply be called “alerts.” You’ll find them, along with provider publications, resources and manuals, within the Blue Cross and BCN payer space. After logging in to Availity, you’ll click on Payer Spaces on the top navigation bar, then click on BCBSM and BCN.

This will bring you to our payer space, which will include information for both Blue Cross and BCN. You’ll see three tabs:

• Applications — Our payer space will always open on the Applications tab. This is where you’ll find applications specific to Blue Cross and BCN. For example, you’ll find e-referral, Benefit Explainer, Health e-Blue℠, and Provider Enrollment and Change Self-Service.

• Resources — Clicking on the Resources tab will show you links to our websites and provider manuals where you can find important information you need.

• News and Announcements — This tab will connect you with our provider alerts, so you can find breaking or critical news you need to know.

Improvements

We’re working to make it easier for you to find what you need. For example, our new Provider Resources website will have information for both Blue Cross and BCN within a single site and will include a new search feature. You can access the website through the payer space Resources tab.

Also, within the payer space Applications and Resources tabs, you’ll be able to select specific items that you use frequently as “favorites.” They’ll be accessible from your Availity top navigation bar no matter where you are in the portal.

Questions?
If you have questions about the move to Availity, please check our Frequently Asked Questions document first. If your question isn’t already answered there, submit your question to ProviderPortalQuestions@bcbsm.com, so we can consider adding it to the FAQ document.

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

2022 HCPCS and CPT Update now available

Each year, we publish our HCPCS and CPT Update document, containing new and deleted HCPCS and CPT codes, and post it on web-DENIS.

To access the 2022 document, follow these steps:

1. From the homepage of web-DENIS, click on BCBSM Provider Publications and Resources.
2. Click on Newsletters and Resources.
3. Click on Clinical Criteria & Resources.
4. Scroll down to the HCPCS and CPT Updates section of the page.

You’ll want to use it as a reference guide for new CPT and HCPCS codes for 2022. As future updates occur throughout the year, we’ll publish Record articles that outline the changes.

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.

Medicare sequestration suspension extended through March 31, 2022

As you may recall, Blue Cross Blue Shield of Michigan and Blue Care Network aligned with the Centers for Medicare & Medicaid Services’ guidance when Congress and the Biden administration suspended the mandatory Medicare 2% sequestration reduction through the end of 2021.

Congress passed legislation on Dec. 9, 2021, that suspends the 2% sequestration reduction through March 31, 2022, and then reduces the sequestration cuts to 1% from April through June 2022. We’ll update you before July 2022 on the status of sequestration after June 30, 2022.

Reminder: The 2% reimbursement adjustment is applied after determining any applicable member deductible, copayment or other required member out-of-pocket costs. The change won’t affect reimbursement to providers who haven’t been affected by sequestration previously, such as providers of durable medical equipment, lab services providers and providers treating patients with end-stage renal disease.

Expansion of existing quantity limit includes new prescriptions for long‑acting opioids and tramadol

Blue Cross Blue Shield of Michigan and Blue Care Network are expanding the existing quantity limits on opioid medications to include long-acting opioids and tramadol. This expansion is in support of the Food and Drug Administration’s efforts to balance the serious risk of opioids with the drugs’ pain management benefits.

Starting Jan. 1, 2022, long-acting opioids and tramadol will have a five-day, first fill limit for commercial members with a new long-acting opioid or tramadol prescription. This change doesn’t apply to members currently taking a long-acting opioid or tramadol, or who are on Medicare.

Improved commercial utilization management medical drug list now available

We’ve published updated documents with utilization management information about drugs covered under the medical benefit for Blue Cross Blue Shield of Michigan and Blue Care Network members. We’ve made changes to the documents, based on feedback from providers and others, to make the information more accessible, clear and streamlined.

The redesigned Blue Cross and BCN utilization management medical drug list:

• Offers a fuller explanation of our medical drug utilization management programs for commercial members
• Indicates more clearly where to submit prior authorization requests — to AIM Specialty Health^® or through the NovoLogix^® online tool
• Specifies which drugs have prior authorization and site-of-care requirements
• Shows the preferred and nonpreferred products for drugs that we’ve designated as preferred products
• No longer contains medical policy information or documentation requirements information, which makes the list shorter and easier to use

The quantity limits information is in a separate document titled Blue Cross and BCN quantity limits for medical drugs. Here are highlights:

• It provides easier access for providers who need only the quantity limits.
• It indicates whether the quantity limits apply to in-state or out-of-state providers or both.
• The Blue Cross and BCN utilization management medical drug list includes a link to the Blue Cross and BCN quantity limits for medical drugs document in the introductory text and in the table heading on each page.

We make these lists available at ereferrals.bcbsm.com:

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

You’ll also be able to find these lists behind the provider portal.

We appreciate the feedback we received from the provider community, and welcome additional comments on the new documents. Blue Cross and BCN are committed to providing reliable, up-to-date, easy-to-use resources to help you navigate the medical-benefit drug utilization management programs we have in place.

Changes to prior authorization list for medical benefit drugs for Medicare Advantage members

We’ve added or removed prior authorization requirements for certain drugs for Medicare Plus Blue℠ and BCN Advantage℠ members as follows.

Additional drug requiring prior authorization

For dates of service on or after Dec. 27, 2021, Susvimo™ (ranibizumab injection, for ocular implant), HCPCS code J3590, requires prior authorization through the NovoLogix^® online tool.

NovoLogix offers real-time status checks and immediate approvals for certain medications. If you have access to Provider Secured Services, you already have access to NovoLogix. If you need to request access to Provider Secured Services, complete the Provider Secured Access Application form and fax it to the number on the form.

We require prior authorization for this drug when it’s administered by a health care professional in a provider office, at the member’s home, in an off-campus or on-campus outpatient hospital or in an ambulatory surgical center (place of service codes 11, 12, 19, 22 and 24) and billed as follows:

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

Drug that no longer requires prior authorization

For dates of service on or after Dec. 1, 2021, Tegsedi^® (inotersen), HCPCS code J3490, no longer requires prior authorization.

List of requirements

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

Changes coming to medical oncology prior authorization list for URMBT members with Blue Cross non‑Medicare plans

For dates of service on or after Feb. 21, 2022, additional drugs will require prior authorization and some drugs will no longer require prior authorization for UAW Retiree Medical Benefits Trust members with Blue Cross Blue Shield of Michigan non-Medicare plans.

Additional drugs to require prior authorization

For dates of service on or after Feb. 21, 2022, we’re adding prior authorization requirements for the following drugs covered under the medical benefit for URMBT members with Blue Cross non-Medicare plans:

• Khapzory™ (levoleucovorin), HCPCS code J0642
• Neupogen^® (filgrastim), HCPCS code J1442

Submit prior authorization requests through AIM Specialty Health^® using one of the following methods:

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

Notes:

• Prior authorization requirements apply when these drugs are administered in an outpatient setting.
• This requirement doesn’t apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714).
• AIM is an independent company that contracts with Blue Cross Blue Shield of Michigan to provide benefit management services.

Drugs that will no longer require prior authorization

For dates of service on or after Feb. 21, 2022, we’re removing prior authorization requirements for the following drugs covered under the medical benefit for URMBT members with Blue Cross non-Medicare plans:

• Nivestym^® (filgrastim-aafi), HCPCS code Q5110
• Udenyca^® (pegfilgrastim-cbqv), HCPCS code Q5111
• Ziextenzo^® (pegfilgrastim-bmez), HCPCS code Q5120

More about authorization requirements

Authorization isn’t a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members.

For additional information on requirements related to drugs covered under the medical benefit for UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans, see:

• Medical oncology prior authorization list for UAW Retiree Medical Benefits Trust PPO non-Medicare members
• Medical Drug Management with Blue Cross for UAW Retiree Medical Benefit Trust PPO non-Medicare Members

We’ll update the appropriate drug lists to reflect the information in this message prior to the effective date.

Note: Accredo, an independent company that works with the URMBT on specialty pharmacy services, manages prior authorization requests for additional medical benefit drugs.

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

Radiology procedure code *71271 will require prior authorization for most Blue Cross, BCN members

AIM Specialty Health^® currently requires prior authorization for radiology procedure code *71271 for most Blue Cross Blue Shield of Michigan commercial members. Effective with dates of service on or after March 1, 2022, AIM will also require prior authorization for radiology procedure code *71271 for the following health plans:

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

Prior authorization will be required to ensure that claims are eligible for reimbursement.

Submitting prior authorization requests

Submit prior authorization requests to AIM. For information on how to submit requests and for other resources, visit these webpages on our ereferrals.bcbsm.com website:

• AIM-managed procedures for Blue Cross members
• AIM-managed procedures for BCN members

We’ve updated the list of procedures that require prior authorization by AIM to reflect this requirement.

Additional information

As a reminder, AIM manages authorizations for various Blue Cross commercial, Medicare Plus Blue, BCN commercial and BCN Advantage members for these services:

• Select cardiology and radiology services
• Medical oncology and supportive care drugs
• High-tech radiology
• In-lab sleep management
• Radiation oncology

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.

Reminder: Our transition to OptumRx

Blue Cross Blue Shield of Michigan and Blue Care Network are transitioning to a new pharmacy benefit manager, moving from Express Scripts, Inc. to OptumRx. This change will take place on Jan. 1, 2022, for commercial individual and group members, and Jan. 1, 2023, for Medicare Advantage individual and group members.

We anticipate the bulk of the transition will be seamless for our members and health care providers. However, members using our current home delivery pharmacy to fill a prescription for a controlled substance — or those with expired prescriptions or prescriptions without refills — should ask their doctor to write a new prescription so it can be filled by OptumRx home delivery pharmacy, starting Jan. 1.

As part of the transition, we’ve mailed about 1.8 million new ID cards to members. Members must show their new cards at the pharmacy starting Jan. 1 to help ensure their prescriptions are covered correctly under their benefits.

We’ve also made some enhancements to our provider-facing tools to assist with prescribing and submitting prior authorizations electronically.

These enhancements will primarily take place behind the scenes and won’t have a major effect on how providers prescribe and submit prior authorizations or check on patients’ benefits.

Continue to use your current electronic medical record system or CoverMyMeds^® to submit electronic prior authorizations for Blue Cross and BCN members. Keep in mind that the BIN number changes to 610011, effective Jan. 1, 2022, for all Blue Cross and BCN commercial members.

Need more information?

• For more information on ePA and CoverMyMeds, see our ePA flyer.
• For more information on the transition to OptumRx, see the September issue of The Record and the November-December issue of Hospital and Physician Update.

Here are the 2022 FEP Blue Cross and Blue Shield Service Benefit Plan benefit changes

Blue Cross and Blue Shield Federal Employee Program^® Service Benefit Plan 2022 benefit changes will take effect Jan. 1, 2022. Below is an overview of the benefit changes.

Breast pump

• Standard Option, Basic Option and FEP Blue Focus
• The selection of breast pumps is expanding. Each breast pump will come with a selection of milk storage bags.

Dental – accidental injury

• Basic Option
• Coinsurance of 30% for all covered dental codes except for the oral examination to promptly repair injury.

Oral/maxillofacial surgery

• Standard Option and Basic Option
• Prior approval is no longer needed for surgery to correct accidental injuries to jaws, cheeks, lips, tongue, roof and floor of mouth for care provided within 72 hours of the accidental injury.

EKG

• Standard Option, Basic Option and FEP Blue Focus
• EKGs will be covered under the regular medical benefits instead of preventive benefits.

Facility

• Standard Option
• For admission to a participating or non-participating facility due to a medical emergency or accidental injury, copayment is reduced to $350 per admission for unlimited days, then benefits cover 100% of the plan allowance.

Gender reassignment surgery

• Standard Option, Basic Option and FEP Blue Focus
• Reconstruction of the nipple after a mastectomy for female to male gender reassignment surgery is covered.

Group counseling

• Standard Option, Basic Option and FEP Blue Focus
• Group counseling for prevention and reduction of health risks, and group nutritional counseling will be covered under the preventive benefit, with no out-of-pocket cost to members who see a Preferred provider.
  

Pharmacy

• Standard Option, Basic Option and FEP Blue Focus
• Tubeless insulin pumps covered under the Tier 2 and Tier 3 pharmacy benefits for Standard and Basic Option members. FEP Blue Focus members will pay a Tier 2 copayment.
• Specialty Pharmacy Program will be administered by CVS Caremark®.
• Standard Option only
• Updates made to the approved drug lists
• Basic Option only
• Copayment changes for members without Medicare Part B
• Tier 4 Preferred specialty drug copayment is now $85 and limited to one purchase of up to a 30-day supply at a Preferred retail pharmacy. All refills must be obtained through the Specialty Pharmacy Program.
• Tier 5 Non-preferred specialty drug copayment is now $110 and limited to one purchase of up to a 30-day supply at a Preferred retail pharmacy. All refills must be obtained through the Specialty Pharmacy Program.
• Copayment changes for members with Medicare Part B primary
• Tier 4 Preferred specialty drug copayment is now $80 and limited to one purchase of up to a 30-day supply at a Preferred retail pharmacy. All refills must be obtained through the Specialty Pharmacy Program.
• Tier 5 Non-preferred specialty drug copayment is now a $100 and limited to one purchase of up to a 30-day supply at a Preferred retail pharmacy. All refills must be obtained through the Specialty Pharmacy Program.
• Updates made to the approved drug lists
• FEP Blue Focus only
• Walgreens^® and Duane Reade^® pharmacies are no longer in network.
• Members must use in-network pharmacies for their pharmacy benefit.
• Updates made to the approved drug lists

Transplants – Blue Distinction^® Centers

• Standard Option and Basic Option
• Kidney transplants now part of the Blue Distinction Centers for Transplant  Program and require prior approval.
• Standard Option, Basic Option and FEP Blue Focus
• Pancreas transplants will no longer be part of the Blue Distinction Centers for Transplants Program.

For complete 2022 Blue Cross and Blue Shield Service Benefit Plan benefit information, go to www.fepblue.org/brochure or call Customer Service at 1-800-482-3600.

Coding Advisor continuing 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 Current Procedural Terminology, or 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 modifier 25, observation care and nursing facility care — on claims submitted to Blue Cross. The program provides useful data insights to the provider community and works to maximize coding efficiency and accuracy through up-front education, rather than a traditional postclaim review process.

Effective Jan. 1, 2022, the Coding Advisor program will expand to include Blue Care Network and BCN Advantage℠. 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

In January, Change Healthcare will reach out by phone or letter to providers who submit claims to Blue Cross and BCN. Coding Advisor will compare the billing of CPT codes to the codes used by a provider’s peers through a physician profile.

For your reference, we’ve included an example of a physician profile at the end of this article.

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

If you have any questions, call the Coding Advisor customer support line at
1-844-592-7009 and select option 3.

Example of a physician profile:

New on‑demand training available

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

We recently added two new webinars to our list of 2021 lunch and learn webinar recordings:

• Coding Scenarios for Primary Care and Specialty — This webinar shares best practices and a detailed scenario review for common coding errors.
• Evaluation and Management Coding Tips — This webinar focuses on best practices and coding tips for 2021 E&M changes.

We also added an updated online course:

Provider Enrollment and Self-service Tool — This course consists of 16 modules that walk you through the major functions and tasks of this tool.

To request access to our training site, follow these steps:

• Open the registration page.
• 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.
• Follow the link to log in.

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

Reminder: Register for Transitions of Care HEDIS measure webinar

As we told you in the December 2021 Record, we’re introducing a new Medicare Star Ratings measure: the HEDIS^® measure called Transitions of Care. The measure has four key components. This short video will explain the measure and help you avoid gaps in care.

Register and attend a webinar
Learn more about Transitions of Care, including requirements and coding tips. To register, click on a sign-up link below.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance.

Remember to conduct annual wellness visits for your Medicare Advantage patients

Blue Cross Blue Shield of Michigan and Blue Care Network cover annual wellness visits with no out-of-pocket costs for Medicare Plus Blue℠ and BCN Advantage℠ individual and group members. Members are eligible for an annual wellness visit if they’ve had Medicare Part B for longer than 12 months.

These visits involve developing or updating a personalized prevention plan services and conducting a health risk assessment for your patients. Providers can complete the annual wellness visit in the following locations: provider’s office, outpatient hospital or a patient’s home.

Services include:

• An age- and gender-appropriate physical exam (including vital signs and measurements) and a cognitive assessment
• Guidance, counseling and risk-factor reduction interventions
• Administration or ordering of immunizations, lab tests or diagnostic procedures

Blue Cross recognizes the importance of preventive care to our members' health and encourages providers to discuss with their patients the risk factors identified in the assessments.

For additional information, including how to bill the initial and subsequent annual wellness visits, refer to Medicare Wellness Visits,** on the Centers for Medicare & Medicaid Services’ Medicare Learning Network webpage.

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

Reminder: Optum provides claim editing for professional and facility claims

In November 2021, Optum began editing commercial claims for Blue Cross Blue Shield of Michigan professional and facility providers. We initially informed you of our partnership with Optum for enhanced claim editing in the August edition of The Record.

Health care providers will see these new edits as we continue our ongoing effort to promote correct coding and enhance our claims payment systems. You'll be able to recognize the edits by the unique provider message codes K500 through K544.

The Optum medical records request component of this initiative is expected to begin during the first quarter of 2022.

If you receive one of these edits, submit a corrected claim when appropriate. Providers should continue to follow the current clinical editing appeals process if they believe the services rendered warrant an exception.

Reminder: Update Provider Authorization form when changes occur

Blue Cross Blue Shield of Michigan is dedicated to safeguarding the protected health information of its members. These safeguards include completion of a Trading Partner Agreement and Provider Authorization form as part of the electronic data interchange setup process. All EDI trading partners must complete a 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 updated. Updating the form also ensures information is routed to the proper destination.

Update the form when you decide you no longer want to receive 835 remittance files or when you switch:

• Service bureaus or clearinghouses
• Software vendors
• Billing services
• Submitter IDs
• 835 file recipients
• Unique 835 receivers or trading partner IDs

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.
Or follow the complete navigation steps to arrive at the TPA login page:

1. Visit bcbsm.com/providers.
2. Scroll down to the Provider resources section and click on Quick Links.
3. Click on Electronic Connectivity EDI.
4. Click on How to use EDI to exchange information with us electronically.
5. Scroll down to the EDI agreements section and click on Update your Provider Authorization Form.

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.

Improved commercial utilization management medical drug list now available

We’ve published updated documents with utilization management information about drugs covered under the medical benefit for Blue Cross Blue Shield of Michigan and Blue Care Network members. We’ve made changes to the documents, based on feedback from providers and others, to make the information more accessible, clear and streamlined.

The redesigned Blue Cross and BCN utilization management medical drug list:

• Offers a fuller explanation of our medical drug utilization management programs for commercial members
• Indicates more clearly where to submit prior authorization requests — to AIM Specialty Health^® or through the NovoLogix^® online tool
• Specifies which drugs have prior authorization and site-of-care requirements
• Shows the preferred and nonpreferred products for drugs that we’ve designated as preferred products
• No longer contains medical policy information or documentation requirements information, which makes the list shorter and easier to use

The quantity limits information is in a separate document titled Blue Cross and BCN quantity limits for medical drugs. Here are highlights:

• It provides easier access for providers who need only the quantity limits.
• It indicates whether the quantity limits apply to in-state or out-of-state providers or both.
• The Blue Cross and BCN utilization management medical drug list includes a link to the Blue Cross and BCN quantity limits for medical drugs document in the introductory text and in the table heading on each page.

We make these lists available at ereferrals.bcbsm.com:

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

You’ll also be able to find these lists behind the provider portal.

We appreciate the feedback we received from the provider community, and welcome additional comments on the new documents. Blue Cross and BCN are committed to providing reliable, up-to-date, easy-to-use resources to help you navigate the medical-benefit drug utilization management programs we have in place.

Changes to prior authorization list for medical benefit drugs for Medicare Advantage members

We’ve added or removed prior authorization requirements for certain drugs for Medicare Plus Blue℠ and BCN Advantage℠ members as follows.

Additional drug requiring prior authorization

For dates of service on or after Dec. 27, 2021, Susvimo™ (ranibizumab injection, for ocular implant), HCPCS code J3590, requires prior authorization through the NovoLogix^® online tool.

NovoLogix offers real-time status checks and immediate approvals for certain medications. If you have access to Provider Secured Services, you already have access to NovoLogix. If you need to request access to Provider Secured Services, complete the Provider Secured Access Application form and fax it to the number on the form.

We require prior authorization for this drug when it’s administered by a health care professional in a provider office, at the member’s home, in an off-campus or on-campus outpatient hospital or in an ambulatory surgical center (place of service codes 11, 12, 19, 22 and 24) and billed as follows:

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

Drug that no longer requires prior authorization

For dates of service on or after Dec. 1, 2021, Tegsedi^® (inotersen), HCPCS code J3490, no longer requires prior authorization.

List of requirements

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

Changes coming to medical oncology prior authorization list for URMBT members with Blue Cross non‑Medicare plans

For dates of service on or after Feb. 21, 2022, additional drugs will require prior authorization and some drugs will no longer require prior authorization for UAW Retiree Medical Benefits Trust members with Blue Cross Blue Shield of Michigan non-Medicare plans.

Additional drugs to require prior authorization

For dates of service on or after Feb. 21, 2022, we’re adding prior authorization requirements for the following drugs covered under the medical benefit for URMBT members with Blue Cross non-Medicare plans:

• Khapzory™ (levoleucovorin), HCPCS code J0642
• Neupogen^® (filgrastim), HCPCS code J1442

Submit prior authorization requests through AIM Specialty Health^® using one of the following methods:

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

Notes:

• Prior authorization requirements apply when these drugs are administered in an outpatient setting.
• This requirement doesn’t apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714).
• AIM is an independent company that contracts with Blue Cross Blue Shield of Michigan to provide benefit management services.

Drugs that will no longer require prior authorization

For dates of service on or after Feb. 21, 2022, we’re removing prior authorization requirements for the following drugs covered under the medical benefit for URMBT members with Blue Cross non-Medicare plans:

• Nivestym^® (filgrastim-aafi), HCPCS code Q5110
• Udenyca^® (pegfilgrastim-cbqv), HCPCS code Q5111
• Ziextenzo^® (pegfilgrastim-bmez), HCPCS code Q5120

More about authorization requirements

Authorization isn’t a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members.

For additional information on requirements related to drugs covered under the medical benefit for UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans, see:

• Medical oncology prior authorization list for UAW Retiree Medical Benefits Trust PPO non-Medicare members
• Medical Drug Management with Blue Cross for UAW Retiree Medical Benefit Trust PPO non-Medicare Members

We’ll update the appropriate drug lists to reflect the information in this message prior to the effective date.

Note: Accredo, an independent company that works with the URMBT on specialty pharmacy services, manages prior authorization requests for additional medical benefit drugs.

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

Radiology procedure code *71271 will require prior authorization for most Blue Cross, BCN members

AIM Specialty Health^® currently requires prior authorization for radiology procedure code *71271 for most Blue Cross Blue Shield of Michigan commercial members. Effective with dates of service on or after March 1, 2022, AIM will also require prior authorization for radiology procedure code *71271 for the following health plans:

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

Prior authorization will be required to ensure that claims are eligible for reimbursement.

Submitting prior authorization requests

Submit prior authorization requests to AIM. For information on how to submit requests and for other resources, visit these webpages on our ereferrals.bcbsm.com website:

• AIM-managed procedures for Blue Cross members
• AIM-managed procedures for BCN members

We’ve updated the list of procedures that require prior authorization by AIM to reflect this requirement.

Additional information

As a reminder, AIM manages authorizations for various Blue Cross commercial, Medicare Plus Blue, BCN commercial and BCN Advantage members for these services:

• Select cardiology and radiology services
• Medical oncology and supportive care drugs
• High-tech radiology
• In-lab sleep management
• Radiation oncology

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.

Here are the 2022 FEP Blue Cross and Blue Shield Service Benefit Plan benefit changes

Blue Cross and Blue Shield Federal Employee Program^® Service Benefit Plan 2022 benefit changes will take effect Jan. 1, 2022. Below is an overview of the benefit changes.

Breast pump

• Standard Option, Basic Option and FEP Blue Focus
• The selection of breast pumps is expanding. Each breast pump will come with a selection of milk storage bags.

Dental – accidental injury

• Basic Option
• Coinsurance of 30% for all covered dental codes except for the oral examination to promptly repair injury.

Oral/maxillofacial surgery

• Standard Option and Basic Option
• Prior approval is no longer needed for surgery to correct accidental injuries to jaws, cheeks, lips, tongue, roof and floor of mouth for care provided within 72 hours of the accidental injury.

EKG

• Standard Option, Basic Option and FEP Blue Focus
• EKGs will be covered under the regular medical benefits instead of preventive benefits.

Facility

• Standard Option
• For admission to a participating or non-participating facility due to a medical emergency or accidental injury, copayment is reduced to $350 per admission for unlimited days, then benefits cover 100% of the plan allowance.

Gender reassignment surgery

• Standard Option, Basic Option and FEP Blue Focus
• Reconstruction of the nipple after a mastectomy for female to male gender reassignment surgery is covered.

Group counseling

• Standard Option, Basic Option and FEP Blue Focus
• Group counseling for prevention and reduction of health risks, and group nutritional counseling will be covered under the preventive benefit, with no out-of-pocket cost to members who see a Preferred provider.
  

Pharmacy

• Standard Option, Basic Option and FEP Blue Focus
• Tubeless insulin pumps covered under the Tier 2 and Tier 3 pharmacy benefits for Standard and Basic Option members. FEP Blue Focus members will pay a Tier 2 copayment.
• Specialty Pharmacy Program will be administered by CVS Caremark®.
• Standard Option only
• Updates made to the approved drug lists
• Basic Option only
• Copayment changes for members without Medicare Part B
• Tier 4 Preferred specialty drug copayment is now $85 and limited to one purchase of up to a 30-day supply at a Preferred retail pharmacy. All refills must be obtained through the Specialty Pharmacy Program.
• Tier 5 Non-preferred specialty drug copayment is now $110 and limited to one purchase of up to a 30-day supply at a Preferred retail pharmacy. All refills must be obtained through the Specialty Pharmacy Program.
• Copayment changes for members with Medicare Part B primary
• Tier 4 Preferred specialty drug copayment is now $80 and limited to one purchase of up to a 30-day supply at a Preferred retail pharmacy. All refills must be obtained through the Specialty Pharmacy Program.
• Tier 5 Non-preferred specialty drug copayment is now a $100 and limited to one purchase of up to a 30-day supply at a Preferred retail pharmacy. All refills must be obtained through the Specialty Pharmacy Program.
• Updates made to the approved drug lists
• FEP Blue Focus only
• Walgreens^® and Duane Reade^® pharmacies are no longer in network.
• Members must use in-network pharmacies for their pharmacy benefit.
• Updates made to the approved drug lists

Transplants – Blue Distinction^® Centers

• Standard Option and Basic Option
• Kidney transplants now part of the Blue Distinction Centers for Transplant  Program and require prior approval.
• Standard Option, Basic Option and FEP Blue Focus
• Pancreas transplants will no longer be part of the Blue Distinction Centers for Transplants Program.

For complete 2022 Blue Cross and Blue Shield Service Benefit Plan benefit information, go to www.fepblue.org/brochure or call Customer Service at 1-800-482-3600.

Coming later in 2022: Coding update for Medicare Plus Blue outpatient emergency department claims

Blue Cross Blue Shield of Michigan will enhance its claim editing process later this year for evaluation and management services on outpatient facility emergency department claims for Medicare Plus Blue℠ members. We’re making this update to promote correct coding and assist with payment accuracy.

This coding update focuses on outpatient facility emergency department claims that are submitted with Level 4 (*99284, G0383) or Level 5 (*99285, G0384) E/M codes. The process was developed to address inconsistencies in coding accuracy nationwide.

It’s based on the E/M coding principles developed by the Centers for Medicare & Medicaid Services. These principles help ensure that hospital emergency department E/M coding guidelines follow the intent of Current Procedural Terminology, or CPT^®, code descriptions and relate to hospital resource use. 

CPT code levels:

• *99281 — ER visit for the evaluation and management of a patient (Level 1)
• *99282 — ER visit for the evaluation and management of a patient (Level 2)
• *99283 — ER visit for the evaluation and management of a patient (Level 3)
• *99284 — ER visit for the evaluation and management of a patient (Level 4)
• *99285 — ER visit for the evaluation and management of a patient (Level 5)

This coding update will apply to all facilities, including freestanding facilities, that submit outpatient emergency department claims with Level 4 or Level 5 E/M codes. The facilities may experience adjustments to the submitted code to reflect an appropriate-level E/M code.

Optum EDC Analyzer™ tool

As part of the implementation of this process, we’ll begin using the Optum EDC Analyzer tool. The tool determines appropriate E/M coding levels based on data from a patient’s claim, and includes the following: 

• Patient’s presenting problem
• Diagnostic services performed during the visit
• Any of the patient’s complicating conditions

To learn more about the EDC Analyzer tool — and even try running a claim through the tool — visit EDCAnalyzer.com.**

Exclusions
Criteria that may exclude outpatient facility claims from these policies include, but are not limited to:

• Claims for patients who were admitted from the emergency department or transferred to another health care setting (for example: a skilled nursing facility or long-term care hospital)
• Claims for patients who received critical care services (*99291, *99292)
• Claims for patients who are younger than 2 years old
• Claims with certain diagnosis codes that when treated in the emergency department most often necessitate greater-than-average resource usage, such as significant nursing time
• Claims for patients who died in the emergency department

Ultimately, the goal of facility coding is to accurately capture emergency department resource utilization and align that with the E/M CPT^® code description for a patient visit per CMS guidance.

Note: The appeal process won’t change. Submitters who believe a higher-level E/M code is justified for the outpatient emergency department visit should send an appeal on the Clinical Editing Appeal Form with the necessary documentation. Remember to 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.

New billing guidelines for cystourethroscopy procedures

Blue Cross Blue Shield of Michigan has discontinued using cystourethroscopy procedure codes *52441 and *52442. These codes are being turned off and replaced with Level II HCPCS procedure codes C9739 and C9740 to accommodate the appropriate reimbursement for multiple quantities.

Facilities should report C9739 when performing a single implant and C9740 for each additional permanent adjustable implant, along with the applicable quantity.

The effective date of this change is retroactive to Jan. 1, 2020, to accommodate the resubmission of claims where the appropriate reimbursement was affected by multiple quantities. Facilities may resubmit claims processed for dates of service Jan. 1, 2020, through the present.  

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.

New on‑demand training available

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

We recently added two new webinars to our list of 2021 lunch and learn webinar recordings:

• Coding Scenarios for Primary Care and Specialty — This webinar shares best practices and a detailed scenario review for common coding errors.
• Evaluation and Management Coding Tips — This webinar focuses on best practices and coding tips for 2021 E&M changes.

We also added an updated online course:

Provider Enrollment and Self-service Tool — This course consists of 16 modules that walk you through the major functions and tasks of this tool.

To request access to our training site, follow these steps:

• Open the registration page.
• 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.
• Follow the link to log in.

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

Reminder: Register for Transitions of Care HEDIS measure webinar

As we told you in the December 2021 Record, we’re introducing a new Medicare Star Ratings measure: the HEDIS^® measure called Transitions of Care. The measure has four key components. This short video will explain the measure and help you avoid gaps in care.

Register and attend a webinar
Learn more about Transitions of Care, including requirements and coding tips. To register, click on a sign-up link below.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance.

Additional update: We’re aligning local rules for acute inpatient medical admissions

For certain conditions, authorization requests for acute medical admissions should be submitted only after the member has spent two days in the hospital. Once two days has elapsed, the facility can submit the request to authorize an inpatient admission on the third day. You must provide clinical documentation that demonstrates that the InterQual^® criteria have been met at the time you submit the request.

Exception: When a member is receiving intensive care services that require a critical care setting, you can submit the request prior to completion of the two-day period, along with all clinical documentation supporting the critical level of care. 

We’re aligning our local rules for all lines of business to reflect this change.

Effective date for this change

This update to local rules will go into for all members on or after March 1, 2022.

This applies to members with the following conditions:

How determinations will be made

Blue Cross and BCN will conduct a medical necessity review based on the clinical documentation you submitted. InterQual criteria will be applied based on the member’s condition at the time the clinical documentation is received:

• If InterQual criteria are met, the authorization request will be approved.
• If InterQual criteria aren’t met, the authorization request will be sent to the plan medical director for review.
• If the member hasn’t been in the hospital for 48 hours and isn’t in the ICU, Blue Cross and BCN will request that the facility wait until the member has been in the hospital for 48 hours to send additional information about the member’s condition. We’ll make the request through the Case Communication field in the e-referral system or by calling the facility, or both.

After receiving the request from the hospital on the third day, Blue Cross and BCN will do the following:

• If the facility sent additional clinical information and it meets criteria, we’ll approve the request.
• If the facility hasn’t sent additional clinical information or has sent additional clinical information but it doesn’t meet criteria, we’ll refer the request to the medical director for review.

For requests that are nonapproved, Blue Cross and BCN will reimburse as observation. The hospital will need to submit a claim for observation reimbursement.

Reason for change

We expect that this change will:

• Reduce the number of communications that typically accompany these types of authorization requests.
• Decrease denials for lack of clinical information because all clinical documentation in support of the admission would be received after two days of hospital care.
• Ensure appropriate reimbursement (inpatient versus observation level of care).

Additional information

For most members, facilities can request peer-to-peer reviews, if desired. Refer to the document How to request a peer-to-peer review with a Blue Cross or BCN medical director.

In addition, facilities can appeal denial decisions as usual. Refer to the provider manual for information on how to submit an appeal.

Reminder: Optum provides claim editing for professional and facility claims

In November 2021, Optum began editing commercial claims for Blue Cross Blue Shield of Michigan professional and facility providers. We initially informed you of our partnership with Optum for enhanced claim editing in the August edition of The Record.

Health care providers will see these new edits as we continue our ongoing effort to promote correct coding and enhance our claims payment systems. You'll be able to recognize the edits by the unique provider message codes K500 through K544.

The Optum medical records request component of this initiative is expected to begin during the first quarter of 2022.

If you receive one of these edits, submit a corrected claim when appropriate. Providers should continue to follow the current clinical editing appeals process if they believe the services rendered warrant an exception.

Reminder: Update Provider Authorization form when changes occur

Blue Cross Blue Shield of Michigan is dedicated to safeguarding the protected health information of its members. These safeguards include completion of a Trading Partner Agreement and Provider Authorization form as part of the electronic data interchange setup process. All EDI trading partners must complete a 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 updated. Updating the form also ensures information is routed to the proper destination.

Update the form when you decide you no longer want to receive 835 remittance files or when you switch:

• Service bureaus or clearinghouses
• Software vendors
• Billing services
• Submitter IDs
• 835 file recipients
• Unique 835 receivers or trading partner IDs

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.
Or follow the complete navigation steps to arrive at the TPA login page:

1. Visit bcbsm.com/providers.
2. Scroll down to the Provider resources section and click on Quick Links.
3. Click on Electronic Connectivity EDI.
4. Click on How to use EDI to exchange information with us electronically.
5. Scroll down to the EDI agreements section and click on Update your Provider Authorization Form.

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.

Expansion of existing quantity limit includes new prescriptions for long‑acting opioids and tramadol

Blue Cross Blue Shield of Michigan and Blue Care Network are expanding the existing quantity limits on opioid medications to include long-acting opioids and tramadol. This expansion is in support of the Food and Drug Administration’s efforts to balance the serious risk of opioids with the drugs’ pain management benefits.

Starting Jan. 1, 2022, long-acting opioids and tramadol will have a five-day, first fill limit for commercial members with a new long-acting opioid or tramadol prescription. This change doesn’t apply to members currently taking a long-acting opioid or tramadol, or who are on Medicare.

Improved commercial utilization management medical drug list now available

We’ve published updated documents with utilization management information about drugs covered under the medical benefit for Blue Cross Blue Shield of Michigan and Blue Care Network members. We’ve made changes to the documents, based on feedback from providers and others, to make the information more accessible, clear and streamlined.

The redesigned Blue Cross and BCN utilization management medical drug list:

• Offers a fuller explanation of our medical drug utilization management programs for commercial members
• Indicates more clearly where to submit prior authorization requests — to AIM Specialty Health^® or through the NovoLogix^® online tool
• Specifies which drugs have prior authorization and site-of-care requirements
• Shows the preferred and nonpreferred products for drugs that we’ve designated as preferred products
• No longer contains medical policy information or documentation requirements information, which makes the list shorter and easier to use

The quantity limits information is in a separate document titled Blue Cross and BCN quantity limits for medical drugs. Here are highlights:

• It provides easier access for providers who need only the quantity limits.
• It indicates whether the quantity limits apply to in-state or out-of-state providers or both.
• The Blue Cross and BCN utilization management medical drug list includes a link to the Blue Cross and BCN quantity limits for medical drugs document in the introductory text and in the table heading on each page.

We make these lists available at ereferrals.bcbsm.com:

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

You’ll also be able to find these lists behind the provider portal.

We appreciate the feedback we received from the provider community, and welcome additional comments on the new documents. Blue Cross and BCN are committed to providing reliable, up-to-date, easy-to-use resources to help you navigate the medical-benefit drug utilization management programs we have in place.

Changes to prior authorization list for medical benefit drugs for Medicare Advantage members

We’ve added or removed prior authorization requirements for certain drugs for Medicare Plus Blue℠ and BCN Advantage℠ members as follows.

Additional drug requiring prior authorization

For dates of service on or after Dec. 27, 2021, Susvimo™ (ranibizumab injection, for ocular implant), HCPCS code J3590, requires prior authorization through the NovoLogix^® online tool.

NovoLogix offers real-time status checks and immediate approvals for certain medications. If you have access to Provider Secured Services, you already have access to NovoLogix. If you need to request access to Provider Secured Services, complete the Provider Secured Access Application form and fax it to the number on the form.

We require prior authorization for this drug when it’s administered by a health care professional in a provider office, at the member’s home, in an off-campus or on-campus outpatient hospital or in an ambulatory surgical center (place of service codes 11, 12, 19, 22 and 24) and billed as follows:

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

Drug that no longer requires prior authorization

For dates of service on or after Dec. 1, 2021, Tegsedi^® (inotersen), HCPCS code J3490, no longer requires prior authorization.

List of requirements

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

Changes coming to medical oncology prior authorization list for URMBT members with Blue Cross non‑Medicare plans

For dates of service on or after Feb. 21, 2022, additional drugs will require prior authorization and some drugs will no longer require prior authorization for UAW Retiree Medical Benefits Trust members with Blue Cross Blue Shield of Michigan non-Medicare plans.

Additional drugs to require prior authorization

For dates of service on or after Feb. 21, 2022, we’re adding prior authorization requirements for the following drugs covered under the medical benefit for URMBT members with Blue Cross non-Medicare plans:

• Khapzory™ (levoleucovorin), HCPCS code J0642
• Neupogen^® (filgrastim), HCPCS code J1442

Submit prior authorization requests through AIM Specialty Health^® using one of the following methods:

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

Notes:

• Prior authorization requirements apply when these drugs are administered in an outpatient setting.
• This requirement doesn’t apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714).
• AIM is an independent company that contracts with Blue Cross Blue Shield of Michigan to provide benefit management services.

Drugs that will no longer require prior authorization

For dates of service on or after Feb. 21, 2022, we’re removing prior authorization requirements for the following drugs covered under the medical benefit for URMBT members with Blue Cross non-Medicare plans:

• Nivestym^® (filgrastim-aafi), HCPCS code Q5110
• Udenyca^® (pegfilgrastim-cbqv), HCPCS code Q5111
• Ziextenzo^® (pegfilgrastim-bmez), HCPCS code Q5120

More about authorization requirements

Authorization isn’t a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members.

For additional information on requirements related to drugs covered under the medical benefit for UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans, see:

• Medical oncology prior authorization list for UAW Retiree Medical Benefits Trust PPO non-Medicare members
• Medical Drug Management with Blue Cross for UAW Retiree Medical Benefit Trust PPO non-Medicare Members

We’ll update the appropriate drug lists to reflect the information in this message prior to the effective date.

Note: Accredo, an independent company that works with the URMBT on specialty pharmacy services, manages prior authorization requests for additional medical benefit drugs.

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

Reminder: Our transition to OptumRx

Blue Cross Blue Shield of Michigan and Blue Care Network are transitioning to a new pharmacy benefit manager, moving from Express Scripts, Inc. to OptumRx. This change will take place on Jan. 1, 2022, for commercial individual and group members, and Jan. 1, 2023, for Medicare Advantage individual and group members.

We anticipate the bulk of the transition will be seamless for our members and health care providers. However, members using our current home delivery pharmacy to fill a prescription for a controlled substance — or those with expired prescriptions or prescriptions without refills — should ask their doctor to write a new prescription so it can be filled by OptumRx home delivery pharmacy, starting Jan. 1.

As part of the transition, we’ve mailed about 1.8 million new ID cards to members. Members must show their new cards at the pharmacy starting Jan. 1 to help ensure their prescriptions are covered correctly under their benefits.

We’ve also made some enhancements to our provider-facing tools to assist with prescribing and submitting prior authorizations electronically.

These enhancements will primarily take place behind the scenes and won’t have a major effect on how providers prescribe and submit prior authorizations or check on patients’ benefits.

Continue to use your current electronic medical record system or CoverMyMeds^® to submit electronic prior authorizations for Blue Cross and BCN members. Keep in mind that the BIN number changes to 610011, effective Jan. 1, 2022, for all Blue Cross and BCN commercial members.

Need more information?

• For more information on ePA and CoverMyMeds, see our ePA flyer.
• For more information on the transition to OptumRx, see the September issue of The Record and the November-December issue of Hospital and Physician Update.