Program provides mobile crisis assessment and stabilization for mental health and substance use

As you may have read last September in The Record, Blue Cross Blue Shield of Michigan began offering a new method of obtaining crisis assessment and stabilization services for mental health and substance use, effective Oct. 1, 2021. This article provides additional details.

Our mobile crisis and crisis stabilization services help ensure that our Blue Cross and Blue Care Network commercial members who are in crisis get prompt and appropriate behavioral health treatment. These services can also help members avoid emergency room visits for mental health issues and substance use disorder, as well as unnecessary hospitalizations.

Central to the success of the program has been the establishment of facilities that provide high-quality mobile crisis and crisis stabilization services. Currently two facilities in Southeast Michigan meet the criteria to provide these services as part of our program: Common Ground Resources and Crisis Center, and Hegira Health’s COPE, which stands for Community Outreach for Psychiatric Emergencies.

Here’s additional information about these centers:

Common Ground Resources and Crisis Center
Phone: 1-800-231-1127
Primary geographic areas covered: Oakland County, Macomb County, west of Macomb County

Hegira Health’s COPE
Phone: 1-734-721-0200
Primary geographic areas covered: Livonia, Wayne County

Currently, Blue Cross is in discussion with other facilities that are interested in providing such services. We also hope to expand these services to our Medicare Advantage members in the future.

“The beauty of these services is they can meet the member where they are and be accessed any way you need to access them,” said Dr. William Beecroft, medical director of behavioral health for Blue Cross.

They can be accessed by a health care provider, the member or other individuals. For example:

• A physician with a patient in crisis can contact one of these centers directly to have the patient be evaluated by a member of the mobile crisis team, either in person or by phone.
• An emergency department at a hospital can contact one of the centers to request assistance in evaluating the patient and determining the best course of treatment, placement and referrals.
• A member can call the number on the back of their ID card to connect with a Blue Cross case manager who can direct them to a crisis counselor at one of the participating facilities.
• Members can call one of the participating centers directly or simply walk into one of the crisis stabilization units.
• A law enforcement officer can call one of the centers for a behavioral health evaluation for a citizen in crisis.

“These services help ensure our members get treated at the right place at the right time and that they’re linked to the appropriate level of care and available community resources,” Beecroft said. “However, as part of the evaluation and treatment process, some members may still require psychiatric hospitalization as part of their treatment plan.”

Mobile crisis services

The mobile crisis mental health team may stay involved for two to four weeks after the initial encounter to ensure patients are connected to the right level of care for mental health or substance use issues.

Following the initial encounter, crisis stabilization services (formerly called psychiatric observation) may take place and include:

• Behavioral health evaluation to initiate appropriate treatment (similar to medical observation services)
• Physical site-based services that are necessary to support the mobile crisis team
• Services include intake assessment, psychiatric evaluation, crisis intervention, psychotherapy, medication administration, therapeutic injection, laboratory and imaging diagnostics, observation and peer support
• Linkages and “warm handoffs” to the appropriate level of care and community resources

Additional benefits

Here are some additional benefits of mobile crisis and crisis stabilization services:

• A speedy, specialty-focused and confidential assessment of their immediate behavioral health (mental health and substance use disorder) needs
• A multidisciplinary evaluation, including the services of a psychiatrist, which leads to a plan of care and placement in the appropriate level of care
• A positive, less stigmatizing experience than with some other systems of care.
• Rapid access to behavioral interventions, including medication, nursing care, psychotherapy and psychoeducation
• Alleviation of a sense of crisis, encouraging feelings of hope

Facilities that offer mobile crisis and crisis stabilization services must meet certain criteria. For example, they must be open 24/7 and incorporate the services of a multidisciplinary staff, including physicians, registered nurses, licensed master social workers, psychologists, clinical supervisors and additional support staff.

For more information

To learn more — or if you’re interested in joining the program as a facility offering these services — contact one of the following:

• Dr. William Beecroft at WBeecroft@bcbsm.com
• William Pompos at WPompos@bcbsm.com

Blue Cross recognized as No. 1 in customer satisfaction among commercial health plans in Michigan

For the second time in three years, Blue Cross Blue Shield of Michigan and Blue Care Network received the J.D. Power Award for ranking first overall with highest member satisfaction among commercial health plans in Michigan. Achieving the top ranking was largely driven by strong scores in coverage and benefits, provider choice and information and communication.

You can view our recent news release about this announcement here. For more details on the J.D. Power 2022 Commercial Health Plan Study℠, visit jdpower.com.**  

J.D. Power is a global leader in consumer insights, advisory services and data and analytics. A pioneer in the use of “big data,” artificial intelligence and algorithmic modeling capabilities to understand consumer behavior, J.D. Power has been delivering incisive industry intelligence on customer interactions with brands and products for more than 50 years. The world's leading businesses across major industries rely on J.D. Power to guide their customer-facing strategies.

J.D. Power has offices in North America, Europe and Asia Pacific. To learn more about the company’s business offerings, visit JDPower.com/business. The J.D. Power auto shopping tool can be found at JDPower.com.

About the study

The U.S. Commercial Member Health Plan Study, now in its 16th year, measures satisfaction among members of 147 health plans in 22 regions throughout the United States by examining six factors (in alphabetical order):

• Billing and payment
• Cost
• Coverage and benefits
• Customer service
• Information and communication
• Provider choice

The study also measures several other key aspects of the experience and member engagement.

The study is based on responses from 36,366 commercial health plan members and was fielded from January through April 2022.

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

Provider Secured Services, including web-DENIS, end date extended for some functions

Blue Cross Blue Shield of Michigan and Blue Care Network are extending the original June 21, 2022, retirement date for some core functions within Provider Secured Services, including web-DENIS.

We encourage you to continue to learn and use the new provider portal, Availity Essentials. Some functions will remain on Provider Secured Services for a limited time, but many links and resource information will only be accessible through Availity^®.

See the provider alert for more details.

Here are resources for learning about our new provider portal

If you’re looking for training or have questions about the new Blue Cross Blue Shield of Michigan and Blue Care Network provider portal, Availity Essentials, take advantage of the following resources.

View recorded trainings

You can view recorded trainings on how to use Availity Essentials for your Blue Cross and BCN business. You must have an Availity^® account to access these recordings. See the section on registration below if you’re not yet registered.

There are two ways to find recorded trainings:

• Go to the Availity Get Up to Speed with Training** webpage. (Note that this website will be available through October 2022.)

• Within the provider portal, you can find the training sessions by following these steps:
1. Log in to our provider portal (availity.com**).
2. Choose Help & Training and then click on Get Trained.
3. In the search field at the top of the screen, enter BCBSM.

Find answers to your questions
Here’s where you can find answers to your questions:

• Call Availity Client Services at 1-800-AVAILITY (282-4548) Monday through Friday from 8 a.m. to 8 p.m. Eastern time (excluding holidays).
• Within Availity, click on Help & Training and then on Availity Support.
• Welcome to Availity special edition newsletter
• Welcome to Availity webpage**
• Transitioning to the Availity provider portal frequently asked questions for providers

Still need to register?

If you haven’t yet registered for an Availity Essentials account, you no longer have access to some Blue Cross Blue Shield of Michigan and Blue Care Network online tools. For information about registering with Availity, go to the Blue Cross and BCN Welcome to Availity** webpage, scroll down the page and click on Register for Availity Essentials.

After registering, your Availity administrator will need to take additional steps for users to access e-referral and Health e-Blue℠. For more information, go to our Register for web tools page and scroll down to Getting access to Blue Cross and BCN tools through our provider portal.

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

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

Clarification: At-home COVID-19 testing policy revised for Blue Cross, BCN commercial plans

We ran an article in March Record and March-April BCN Provider News about our revised at-home COVID-19 testing policy. On May 19, we posted a provider alert clarifying how frequently members can obtain at-home rapid diagnostic COVID-19 tests, changing the wording from “monthly” to “every 30 days.” Currently, commercial members with pharmacy coverage through Blue Cross Blue Shield of Michigan or Blue Care Network have coverage for up to eight FDA-approved, over-the-counter at-home rapid diagnostic COVID-19 tests every 30 days.

The federal government’s website has also been updated and the quantity and timing on shipping has been removed as this continues to change.

See the May 19 provider alert and the articles in the March Record and March-April BCN Provider News for additional details.

Amendments made to Trading Partner Agreement

Effective Sept. 1, the Blue Cross Blue Shield of Michigan Trading Partner Agreement will be amended to include Blue Care Network of Michigan when Blue Cross is functioning as a health plan. All terms of paragraph 14 of the TPA, which governs Blue Cross’ relationship with non-participating providers, will also include Blue Care Network.

The TPA is the document that governs how electronic data interchange and electronic transactions, including electronic claims, will be conducted between Blue Cross and its trading partner — typically health care providers, billing agents and other health plans.

No action is needed on your part for this change to occur.

Chippewa County War Memorial Hospital changed its name

On April 1, 2022, Chippewa County War Memorial Hospital officially changed its name to MyMichigan Medical Center Sault. The hospital is located in Sault Ste Marie, Michigan. You’ll want to make a note of this for your files and for billing purposes.

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.

Blue Cross and BCN add new virtual option for behavioral health care

Blue Cross Blue Shield of Michigan and Blue Care Network are providing members with expanded access to behavioral health providers by offering a new virtual option for anxiety and depression treatment, effective July 15, 2022.

We’ve contracted with AbleTo, an independent company with a network of more than 2,000 therapists serving adults 18 and older, to offer virtual mental health services in all 50 states. This option is available for members with Blue Cross commercial, Medicare Plus Blue℠, BCN commercial and BCN Advantage℠ coverage.

AbleTo provides adult members with a structured and evidence-based eight-week cognitive behavioral treatment program for anxiety and depression, the most common behavioral health conditions. The program includes access to weekly sessions with a licensed master’s level clinician and access to digital tools, resources and relaxation activities for practice between sessions.

If you have a patient struggling to find a behavioral health therapist in their area or get an appointment as quickly as they want it, you may want to refer them to AbleTo, ableto.com/bcbsm,** beginning July 15. Note: Website may not be operational until July 15.

AbleTo intends to also refer patients to other in-network health care providers as needed.

Members can find an AbleTo provider by calling the number on the back of their member ID card or going to the AbleTo website.

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

Clinical quality corner: Coordination of care

This new column by Dr. William Beecroft, medical director of behavioral health, will feature topics recommended by the Clinical Quality Committee.

Blue Cross Blue Shield of Michigan promotes the importance of coordination of care among contracted providers, including the primary care provider and behavioral health specialist. Coordination of care is crucial to ensuring that everyone on the treatment team is aware of others who may be involved in the care of the patient. This helps eliminate so-called silos of care and leads, ultimately, to optimal patient outcomes.

We’ve added language to our insurance certificates that provides our members with information about this key component of their care. The certificates indicate that the primary care physician is the participating provider a member chooses to provide or coordinate all their medical health care, including specialty and hospital care. The primary care physician is licensed in one of the following medical fields:

• Family Practice
• General Practice
• Internal Medicine
• Pediatrics

We encourage you to explain to your patients why coordination of care is so important and ask them to let you know if they’re seeing other health care providers.

The Michigan Department of Health and Human Services has made available a standard consent form** that providers can use for sharing mental health and substance use disorder treatment information.

For more information, see the Coordination of care section of the “Behavioral Health chapter” in your online provider manual.

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

Landmark Health high-intensity in-home care program expands Oct. 1

On July 1, 2022, Blue Cross Blue Shield of Michigan and Blue Care Network expanded the high-intensity in-home care program by Landmark Health to include all Medicare Advantage members with multiple chronic conditions who reside in Southeast Michigan counties, as well as in the Lansing and Flint areas.

Starting Oct. 1, 2022, the program will be available to members in the following additional counties:

• Arenac
• Bay
• Calhoun
• Gladwin
• Gratiot
• Huron
• Jackson
• Kalamazoo
• Lenawee
• Midland
• Sanilac
• Tuscola

For high-level information about the program, see this provider alert.

For detailed information about the program, see the document titled High-intensity in-home care program: Frequently asked questions for providers.

Landmark Health, L.L.C., is an independent company that provides select services for Blue Cross Blue Shield of Michigan and Blue Care Network members who have Medicare Advantage plans.

We’re removing age limits for autism spectrum disorder services

We’re removing age limits for autism spectrum disorder services, including applied behavior analysis, or ABA. This change is retroactive to Jan. 1, 2022, to ensure continued access to treatment for Blue Cross Blue Shield of Michigan commercial and Blue Care Network commercial members whose plan benefits include ABA treatment, other autism services or both.

For dates of service on or after Jan. 1, 2022, we’ll reprocess claims for ASD services that were rejected due to age limits. You don’t need to resubmit the claims. 

Members who aged out of eligibility for ASD services in 2022 will remain eligible to continue receiving ASD services that are medically necessary.

Background

Previously, following state of Michigan legal guidelines, children aged out of eligibility for certain ASD services when they turned 19. We’re updating our benefits to allow members over the age of 19 to receive these ASD services when medically necessary.

We’re making this change because recent medical evidence indicates that age limits are no longer an appropriate method for determining whether ABA treatment is medically necessary.

This change is consistent with recent guidance from the Michigan Department of Insurance and Financial Services, and the federal government.

Additional information

We’re updating our Autism Spectrum Disorder Services medical policy and provider communications — including provider manuals — to reflect this change.

We’ll update our certificate and benefit documents to reflect this change by Jan. 1, 2023.

Reminder: Members can’t receive prescriptions for DME/P&O items through telehealth visits

As we told you in an October 2018 Record article, effective Nov. 1, 2018, health care providers aren’t able to prescribe or issue durable medical equipment and prosthetic and orthotic supplies during telehealth visits. A telehealth visit doesn’t meet the medical necessity requirements for prescribing these items. Prescription and issuance resulting from a telehealth visit may be subject to audit review and recovery.
A telehealth visit includes:

• Phone call
• Both email and postal mail
• Video chat

All telehealth formats are excluded from issuing DME and prosthetic and orthotic items.

All behavioral health practitioner specialty changes require new enrollment

A new mental health practitioner enrollment application is required when you’re making changes to your specialty or licensure. Any groups you currently practice with will need to update their records to reflect your change.

For information on enrollment and credentialing with Blue Cross Blue Shield of Michigan, visit the Join Our Provider Network section of bcbsm.com. The credentialing process verifies the licenses and qualifications of a health care provider and ensures that they meet the state requirements for health care.

Additionally, you’ll want to make sure you’re reviewing and submitting all required documents for your new specialty or license. See the Provider Enrollment and Change Process Required Document Checklist, which is also on our website.

Examples:

• If you’re a limited licensed psychologist, or LLP, who has recently become a fully licensed psychologist, a new mental health enrollment application is required. After your new enrollment application is processed, you must submit a request to terminate the LLP profile.
• If you’re a clinical licensed master’s social worker, or LMSW, who has recently become a licensed professional counselor, a new mental health enrollment application is required. After new mental enrollment application is processed you must submit a request to terminate the LMSW profile.

Note: You can terminate the previous profile by filling out and faxing the “Terminate Practitioner” paperwork in the Provider Enrollment section of our website.

If you have any questions or need additional information, contact Provider Enrollment Data Management at 1-800-822-2761.

2022 InterQual criteria to be implemented Aug. 1

Blue Cross Blue Shield of Michigan and Blue Care Network will start using 2022 InterQual^® criteria on Aug. 1, 2022, to make utilization management determinations.

Keep in mind that there are InterQual criteria for behavioral health services, as well as non-behavioral health services. However, New Directions^® Behavioral Health, an independent company that managers authorizations for behavioral health and autism services for most Blue Cross commercial members, uses its own criteria for making determinations on behavioral health authorization requests.

Additional information about behavioral health services is at the end of this article.

Non-behavioral health services
We’ll use updated criteria for all levels of care to make utilization management determinations for requests to authorize non-behavioral health services, subject to review, for the following members:

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

When clinical information is requested for a medical or surgical admission or for other services, we require submission of the specific components of the medical record that validate that the request meets the criteria.

Blue Cross and BCN also use local rules — modifications of InterQual criteria — in making utilization management determinations. The 2022 local rules for acute care inpatient medical admissions were implemented on March 1, 2022. The 2022 local rules for post-acute care will be announced at a later date.

You can access the modifications (local rules), as applicable, for:

• Blue Cross — on the Authorization Requirements & Criteria page in the Blue Cross section of our ereferrals.bcbsm.com website. You’ll see links to the criteria in both the Blue Cross commercial and Medicare Plus Blue sections of that page.
• BCN — on the Authorization Requirements & Criteria page in the BCN section of our ereferrals.bcbsm.com website. Look under the Referral and authorization information heading.

Refer to the table below for more specific information about which criteria are used in making determinations for various types of non-behavioral health authorization requests.

Note: The information in the table above applies to lines of business and members whose authorizations are managed by Blue Cross or BCN directly and not by an independent company that provides services to Blue Cross Blue Shield of Michigan.

Behavioral health services

On Aug. 1, 2022, we’ll begin using the 2022 InterQual criteria to make utilization management determinations for behavioral health services for these members:

• Medicare Plus Blue
• BCN commercial
• BCN Advantage

In addition, certain types of determinations will be based on modifications to InterQual criteria or on local rules or medical policies, as shown in the table below.

For more information on telemedicine, refer to the Blue Cross and BCN: Telehealth for behavioral health providers document.

In early July, we’ll have links to the updated versions of the modified behavioral health and autism local rules and to the medical policies. Those links will be located on these pages on our ereferrals.bcbsm.com website:

• Blue Cross Behavioral Health
• BCN Behavioral Health
• Blue Cross Autism
• BCN Autism

As noted earlier in the article, determinations on Blue Cross commercial behavioral health authorization requests are handled by New Directions. New Directions uses its own Medical Necessity Criteria.**

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

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 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 use of modifier 25, observation care and nursing facility care — on claims submitted to Blue Cross. While Change Healthcare won’t review Evaluation and Management 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 provides useful data insights to the provider community and works to maximize coding efficiency and accuracy through up-front education, rather than taking a traditional post-claim review process.

Effective July 1, 2022, the Coding Advisor program will expand to include the review of the Global Surgical Package. The GSP review is meant to help ensure the surgeon is using global service modifiers appropriately, based on modifier definitions. Global surgery applies in any setting, including an inpatient hospital, outpatient hospital, outpatient surgical center and physician’s office.

Throughout the course of 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 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.

For reference, here’s an example of a physician profile:

Update: Reminder of appropriate use of modifier 59 and related X modifiers for Medicare Plus Blue claims

In the June Record, we communicated about the appropriate use of modifier 59 for Medicare Plus Blue℠ claims. We’ve updated the article to indicate that the guidelines that apply when appending modifier 59 also apply to related X modifiers. Use the revised article below as your reference going forward.

As a reminder, you’ll want to continue to follow the guidelines communicated in the September 2021 Record article when appending modifier 59 Medicare Plus Blue℠ claims — and keep in mind that the guidelines also apply to related X modifiers. We’ve begun editing claim lines when modifier 59 and related X modifiers are appended on Medicare Plus Blue claims.

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

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

The X modifiers are defined below:

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

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

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

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

Follow these billing guidelines for removal of impacted cerumen

The removal of cerumen is a procedure that’s different from routine earwax removal. Routine earwax removal is performed to facilitate the ear examination portion of a physical examination.

Blue Cross Blue Shield of Michigan requires that procedure codes *69209, *69210 and G0268 should only be reported for removal of cerumen when all of these statements apply:

• Impacted cerumen, an immovable collection of compressed or hardened earwax in the external ear canal, is symptomatic and can’t be dislodged.
• Treatment requires extensive use of a spoon, loop, suction device or an agent that degrades the earwax for irrigation.
• The procedure requires the personal attention of the physician.
• The removal of the impacted cerumen is the major part of the encounter.

Note: Cleaning earwax from the external ear canal involves removing the soft, brownish, yellow, wax-like secretion of the ceruminous glands of the external auditory canal. It can easily be removed using a spoon, loop or bulb syringe. For this service, the physician typically takes one to two minutes, and the service shouldn’t be reported separately.

Removal of impacted cerumen (*69209, *69210, G0268) will only be considered as medically necessary when reported with a diagnosis of impacted cerumen (ICD-10 H61.20-H61.23) in accordance with the AMA CPT and HCPCS Level II manuals.

Therefore, CPT codes *69209, *69210 or G0268 billed with any other diagnosis will be denied or recovered.

Leqvio to have site-of-care requirement for commercial members, starting Aug. 1

Leqvio^® (inclisiran), HCPCS code J3590, will have a site-of-care requirement, in addition to its current prior authorization requirement for Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members, starting Aug. 1, 2022.

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

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

Members who start treatment in a location other than those outlined above prior to Aug. 1, 2022, will be able to continue receiving the drug in that location until their current authorization expires. Providers should then transition members to one of the above sites of care.

Notes:

• Starting July 1, 2022, the HCPCS code for this drug will be J1306.
• This drug is part of members’ medical benefits, not their pharmacy benefits.
• As a reminder, prior authorization requests are submitted using the NovoLogix^® online tool.

Some Blue Cross commercial groups not subject to these requirements

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

Note: Blue Cross and Blue Shield Federal Employee Program^® members and UAW Retiree Medical Benefits Trust (non-Medicare) members don't participate in the standard prior authorization program.

List of requirements

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

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

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

Authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

Fyarro to require prior authorization for most members, starting Aug. 16

For dates of service on or after Aug. 16, 2022, Fyarro™ (sirolimus protein-bound particles), HCPCS code J9331, will require prior authorization through AIM Specialty Health^®. This drug is part of members’ medical benefits, not their pharmacy benefits.

Prior authorization requirements apply when this drug is administered in outpatient settings for:

• Blue Cross Blue Shield of Michigan commercial — Members who have coverage through fully insured groups and members with individual coverage

Note: This requirement doesn’t apply to members who have coverage through Blue Cross commercial self-funded groups, including the Blue Cross and Blue Shield Federal Employee Program^® and UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans.

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

How to submit authorization requests

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

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

More about the authorization requirements

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

For additional information on requirements related to drugs covered under the medical benefit, see:

• Blue Cross commercial and BCN commercial:
• Medical oncology prior authorization list for Blue Cross commercial fully insured and BCN commercial members
• Blue Cross and BCN utilization management medical drug list
• Medicare Advantage:
• Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members

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

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. For more information, go to our ereferrals.bcbsm.com website.

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

Fyarro and Tivdak will have requirements for URMBT members with Blue Cross non-Medicare plans

For dates of service on or after Aug. 16, 2022, the drugs listed below will require prior authorization through AIM Specialty Health^® and may also have site-of-care requirements, quantity limit requirements or both. These requirements will apply to UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans. These drugs are part of members’ medical benefits, not their pharmacy benefits.

See the table for more information. When a cell is blank, the drug doesn’t have that requirement.

Brand name	Generic name	HCPCS code	Requirements
			Prior authorization	Site of care	Quantity limits
Fyarro™	sirolimus protein-bound particles	J9331	✓
Tivdak®	tisotumab vedotin-tftv	J9273	✓

These requirements apply only when these drugs are administered in an outpatient setting.

Note: These requirements don’t apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714).

How to submit authorization requests

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

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

More about the authorization requirements

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

For additional information on requirements related to drugs covered under the medical benefit for URMBT members with 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 pertinent drug lists to reflect the information in this article prior to the effective date.

Note: Accredo manages prior authorization requests for additional medical benefit drugs for these members.

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. For more information, go to our ereferrals.bcbsm.com website.

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

Fusilev no longer requires prior authorization

Because Spectrum Pharmaceuticals has stopped manufacturing Fusilev^® (levoleucovorin), HCPCS code J0641, we no longer require prior authorization through AIM Specialty Health^® for dates of service on or after May 31, 2022. The drug was part of members’ medical benefits, not their pharmacy benefits.
This change applies to:

• Blue Cross Blue Shield of Michigan commercial:
• Members who have coverage through fully insured groups
• Members with individual coverage
• UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans
• Medicare Plus Blue℠ members
• Blue Care Network commercial members
• BCN Advantage℠ members

For additional information on requirements related to drugs covered under the medical benefit, refer to the following drug lists:

• Blue Cross and BCN commercial members:
• Medical oncology prior authorization list for Blue Cross commercial fully insured and BCN commercial members
• Blue Cross and BCN utilization management medical drug list
• URMBT members with Blue Cross non-Medicare plans:
• 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

Note: Accredo manages prior authorization requests for additional medical benefit drugs for these members.

• Medicare Plus Blue and BCN Advantage members:
• Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members

What you need to know about submitting medical benefit drug prior authorization requests for Medicare Advantage members

Blue Cross Blue Shield of Michigan and Blue Care Network recently transitioned to a new provider portal, Availity Essentials. You should continue to submit prior authorization requests for most medical benefit drugs, including CAR-T cell therapy drugs, for Medicare Plus Blue℠ and BCN Advantage℠ members in one of the following ways:

• Preferred method: Through the NovoLogix^® online tool. See the next section for the steps you need to take to access NovoLogix through Availity^®.
• For providers who aren’t able to submit requests through NovoLogix: You have two options:
• Use the new global Medication Authorization Request Form (for any medication), which we created to reduce the number of forms you have to manage. Fax the completed form to 1-866-392-6465.
• Call our Pharmacy Clinical Help Desk at 1‑800-437-3803.

Preferred method for submitting prior authorization requests

The preferred method continues to be submitting requests through NovoLogix.

Note: If you haven’t already done so, be sure to register for Availity so you can continue to submit requests through NovoLogix.

If you have an Availity account, you have access to NovoLogix.

To submit requests through Availity:

1. Log in to our provider portal (availity.com**).
2. Click on Payer Spaces on the Availity menu bar.
3. Click on the BCBSM and BCN logo.
4. In the Applications tab, click on the appropriate tile:
• NovoLogix MAPPO
• NovoLogix BCN/BCN Advantage

Additional information

You can access the Medication Authorization Request Form (for any medication) on the For Providers: How do I Submit a Drug Prior Authorization Request for Medicare Plus Blue PPO and BCN Advantage? page of the bcbsm.com website. Later this year, we’ll remove the medical drug prior authorization request forms for specific medications.

For more information about submitting requests and to view the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members, see the following pages of ereferrals.bcbsm.com website:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

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

Cortrophin and Ryplazim to have requirements for URMBT members with Blue Cross non-Medicare plans

For dates of service on or after Sept. 1, 2022, the following drugs will require prior authorization through the NovoLogix^® online tool and may also have site-of-care requirements, quantity limit requirements or both. These requirements will apply to UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans. These drugs are part of members’ medical benefits, not their pharmacy benefits.

See the table for more information. When a cell is blank, the drug doesn’t have that requirement.

Brand name	Generic name	HCPCS code	Requirements
			Prior authorization	Site of care	Quantity limits
Cortrophin®	corticotropin	J3490/J3590	✓
Ryplazim®	plasminogen, human-tvmh	J3590/C9090	✓		✓

These requirements apply only when these drugs are administered in an outpatient setting.

Note: These requirements don’t apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714).

How to submit authorization requests

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

To learn how to submit requests through NovoLogix, go to our Blue Cross Medical Benefit Drugs page, scroll to the Blue Cross commercial column and review the information in the How to submit authorization requests electronically using NovoLogix section.

More about the authorization requirements

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

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

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

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

Note: Accredo manages prior authorization requests for additional medical benefit drugs for these members.

AllianceRx Walgreens Prime is now AllianceRx Walgreens Pharmacy

Effective June 24, 2022, AllianceRx Walgreens Prime, a provider of specialty pharmacy services, changed its name to AllianceRx Walgreens Pharmacy. 

AllianceRx Walgreens Pharmacy will continue to provide Blue Cross Blue Shield of Michigan members with specialty medications used to treat chronic, complex or rare conditions.

Blue Cross introducing payment policy for multiple therapy services

Starting in October, Blue Cross Blue Shield of Michigan will use a new payment reduction procedure for physical, occupational and speech therapy.

This policy will reduce reimbursement for the practice expense portions of therapy procedures when those services are the secondary or subsequent procedures provided on a single date of service by the same physician or other qualified health care professional. The change is being made to align with the Centers for Medicare & Medicaid Services’ Multiple Therapy Policy.

The service with the highest Relative Value Unit, or RVU, is considered the primary service. The practice expense RVU includes the nonphysician clinical and nonclinical labor of the practice, as well as expenses for building space, equipment and office supplies. Such expenses are considered duplicative for each subsequent therapy service and therefore will be reduced by 50% accordingly.

This practice expense reduction will result in an approximate average reimbursement of 83% of the allowed amount for all subsequent therapy services rendered on the same day.  

In the Facility section of this issue of the newsletter, we provide details on how facilities can provide input on this new procedure.

Reminder: 2% Medicare sequestration reduction slated to resume July 1

We’re reminding health care providers that Medicare sequestration reduction is scheduled to resume July 1, 2022, at 2%. Blue Cross Blue Shield of Michigan and Blue Care Network are aligned with the Centers for Medicare & Medicaid Services’ guidance regarding Medicare sequestration reductions.

You may recall that the U.S. Congress and Biden administration suspended the mandatory Medicare 2% sequestration reduction through March 31, 2022, and reduced the sequestration cuts to 1% from April through June 2022.

The suspension was made to offset the decrease in payments to health care providers because of the COVID-19 public health emergency. If the suspension is extended after June 30, we’ll update you with a provider alert.

Note: 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 reimbursements to providers who haven’t been affected by sequestration previously.

New on-demand training available

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

We recently added the following new learning opportunity:

• Avalon laboratory services overview — This recorded webinar discusses the laboratory benefits management program supported by Avalon Healthcare Solutions, lab policy administration and the trial claim advice tool.

Our provider training site is available to enhance the training experience for health care providers and staff. To request access, complete the following steps:

• Open the registration page.
• Complete the registration. We recommend using the same email you use to communicate with Blue Cross for other 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.

Lunch and learn webinars focus on risk adjustment, coding

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

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

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

Click here if you are already registered for the site.

To request access to the provider training website:

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

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

Do we have your medical records request address?

As a reminder, please ensure that we have your correct medical records request address on file. In the April 2022 Record, we let you know we’ll be working with Optum to implement some new edits. Optum is an independent company that contracts with Blue Cross Blue Shield of Michigan to identify professional and facility claims that require additional review.

One component of our relationship with Optum involves medical records requests.
To prevent claim processing delays, we need to keep your medical records request address on file. If you haven’t provided it yet or need to make changes, use the Enrollment and Change Self-Service Tool, located on the Applications tab of our payer space on the provider portal.

Here are the step-by-step directions:

1. Log in to our provider portal (availity.com**).
2. Click on Payer Spaces on the Availity menu bar.
3. Click on the BCBSM and BCN logo.
4. Click on Provider Enrollment and Change Self-Service on the Applications tab.

If we don’t have a medical record request address on file, the request will be sent to the mailing address. If there’s no mailing address on file, the request will be sent to the billing address. And if there’s no billing address on file, the request will be sent to the address shown on the claim.

Help us streamline the claim processing process by making sure we have your correct medical records request address on file.

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

Learn what you can do to better manage osteoporosis and limit disability

Musculoskeletal conditions are the second largest contributor to disability, according to the World Health Organization.

Osteoporosis Management in Women who had a Fracture (OMW), a HEDIS^® Star measure, assesses women 67 to 85 years of age who suffered a fracture and had either a bone mineral density test or received a prescription to treat osteoporosis within six months of the fracture.

Read this tip sheet to learn more about the measure and find out what information to include in medical records.  

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

Remember to discuss fall risk, urinary incontinence and physical activity with Medicare patients

According to the National Committee for Quality Assurance, or NCQA:

• Falls are the leading cause of death by injury in people 65 and older. Every year, 1 in 4 older adults fall.
• Urinary incontinence is significantly underreported and underdiagnosed.
• Any amount of physical activity reduces the risk of developing certain chronic conditions and increases quality of life.

Due to the risks posed by falls and urinary incontinence, the Medicare Health Outcomes Survey, or HOS, measures patient-reported outcomes for three HEDIS^® Effectiveness of Care measures:

• Fall Risk Management
• Management of Urinary Incontinence in Older Adults
• Physical Activity in Older Adults

The survey, which runs from August through November, asks randomly selected Medicare Advantage members questions about how their health care providers talk with them about these important topics.

Read the HOS tip sheet to learn more, including what questions are members are being asked and how you can address care opportunities with your patients.

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

Prenatal, well-child support for FEP members with growing families

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

The Blue Cross and Blue Shield Federal Employee Program^® recognizes the importance of preventive care for pregnant women and growing families. Pregnant women should be seen regularly for prenatal care, especially in the first trimester. Parents are also encouraged to schedule regular well-child visits for their children, particularly in the first 15 months of life.

Here are some resources to share with FEP patients:

• Online information at fepblue.org/maternity:
• Tips for a healthy pregnancy
• Breastfeeding support
• The Pregnancy Care Incentive Program is available to members with the Standard and Basic Option. The program encourages early and ongoing prenatal care. Pregnant members can earn a Pregnancy Care Box that includes pregnancy gifts, information and $75 toward a health account for members who complete all requirements.
• The Summer Health Checklist For Families has reminders for families about well-child visits, immunizations and more.
• Bright Futures,** led by the American Academy of Pediatrics, provides guidance for all preventive care screenings and well-child visits.

If you or FEP members have questions about benefits, call Customer Service at 1-800-482-3600.

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

Additional procedures codes payable to OPC providers for Blue Cross commercial members, starting July 1

For members with Blue Cross Blue Shield of Michigan commercial plans, we’ve updated our systems to make additional services payable to providers at outpatient psychiatric care facilities.

For dates of service on or after July 1, 2022, the following procedure codes will be payable to the OPC providers specified below for Blue Cross commercial members:

This change brings the list of procedure codes that are payable to OPC providers for Blue Cross commercial members more in line with those that are payable to OPC providers for Blue Care Network members.

Billing instructions

When billing these procedure codes, include the following in the order specified below:

1. The modifier that indicates the licensure level (level of care) for the rendering provider (such as: AH, AJ, HO)
2. If the service was delivered via telemedicine: The telemedicine modifier (either GT or 95)
3. The place of service:
• If the service was delivered in person: Include place of service 11.
• If the service was delivered via telemedicine: Include place of service code 11, 02 or 10.

To view detailed billing instructions for services delivered via telemedicine, see the “Billing telehealth visits” section of the Telehealth for behavioral health providers document. Refer to the “Outpatient psychiatric care facilities” subsection.

By July 1, we’ll update the Telehealth for behavioral health providers document to reflect the additional codes that are payable for Blue Cross commercial members.

Blue Cross commercial OPC fee schedule

By July 1, we’ll update the OPC fee schedule to reflect this change. You can access the fee schedule as follows:

1. Log in to our provider portal (availity.com**).
2. Click on Payer Spaces on the Availity menu bar.
3. Click on the BCBSM and BCN logo.
4. Click on Secure Provider Resources (Blue Cross and BCN) on the Resources tab.
5. Choose Fee Schedules > Blue Cross Facility Fee Schedules.
6. If prompted, accept the End User License Agreement.
7. Click on Outpatient Psychiatric Care on the left.
8. Click on the link to open the 2022 fee schedule.

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

2022 InterQual criteria to be implemented Aug. 1

Blue Cross Blue Shield of Michigan and Blue Care Network will start using 2022 InterQual^® criteria on Aug. 1, 2022, to make utilization management determinations.

Keep in mind that there are InterQual criteria for behavioral health services, as well as non-behavioral health services. However, New Directions^® Behavioral Health, an independent company that managers authorizations for behavioral health and autism services for most Blue Cross commercial members, uses its own criteria for making determinations on behavioral health authorization requests.

Additional information about behavioral health services is at the end of this article.

Non-behavioral health services
We’ll use updated criteria for all levels of care to make utilization management determinations for requests to authorize non-behavioral health services, subject to review, for the following members:

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

When clinical information is requested for a medical or surgical admission or for other services, we require submission of the specific components of the medical record that validate that the request meets the criteria.

Blue Cross and BCN also use local rules — modifications of InterQual criteria — in making utilization management determinations. The 2022 local rules for acute care inpatient medical admissions were implemented on March 1, 2022. The 2022 local rules for post-acute care will be announced at a later date.

You can access the modifications (local rules), as applicable, for:

• Blue Cross — on the Authorization Requirements & Criteria page in the Blue Cross section of our ereferrals.bcbsm.com website. You’ll see links to the criteria in both the Blue Cross commercial and Medicare Plus Blue sections of that page.
• BCN — on the Authorization Requirements & Criteria page in the BCN section of our ereferrals.bcbsm.com website. Look under the Referral and authorization information heading.

Refer to the table below for more specific information about which criteria are used in making determinations for various types of non-behavioral health authorization requests.

Note: The information in the table above applies to lines of business and members whose authorizations are managed by Blue Cross or BCN directly and not by an independent company that provides services to Blue Cross Blue Shield of Michigan.

Behavioral health services

On Aug. 1, 2022, we’ll begin using the 2022 InterQual criteria to make utilization management determinations for behavioral health services for these members:

• Medicare Plus Blue
• BCN commercial
• BCN Advantage

In addition, certain types of determinations will be based on modifications to InterQual criteria or on local rules or medical policies, as shown in the table below.

For more information on telemedicine, refer to the Blue Cross and BCN: Telehealth for behavioral health providers document.

In early July, we’ll have links to the updated versions of the modified behavioral health and autism local rules and to the medical policies. Those links will be located on these pages on our ereferrals.bcbsm.com website:

• Blue Cross Behavioral Health
• BCN Behavioral Health
• Blue Cross Autism
• BCN Autism

As noted earlier in the article, determinations on Blue Cross commercial behavioral health authorization requests are handled by New Directions. New Directions uses its own Medical Necessity Criteria.**

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

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 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 use of modifier 25, observation care and nursing facility care — on claims submitted to Blue Cross. While Change Healthcare won’t review Evaluation and Management 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 provides useful data insights to the provider community and works to maximize coding efficiency and accuracy through up-front education, rather than taking a traditional post-claim review process.

Effective July 1, 2022, the Coding Advisor program will expand to include the review of the Global Surgical Package. The GSP review is meant to help ensure the surgeon is using global service modifiers appropriately, based on modifier definitions. Global surgery applies in any setting, including an inpatient hospital, outpatient hospital, outpatient surgical center and physician’s office.

Throughout the course of 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 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.

For reference, here’s an example of a physician profile:

Here’s what you need to know about Prepayment Laboratory Claim Edits and how to provide input

Blue Cross Blue Shield of Michigan is proposing fourth-quarter implementation of a laboratory benefits management program through Avalon Healthcare Solutions. This program will affect independent and facility outpatient lab services for our commercial Blue Cross members.

Avalon is an independent company that contracts with Blue Cross to provide laboratory benefits management.

Avalon’s automated policy enforcement (post-service) edits will be applied to claims reporting laboratory services performed in office, hospital outpatient and independent laboratory locations. Laboratory services, tests and procedures provided in emergency department, hospital observation and hospital inpatient settings are excluded from this program.

This program will:

• Promote consistency of routine testing across all patients and places of service.
• Reduce fraud, waste and abuse.
• Enhance the patient health care experience, ensuring it’s aligned with scientific evidence-based guidelines.
• Deliver value-driven care by improving quality and appropriateness of lab services.
• Increase payment accuracy as it relates to allowable provider reimbursement associated with lab claims.

What this means to facilities

The lab claim edits will support our medical policy in cases where there’s fixed criteria, specificity and no risk of a different interpretation that would require a medical review. Edit types include:

• History
• Quantity
• Frequency
• Procedure code-diagnosis code comparison
• Incompatibility
• Age

The claim edits will focus on high-volume, low-cost tests, such as vitamin D, thyroid, cholesterol and A1c. They will identify unnecessary units (excessive units, unnecessary testing and over-frequency).

Facilities need to be aware of the new and revised laboratory medical policies and guidelines, as these polices and guidelines affect certain laboratory services, tests and procedures. Facility and independent lab reimbursement may be reduced if the lab tests ordered by the physician and provided by the labs don’t meet these policies, which became effective June 1, 2022.

To review laboratory medical policies, click on this link.** The following polices are expected to have the most significant effect on facilities:

• Prescription Medication and Illicit Drug Testing in the Outpatient Setting
• Vitamin D Testing — variance
• Vitamin B12 and Methylmalonic Acid Testing
• Cardiovascular Disease Risk Assessment
• Thyroid Disease Testing
• Testosterone Testing

Trial Claim Advice Tool

Before ordering a test, health care providers can use the Trial Claim Advice Tool to simulate a trial claim by inputting codes for services, along with patients’ diagnoses, to determine possible edits in advance of submitting claims. To access the tool, follow these steps:

• Log in to our provider portal (availity.com).**
• Click on Payer Spaces on the Availity menu bar.
• Click on the BCBSM and BCN logo.
• Click on Avalon Lab Claim Editing on the Applications tab.

This tool will review claims with laboratory services for adherence and consistency with our laboratory policies, such as:

• Meeting policy coverage criteria
• Appropriateness for patient’s age
• Frequency of services
• Whether a procedure is considered experimental or investigational
• Whether it’s appropriate for the clinical situation

Notes:

• This is a simulation tool and doesn’t guarantee approval or reimbursement of a claim.
• It’s expected that health care providers who order lab tests are doing so appropriately, according to medical necessity and relevant guidelines.
• Blue Cross and Avalon will offer health care provider education seminars prior to implementation. Ongoing support tools will also be available through provider portals.

Input requested

According to the Contract Administration Process — part of the Participating Hospital Agreement that went into effect July 1, 2021 — we allow nonbinding input from participating facilities about such proposals.

Input from facilities is requested by July 31, 2022. Send any input you may have to Liz Bowman at ebowman@bcbsm.com.

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

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

What facilities need to know about proposed new policy for multiple therapy services and how to provide input

Blue Cross Blue Shield of Michigan is proposing implementation of a new payment reduction policy for physical, occupational and speech therapy. Program implementation is scheduled for the fourth quarter of 2022 for Blue Cross commercial members.

This policy will reduce reimbursement for the practice expense portions of therapy procedures when those services are the secondary or subsequent procedures provided on a single date of service by the same physician or other qualified health care professional. This change is being made to align with the Centers for Medicare & Medicaid Services’ Multiple Therapy Policy.

The policy doesn’t interfere with benefit limits. Blue Cross allows 90 therapy visits per calendar year, and these rules won’t affect those limits.

What this means to facilities

When multiple therapy services are rendered on the same day, we’ll apply a “therapy pay percent edit.” The primary service will be reimbursed at 100% of the allowed amount, while secondary procedures performed on the same day will be reduced by 50% of the practice expense relative value unit, or RVU.

The service with the highest RVU is considered the primary service. The practice expense RVU includes the nonphysician clinical and nonclinical labor of the practice, as well as expenses for building space, equipment and office supplies. Such expenses are considered duplicative for each subsequent therapy service and therefore will be reduced accordingly.

This practice expense reduction will result in an approximate average reimbursement of 83% of the allowed amount for all subsequent therapy services rendered on the same day.

The top five procedure codes that would receive the facility edit (reduced payment) include:

• *97140 – MANUAL THERAPY 1/> REGIONS
• *97110 – THERAPEUTIC EXERCISES
• *97530 – THERAPEUTIC ACTIVITIES
• *97112 – NEUROMUSCULAR REEDUCATION
• *97116 – GAIT TRAINING THERAPY

Input requested

According to the Contract Administration Process — part of the Participating Hospital Agreement that went into effect July 1, 2021 — we allow non-binding input from participating facilities about such proposals.
Input from facilities is requested by July 31, 2022. Send any input you may have to Liz Bowman at ebowman@bcbsm.com.

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

Update: DRG Clinical Validation Audit implementation

In a February Record article, we wrote about the proposed implementation of the Diagnosis-related Group Clinical Validation Audits and asked for facility input. Based on that input, we’re providing some additional information below:

• Change Healthcare** clinical review of the physician documentation will determine if the patient diagnosis is consistent with the clinical documentation in the medical record. These claim rules align with Blue Cross Blue Shield of Michigan policy.
• According to guidelines from the Centers for Medicare & Medicaid Services, DRG clinical validation is a separate process from DRG coding validation. DRG coding validation involves a clinical review of a case to determine whether the patient has the conditions that were documented. Because this is a clinical DRG validation audit, it should be performed by a clinician or a clinician with approved coding credentials and doesn’t require a certified coder.
• Adding this type of audit won’t increase the number of audits a hospital is subject to as we have established inpatient audit limits. Since we aren’t auditing additional claims, there shouldn’t be an increased administrative burden.
• As DRG clinical validation is a separate process from DRG coding validation, it’s possible to have a claim that is correctly coded based on national coding guidelines, but where the clinical indicators aren’t met.
• DRG clinical validation audits will exclude hospitals who have prospective rate agreements.

Following Blue Cross Blue Shield of Michigan’s review of facility input, we’ll be moving forward with this program, effective Aug. 1, 2022. Details about the DRG Clinical Validation Audits were presented at the May 16 Staff Liaison Group meeting, which included leadership from the Michigan Health and Hospital Association and Blue Cross, and the PHA Advisory Committee on June 21.

**Change Healthcare is an independent company that contracts with Blue Cross Blue Shield of Michigan to provide audit services.

Update: Emergency Department Claims Analyzer implementation

In a February Record article, we wrote about the proposed expansion of Blue Cross Blue Shield of Michigan’s claim editing process, aimed at promoting correct coding through the Optum Emergency Department Claim Analyzer tool, and asked for input from our facilities. Based on that input, we’re providing some additional information below:

• Currently, the EDC Analyzer only recodes from a higher-level Evaluation and Management, or E/M code, to a lower-level code.
• To appeal an EDC Analyzer claim, follow the current clinical editing appeals process.
• EDC Analyzer is now the Blue Cross payment policy, and claims can be modeled at EDSAnalyzer.com.**
• Blue Cross recognizes that there are different methodologies that can be used to arrive at the appropriate CPT code. However, we’ll adhere to the EDC Analyzer tool, which uses ICD-10 and CPT codes as the basis for E/M selection.   
• This is how EDC Analyzer claims will be processed:
• Hospitals that are reimbursed through a fee schedule for outpatient services won’t have their claims denied, but instead will be reimbursed using the EDC Analyzer recommended code.
• Hospitals that are reimbursed a percentage of the charge for outpatient services will have their claims denied if submitted with an incorrect code and the recommended E/M code will be reflected on the voucher. Hospitals should rebill with the EDC Analyzer recommended code.

Following Blue Cross Blue Shield of Michigan’s review of facility input, we’ll be moving forward with this program, effective early October 2022. Details about the EDC Analyzer were also presented at the May 16 Staff Liaison Group meeting, which included leadership from the Michigan Health and Hospital Association and Blue Cross, and the PHA Advisory Committee, which was held on June 21.

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

We’ve updated Addendum C of Blue Cross’ Ambulatory Surgical Facility Traditional Participation Agreement

Blue Cross Blue Shield of Michigan has made changes to the participating agreement for ambulatory surgical facilities. The changes are to Addendum C, Reimbursement Methodology, and are effective Oct. 1, 2022.

The new participating agreement is accessible from the Ambulatory Surgical Facilities section of Provider Enrollment on bcbsm.com/providers.

Leqvio to have site-of-care requirement for commercial members, starting Aug. 1

Leqvio^® (inclisiran), HCPCS code J3590, will have a site-of-care requirement, in addition to its current prior authorization requirement for Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members, starting Aug. 1, 2022.

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

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

Members who start treatment in a location other than those outlined above prior to Aug. 1, 2022, will be able to continue receiving the drug in that location until their current authorization expires. Providers should then transition members to one of the above sites of care.

Notes:

• Starting July 1, 2022, the HCPCS code for this drug will be J1306.
• This drug is part of members’ medical benefits, not their pharmacy benefits.
• As a reminder, prior authorization requests are submitted using the NovoLogix^® online tool.

Some Blue Cross commercial groups not subject to these requirements

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

Note: Blue Cross and Blue Shield Federal Employee Program^® members and UAW Retiree Medical Benefits Trust (non-Medicare) members don't participate in the standard prior authorization program.

List of requirements

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

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

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

Authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

Fyarro to require prior authorization for most members, starting Aug. 16

For dates of service on or after Aug. 16, 2022, Fyarro™ (sirolimus protein-bound particles), HCPCS code J9331, will require prior authorization through AIM Specialty Health^®. This drug is part of members’ medical benefits, not their pharmacy benefits.

Prior authorization requirements apply when this drug is administered in outpatient settings for:

• Blue Cross Blue Shield of Michigan commercial — Members who have coverage through fully insured groups and members with individual coverage

Note: This requirement doesn’t apply to members who have coverage through Blue Cross commercial self-funded groups, including the Blue Cross and Blue Shield Federal Employee Program^® and UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans.

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

How to submit authorization requests

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

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

More about the authorization requirements

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

For additional information on requirements related to drugs covered under the medical benefit, see:

• Blue Cross commercial and BCN commercial:
• Medical oncology prior authorization list for Blue Cross commercial fully insured and BCN commercial members
• Blue Cross and BCN utilization management medical drug list
• Medicare Advantage:
• Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members

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

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. For more information, go to our ereferrals.bcbsm.com website.

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

Fyarro and Tivdak will have requirements for URMBT members with Blue Cross non-Medicare plans

For dates of service on or after Aug. 16, 2022, the drugs listed below will require prior authorization through AIM Specialty Health^® and may also have site-of-care requirements, quantity limit requirements or both. These requirements will apply to UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans. These drugs are part of members’ medical benefits, not their pharmacy benefits.

See the table for more information. When a cell is blank, the drug doesn’t have that requirement.

Brand name	Generic name	HCPCS code	Requirements
			Prior authorization	Site of care	Quantity limits
Fyarro™	sirolimus protein-bound particles	J9331	✓
Tivdak®	tisotumab vedotin-tftv	J9273	✓

These requirements apply only when these drugs are administered in an outpatient setting.

Note: These requirements don’t apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714).

How to submit authorization requests

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

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

More about the authorization requirements

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

For additional information on requirements related to drugs covered under the medical benefit for URMBT members with 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 pertinent drug lists to reflect the information in this article prior to the effective date.

Note: Accredo manages prior authorization requests for additional medical benefit drugs for these members.

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. For more information, go to our ereferrals.bcbsm.com website.

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

Fusilev no longer requires prior authorization

Because Spectrum Pharmaceuticals has stopped manufacturing Fusilev^® (levoleucovorin), HCPCS code J0641, we no longer require prior authorization through AIM Specialty Health^® for dates of service on or after May 31, 2022. The drug was part of members’ medical benefits, not their pharmacy benefits.
This change applies to:

• Blue Cross Blue Shield of Michigan commercial:
• Members who have coverage through fully insured groups
• Members with individual coverage
• UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans
• Medicare Plus Blue℠ members
• Blue Care Network commercial members
• BCN Advantage℠ members

For additional information on requirements related to drugs covered under the medical benefit, refer to the following drug lists:

• Blue Cross and BCN commercial members:
• Medical oncology prior authorization list for Blue Cross commercial fully insured and BCN commercial members
• Blue Cross and BCN utilization management medical drug list
• URMBT members with Blue Cross non-Medicare plans:
• 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

Note: Accredo manages prior authorization requests for additional medical benefit drugs for these members.

• Medicare Plus Blue and BCN Advantage members:
• Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members

What you need to know about submitting medical benefit drug prior authorization requests for Medicare Advantage members

Blue Cross Blue Shield of Michigan and Blue Care Network recently transitioned to a new provider portal, Availity Essentials. You should continue to submit prior authorization requests for most medical benefit drugs, including CAR-T cell therapy drugs, for Medicare Plus Blue℠ and BCN Advantage℠ members in one of the following ways:

• Preferred method: Through the NovoLogix^® online tool. See the next section for the steps you need to take to access NovoLogix through Availity^®.
• For providers who aren’t able to submit requests through NovoLogix: You have two options:
• Use the new global Medication Authorization Request Form (for any medication), which we created to reduce the number of forms you have to manage. Fax the completed form to 1-866-392-6465.
• Call our Pharmacy Clinical Help Desk at 1‑800-437-3803.

Preferred method for submitting prior authorization requests

The preferred method continues to be submitting requests through NovoLogix.

Note: If you haven’t already done so, be sure to register for Availity so you can continue to submit requests through NovoLogix.

If you have an Availity account, you have access to NovoLogix.

To submit requests through Availity:

1. Log in to our provider portal (availity.com**).
2. Click on Payer Spaces on the Availity menu bar.
3. Click on the BCBSM and BCN logo.
4. In the Applications tab, click on the appropriate tile:
• NovoLogix MAPPO
• NovoLogix BCN/BCN Advantage

Additional information

You can access the Medication Authorization Request Form (for any medication) on the For Providers: How do I Submit a Drug Prior Authorization Request for Medicare Plus Blue PPO and BCN Advantage? page of the bcbsm.com website. Later this year, we’ll remove the medical drug prior authorization request forms for specific medications.

For more information about submitting requests and to view the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members, see the following pages of ereferrals.bcbsm.com website:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

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

Cortrophin and Ryplazim to have requirements for URMBT members with Blue Cross non-Medicare plans

For dates of service on or after Sept. 1, 2022, the following drugs will require prior authorization through the NovoLogix^® online tool and may also have site-of-care requirements, quantity limit requirements or both. These requirements will apply to UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans. These drugs are part of members’ medical benefits, not their pharmacy benefits.

See the table for more information. When a cell is blank, the drug doesn’t have that requirement.

Brand name	Generic name	HCPCS code	Requirements
			Prior authorization	Site of care	Quantity limits
Cortrophin®	corticotropin	J3490/J3590	✓
Ryplazim®	plasminogen, human-tvmh	J3590/C9090	✓		✓

These requirements apply only when these drugs are administered in an outpatient setting.

Note: These requirements don’t apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714).

How to submit authorization requests

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

To learn how to submit requests through NovoLogix, go to our Blue Cross Medical Benefit Drugs page, scroll to the Blue Cross commercial column and review the information in the How to submit authorization requests electronically using NovoLogix section.

More about the authorization requirements

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

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

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

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

Note: Accredo manages prior authorization requests for additional medical benefit drugs for these members.

We’re sharing skilled nursing facilities’ performance reporting for Medicare Advantage members

In late June, Blue Cross Blue Shield of Michigan and Blue Care Network began sharing skilled nursing facility performance data for Medicare Advantage members with providers in risk-based contracts. Information being shared includes member volumes at each facility and specific performance metrics.

This is part of an effort to foster increased collaboration between our health care providers in risk contracts and the skilled nursing facilities that provide services to their patients. “We hope this additional reporting will continue to help build relationships between skilled nursing facilities and the hospital providers sending patients to these facilities,” said Karolina Skrzypek, M.D., medical director with Provider Engagement.

Lunch and learn webinars focus on risk adjustment, coding

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

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

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

Click here if you are already registered for the site.

To request access to the provider training website:

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

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

Do we have your medical records request address?

As a reminder, please ensure that we have your correct medical records request address on file. In the April 2022 Record, we let you know we’ll be working with Optum to implement some new edits. Optum is an independent company that contracts with Blue Cross Blue Shield of Michigan to identify professional and facility claims that require additional review.

One component of our relationship with Optum involves medical records requests.
To prevent claim processing delays, we need to keep your medical records request address on file. If you haven’t provided it yet or need to make changes, use the Enrollment and Change Self-Service Tool, located on the Applications tab of our payer space on the provider portal.

Here are the step-by-step directions:

1. Log in to our provider portal (availity.com**).
2. Click on Payer Spaces on the Availity menu bar.
3. Click on the BCBSM and BCN logo.
4. Click on Provider Enrollment and Change Self-Service on the Applications tab.

If we don’t have a medical record request address on file, the request will be sent to the mailing address. If there’s no mailing address on file, the request will be sent to the billing address. And if there’s no billing address on file, the request will be sent to the address shown on the claim.

Help us streamline the claim processing process by making sure we have your correct medical records request address on file.

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

Additional procedures codes payable to OPC providers for Blue Cross commercial members, starting July 1

For members with Blue Cross Blue Shield of Michigan commercial plans, we’ve updated our systems to make additional services payable to providers at outpatient psychiatric care facilities.

For dates of service on or after July 1, 2022, the following procedure codes will be payable to the OPC providers specified below for Blue Cross commercial members:

This change brings the list of procedure codes that are payable to OPC providers for Blue Cross commercial members more in line with those that are payable to OPC providers for Blue Care Network members.

Billing instructions

When billing these procedure codes, include the following in the order specified below:

1. The modifier that indicates the licensure level (level of care) for the rendering provider (such as: AH, AJ, HO)
2. If the service was delivered via telemedicine: The telemedicine modifier (either GT or 95)
3. The place of service:
• If the service was delivered in person: Include place of service 11.
• If the service was delivered via telemedicine: Include place of service code 11, 02 or 10.

To view detailed billing instructions for services delivered via telemedicine, see the “Billing telehealth visits” section of the Telehealth for behavioral health providers document. Refer to the “Outpatient psychiatric care facilities” subsection.

By July 1, we’ll update the Telehealth for behavioral health providers document to reflect the additional codes that are payable for Blue Cross commercial members.

Blue Cross commercial OPC fee schedule

By July 1, we’ll update the OPC fee schedule to reflect this change. You can access the fee schedule as follows:

1. Log in to our provider portal (availity.com**).
2. Click on Payer Spaces on the Availity menu bar.
3. Click on the BCBSM and BCN logo.
4. Click on Secure Provider Resources (Blue Cross and BCN) on the Resources tab.
5. Choose Fee Schedules > Blue Cross Facility Fee Schedules.
6. If prompted, accept the End User License Agreement.
7. Click on Outpatient Psychiatric Care on the left.
8. Click on the link to open the 2022 fee schedule.

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

Leqvio to have site-of-care requirement for commercial members, starting Aug. 1

Leqvio^® (inclisiran), HCPCS code J3590, will have a site-of-care requirement, in addition to its current prior authorization requirement for Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members, starting Aug. 1, 2022.

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

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

Members who start treatment in a location other than those outlined above prior to Aug. 1, 2022, will be able to continue receiving the drug in that location until their current authorization expires. Providers should then transition members to one of the above sites of care.

Notes:

• Starting July 1, 2022, the HCPCS code for this drug will be J1306.
• This drug is part of members’ medical benefits, not their pharmacy benefits.
• As a reminder, prior authorization requests are submitted using the NovoLogix^® online tool.

Some Blue Cross commercial groups not subject to these requirements

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

Note: Blue Cross and Blue Shield Federal Employee Program^® members and UAW Retiree Medical Benefits Trust (non-Medicare) members don't participate in the standard prior authorization program.

List of requirements

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

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

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

Authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

Fyarro to require prior authorization for most members, starting Aug. 16

For dates of service on or after Aug. 16, 2022, Fyarro™ (sirolimus protein-bound particles), HCPCS code J9331, will require prior authorization through AIM Specialty Health^®. This drug is part of members’ medical benefits, not their pharmacy benefits.

Prior authorization requirements apply when this drug is administered in outpatient settings for:

• Blue Cross Blue Shield of Michigan commercial — Members who have coverage through fully insured groups and members with individual coverage

Note: This requirement doesn’t apply to members who have coverage through Blue Cross commercial self-funded groups, including the Blue Cross and Blue Shield Federal Employee Program^® and UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans.

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

How to submit authorization requests

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

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

More about the authorization requirements

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

For additional information on requirements related to drugs covered under the medical benefit, see:

• Blue Cross commercial and BCN commercial:
• Medical oncology prior authorization list for Blue Cross commercial fully insured and BCN commercial members
• Blue Cross and BCN utilization management medical drug list
• Medicare Advantage:
• Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members

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

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. For more information, go to our ereferrals.bcbsm.com website.

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

Fyarro and Tivdak will have requirements for URMBT members with Blue Cross non-Medicare plans

For dates of service on or after Aug. 16, 2022, the drugs listed below will require prior authorization through AIM Specialty Health^® and may also have site-of-care requirements, quantity limit requirements or both. These requirements will apply to UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans. These drugs are part of members’ medical benefits, not their pharmacy benefits.

See the table for more information. When a cell is blank, the drug doesn’t have that requirement.

Brand name	Generic name	HCPCS code	Requirements
			Prior authorization	Site of care	Quantity limits
Fyarro™	sirolimus protein-bound particles	J9331	✓
Tivdak®	tisotumab vedotin-tftv	J9273	✓

These requirements apply only when these drugs are administered in an outpatient setting.

Note: These requirements don’t apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714).

How to submit authorization requests

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

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

More about the authorization requirements

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

For additional information on requirements related to drugs covered under the medical benefit for URMBT members with 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 pertinent drug lists to reflect the information in this article prior to the effective date.

Note: Accredo manages prior authorization requests for additional medical benefit drugs for these members.

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. For more information, go to our ereferrals.bcbsm.com website.

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

Fusilev no longer requires prior authorization

Because Spectrum Pharmaceuticals has stopped manufacturing Fusilev^® (levoleucovorin), HCPCS code J0641, we no longer require prior authorization through AIM Specialty Health^® for dates of service on or after May 31, 2022. The drug was part of members’ medical benefits, not their pharmacy benefits.
This change applies to:

• Blue Cross Blue Shield of Michigan commercial:
• Members who have coverage through fully insured groups
• Members with individual coverage
• UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans
• Medicare Plus Blue℠ members
• Blue Care Network commercial members
• BCN Advantage℠ members

For additional information on requirements related to drugs covered under the medical benefit, refer to the following drug lists:

• Blue Cross and BCN commercial members:
• Medical oncology prior authorization list for Blue Cross commercial fully insured and BCN commercial members
• Blue Cross and BCN utilization management medical drug list
• URMBT members with Blue Cross non-Medicare plans:
• 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

Note: Accredo manages prior authorization requests for additional medical benefit drugs for these members.

• Medicare Plus Blue and BCN Advantage members:
• Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members

What you need to know about submitting medical benefit drug prior authorization requests for Medicare Advantage members

Blue Cross Blue Shield of Michigan and Blue Care Network recently transitioned to a new provider portal, Availity Essentials. You should continue to submit prior authorization requests for most medical benefit drugs, including CAR-T cell therapy drugs, for Medicare Plus Blue℠ and BCN Advantage℠ members in one of the following ways:

• Preferred method: Through the NovoLogix^® online tool. See the next section for the steps you need to take to access NovoLogix through Availity^®.
• For providers who aren’t able to submit requests through NovoLogix: You have two options:
• Use the new global Medication Authorization Request Form (for any medication), which we created to reduce the number of forms you have to manage. Fax the completed form to 1-866-392-6465.
• Call our Pharmacy Clinical Help Desk at 1‑800-437-3803.

Preferred method for submitting prior authorization requests

The preferred method continues to be submitting requests through NovoLogix.

Note: If you haven’t already done so, be sure to register for Availity so you can continue to submit requests through NovoLogix.

If you have an Availity account, you have access to NovoLogix.

To submit requests through Availity:

1. Log in to our provider portal (availity.com**).
2. Click on Payer Spaces on the Availity menu bar.
3. Click on the BCBSM and BCN logo.
4. In the Applications tab, click on the appropriate tile:
• NovoLogix MAPPO
• NovoLogix BCN/BCN Advantage

Additional information

You can access the Medication Authorization Request Form (for any medication) on the For Providers: How do I Submit a Drug Prior Authorization Request for Medicare Plus Blue PPO and BCN Advantage? page of the bcbsm.com website. Later this year, we’ll remove the medical drug prior authorization request forms for specific medications.

For more information about submitting requests and to view the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members, see the following pages of ereferrals.bcbsm.com website:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

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

Cortrophin and Ryplazim to have requirements for URMBT members with Blue Cross non-Medicare plans

For dates of service on or after Sept. 1, 2022, the following drugs will require prior authorization through the NovoLogix^® online tool and may also have site-of-care requirements, quantity limit requirements or both. These requirements will apply to UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans. These drugs are part of members’ medical benefits, not their pharmacy benefits.

See the table for more information. When a cell is blank, the drug doesn’t have that requirement.

Brand name	Generic name	HCPCS code	Requirements
			Prior authorization	Site of care	Quantity limits
Cortrophin®	corticotropin	J3490/J3590	✓
Ryplazim®	plasminogen, human-tvmh	J3590/C9090	✓		✓

These requirements apply only when these drugs are administered in an outpatient setting.

Note: These requirements don’t apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714).

How to submit authorization requests

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

To learn how to submit requests through NovoLogix, go to our Blue Cross Medical Benefit Drugs page, scroll to the Blue Cross commercial column and review the information in the How to submit authorization requests electronically using NovoLogix section.

More about the authorization requirements

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

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

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

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

Note: Accredo manages prior authorization requests for additional medical benefit drugs for these members.

AllianceRx Walgreens Prime is now AllianceRx Walgreens Pharmacy

Effective June 24, 2022, AllianceRx Walgreens Prime, a provider of specialty pharmacy services, changed its name to AllianceRx Walgreens Pharmacy. 

AllianceRx Walgreens Pharmacy will continue to provide Blue Cross Blue Shield of Michigan members with specialty medications used to treat chronic, complex or rare conditions.

Reminder: Members can’t receive prescriptions for DME/P&O items through telehealth visits

As we told you in an October 2018 Record article, effective Nov. 1, 2018, health care providers aren’t able to prescribe or issue durable medical equipment and prosthetic and orthotic supplies during telehealth visits. A telehealth visit doesn’t meet the medical necessity requirements for prescribing these items. Prescription and issuance resulting from a telehealth visit may be subject to audit review and recovery.
A telehealth visit includes:

• Phone call
• Both email and postal mail
• Video chat

All telehealth formats are excluded from issuing DME and prosthetic and orthotic items.