Act now to maintain online access to Blue Cross, BCN information

The old adage is true: An ounce of prevention really is worth a pound of cure. Thanks to all of you who’ve registered for and participated in training for our new provider portal, Availity Essentials.

If you haven’t yet had the chance to register and train, time is running out. Blue Cross and BCN’s Provider Secured Services and web-DENIS will have their last day of operation June 21. Beginning June 22, these tools will be retired and no longer available.

Don’t miss out on being able to access information online. Register for Availity Essentials and participate in training now. See Notice: Last day for Provider Secured Services and web-DENIS is June 21 in the May issue of The Record.

Need help?

Here’s where you can find it:

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

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

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

Reminder: Availity administrators must take action now to ensure access to e-referral and Health e-Blue tools within Availity

Time is running out. June 21, 2022, is the last day to access e-referral and Health e-Blue℠ through Provider Secured Services and web-DENIS.

If they haven’t already done so, Availity^® administrators need to take action to set up access to e-referral and (if appropriate) Health e-Blue. This will ensure users can access these tools through Availity Essentials.

Here’s how these tools are used:

• The e-referral tool is used to submit requests for referrals and authorizations.
• The Health e-Blue tools provide patient health reporting on conditions, treatment opportunities, pharmacy claims, diagnosis gaps and more.

Each organization (office, practice or facility) must have at least one Availity administrator. Administrators handle access for other Availity users; users can’t set up their own access. The provider alerts we’ve linked to below describe how to identify the Availity administrator for your organization.

Be sure your Availity administrator sets up access to these tools for all users who need to obtain information for patients who have coverage through Blue Cross Blue Shield of Michigan and Blue Care Network.

If your Availity administrator doesn’t take action, users of these tools won’t be able to access them through Availity and may receive error messages when they try.

Setup instructions

To view step-by-step setup instructions for Availity administrators, see the following provider alerts:

• Availity^® administrators: Set up the e-referral tool within Availity
• Availity^® administrators: Set up Health e-Blue℠ tools within Availity

The following videos also show the setup steps:

• Getting Started with e-referral on Availity Essentials**
• Getting Started with Health e-Blue on Availity Essentials**

Additional information

See the Welcome to Availity special edition newsletter for additional information about Availity.

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

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

Private duty nursing will soon require prior authorization

Starting Oct. 1, 2022, private duty nursing agencies will have the opportunity to participate in Blue Cross Blue Shield of Michigan’s Traditional and TRUST PPO (commercial) network. Participating agencies can receive direct reimbursement for covered services within the scope of their licensure.

This change will affect Blue Cross benefit plans that cover services these providers are licensed to provide. To find out if a member has coverage, check our provider portal for member benefits and eligibility, or call Provider Inquiry at 1‑800‑344‑8525.

Requirements

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

Stay tuned

More information about this program, including enrollment, claims submission requirements and available training, will be coming soon.

2022 COVID-19 HCPCS update: New code added

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

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.

2^nd-quarter 2022 early release CPT code update

Category III codes

Category III codes

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.

News and information roundup

Following are brief summaries of a few articles that were featured in the May-June issue of Hospital and Physician Update that we thought you might be interested in.

Blue Cross launches new CQI to improve suicide prevention efforts
Blue Cross Blue Shield of Michigan is joining forces with Henry Ford Health to launch a new Collaborative Quality Initiative called the Michigan Mental health Innovation Network for clinical Design, or MiMIND. The goal of MiMIND is to engage psychiatrists, psychologists and primary care physicians in a collaborative approach to improve suicide prevention efforts across Michigan. For more information, click here.

New Pediatric Weight Management Initiative designed to decrease childhood obesity in Michigan
Dr. Martha Walsh, medical director, Clinical Partnerships and Engagement, discusses the problem of childhood obesity and a new pediatric weight management incentive for pediatricians who participate in our Provider-Delivered Care Management program. For more information, click here.

Michigan Opioid Collaborative: Making a difference in patients' lives
The Michigan Opioid Collaborative is transforming the delivery of services to Michiganders with opioid use disorder. To learn more, click here.

Blue Cross focuses on maternal health, announces core measures
As part of a series on health and health care disparities in Michigan, we’re showcasing Blue Cross Blue Shield of Michigan’s efforts to reduce maternal health disparities. For more information, click here.

To subscribe to Hospital and Physician Update or other provider-focused publications, click here.

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.

We invite you to join PGIP as a physician organization

We’re pleased to announce that we’ll accept applications for the Physician Group Incentive Program from new physician organizations from July 1 through July 31, 2022.

PGIP offers incentives to participating physician organizations for improving health care delivery.

To request application materials, send an email to valuepartnerships@bcbsm.com.

About PGIP
The Physician Group Incentive Program was developed with input from providers across Michigan to help improve the quality and efficiency of health care in the state. PGIP facilitates change through a wide range of initiatives, including our nationally recognized Patient-Centered Medical Home program.

Through PGIP, we reward physician organizations for improving health care delivery to their attributed patient population. PGIP-participating physicians are subsequently eligible for value-based reimbursement consideration as a result of program efforts.

A PGIP physician organization consists of physicians participating in our PPO or Traditional network, working together to:

• Transform systems of care to effectively manage patient populations.
• Build the infrastructure needed to optimize, measure and monitor quality of care.
• Promote collaborative relationships.
• Support the most cost-effective delivery of services to improve patient outcomes.

To learn more

• If you’re interested in participating in PGIP as an individual practitioner, click here to learn more about PGIP physician organizations.

• For more information on PGIP and its initiatives, visit the Physician Group Incentive Program section of valuepartnerships.com.

Practitioners can receive reimbursement for lung health education for patients with Blue Cross Complete

Despite a strong correlation between asthma education and improved patient outcomes, fewer than 10% of Michigan asthma patients receive regular self-management education during health care visits, according to medical billing records. Additionally, research has shown that children with asthma who receive regular education have improved lung function, reduced school absenteeism and fewer visits to emergency departments.

Increasing patient education is a core mission of Inspiring Health Advances in Lung Care, or INHALE, a recently launched collaborative quality initiative that is supported by Blue Cross Blue Shield of Michigan. INHALE leadership identified the low education rate as an early priority for the CQI and worked collaboratively with the Asthma Initiative of Michigan to advocate for the Michigan Department of Health and Human Services to accept asthma education as a Medicaid-covered service for Michigan providers.

As a result of these efforts, demonstrating and evaluating patient use of respiratory medications and devices became a covered service for Michigan physicians, practitioners, medical clinics, health departments and child and adolescent health centers providing services to patients with Blue Cross Complete, Blue Cross’ Medicaid plan, in January 2022. The anticipated reimbursement rate is $9.91 per visit through CPT code *94664.

“Drug delivery to the lungs is exceptionally difficult, and teaching patients how to use their medications reduces side effects and improves asthma control and quality of life,” said Njira Lugogo, M.D., INHALE’s program director and Michigan Medicine’s asthma program director. “This change in billing coverage enables providers to receive reimbursement for patient education, which is a critical component of asthma care. Ultimately, the goal is for patients with asthma to live full and productive lives unaffected by asthma.”

For more information

• To learn more about INHALE, see the article in the May-June issue of Hospital and Physician Update.
• Providers who have questions about INHALE are encouraged to email contact@inhalecqi.org.

Blue Cross follows CMS guidelines for use of JW modifier to indicate drug waste

As a reminder, Blue Cross Blue Shield of Michigan follows the Centers for Medicare & Medicaid Services’ standard billing guidelines for the use of the JW modifier to identify unused drugs or biologicals from single-use vials or single-use packages that are appropriately discarded. (Multiuse vials aren’t subject to payment for discarded amounts of drug.) This applies to professional claims only.

The JW modifier, billed on a separate line, will provide payment for the amount of the discarded drug or biological.

Example: A single-use vial that is labeled to contain 100 units of a drug has 95 units administered to the patient and five units discarded. The 95 unit dose is billed on one line, while the discarded five units will be billed on another line by using the JW modifier. Both line items would be processed for payment. Providers must record the discarded amounts of drugs and biologicals in the patient’s medical record.

Beginning in the fourth quarter of this year, some drug wastage will be reimbursed at a reduced rate for Blue Cross commercial. Refer to future minimum fee schedule for details.

For more information, check out the CMS article “Billing and Coding: JW Modifier Billing Guidelines.”**

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

Reminder: Appropriate use of modifier 59 for Medicare Plus Blue claims

As a reminder, follow the guidelines communicated in the September 2021 Record article when appending modifier 59 on Medicare Plus Blue℠ claims. We have begun editing claim lines when modifier 59 is 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 is 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 to automatically bypass the NCCI code-pair edits.

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.

Landmark Health program expands to Medicare Advantage members in additional Michigan counties

Blue Cross Blue Shield of Michigan and Blue Care Network have been working with Landmark Health, a mobile provider group, to make high-intensity in-home care available to Medicare Advantage members with multiple chronic conditions. Landmark delivers in-home medical services for patients with multiple chronic conditions to help them stay healthy at home and reduce avoidable emergency department visits and hospital admissions.

Currently, the program is available to a select group of Medicare Plus Blue℠ and BCN Advantage℠ members. Beginning July 1, 2022, we’re expanding the program to include additional members in Southeast Michigan counties, as well as members in the Lansing and Flint areas. Future expansions will make the program available to members in additional counties in Michigan’s Lower Peninsula.

By providing these members with more targeted support, we’ll help to improve their experience and coordination of care, resulting in better overall health and reduced costs. Using a physician-led, interdisciplinary team, the program will complement office-based primary care with services such as:

• Home-based medical care and documentation of medical conditions and health history by a physician, nurse practitioner or physician assistant
• In-home routine, urgent and post-acute care visits
• 24/7 clinical phone support
• Team-based interdisciplinary care from behavioral health, palliative care and pharmacy providers; dietitians, and social workers
• Care management, behavior management and medication management
• Assessment of social determinants of health
• Education of patients and caregivers
• Care coordination from nurse care managers
• Partnership, communication and integration with primary care physician workflows

You’ll receive a list of your patients who are eligible for the program before Landmark contacts the patients.
This program furthers our focus on home care that started with such programs as Hospital Care at Home with Michigan Medicine and High-Intensity Care Management.

For more information on the Landmark program, review our Frequently asked questions for providers document. Look for information about further program expansions in future issues of The Record and BCN Provider News.

Reimbursement for compounded Avastin eye injections changing in August for Medicare Advantage members

For claims received on or after Aug. 1, 2022, reimbursement will change to $160 per eye injected with compounded Avastin^® (bevacizumab) eye injections for Medicare Plus Blue℠ and BCN Advantage℠ members.

This change for medical drug claims for Medicare Plus Blue and BCN Advantage members aligns with reimbursement in the marketplace. It’s based on clinical trials that demonstrate the product’s safety and effectiveness.

Here’s the information to include on the claim:

• HCPCS code number
• For Medicare Plus Blue: J3590
• For BCN Advantage: J9035
• National Drug Code
• NDC units (example: 0.05 ml)
• Exact dose in milligrams (example: 1.25 mg)
• Specific ICD codes pertinent to eye disease

Note: Avastin eye injections don’t require authorization.

Inflectra, Avsola will be preferred infliximab products for pediatric commercial members starting in July

Starting July 1, 2022, the following drugs will be the preferred infliximab products for pediatric Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members:

• Inflectra^® (infliximab-dyyb), HCPCS code Q5103
• Avsola^® (infliximab-axxq), HCPCS code Q5121

The nonpreferred infliximab products will be:

• Remicade^® (infliximab), HCPCS code J1745
• Renflexis^® (infliximab-abda), HCPCS code Q5104

These drugs already require prior authorization for both adult and pediatric members.

How this will affect pediatric members

• Pediatric members who have an active authorization for a preferred infliximab product as of July 1, 2022, won’t be affected by this change.
• For pediatric members who have an active authorization for a nonpreferred product, their authorization will remain in effect through Aug. 31, 2022. In addition, we have approved authorizations for Inflectra and Avsola from July 1, 2022, through Aug. 31, 2023, so these members can continue their infliximab therapy without interruption. Health care providers don’t need to submit prior authorization requests for dates of service within this time frame.
• For pediatric members who will be initiating therapy for an infliximab product, submit a prior authorization request.

How to submit prior authorization requests

Submit prior authorization requests through the NovoLogix^® online tool. To learn how, visit ereferrals.bcbsm.com and do the following:

• For Blue Cross commercial members: Click on Blue Cross and then click on Medical Benefit Drugs. In the Blue Cross commercial column, see the How to submit requests electronically using NovoLogix section.
• For BCN commercial members: Click on BCN and then click on Medical Benefit Drugs. In the BCN commercial column, see the How to submit requests electronically using NovoLogix section.

Definition of pediatric members

Pediatric members fit into one of these categories:

• 15 years old or younger, regardless of weight
• 16 through 18 years old who weigh 50 kilograms or less

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.

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.
Authorization isn't a guarantee of payment. As always, health care practitioners should verify eligibility and benefits for our members.

Here are time frames for determinations on authorization requests for acute inpatient medical admissions

The time frame within which Blue Cross Blue Shield of Michigan and Blue Care Network must make a determination on a request to authorize an acute inpatient medical admission depends on the type of request.

We’ve updated the document Submitting acute inpatient authorization requests: Frequently asked question for providers to include information on the time frames for determinations. You can access that document on these webpages:

• Blue Cross Authorization Requirements & Criteria
• BCN Authorization Requirements & Criteria

For easy reference, we also included the details in the table below. This information applies only to acute inpatient medical admissions, not to behavioral health inpatient admissions.

Here’s more information about the types of requests:

• Standard: Request to reimburse for services.
• Expedited: Request when standard time frame could seriously jeopardize the life or health of a member or the member’s ability to regain maximum function. Requires that a physician attest to the need for an expedited request.
• Preservice: Request is received prior to receipt of care.
• Concurrent: Request is received while member is receiving care.
• Postservice: Request is received after member has been discharged.

Reminders:

• We don’t use the Centers for Medicare & Medicaid Services two-midnight rule; we require authorization for all hospital admissions, both Medicare Advantage and commercial.
• Our authorization program is oriented toward providers, not members. We don’t deny care, services or treatment. Our program determines the appropriate level of care for reimbursement (observation versus inpatient).

CareCentrix removes HIPPS questionnaire from HomeBridge portal

On March 20, 2022, CareCentrix^® removed the HIPPS Questionnaire from the HomeBridge^® portal. CareCentrix now accepts Health Insurance Prospective Payment System, or HIPPS, codes generated by home health agencies.

Blue Cross Blue Shield of Michigan and CareCentrix made this change, which affects Medicare Plus Blue℠ members who receive services in Michigan, based on feedback from home health agencies.

This change doesn’t affect Medicare Plus Blue members who receive services outside of Michigan or BCN Advantage℠ members.

For more information about working in the HomeBridge portal, see the CareCentrix document titled Accessing and Navigating the Updated HIPPS Template in the CareCentrix Provider Portal.**

For more information about this change and reminders, see this news item on ereferrals.bcbsm.com.

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

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

Blue Cross payment policy for hyperbaric oxygen therapy will align with our medical policy

In support of correct coding and payment accuracy, Blue Cross Blue Shield of Michigan’s payment policy for hyperbaric oxygen therapy will align with our medical policy.
 
Claims submitted with CPT code *99183 and HCPCS code G0277 will be evaluated to ensure that they include a diagnosis code that aligns with our established medical policy.

• *99183 — Hyperbaric oxygen therapy
• G0277 — Hyperbaric oxygen under pressure, per 30-minute interval

Claims that don’t contain a requisite diagnosis may receive a denial.   

The medical policy for hyperbaric oxygen therapy is available online.

Prior authorization requirements change for radiology code *71271

Radiology code *71271 no longer requires prior authorization through AIM Specialty Health^® for these members:

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

This information is intended to clarify earlier communications about prior authorization requirements for this procedure code.

We’ve updated the document Procedures that require prior authorization by AIM Specialty Health: Cardiology, radiology (high technology) and sleep studies (in lab) to reflect this.

As a reminder, AIM Specialty Health makes authorization determinations for select high-tech imaging services and other services performed in freestanding facilities, outpatient hospital settings, ambulatory surgery centers and physician offices.

For additional information about submitting prior authorization requests to AIM, visit these webpages at ereferrals.bcbsm.com:

• Blue Cross AIM-Managed Procedures
• BCN AIM-Managed Procedures

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.

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.

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

Important updates to training courses; new on-demand training available

In support of Blue Cross Blue Shield of Michigan and Blue Care Network’s transition to a new provider portal, Availity^®, Provider Experience has updated many of its existing training courses with new screen examples and steps to align with the change. To access these courses, follow the steps at the end of this article.

Availity
For training related to our new provider portal, go to the Availity Get Up to Speed with Training webpage designed specifically for Blue Cross and BCN. This page provides you with the latest dates and times for Blue Cross- and BCN-specific webinars. You can register for the webinars, download handouts and view webinar recordings from this website by clicking on the link and signing into Availity.

For more information about Availity, see the following articles in this issue of The Record:

• “Act now to maintain online access to Blue Cross, BCN information”
• “Reminder: Availity administrators must take action now to ensure access to e-referral and Health e-Blue tools within Availity”

Training resources from Provider Experience
Provider Experience also 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 and BCN.
We recently added the following new learning opportunity:

• Risk adjustment review recorded webinar — This lunch and learn webinar shares new information on documentation and coding of common and challenging diagnoses. Topics include a review of risk adjustment and hierarchical condition categories.

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 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.

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

Register now for 2022 virtual provider symposium sessions

This year’s virtual provider symposiums will continue in June. Physicians, physician assistants, nurse practitioners, nurses and coders can receive continuing education credits for attending. You’re welcome to register for any session listed below.

We are Stars — HEDIS^® and Star measure details and exclusions: For physicians and office staff responsible for closing gaps in care related to quality adult measures.

Click below to register:

• Thursday, June 9 — 8 to 10 a.m.

Patient Experience — Providing great service 2.0: For physicians and office staff responsible for creating positive patient experiences.

Select a date to register:

• Tuesday, June 7 — noon to 1:30 p.m.
• Tuesday, June 14 — 9 to 10:30 a.m.

Medical record documentation and coding update: For physicians, coders, billers and administrative staff.

Select a date to register:

• Thursday, June 2 — 2 to 3 p.m.
• Wednesday, June 8 — noon to 1 p.m.

Questions?
Contact Ellen Kraft at ekraft@bcbsm.com if you have questions about the sessions or Patricia Scarlett at pscarlett@bcbsm.com if you have registration questions.

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

Accreditation statement: This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the Minnesota Medical Association and Blue Cross Blue Shield of Michigan. The Minnesota Medical Association (MMA) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CME Statement: The Minnesota Medical Association designates this internet live activity for a maximum of 4.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Survey offers insights into how we’re meeting expectations of health care providers

We conducted 10-minute surveys of Blue Cross Blue Shield of Michigan physicians and office staff, beginning late last year. The physician survey was fielded from Nov. 9 through Dec. 22, 2021, while the office staff survey was open from Nov. 12 through Jan. 3, 2022. For more details about the survey methodology, see the “How we conducted the survey” section at end of this article.

Following is an overview of the survey findings.

Blue Cross scores high on commitment to health and providing support for patient care
Blue Cross Blue Shield of Michigan and Blue Care Network received high marks from providers and office staff on many elements of their experiences with us, including the value of provider network participation, our commitment to improving health care in Michigan and the support we offer to help deliver patient care. In fact, Blue Cross outperforms other health plans on all experience measures.

However, they want us to do more to enhance their understanding of which procedures need authorization. Also, physicians indicated they want to have input into new programs and policies that affect patient care.

For providers, the highest ratings were for the overall relationship with Blue Cross, our demonstrated commitment to improve health and health care in Michigan and the value of participating in the provider network. Here are several key metrics:

• Seventy-six percent of providers said they were somewhat or very satisfied (score of 6 through 10 on a 0 to 10 scale) with the value of participating in the provider network. 
• Seventy-three percent of providers were very satisfied with our dedicated commitment to improve health and health care in Michigan.
• Seventy-four percent of providers were very satisfied in their overall relationship with Blue Cross.
• Seventy-three percent of providers were very satisfied with the ease of doing business with Blue Cross.
• Seventy-one percent of providers were somewhat or very satisfied with the overall support Blue Cross provides to help deliver patient care.
• Sixty-five percent of providers were somewhat or very satisfied with the support and resources offered during the pandemic.
• Seventy-one percent of providers said they were somewhat or very satisfied with the direction Blue Cross is headed for the future.

By comparison, other health plans in Michigan scored in the range of 50% to 60% satisfaction on the above statements.

Physicians want a partnership
Physicians want to have a say in the strategic decisions Blue Cross is considering when it will affect patient care and they also want fair compensation. Gathering feedback from research efforts, such as the following, is one way that we’re listening to providers.

• Fifty-four percent of providers agreed or strongly agreed that Blue Cross trusts their expertise as a medical doctor.
• Forty-nine percent of providers somewhat or strongly agree that Blue Cross is a partner to their practice by providing tools and support to provide quality care to their patients.
• Fifty-five percent of providers somewhat or strongly agree that Blue Cross provides fair compensation.

Provider Inquiry can be improved
Long wait times for provider inquiry help are a primary concern for office staff. Only 25% of office staff respondents agree that Provider Inquiry has gotten somewhat or much better in the last 12 months. However, 80% of office staff were somewhat or very satisfied that Provider Inquiry information is accurate regarding patient eligibility and benefits.

In addition:

• Sixty-nine percent of office staff said they were somewhat or very satisfied with the ease of finding accurate patient eligibility and benefits information.
• Sixty-three percent of office staff said they were somewhat or very satisfied with representatives’ ability to resolve issues and concerns.

Prior authorizations
Understanding when prior authorizations are required is an ongoing pain point for physicians and office staff. Fifty percent of Blue Cross providers and office staff somewhat or strongly agree that they know when prior authorization is required.

Nearly half (47%) of physicians and office said they understand Blue Cross prior authorization and medical criteria. And approximately one-third (31%) of office staff respondents said it was easy to determine which medical services require authorization.

Our move to Availity^®
Providing extra support and education around the benefits of Availity may ease hesitancy toward the switch from web-DENIS. Among those who have experience with Availity, 6 in 10 are satisfied, while others are hesitant to switch from web-DENIS to Availity.

To help with the transition to Availity, we’ve provided communications in our newsletters for the past year and have recently posted a special edition newsletter about Availity on March 16, including how to register and how to access training.

Providers find our communications helpful
The majority of providers find Blue Cross and BCN communications informative and relevant with heaviest utilization among office staff. Fifty-three percent of providers and 79% of office staff said they somewhat or strongly agree that our provider communications keep them abreast of information relevant to them. The Record and BCN Provider News were the most popular and useful publications for office staff. Hospital & Physician Update isthe most useful for physicians.

How we conducted the survey
Our survey of physicians and office staff was administered by Gongos, an independent firm that contracts with Blue Cross.

• Physicians completed the survey online and were sent invitations by email and fax. Additional reminders were sent by fax as well.
• Invitations for office staff were sent by mail, offering the option to complete online or by mail. Postcard reminders were also sent.
• A total of 428 physicians and 283 office staff completed a survey.

Keep your Provider Authorization form updated

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

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

Update the form when you:

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

Review the form when you:

• Join a new group practice.
• Leave a group practice and start billing using your own NPI.
• Hire a new billing service.
• Start submitting claims through a clearinghouse or when you’ve changed clearinghouses.
• Select a new destination for your 835.

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

How to change your EDI setup
To make changes to your EDI setup, log in to the Trading Partner Agreement webpage. Or follow the steps below to arrive at the TPA login page at bcbsm.com/providers/help/edi:

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

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

Some resources, fact sheets about cancer screenings to share with patients

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

Cancer is the second leading cause of death in the U.S., according to the Centers for Disease Control and Prevention. Regular screenings for breast, cervical and colorectal cancer offer the best chance to find cancer early when treatment is most effective.  

To help people keep track of the screenings they need, the CDC created fact sheets about cancer prevention and the importance of cancer screenings.

Share these fact sheets with your patients:

• Colorectal Screening Tests At-A-Glance**
• Breast Cancer: Things You Should Know**
• Cervical Cancer Inside Knowledge About Gynecologic Cancer**

The CDC offers additional resources on cancer screenings and prevention for health care providers that include continuing medical education courses,** simulations,** webinars,** screening guidelines and other resources.**

The Blue Cross and Blue Shield Federal Employee Program^® covers cancer screenings for colorectal, cervical and breast cancer. There are no out-of-pocket costs for members when they have their screenings once per calendar year and the procedure is performed by a Preferred provider.

If you or a member has questions about FEP benefits, call Customer Service at 1-800-482-3600 or go online to fepblue.org.

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

Acute low back pain doesn’t always require imaging

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

Low back pain is among the most common causes of disability and lost productivity in the U.S. More than 80% of the population will experience low back pain in their lifetime, according to the National Institute of Neurological Disorders and Stroke. Many patients with low back pain receive routine spinal imaging, such as X-rays, CT scans or MRIs. However, imaging isn’t recommended for most patients with acute low back pain in the absence of red flags.

Red flags include:

• Severe or progressive neurologic deficits (loss of ability to move an arm or leg on one side of your body)
• Fever
• Sudden back pain with spinal tenderness
• Trauma
• Loss of bladder control or bowel control

In the absence of red flags, the American Association of Neurological Surgeons recommends a conservative approach, such as:

• Instructing the patient to stay active as tolerated by pain
• Avoiding bed rest
• Doing back exercises and stretches
• Injury prevention
• Using over-the-counter pain relievers

The Michigan Quality Improvement Consortium guideline for Management of Acute Low Back Pain in Adults** provides recommendations for assessment, diagnosis and treatment of acute low back pain in adults.

Share this information with your patients, and if you or a member has questions about Blue Cross and Blue Shield Federal Employee Program^® benefits, call Customer Service at 1-800-482-3600 or go online to fepblue.org.

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

CQI incentive program now available for ambulatory surgery facilities

Our Collaborative Quality Initiatives are statewide, clinician-led quality improvement initiatives that address many of the most common areas of surgical and medical care in Michigan. Historically, the CQI program has involved the engagement and participation of hospitals and physician practices in CQI activities.

We recently expanded the program to include procedures performed at independent, free-standing ambulatory surgery facilities.** As a result, we’ve developed a CQI incentive program for ambulatory surgery facilities to support their participation and engagement in specific CQIs.  

This CQI incentive will reward ambulatory surgery facilities that meet all of these requirements:

• They participate in our CQI program.
• They contribute data to the statewide registry.
• They learn and share best practices.
• They participate in continuous quality improvement activities.

Ambulatory surgery facilities that participate in this CQI incentive program will be eligible for a facility fee increase of 1%, or 101% of the standard fee schedule amount for Blue Cross Blue Shield of Michigan and Blue Care Network commercial members. 

This increase will apply to all services reimbursed at the facility level. The following CQIs are participating in the CQI incentive program for ambulatory surgery facilities:

• The Michigan Arthroplasty Registry Collaborative Quality Initiative (marcqi.org***)
• The Michigan Spine Surgery Improvement Collaborative (mssic.org***)

Ambulatory surgery facilities must meet specific eligibility requirements, including procedure volumes and participation expectations, to be involved with this program.

To learn more about the eligibility requirements and participation expectations for the ambulatory surgery facilities CQI incentive, refer to the 2022 Blue Cross Blue Shield of Michigan and Blue Care Network Collaborative Quality Initiative ASF CQI Incentive Program for Independent Free-Standing Ambulatory Surgery Facilities.

**Independent free-standing ASFs are entities that operate exclusively for the purpose of providing outpatient surgical services to patients and aren’t associated with one or more of Blue Cross Blue Shield of Michigan’s participating hospital agreements related to hospital outpatient services.

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

Medicare Advantage post-acute care: New 7-day limit on documents in naviHealth’s nH Access portal

Effective June 3, 2022, documents for Medicare Plus Blue℠ and BCN Advantage℠ members will be available within nH Access™ for only seven days from the day they were posted.

If you need to access a document after it’s been removed from nH Access, contact your naviHealth care coordinator.

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

Note: Since Feb. 11, 2022, documents have been available in the nH Access portal for 30 days.

naviHealth is committed to improving the post-acute care experience for our Medicare Advantage members. As part of this commitment, naviHealth provides access to patient information and documentation during the prior authorization process by making documents available through nH Access.

As a reminder, naviHealth:

• Authorizes patient-driven payment model levels during the patient's skilled nursing facility stay (from preservice through discharge)
• Authorizes patient-driven payment model levels based on medical-necessity review and their proprietary naviHealth Predict functional assessment
• Works with skilled nursing facilities to ensure billers submit proper PDPM levels for reimbursement

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

naviHealth Inc. is an independent company that manages authorizations for post-acute care services for Blue Cross Blue Shield of Michigan and Blue Care Network members who have Medicare Advantage plans.

We’re designating preferred and nonpreferred IV iron therapy replacement drugs for Medicare Advantage members

Starting Aug. 8, 2022, we’re designating certain intravenous iron replacement therapy drugs as preferred or nonpreferred for our Medicare Plus Blue℠ and BCN Advantage℠ members. These drugs are covered under members’ medical benefits.

If you are currently treating one of our Medicare Advantage members with a drug that will be designated as nonpreferred, we encourage you to transition to them to a preferred drug as soon as possible.

Preferred medications won’t require prior authorization
The preferred IV iron therapy replacement medications are:

• Ferrlecit^® (sodium ferric gluconate), HCPCS code J2916        
• Feraheme^® (ferumoxytol), HCPCS code Q0138
• Venofer^® (iron sucrose), HCPCS code J1756
• INFeD^® (iron dextran), HCPCS code J1750

Nonpreferred medications will require prior authorization
The nonpreferred IV iron therapy replacement medications are:

• Injectafer^® (ferric carboxymaltose), HCPCS code J1439
• Monoferric^® (ferric derisomaltose), HCPCS code J1437

For dates of service on or after Aug. 8, 2022, we’ll require prior authorization for these nonpreferred IV iron therapy medications.

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

Exception: In line with Original Medicare guidelines, Injectafer and Monoferric won’t require prior authorization when members receive them through a dialysis facility. Refer to the ESRD PPS Drug Designation Process** guidelines published by the Centers for Medicare & Medicaid Services.

When prior authorization is required
We require prior authorization for the nonpreferred drugs when they are administered in any site of care other than inpatient hospital (place of service code 21) and are billed as follows:

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

Submitting prior authorization requests
Submit requests for the nonpreferred drugs using the NovoLogix online tool. It offers real-time status checks and immediate approvals for certain medications.

If you have access to the Availity^® Essentials provider portal, you already have access to NovoLogix. If you need to request access to Availity, follow the instructions on the Register for web tools webpage at bcbsm.com/providers.

After you’ve logged in to Availity, click on Payer Spaces and then click on the BCBSM and BCN logo. This will take you to the Blue Cross and BCN payer space, where you’ll find links to the NovoLogix tools on the Applications tab.

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

We’ll update the list to reflect these changes prior to the effective date.

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

Reimbursement for compounded Avastin eye injections changing in August for Medicare Advantage members

For claims received on or after Aug. 1, 2022, reimbursement will change to $160 per eye injected with compounded Avastin^® (bevacizumab) eye injections for Medicare Plus Blue℠ and BCN Advantage℠ members.

This change for medical drug claims for Medicare Plus Blue and BCN Advantage members aligns with reimbursement in the marketplace. It’s based on clinical trials that demonstrate the product’s safety and effectiveness.

Here’s the information to include on the claim:

• HCPCS code number
• For Medicare Plus Blue: J3590
• For BCN Advantage: J9035
• National Drug Code
• NDC units (example: 0.05 ml)
• Exact dose in milligrams (example: 1.25 mg)
• Specific ICD codes pertinent to eye disease

Note: Avastin eye injections don’t require authorization.

Inflectra, Avsola will be preferred infliximab products for pediatric commercial members starting in July

Starting July 1, 2022, the following drugs will be the preferred infliximab products for pediatric Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members:

• Inflectra^® (infliximab-dyyb), HCPCS code Q5103
• Avsola^® (infliximab-axxq), HCPCS code Q5121

The nonpreferred infliximab products will be:

• Remicade^® (infliximab), HCPCS code J1745
• Renflexis^® (infliximab-abda), HCPCS code Q5104

These drugs already require prior authorization for both adult and pediatric members.

How this will affect pediatric members

• Pediatric members who have an active authorization for a preferred infliximab product as of July 1, 2022, won’t be affected by this change.
• For pediatric members who have an active authorization for a nonpreferred product, their authorization will remain in effect through Aug. 31, 2022. In addition, we have approved authorizations for Inflectra and Avsola from July 1, 2022, through Aug. 31, 2023, so these members can continue their infliximab therapy without interruption. Health care providers don’t need to submit prior authorization requests for dates of service within this time frame.
• For pediatric members who will be initiating therapy for an infliximab product, submit a prior authorization request.

How to submit prior authorization requests

Submit prior authorization requests through the NovoLogix^® online tool. To learn how, visit ereferrals.bcbsm.com and do the following:

• For Blue Cross commercial members: Click on Blue Cross and then click on Medical Benefit Drugs. In the Blue Cross commercial column, see the How to submit requests electronically using NovoLogix section.
• For BCN commercial members: Click on BCN and then click on Medical Benefit Drugs. In the BCN commercial column, see the How to submit requests electronically using NovoLogix section.

Definition of pediatric members

Pediatric members fit into one of these categories:

• 15 years old or younger, regardless of weight
• 16 through 18 years old who weigh 50 kilograms or less

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.

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.
Authorization isn't a guarantee of payment. As always, health care practitioners should verify eligibility and benefits for our members.

Here are time frames for determinations on authorization requests for acute inpatient medical admissions

The time frame within which Blue Cross Blue Shield of Michigan and Blue Care Network must make a determination on a request to authorize an acute inpatient medical admission depends on the type of request.

We’ve updated the document Submitting acute inpatient authorization requests: Frequently asked question for providers to include information on the time frames for determinations. You can access that document on these webpages:

• Blue Cross Authorization Requirements & Criteria
• BCN Authorization Requirements & Criteria

For easy reference, we also included the details in the table below. This information applies only to acute inpatient medical admissions, not to behavioral health inpatient admissions.

Here’s more information about the types of requests:

• Standard: Request to reimburse for services.
• Expedited: Request when standard time frame could seriously jeopardize the life or health of a member or the member’s ability to regain maximum function. Requires that a physician attest to the need for an expedited request.
• Preservice: Request is received prior to receipt of care.
• Concurrent: Request is received while member is receiving care.
• Postservice: Request is received after member has been discharged.

Reminders:

• We don’t use the Centers for Medicare & Medicaid Services two-midnight rule; we require authorization for all hospital admissions, both Medicare Advantage and commercial.
• Our authorization program is oriented toward providers, not members. We don’t deny care, services or treatment. Our program determines the appropriate level of care for reimbursement (observation versus inpatient).

CareCentrix removes HIPPS questionnaire from HomeBridge portal

On March 20, 2022, CareCentrix^® removed the HIPPS Questionnaire from the HomeBridge^® portal. CareCentrix now accepts Health Insurance Prospective Payment System, or HIPPS, codes generated by home health agencies.

Blue Cross Blue Shield of Michigan and CareCentrix made this change, which affects Medicare Plus Blue℠ members who receive services in Michigan, based on feedback from home health agencies.

This change doesn’t affect Medicare Plus Blue members who receive services outside of Michigan or BCN Advantage℠ members.

For more information about working in the HomeBridge portal, see the CareCentrix document titled Accessing and Navigating the Updated HIPPS Template in the CareCentrix Provider Portal.**

For more information about this change and reminders, see this news item on ereferrals.bcbsm.com.

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

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

Blue Cross payment policy for hyperbaric oxygen therapy will align with our medical policy

In support of correct coding and payment accuracy, Blue Cross Blue Shield of Michigan’s payment policy for hyperbaric oxygen therapy will align with our medical policy.
 
Claims submitted with CPT code *99183 and HCPCS code G0277 will be evaluated to ensure that they include a diagnosis code that aligns with our established medical policy.

• *99183 — Hyperbaric oxygen therapy
• G0277 — Hyperbaric oxygen under pressure, per 30-minute interval

Claims that don’t contain a requisite diagnosis may receive a denial.   

The medical policy for hyperbaric oxygen therapy is available online.

Prior authorization requirements change for radiology code *71271

Radiology code *71271 no longer requires prior authorization through AIM Specialty Health^® for these members:

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

This information is intended to clarify earlier communications about prior authorization requirements for this procedure code.

We’ve updated the document Procedures that require prior authorization by AIM Specialty Health: Cardiology, radiology (high technology) and sleep studies (in lab) to reflect this.

As a reminder, AIM Specialty Health makes authorization determinations for select high-tech imaging services and other services performed in freestanding facilities, outpatient hospital settings, ambulatory surgery centers and physician offices.

For additional information about submitting prior authorization requests to AIM, visit these webpages at ereferrals.bcbsm.com:

• Blue Cross AIM-Managed Procedures
• BCN AIM-Managed Procedures

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.

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.

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

Keep your Provider Authorization form updated

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

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

Update the form when you:

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

Review the form when you:

• Join a new group practice.
• Leave a group practice and start billing using your own NPI.
• Hire a new billing service.
• Start submitting claims through a clearinghouse or when you’ve changed clearinghouses.
• Select a new destination for your 835.

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

How to change your EDI setup
To make changes to your EDI setup, log in to the Trading Partner Agreement webpage. Or follow the steps below to arrive at the TPA login page at bcbsm.com/providers/help/edi:

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

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

Reimbursement for compounded Avastin eye injections changing in August for Medicare Advantage members

For claims received on or after Aug. 1, 2022, reimbursement will change to $160 per eye injected with compounded Avastin^® (bevacizumab) eye injections for Medicare Plus Blue℠ and BCN Advantage℠ members.

This change for medical drug claims for Medicare Plus Blue and BCN Advantage members aligns with reimbursement in the marketplace. It’s based on clinical trials that demonstrate the product’s safety and effectiveness.

Here’s the information to include on the claim:

• HCPCS code number
• For Medicare Plus Blue: J3590
• For BCN Advantage: J9035
• National Drug Code
• NDC units (example: 0.05 ml)
• Exact dose in milligrams (example: 1.25 mg)
• Specific ICD codes pertinent to eye disease

Note: Avastin eye injections don’t require authorization.

Inflectra, Avsola will be preferred infliximab products for pediatric commercial members starting in July

Starting July 1, 2022, the following drugs will be the preferred infliximab products for pediatric Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members:

• Inflectra^® (infliximab-dyyb), HCPCS code Q5103
• Avsola^® (infliximab-axxq), HCPCS code Q5121

The nonpreferred infliximab products will be:

• Remicade^® (infliximab), HCPCS code J1745
• Renflexis^® (infliximab-abda), HCPCS code Q5104

These drugs already require prior authorization for both adult and pediatric members.

How this will affect pediatric members

• Pediatric members who have an active authorization for a preferred infliximab product as of July 1, 2022, won’t be affected by this change.
• For pediatric members who have an active authorization for a nonpreferred product, their authorization will remain in effect through Aug. 31, 2022. In addition, we have approved authorizations for Inflectra and Avsola from July 1, 2022, through Aug. 31, 2023, so these members can continue their infliximab therapy without interruption. Health care providers don’t need to submit prior authorization requests for dates of service within this time frame.
• For pediatric members who will be initiating therapy for an infliximab product, submit a prior authorization request.

How to submit prior authorization requests

Submit prior authorization requests through the NovoLogix^® online tool. To learn how, visit ereferrals.bcbsm.com and do the following:

• For Blue Cross commercial members: Click on Blue Cross and then click on Medical Benefit Drugs. In the Blue Cross commercial column, see the How to submit requests electronically using NovoLogix section.
• For BCN commercial members: Click on BCN and then click on Medical Benefit Drugs. In the BCN commercial column, see the How to submit requests electronically using NovoLogix section.

Definition of pediatric members

Pediatric members fit into one of these categories:

• 15 years old or younger, regardless of weight
• 16 through 18 years old who weigh 50 kilograms or less

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.

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.
Authorization isn't a guarantee of payment. As always, health care practitioners should verify eligibility and benefits for our members.

Here are time frames for determinations on authorization requests for acute inpatient medical admissions

The time frame within which Blue Cross Blue Shield of Michigan and Blue Care Network must make a determination on a request to authorize an acute inpatient medical admission depends on the type of request.

We’ve updated the document Submitting acute inpatient authorization requests: Frequently asked question for providers to include information on the time frames for determinations. You can access that document on these webpages:

• Blue Cross Authorization Requirements & Criteria
• BCN Authorization Requirements & Criteria

For easy reference, we also included the details in the table below. This information applies only to acute inpatient medical admissions, not to behavioral health inpatient admissions.

Here’s more information about the types of requests:

• Standard: Request to reimburse for services.
• Expedited: Request when standard time frame could seriously jeopardize the life or health of a member or the member’s ability to regain maximum function. Requires that a physician attest to the need for an expedited request.
• Preservice: Request is received prior to receipt of care.
• Concurrent: Request is received while member is receiving care.
• Postservice: Request is received after member has been discharged.

Reminders:

• We don’t use the Centers for Medicare & Medicaid Services two-midnight rule; we require authorization for all hospital admissions, both Medicare Advantage and commercial.
• Our authorization program is oriented toward providers, not members. We don’t deny care, services or treatment. Our program determines the appropriate level of care for reimbursement (observation versus inpatient).