November is Lung Cancer Awareness Month

Lung cancer is the leading cause of cancer death worldwide, according to the Lung Cancer Research Association. An estimated 236,740 people will be diagnosed with lung cancer in the U.S. this year.

The good news is that the number of new lung cancer diagnoses has been declining steadily. From 2009 to 2018, the incidence rate decreased by 2.8% per year in men and 1.4% in women.

While smoking is the leading risk factor for lung cancer, people who have never smoked account for 20% of lung cancer deaths. Other risk factors include exposure to radon, asbestos and secondhand smoke.

Common symptoms of lung cancer

The Lung Cancer Research Association uses the word “breathe” as an aid to remembering the common symptoms of lung cancer:

B – Blood when you cough or spit
R – Recurring respiratory infections
E – Enduring cough that is new or different
A – Ache or pain in shoulder, back or chest
T – Trouble breathing
H – Hoarseness or wheezing
E – Exhaustion, weakness or loss of appetite

We recommend that our members see their doctor if they experience any of those symptoms.

MQIC guidelines

According to the Michigan Quality Improvement Consortium, people ages 50 to 80 who have a 20-pack-a-year smoking history and currently smoke or have quit within the past 15 years should be screened annually with a low-dose CT scan. Screening should be discontinued once the person has been smoke-free for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.

For more information on recommended screenings for lung cancer and other conditions for people age 50 and older, see MQIC’s Adult Preventive Services document.

Have questions about our policies? Check out these online resources

Here’s key information our participating health care providers need to know about doing business with Blue Cross Blue Shield of Michigan.

How to access our online provider manuals

Everything you need to do business with Blue Cross is included in our online provider manuals. To access the provider manual through our new provider portal:

1. Log in to availity.com.**
2. Click on Payer Spaces on the Availity menu bar.
3. Click on the BCBSM and BCN logo.
4. Click on Provider manuals under the Resources tab.

Access and availability guidelines

When a member requests an appointment, Blue Cross providers are required to comply with the following standards.

For more detailed information, see the “PPO Policies” chapter in the provider manual or contact your provider consultant.

Affirmative statement about incentives

Medical decisions are based only on appropriateness of care and service and existence of coverage. See the affirmation statement in the “Participation” chapter of the provider manual. It’s located in the section titled “Requirements and Guidelines.”

Clinical practice guidelines

For medical and behavioral health care, Blue Cross follows Michigan Quality Improvement Consortium guidelines, which can be found on the mqic.org** website.

Comprehensive care management

To learn about Blue Cross comprehensive care management, review the “Health, Well-being and Care Management” chapter in your online provider manual. To find the information on bcbsm.com, click on the Providers tab. Type Blue Cross Coordinated Care in the search engine. Scroll down to For Providers: Blue Cross Coordinated Care.

Criteria used for level of care utilization management decisions

For hospitals and facilities, Blue Cross uses InterQual criteria to assess medical necessity and the appropriate level of care. Criteria encompasses acute care (adult and pediatric), rehabilitation (adult and pediatric), long-term acute care, skilled nursing facility and home health care.

Blue Cross modifications of the InterQual criteria (local rules) can be accessed online by following these steps:

1. Log in at availity.com.**
2. Click on Payer Spaces at the top.
3. Click on the BCBSM and BCN logo to reach our payer space.
4. Click on Secure Provider Resources (Blue Cross and BCN) on the Resources tab.
5. Click on Codes and Criteria on the Billing and Claims tab.

If you have questions about InterQual, send an email to InterQualSupport@ChangeHealthcare.com. Provide your name and address, and reference that the question pertains to InterQual.

Note: Policies and criteria for Federal Employee Program^® utilization management decision-making can be found at fepblue.org.

Medical policies

To review additional Blue Cross medical policies, go to bcbsm.com/providers.

1. Click on Quick Links.
2. Click on Preauthorization and precertification.
3. Click on Medical policy, precertification and preauthorization router. Use the button to select Medical Policy, then follow online prompts.

Member rights and responsibilities

Blue Cross outlines the rights and responsibilities of our members, including how members can file a complaint or grievance. For more information, go to the Important Information page on our website, and click on Understanding member rights and responsibilities under Important Notices About How Your Coverage Works.

Pharmacy management

It’s important for you to be familiar with our drug lists and our pharmacy management programs, such as step therapy, quantity limits, dose optimization, use of generics and specialty pharmacy. You also need to know how to request prior authorization or exception requests and the information needed to support your request.

Note: Generic substitution may be required for Blue Cross members. If both the generic and brand name are listed on our drug list, members are encouraged to receive the generic equivalent when available. Some members may be required to pay the difference between the brand-name and generic drug, as well as applicable copay, depending on the member’s plan.

See the For Providers: Drug Lists page on our website for more details. The page contains links to the drug lists, prior authorization, step therapy requirements, quantity limit lists and alternatives for nonpreferred brand and nonformulary drugs.

We recommend that you visit this page at least quarterly to access our pharmacy procedures, drug lists and to view updates. Go to bcbsm.com/providers. You can also call 1-800-437-3803 for the most up-to-date pharmaceutical information.

Translation services

Members who need language assistance can call the Customer Service number on the back of their member ID card. TTY users should call 711.

Utilization management staff availability

Department telephone numbers and hours are shown in the “Preapproval Decisions/Utilization Management Decisions” section of the “Appeals and problem resolution” chapter of the provider manuals.

Behavioral health care — New Directions

New Directions Behavioral Health is an independent company administering behavioral health benefits on behalf of Blue Cross. For information on the New Directions Behavioral Health Quality Improvement Program, click here.**

Contact information:

• Commercial PPO and Traditional programs: 1-800-762-2382
• Federal Employee Program: 1-800-342-5891
• United Auto Workers Retiree Medical Benefits Trust, or URMBT employer group: 1-877-228-3912

For more information

• Information about our programs and additional resources are available on the Important Information page of our website.
• To request a printed copy of any of the information contained in this article, call HCV Quality Management at 248-455-2808.
• If you have any questions about the information in this article, contact your provider consultant.

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

Submit application to join Blue High Performance Network

Blue Cross Blue Shield of Michigan is opening applications to hospital systems, their physician partners and other types of health care providers for the Detroit-area Blue High Performance Network℠. Blue Cross will select providers for the network based on the criteria outlined in the BlueHPN request for applications, or RFA. Criteria and participation status will be effective, starting Jan. 1, 2024.

Physician organizations, hospitals and integrated health systems interested in the BlueHPN must at minimum:

• Be located in the following counties or provide services to Blue Cross members in: Genesee, Macomb, Oakland, St. Clair, Washtenaw and Wayne counties
• Meet all Blue Cross credentialing and privileging standards, and be in good standing in the TRUST PPO or Traditional network, depending on the provider type
• Partner together to achieve a total cost of care savings of 8% — cost target illustrated in the RFA
• Agree to achieve and maintain quality performance measures as illustrated in the RFA
• Be affiliated with a Blue High Performance Network hospital

Final Provider Secured Services and web-DENIS retirement dates announced along with Availity enhancements

The phased retirement of Blue Cross Blue Shield of Michigan and Blue Care Network’s Provider Secured Services and web-DENIS is continuing. If you’re still using our old online systems, take note of these key dates:

Nov. 18, 2022: The eligibility and benefits tool within web-DENIS will no longer be available.
Dec. 16, 2022: You’ll no longer be able to log in to Provider Secured Services or web-DENIS.

For a complete list of applications that are now only available on our new provider portal, view Applications removed from Provider Secured Services.

To maintain access to Blue Cross and BCN online information, it’s important that you register for Availity Essentials, take advantage of online training and begin using our new provider portal today. For help getting started with Availity Essentials, see the “Resources” section at the end of this article.

Enhancements to our new provider portal

We continue to enhance the information you’ll find for Blue Cross and BCN in Availity Essentials. Here are some of the latest changes we’re making to help you do your work faster and easier.

• New claims status fields (coming soon): When you check claim status in Availity Essentials for your Blue Cross and BCN patients, you’ll find more comprehensive information, including:
• Member cost share fields (copay, coinsurance and deductible) at both the claim line level as well as a summary
• Claim received date, received date and other applicable dates (admission date or pended date)
• Authorization number
• Allowed amount

• HCPCS Lookup (recently added): Many of you told us you wanted our new provider portal to include the HCPCS Payment Rule Display tool that we had in the Facility Claims section of web-DENIS. We have responded to your request. You'll be able to find this tool in Availity^® through the BCBSM and BCN Payer Space Applications tab.

• BCN capitation tool (coming soon): You'll be able to find BCN capitation reports within Availity. The new report is called BCN Capitation and Zero-Dollar Voucher Lookup. You can now find this tool in Availity through the BCBSM and BCN Payer Space Applications tab.

Learn more about updates to our new provider portal

We’ve created a new document, Provider Portal Change and Status Updates, to keep you informed about:

• New provider portal features and functionality
• Issues we’re working to address
• Improvements we’ve made to the portal

Here’s how to find Provider Portal Change and Status Updates:

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

Watch for additional announcements

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

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

• Provider alert: Provider Secured Services and web-DENIS retirement continues on Oct. 25
• October Record article: Next phase of Provider Secured Services and web-DENIS retirement to occur Oct. 25
• Provider alert: Next phase of Provider Secured Services and web-DENIS retirement is Sept. 15
• September Record article: Announcing next phase of Provider Secured Services and web-DENIS retirement
• July Record article: Provider Secured Services, including web-DENIS, end date extended for some functions
• Provider alert: Provider Secured Services, including web-DENIS, end date extended for some functions

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

1. Click on Payer Spaces on the menu bar.
2. Click on the BCBSM and BCN logo.
3. Click on the Resources tab.
4. Click on Secure Provider Resources (Blue Cross and BCN).
5. Click on Read Alerts.

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

Resources

• Register for Availity Essentials.** Learn more at Get Started with Availity Essentials.**
• Learn how to use Availity Essentials on Get Up to Speed with Training.**
• Check out our Frequently asked questions about transitioning to the Availity^® provider portal.
• Need help? Call Availity Client Services at 1-800-AVAILITY (282-4548), from 8 a.m. to 8 p.m. Eastern time, Monday through Friday (excluding holidays).

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.

Estimate Your Cost tool to launch Jan. 1

On Jan. 1, 2023, Blue Cross Blue Shield of Michigan is launching the Estimate Your Cost tool on the member site at bcbsm.com. The tool will empower members to:

• Compare prices for in-network health care providers and their services
• Get an estimation of Blue Cross’ payment for out-of-network services

This innovative, web-based tool will be available to all commercial underwritten and commercial self-funded members, as well as all federal employees with a BCN plan. Blue Cross and Blue Shield Federal Employee Program^® members will have access via fepblue.org. It won’t be available to Medicare, Medicare Advantage or Medicaid members.

The Estimate Your Cost tool will support two federal mandates: The Payer Transparency Final Rule and the Consolidation Appropriation Act — Price Comparison Tool:

• Payer Transparency Final Rule: This law requires health plans to provide members with personalized, out-of-pocket cost estimates for all covered health care items and services.
  
  The tool will make available:
• About 500 shoppable items and services, beginning Jan. 1, 2023
• All other items and services, beginning Jan. 1, 2024

• Consolidation Appropriation Act — Price Comparison Tool: Health plans must offer price comparison guidance by telephone or mail within two business days, and make available a price comparison tool through a website.

The web-based tool must allow members to compare cost-sharing information under their plan or coverage for specific health care items or services delivered by in-network providers. The information provided will be specific to the plan year, geographic region and provider participation status for the respective plan or coverage type.

More information to come

Be sure to look to future issues of The Record for more information on how members will be able to use this new web-based tool to select cost-effective items and services that meet both their health care and financial needs.

Reminder: Access the Blue Cross Commercial Provider Manual on our new provider portal

The Blue Cross Commercial Provider Manual has moved from Benefit Explainer and is only accessible through our new provider portal (availity.com**). The last day you can find the PPO Provider Manual tab in Benefit Explainer will be Nov. 29, 2022.

How to access the manual\

To access the provider manual through our new provider portal:

1. Log in to availity.com.**
2. Click on Payer Spaces on the Availity^® menu bar.
3. Click on the BCBSM and BCN logo.
4. Click on Provider manuals under the Resources tab.

You can also access the provider manual from our secure Provider Resources website. Within the Blue Cross and BCN Payer Space follow these steps:

1. Click on Secure Provider Resources (Blue Cross and BCN) on the Resources tab.
2. Click on Provider manuals in the Easy Access panel.

For more details on how to use the new provider manual and additional features, see the May 2022 issue of The Record.

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: Use U09.9 for long-term COVID-19 as a secondary diagnosis code

When treating patients for documented residual or long-term effects of COVID-19, use diagnosis codes for the specific symptoms. In addition, be sure to include U09.9 as a secondary diagnosis code. Including U09.9 is important for tracking the number of patients with long-term COVID-19.

More information about diagnosis codes for COVID-19 treatment is available in the Billing tips for COVID-19 and Billing tips for COVID-19 at a Glance documents on our COVID-19 webpage for health care providers.

This information is also available on our provider portal. Here’s how to find it:

1. Log in to our provider portal (availity.com**).
2. Click on Payer Spaces on the menu bar and then click on the BCBSM and BCN logo.
3. Click on the Resources tab.
4. Click on Secure Provider Resources (Blue Cross and BCN).
5. Under Easy Access, click on Coronavirus information.

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.

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

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.

Community health care workers can address social needs and improve health outcomes

As part of our efforts to consider social determinants of health as key factors in achieving health equity across the state, Blue Cross Blue Shield of Michigan is launching a new incentive to encourage physician organizations to hire or train individuals to serve as community health workers. These staff members would assist health care providers in addressing the social risk factors that may affect the health of their patient population.

Courses to achieve certification as a community health worker could be offered to existing staff members, or POs could hire certified community health workers or other community resource navigators.

“This opportunity is offered at the PO level with the intention that the community health workers could support the PO affiliated practices to address social risk factors,” said David Bye, a health care manager in Value Partnerships. “The community health worker initiative will support POs in utilizing staff members who are well-acquainted with the community to meet social needs identified by patients within their practices.”

Earlier this year, Blue Cross launched a social determinants of health screening and data collection initiative, which has led to additional screening by providers and has highlighted why additional support is needed to address social needs. POs have been asked to opt in to the program by Nov. 4, 2022, if they’re interested in participating.

FAQ

Here are some answers to frequently asked questions.

What are the benefits to providers?

This initiative enables doctors and other members of the care team to direct their efforts to clinically specific tasks, while allowing community health workers to use their knowledge and understanding of the community to meet social needs that could affect health outcomes.

What are the benefits to patients?

Community health workers, who typically come from backgrounds similar to patients with specific social needs, can help ease patient discomfort about disclosing their needs. They can work closely with the patients to find sustainable assistance options.

What types of interventions might a community health worker use?

Interventions can vary in type and intensity and may include the following:

• Warm handoffs between the screening facilities, often the PO or the practice, and community resources specific to any identified need
• Phone consultations to identify social risks, which could affect patient health, and identify which patients could benefit from intervention
• In-person visits for patients that benefit from more involved interactions

What outcomes can be expected from using the services of a community health worker?

Potential outcomes include:

• Increased use of primary care
• Decreased hospital readmissions
• Decreased emergency department visits
• Increased medication adherence
• Cost avoidance (when comparing overall health care costs pre- and post-intervention)

If you have any additional questions, reach out to POprograms@bcbsm.com.

Requirements changed for some commercial medical benefit drugs

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

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

**Will become a unique code

For additional details, see the Blue Cross and BCN utilization management medical drug list. This list is available on the following pages of the ereferrals.bcbsm.com website:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

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

Additional information

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

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

Cimerli now requires prior authorization for Medicare Advantage members

For dates of service on or after Oct. 3, 2022, we’ve added a prior authorization requirement for Medicare Plus Blue℠ and BCN Advantage℠ members for the following drug:

• Cimerli™ (ranibizumab-eqrn), HCPCS code J3590

For Lucentis^®, Cimerli is the second biosimilar and the first interchangeable biosimilar.

Both Cimerli and Lucentis will continue to require the member to first try and fail Avastin^® (bevacizumab).

The HCPCS codes for Avastin are J3590 for Medicare Plus Blue and J9035 for BCN Advantage.

As a reminder, Lucentis already requires prior authorization. Avastin doesn’t require prior authorization when used for retinal conditions.

All these drugs are part of members’ medical benefits, not their pharmacy benefits.

When prior authorization is required

Cimerli requires prior authorization when it’s administered by a health care provider in an outpatient facility or a physician’s office and billed in one of the following ways:

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

Submit prior authorization requests through the NovoLogix tool

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

After you’ve logged in to Availity, click on Payer Spaces and then 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. 

Reminder about requirements for other retinal drugs

As a reminder, all other intravitreal medications for retinal conditions continue to have Avastin as a step therapy requirement. These are:

• Eylea^® (aflibercept), HCPCS code J0178
• Beovu^® (rolucizumab-dbll), HCPCS code J0179
• Vabysmo^® (facricimab-svoa), HCPCS codes C9097 and J3590
• Byooviz^® (ranibizumab-nuna) HCPCS code Q5124
• Susvimo™ (ranibizumab injection, for ocular implant), HCPCS code J2779

List of requirements

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

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.

Prior authorization required for Spevigo for Medicare Advantage members

A prior authorization requirement has been added for Medicare Plus Blue℠ and BCN Advantage℠ members for dates of service on or after Sept. 26, 2022, for the following medication:

• Spevigo^® (spesolimab-sbzo), HCPCS code J3590

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

This medication is part of members’ medical benefits, not their pharmacy benefits.

When prior authorization is required

This medication requires prior authorization when it’s administered by a health care provider in an outpatient facility or a physician’s office and billed in one of the following ways:

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

Submit prior authorization requests through the NovoLogix tool

If you have access to the Availity Essentials provider portal (availity.com**), you already have access to NovoLogix. If you need to request access to Availity^®, follow the instructions on the Register for webtools 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 the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members.

We updated the list to reflect this change.

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 website don’t own or control this website.

Starting Jan. 1, we’ll change how we cover some prescription drugs

As we’ve stated before, our goal at Blue Cross Blue Shield of Michigan and Blue Care Network is to provide our members with safe, high-quality prescription drug therapies. We continually review our practices regarding prescription drugs to provide the best value for our members, control costs and make sure our members are using the right drug for the right situation.

Starting Jan. 1, 2023, we’ll change how we cover some medications on the drug lists associated with our prescription drug plans. We’ll send letters to notify affected members, their groups and their health care providers about these changes.

Read the following for an explanation of these changes:

Drugs that won’t be covered
We’ll no longer cover the following drugs. Unless noted, both the brand-name and available generic equivalents won’t be covered. For drugs with a generic equivalent available, the example brand names are listed for reference. If members fill a prescription for one of these drugs on or after Jan. 1, 2023, they’ll be responsible for the full cost.

The drugs that won’t be covered are listed along with suggested covered preferred alternatives that have similar effectiveness, quality and safety. When pharmacies fill prescriptions with preferred alternatives, the generic equivalents are dispensed, if available. Additional coverage requirements may apply for preferred alternatives, such as prior authorization.

Drugs that will have a higher copayment

The brand-name drugs that will have a higher copayment are listed along with suggested covered preferred alternatives that have similar effectiveness, quality and safety. When pharmacies fill prescriptions with preferred alternatives, the generic equivalents are dispensed, if available. Additional coverage requirements may apply for preferred alternatives.

**Nonpreferred brand-name drugs aren’t covered for members with a closed benefit.
***Applies to Blue Care Network only

Drugs that will have quantity limit changes
These drugs will have changes to the amount that can be filled.

Preventive drug coverage updates

Under the Affordable Care Act, most health plans must cover certain preventive services and prescription drugs with no out-of-pocket costs, based on recommendations by the U.S. Preventive Services Task Force.

The USPSTF is a panel of national experts in prevention and evidence-based medicine. The panel works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services, such as screenings, counseling services and preventive medications.

The USPSTF no longer recommends the use of aspirin for prevention of cardiovascular disease or colorectal cancer, so we’re no longer covering aspirin 325mg. Aspirin 81mg will remain covered for members at high risk of preeclampsia per the USPSTF’s recommendations.

If members fill a prescription for aspirin 325 mg on or after Jan. 1, 2023, they’ll be responsible for the full cost. Aspirin 325 mg is available for purchase over the counter.

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

We’re changing how we manage biologic asthma therapies, starting Jan. 1

Starting Jan. 1, 2023, Blue Cross Blue Shield of Michigan and Blue Care Network are changing how we manage some biologic asthma medications for all Blue Cross and BCN group and individual commercial members.

The following biologic asthma therapies will be affected by this change:

• Fasenra^® (benralizumab), HCPCS code J0517
• Nucala^® (mepolizumab), HCPCS code J2182

Fasenra and Nucala will continue to be covered under the medical benefit when administered by a health care professional. They’ll be managed under the pharmacy benefit when self-administered.

Starting Jan. 1, these drugs will no longer be covered under the medical benefit when they’re self-administered by a member.

Note: We’ve updated the medical policies for these drugs to reflect this change. You can view the medical policies through the Medical Policy Router Search page of bcbsm.com.

How to submit prior authorization requests

When Fasenra or Nucala will be self-administered, submit the request using an electronic prior authorization, or ePA, tool such as CoverMyMeds^® or Surescripts^®.

When Fasenra or Nucala needs to be administered by a health care professional, submit the request through the NovoLogix^® online tool.

What you need to do for members who self-administer these drugs

For members who self-administer these drugs and don’t have pharmacy benefits through Blue Cross or BCN, providers need to work with the member’s pharmacy vendor to ensure that the drug is covered.

For members who self-administer these drugs and do have pharmacy benefits through Blue Cross or BCN, providers will need to submit a prior authorization request under the member’s pharmacy benefit.

Members can obtain these drugs through an AllianceRx Walgreens Pharmacy.

Why we’re making this change

We’re making this change as part of our continued effort to provide members with access to the best health care at the lowest cost. The management changes for this drug class ensure that we’re taking the most cost-effective approach by reducing the cost to our members and to the plan. In addition, these changes ensure that patient health and outcomes aren’t affected while delivering value to members.

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.

For a full list of requirements related to drugs covered under the pharmacy benefit, see the Prior authorization and step therapy coverage criteria.

We'll update these lists to reflect the changes related to these drugs prior to the effective dates.

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

For some providers, process for updating your information with us changing in November

Starting Nov. 3, 2022, you may need to complete two forms to update any of the following information in the Blue Cross Blue Shield of Michigan and Blue Care Network online provider directory:

• Name
• Specialty
• Address
• Telephone number
• Digital contact information

We’re changing the process of updating information to comply with provisions of the Consolidated Appropriations Act, or CAA, of 2021.

Types of providers affected

This change will affect all providers except:

• Hospitals
• Group and individual providers

What you need to update

When making a change, refer to the table below:

**You’ll find a link to the new Provider Directory Change Form near the links to the BCBSM/BCN Facility Change Form and the Allied Provider Change Form.

Accessing the forms

To access the forms, follow these steps:

1. Visit bcbsm.com/providers.
2. Click on Enrollment.
3. Click on Enroll Now.
4. Follow the prompts.

Fax the completed forms to the Provider Enrollment department at 1-866-900-0250. This fax number is shown on each form.

Need help?

For assistance completing the correct forms, call the Provider Enrollment department at 1-800-822-2761.

New and updated questionnaires in e-referral system

On Aug. 28 and Sept. 11, 2022, we added and updated questionnaires in the e-referral system. We also added and updated the corresponding preview questionnaires on the ereferrals.bcbsm.com website.

As a reminder, we use our authorization criteria, our medical policies and your answers to the questionnaires in the e-referral system when making utilization management determinations on your prior authorization requests.

New questionnaires

We added the following questionnaires for BCN commercial and BCN Advantage℠ members:

• Breast elastography — For adult members. Opens for procedure codes *76391, *76981 and *76982.
• Responsive neurostimulator/deep brain stimulation trigger — For pediatric and adult members. Opens for procedure codes *61863, *61864, *61868, *61880, *61885 and *61888.
• Responsive neurostimulation for the treatment of refractory partial epilepsy — For adult members. Opens for procedure codes *61863, *61864, *61868, *61880, *61885, *61888 and *95836.

Updated questionnaires

We updated the following questionnaires:

• Cosmetic or reconstructive surgery — For adult Medicare Plus Blue℠, BCN commercial and BCN Advantage members. This questionnaire now opens for procedure codes *21742, *21743 and *36468.
• Deep brain stimulation — For adult Medicare Plus Blue, BCN commercial and BCN Advantage members. This questionnaire no longer opens for procedure code *61850 because this code no longer requires prior authorization.
• Dermal chemical peels — For adult and pediatric BCN commercial and BCN Advantage members. We updated a question.
• Hyperbaric oxygen therapy — For adult and pediatric BCN commercial and BCN Advantage members. There are separate questionnaires for BCN commercial and BCN Advantage. We updated questions in both questionnaires.
• Orthognathic surgery — For adult and pediatric BCN commercial and BCN Advantage members. We updated a question.
• Prostatic urethral lift — For adult BCN commercial and BCN Advantage members. We updated a question.
• Varicose vein — For adult BCN commercial and BCN Advantage members. This questionnaire now opens for procedure code *36466. It no longer opens for procedure codes *37765, *37766 or *36468. Note that procedure codes *37765 and *37766 no longer require prior authorization.

Preview questionnaires

You can access preview questionnaires at ereferrals.bcbsm.com. You’ll see the questions you'll need to answer in the questionnaires that open in the e-referral system so you can prepare your answers ahead of time.

To find the preview questionnaires:

• Click on Blue Cross and then click on Authorization Requirements & Criteria. Scroll down and look under the “Authorization criteria and preview questionnaires – Medicare Plus Blue” heading.
• Click on BCN and then click on Authorization Requirements & Criteria. Scroll down and look under the “Authorization criteria and preview questionnaires” heading.

Authorization criteria and medical policies

The pertinent authorization criteria and medical policies are also available on the Authorization Requirements & Criteria pages.

Benefit changes coming in 2023 for UAW Retiree Medical Benefits Trust members

Starting Jan. 1, 2023, there will be several changes to the UAW Retiree Medical Benefits Trust members’ health plan benefits. A summary of those changes is included below.

For BCN HMO and BCN Advantage℠:

Benefit changes

• Members will be allowed unlimited, in-network skilled nursing facility, or SNF, days.

For Enhanced Care Plan (ECP) and Traditional Care Network (TCN) plans:

Cost share changes

• The in-network deductible is reduced to $325 for individuals and $600 for families.
• The in-network out-of-pocket maximum is reduced to $650 for individuals and $1,325 for families.

Note: This change excludes Ford Protected members as the current in-network deductible and out-of-pocket maximum is $0.

Benefit changes

• Skilled nursing facility, or SNF, benefit
• Members will be allowed unlimited SNF days.
• Inpatient hospital admissions and home health care
• Members will be allowed unlimited days for inpatient hospital admissions, and
• Unlimited visits for home health care
• Hospice day maximum will now follow Medicare’s guidelines. Members are allowed two 90-day benefit periods followed by unlimited 60-day benefit periods.
• Cardiac rehabilitation, pulmonary rehabilitation and respiratory rehabilitation are covered at 100% of the in-network allowed amount.
• All in-network and out-of-network outpatient behavioral health visits are covered at 100% of the allowed amount. Services rendered by nonparticipating providers aren’t covered.

For Medicare Plus Blue PPO:

Cost share changes

• The in-network deductible is reduced to $150.
• The in-network out-of-pocket maximum is reduced to $500.

Note: This change excludes Protected plans as the current in-network deductible and out-of-pocket maximum is $0.

Benefit changes

(Protected plans are not subject to cost share. Therefore, they’re excluded from the following cost share changes. All other benefit changes apply unless otherwise stated.)

• This plan is now a Medicare Advantage Prescription Drug Plan, effective Jan. 1, 2023. Members will have prescription drug coverage through Blue Cross Blue Shield of Michigan (Optum Rx).
• In-network medical drugs (Part B)
• Outpatient — Subject to 10% coinsurance after deductible
• Office — Subject to $10 primary care provider copay and $20 specialist copay
• Home — Covered at 100% of the allowed amount and follows the home health care benefit
• Skilled nursing facility, or SNF, benefit
• Members will be allowed unlimited SNF days.
• Days 1-20 are subject to in-network deductible, then services are covered at 100% of the allowed amount. Days 21 and over are subject to 10% coinsurance.
• Members will be allowed unlimited days for partial hospitalization.
• Allergy testing and treatment
• Allergy testing, therapy and administration services are covered in-network at 100% of the allowed amount.
• Additional professional services provided during the visit are subject to in-network office visit and outpatient care cost share.
• In-network virtual/telehealth visits rendered by a specialist are subject to a $10 copay.
• Blood, blood storage and administration services are covered in-network at 100% of the allowed amount.
• Foot care — podiatry services
• Allows six visits in-network, subject to a $20 copay for General Members and $0 copay for Protected members. These visits are in addition to podiatry services that are covered under the standard Medicare benefit.
• Services related to wigs are covered without diagnosis restrictions.

As always, be sure to check online for benefits and eligibility.

Management of medical benefit drugs moving from Accredo to Blue Cross for URMBT Blue Cross non-Medicare members

Starting Jan. 1, 2023, Blue Cross Blue Shield of Michigan will manage prior authorizations for additional medical benefit drugs for which Accredo previously managed prior authorizations. You’ll find a list of these drugs later in this article.

This change affects UAW Retiree Medical Benefits Trust Blue Cross non-Medicare members.

These requirements don’t apply:

• When these drugs are administered in an inpatient setting
• To the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714)

How will this change be rolled out?

• For members for whom Accredo approved authorization requests on or before Aug. 31, 2022: Blue Cross will automatically issue a new authorization. These authorizations will be in effect indefinitely. We’ll send letters to notify affected members.
• For members who begin therapies from Sept. 1 through Dec. 31, 2022: Providers don’t need to submit authorization requests. Blue Cross will automatically issue authorizations for the drugs. These authorizations will be in effect indefinitely. We’ll send letters to notify affected members.
• For members who begin therapies on or after Jan. 1, 2023: Providers must submit prior authorization requests to AIM Specialty Health^® or through the NovoLogix^® online tool, as specified in the table below.

How will I submit prior authorization requests starting Jan. 1?

Note: If you need access to Availity^®, follow the instructions on the Register for web tools webpage at bcbsm.com/providers.

What drugs will be affected by this change?

See the list below. For information about additional requirements, such as site of care and quantity limits, see the appropriate drug lists. Access the drug list using the links in the "More about the authorization requirements" section later in this article.

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 these changes 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.

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.

Additional medical benefit drugs will require prior authorization for URMBT members with Blue Cross non-Medicare plans starting Jan. 1

For dates of service on or after Jan. 1, 2023, Blue Cross Blue Shield of Michigan will manage prior authorizations for additional medical benefit drugs for UAW Retiree Medical Benefits Trust members with Blue Cross non‑Medicare plans.

You’ll find a list of these drugs later in this article. You’ll need to submit prior authorization requests either to AIM Specialty Health^® or through the NovoLogix^® online tool.

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

The following requirements don’t apply:

• When these drugs are administered in an inpatient setting
• To the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714)

How to submit prior authorization requests

Note: If you need access to Availity^®, follow the instructions on the Register for web tools webpage at bcbsm.com/providers.

Which drugs will be affected by this change?

The drugs in the following table will be affected by this change.

For information about additional requirements, such as site of care and quantity limits, see the appropriate drug lists. Access the drug list using the links in the "More about the authorization requirements" section later in this article.

⁽¹⁾Prior to Jan. 1, 2023, this drug is a covered benefit but doesn’t require prior authorization.
⁽²⁾Prior to Jan. 1, 2023, this drug isn’t a covered benefit.

More about prior 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.

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.

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.

Coding update coming next year for Medicare Plus Blue pathology claims

To promote correct coding and assist with payment accuracy, Blue Cross Blue Shield of Michigan will enhance its claim editing process next year for pathology services on Medicare Plus Blue℠ outpatient facility and professional claims.

This coding update focuses on:

• Professional claims for pathology services when an ICD-10 code beginning with R is billed in the primary diagnosis position.
• Outpatient facility claims for pathology services when an R ICD-10 code is the only submitted diagnosis on the claim.

This coding update will exclude claim lines with modifier TC appended.

ICD-10-CM guidance indicates R codes are used for signs and symptoms instead of diagnoses. ICD-10-CM allows these codes in a primary spot when a diagnosis hasn’t been established by the provider. However, if the patient is receiving diagnostic services only (particularly those needing interpretation by a physician), the confirmed or definitive diagnosis should be coded.

In these cases, related signs and symptoms should not be coded as diagnoses. In the pathology realm, once pathology codes are submitted, a definitive diagnosis is typically determined. Therefore, the defined diagnosis should be provided in the first position, as opposed to a symptom-based diagnosis.

Based on the CPT, ICD-10-CM and guidelines from the Centers for Disease Control and Prevention, the pathologist should report a first-listed diagnosis based on the gross/microscopic examination.

The 2022 edition of the ICD-10-CM coding manual, Chapter 18, section B, under “Use of a symptom code with a definitive diagnosis code,” states: “Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis, such as the various signs and symptoms associated with complex syndromes. The definitive diagnosis code should be sequenced before the symptom code.”

Notes:

• If a claim is rejected due to edits that are needed, submit a corrected claim.
• If it’s necessary to submit an appeal, keep in mind that 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.

New HEDIS measure: Follow-up after emergency department visit is key to good patient care

Many patients discharged from the emergency department require urgent follow-up care with their providers due to high-risk chronic conditions. Often, an ED discharge is based on the presumption of continued care, and if it doesn’t happen, problems can arise.

The Follow-Up After Emergency Department Visit for People with Multiple High-Risk Chronic Conditions (FMC) is a new HEDIS^® measure that is also a Medicare Star Ratings measure. It focuses on the percentage of members ages 18 and older who have multiple high-risk chronic conditions and who had a follow-up visit within seven days of an emergency department visit.

There are many ways to conduct a follow-up visit, including:

• Outpatient visit
• By telephone
• Through Transitional Care Management, case management or complex care management
• Outpatient or telehealth behavioral health visit
• Intensive outpatient encounter or partial hospitalization
• Community mental health center visit
• Through electroconvulsive therapy
• Through a telehealth appointment, observation stay, e-visit or virtual check-in

Read this tip sheet to learn more about this measure, including information about eligible chronic conditions, exclusions, best practices, documentation requirements and more.  

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

Transitions of Care HEDIS measure focuses on medication management and care coordination

When a patient is transferred from one care setting (for example, a hospital, nursing facility, primary care provider, long-term care, home health care, specialist care) to another in an ineffective way, it can lead to confusion about treatment plans, missed follow-up appointments, patient dissatisfaction, medication nonadherence and, most importantly, unnecessary readmissions, according to the American Journal of Managed Care.

The Transitions of Care (TRC) HEDIS^® measure, which is also included in our series of Star Measure Tips, focuses on the percentage of members who had an acute or non-acute inpatient discharge during the measurement year and who had each of the following:

• Notification of inpatient admission
• Receipt of discharge information
• Patient engagement after inpatient discharge
• Medication reconciliation post-discharge

Documentation of all four components must be in any outpatient record, as well as accessible by the primary care doctor or ongoing care provider.

We encourage you to establish an office practice that explains to patients why it’s crucial that they inform your office about their hospital admissions and discharges. Let them know it’s important because it can improve their care coordination and help maintain their health and safety.

Read this tip sheet to learn more about the measure, including exclusions, best practices, and documentation requirements.

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

HEDIS measure focuses on helping prevent unnecessary hospital readmissions

Readmission to the hospital within 30 days of discharge is frequently avoidable and can lead to adverse patient outcomes and higher costs, according to the Centers for Medicare & Medicaid Services.

The Plan All-Cause Readmissions (PCR) HEDIS^® measure — which is also a Medicare Star Ratings measure — assesses the percentage of acute inpatient and observation stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission.

Coordinating care from the hospital to home and ensuring a follow-up visit with the patient’s primary care provider can help avoid a readmission.

Read this tip sheet to learn more about this measure, including information about exclusions, best practices and tips for success when talking with patients.  

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

We’ve updated and posted our 2022 HEDIS tip sheets

Did you know that our 2022 HEDIS tip sheets are posted in the Clinical Quality section of Secure Provider Resources on our provider portal? Each year, we update and post our HEDIS and Star measure tip sheets. The Star Measure Tips were posted earlier this year. 

About our tip sheets

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

Accessing the tip sheets

To access our tip sheets, follow these steps:

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

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

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

Clarification: DME/P&O and telehealth visits

The July 2022 issue of The Record included an article that referenced a Blue Cross Blue Shield of Michigan medical policy, updated in 2018 and indicating that health care providers can’t prescribe or issue durable medical equipment and prosthetics, orthotics and medical supplies during telehealth visits. The article should have indicated that exceptions are in place that allow telehealth visits for these purposes due to the COVID-19 public health emergency.

Blue Cross and Blue Care Network follow the Centers for Medicare & Medicaid Services COVID-19 PHE Interim Final Rules for DME/P&O items that allow exceptions to requirements for face-to-face encounters to avoid exposure of vulnerable populations. Telehealth visits can be used to prescribe DME/P&O items and medical supplies, effective March 18, 2020, until the end of the public health emergency, as indicated in our Temporary changes due to the COVID-19 pandemic document. For more information, see the CMS Medicare Learning Network guidance.**

We apologize for any confusion caused by the July article. We’ll communicate updated telehealth requirements for DME/P&O and medical supplies after the PHE has ended.

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

Closing HEDIS gaps for medication compliance

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

Studies have shown that medication compliance can help reduce emergency department visits and inpatient admissions for patients with chronic conditions. Below are links to tip sheets that were designed to help health care providers and their patients close HEDIS^® gaps in care that may lead to hospitalization.

Resources for providers:

• Overcoming Barriers to Statin Therapy
• Medication Adherence Summary
• Asthma Medication Ratio

Resources to share with patients who are Blue Cross and Blue Shield Service Benefit Plan members:

• Diabetes Quick Reference Guide
• Blood Pressure Quick Reference Guide
• Managing your Cholesterol
• How to Manage Asthma

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

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

Avsola to require prior authorization for Blue Cross and Blue Shield Federal Employee Program non-Medicare members starting Jan. 1

For dates of service on or after Jan. 1, 2023, we're adding a prior authorization requirement for Blue Cross and Blue Shield FEP^® non-Medicare members for the following drug covered under the medical benefit:

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

For members who begin therapies prior to Dec. 31, 2022

Providers won’t need to submit prior authorization requests. Blue Cross will automatically issue authorizations for the drugs; these authorizations will be valid for six months.

For members who begin therapies on or after Jan. 1

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

If you have access to our provider portal (availity.com**), you already have access to NovoLogix. If you need access to Availity^®, follow the instructions on the Register for webtools webpage on bcbsm.com/providers.

After you’ve logged in to Availity, click on Payer Spaces and then on the BCBSM and BCN logo. Then you’ll see  links to the NovoLogix tools on the Applications tab.

List of requirements

For a full list of requirements related to drugs covered under the medical benefit, see the Utilization management medical drug list for Blue Cross and Blue Shield Federal Employee Program^® non-Medicare members. We’ll update this list prior to the effective date of the change.

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.

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

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

Follow these guidelines for billing genetic testing

When billing for genetic testing, keep the following policy guidelines in mind:

• Individual carrier screening procedure codes may receive a denial when a single comprehensive code is more appropriate.
• BRCA1 and BRCA2 genetic testing should be billed with the appropriate diagnosis and for the appropriate patient age.
• Lynch syndrome genetic testing may receive a denial when microsatellite instability analysis or immunohistochemistry testing hasn’t been billed in the previous 30 days.
• BRCA gene variant combinations should be billed with appropriate diagnosis codes.
• Cystic fibrosis transmembrane conductance regulator, or CFTR, gene variant combinations should be billed with appropriate diagnosis codes.
• Genetic analysis for non-invasive prenatal screening testing for fetal aneuploidy should be billed with appropriate diagnosis codes.
• Gap junction beta 2, or GJB2, gene variant combinations should be billed with appropriate diagnosis codes.

If you think the services rendered warrant an exception, follow the current clinical editing appeals process.

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.

Medicare Plus Blue and BCN Advantage claims audits transitioning from HMS to Cotiviti

Effective Dec. 1, 2022, Blue Cross Blue Shield of Michigan and Blue Care Network will transition their audit services from HMS to Cotiviti for Medicare Plus Blue℠ and BCN Advantage℠ claim reviews.

Here’s how the transition will work:

• For reviews already in progress, all communication will continue under the HMS name until the reviews are complete.
• As of Dec. 1, 2022, completed reviews and new requests for medical records will come directly from Cotiviti.

Note: During the transition, providers may receive communications from both HMS and Cotiviti.

Cotiviti has established relationships with several copy service companies, including MRO, Ciox, and ScanStat. Through these relationships, they acquire electronic medical records. Cotiviti also collaborates with provider groups, allowing them access to their electronic medical records.

Cotiviti typically sends requests for medical records soon after Blue Cross and BCN approve claims to be audited. Reminders are sent 30 days after the initial request and every 30 days thereafter. 

Audit and appeal determinations are sent within 50 days after provider documentation is received. The CCV includes instructions for requesting a review of the audit findings.

If you didn’t receive or have misplaced audit correspondence, contact Cotiviti Provider Services to receive a copy that will be mailed through the U.S. Postal Service.

If you have questions, need additional information or have updates to provider contact information, contact Cotiviti Provider Services at 770-379-2009 from 8 a.m. to 5 p.m. Eastern time, Monday through Friday.

HMS and Cotiviti, are independent companies that provide auditing support services for Blue Cross and BCN.

Requirements changed for some commercial medical benefit drugs

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

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

**Will become a unique code

For additional details, see the Blue Cross and BCN utilization management medical drug list. This list is available on the following pages of the ereferrals.bcbsm.com website:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

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

Additional information

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

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

Cimerli now requires prior authorization for Medicare Advantage members

For dates of service on or after Oct. 3, 2022, we’ve added a prior authorization requirement for Medicare Plus Blue℠ and BCN Advantage℠ members for the following drug:

• Cimerli™ (ranibizumab-eqrn), HCPCS code J3590

For Lucentis^®, Cimerli is the second biosimilar and the first interchangeable biosimilar.

Both Cimerli and Lucentis will continue to require the member to first try and fail Avastin^® (bevacizumab).

The HCPCS codes for Avastin are J3590 for Medicare Plus Blue and J9035 for BCN Advantage.

As a reminder, Lucentis already requires prior authorization. Avastin doesn’t require prior authorization when used for retinal conditions.

All these drugs are part of members’ medical benefits, not their pharmacy benefits.

When prior authorization is required

Cimerli requires prior authorization when it’s administered by a health care provider in an outpatient facility or a physician’s office and billed in one of the following ways:

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

Submit prior authorization requests through the NovoLogix tool

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

After you’ve logged in to Availity, click on Payer Spaces and then 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. 

Reminder about requirements for other retinal drugs

As a reminder, all other intravitreal medications for retinal conditions continue to have Avastin as a step therapy requirement. These are:

• Eylea^® (aflibercept), HCPCS code J0178
• Beovu^® (rolucizumab-dbll), HCPCS code J0179
• Vabysmo^® (facricimab-svoa), HCPCS codes C9097 and J3590
• Byooviz^® (ranibizumab-nuna) HCPCS code Q5124
• Susvimo™ (ranibizumab injection, for ocular implant), HCPCS code J2779

List of requirements

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

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.

Prior authorization required for Spevigo for Medicare Advantage members

A prior authorization requirement has been added for Medicare Plus Blue℠ and BCN Advantage℠ members for dates of service on or after Sept. 26, 2022, for the following medication:

• Spevigo^® (spesolimab-sbzo), HCPCS code J3590

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

This medication is part of members’ medical benefits, not their pharmacy benefits.

When prior authorization is required

This medication requires prior authorization when it’s administered by a health care provider in an outpatient facility or a physician’s office and billed in one of the following ways:

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

Submit prior authorization requests through the NovoLogix tool

If you have access to the Availity Essentials provider portal (availity.com**), you already have access to NovoLogix. If you need to request access to Availity^®, follow the instructions on the Register for webtools 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 the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members.

We updated the list to reflect this change.

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 website don’t own or control this website.

Starting Jan. 1, we’ll change how we cover some prescription drugs

As we’ve stated before, our goal at Blue Cross Blue Shield of Michigan and Blue Care Network is to provide our members with safe, high-quality prescription drug therapies. We continually review our practices regarding prescription drugs to provide the best value for our members, control costs and make sure our members are using the right drug for the right situation.

Starting Jan. 1, 2023, we’ll change how we cover some medications on the drug lists associated with our prescription drug plans. We’ll send letters to notify affected members, their groups and their health care providers about these changes.

Read the following for an explanation of these changes:

Drugs that won’t be covered
We’ll no longer cover the following drugs. Unless noted, both the brand-name and available generic equivalents won’t be covered. For drugs with a generic equivalent available, the example brand names are listed for reference. If members fill a prescription for one of these drugs on or after Jan. 1, 2023, they’ll be responsible for the full cost.

The drugs that won’t be covered are listed along with suggested covered preferred alternatives that have similar effectiveness, quality and safety. When pharmacies fill prescriptions with preferred alternatives, the generic equivalents are dispensed, if available. Additional coverage requirements may apply for preferred alternatives, such as prior authorization.

Drugs that will have a higher copayment

The brand-name drugs that will have a higher copayment are listed along with suggested covered preferred alternatives that have similar effectiveness, quality and safety. When pharmacies fill prescriptions with preferred alternatives, the generic equivalents are dispensed, if available. Additional coverage requirements may apply for preferred alternatives.

**Nonpreferred brand-name drugs aren’t covered for members with a closed benefit.
***Applies to Blue Care Network only

Drugs that will have quantity limit changes
These drugs will have changes to the amount that can be filled.

Preventive drug coverage updates

Under the Affordable Care Act, most health plans must cover certain preventive services and prescription drugs with no out-of-pocket costs, based on recommendations by the U.S. Preventive Services Task Force.

The USPSTF is a panel of national experts in prevention and evidence-based medicine. The panel works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services, such as screenings, counseling services and preventive medications.

The USPSTF no longer recommends the use of aspirin for prevention of cardiovascular disease or colorectal cancer, so we’re no longer covering aspirin 325mg. Aspirin 81mg will remain covered for members at high risk of preeclampsia per the USPSTF’s recommendations.

If members fill a prescription for aspirin 325 mg on or after Jan. 1, 2023, they’ll be responsible for the full cost. Aspirin 325 mg is available for purchase over the counter.

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

We’re changing how we manage biologic asthma therapies, starting Jan. 1

Starting Jan. 1, 2023, Blue Cross Blue Shield of Michigan and Blue Care Network are changing how we manage some biologic asthma medications for all Blue Cross and BCN group and individual commercial members.

The following biologic asthma therapies will be affected by this change:

• Fasenra^® (benralizumab), HCPCS code J0517
• Nucala^® (mepolizumab), HCPCS code J2182

Fasenra and Nucala will continue to be covered under the medical benefit when administered by a health care professional. They’ll be managed under the pharmacy benefit when self-administered.

Starting Jan. 1, these drugs will no longer be covered under the medical benefit when they’re self-administered by a member.

Note: We’ve updated the medical policies for these drugs to reflect this change. You can view the medical policies through the Medical Policy Router Search page of bcbsm.com.

How to submit prior authorization requests

When Fasenra or Nucala will be self-administered, submit the request using an electronic prior authorization, or ePA, tool such as CoverMyMeds^® or Surescripts^®.

When Fasenra or Nucala needs to be administered by a health care professional, submit the request through the NovoLogix^® online tool.

What you need to do for members who self-administer these drugs

For members who self-administer these drugs and don’t have pharmacy benefits through Blue Cross or BCN, providers need to work with the member’s pharmacy vendor to ensure that the drug is covered.

For members who self-administer these drugs and do have pharmacy benefits through Blue Cross or BCN, providers will need to submit a prior authorization request under the member’s pharmacy benefit.

Members can obtain these drugs through an AllianceRx Walgreens Pharmacy.

Why we’re making this change

We’re making this change as part of our continued effort to provide members with access to the best health care at the lowest cost. The management changes for this drug class ensure that we’re taking the most cost-effective approach by reducing the cost to our members and to the plan. In addition, these changes ensure that patient health and outcomes aren’t affected while delivering value to members.

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.

For a full list of requirements related to drugs covered under the pharmacy benefit, see the Prior authorization and step therapy coverage criteria.

We'll update these lists to reflect the changes related to these drugs prior to the effective dates.

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

For some providers, process for updating your information with us changing in November

Starting Nov. 3, 2022, you may need to complete two forms to update any of the following information in the Blue Cross Blue Shield of Michigan and Blue Care Network online provider directory:

• Name
• Specialty
• Address
• Telephone number
• Digital contact information

We’re changing the process of updating information to comply with provisions of the Consolidated Appropriations Act, or CAA, of 2021.

Types of providers affected

This change will affect all providers except:

• Hospitals
• Group and individual providers

What you need to update

When making a change, refer to the table below:

**You’ll find a link to the new Provider Directory Change Form near the links to the BCBSM/BCN Facility Change Form and the Allied Provider Change Form.

Accessing the forms

To access the forms, follow these steps:

1. Visit bcbsm.com/providers.
2. Click on Enrollment.
3. Click on Enroll Now.
4. Follow the prompts.

Fax the completed forms to the Provider Enrollment department at 1-866-900-0250. This fax number is shown on each form.

Need help?

For assistance completing the correct forms, call the Provider Enrollment department at 1-800-822-2761.

Benefit changes coming in 2023 for UAW Retiree Medical Benefits Trust members

Starting Jan. 1, 2023, there will be several changes to the UAW Retiree Medical Benefits Trust members’ health plan benefits. A summary of those changes is included below.

For BCN HMO and BCN Advantage℠:

Benefit changes

• Members will be allowed unlimited, in-network skilled nursing facility, or SNF, days.

For Enhanced Care Plan (ECP) and Traditional Care Network (TCN) plans:

Cost share changes

• The in-network deductible is reduced to $325 for individuals and $600 for families.
• The in-network out-of-pocket maximum is reduced to $650 for individuals and $1,325 for families.

Note: This change excludes Ford Protected members as the current in-network deductible and out-of-pocket maximum is $0.

Benefit changes

• Skilled nursing facility, or SNF, benefit
• Members will be allowed unlimited SNF days.
• Inpatient hospital admissions and home health care
• Members will be allowed unlimited days for inpatient hospital admissions, and
• Unlimited visits for home health care
• Hospice day maximum will now follow Medicare’s guidelines. Members are allowed two 90-day benefit periods followed by unlimited 60-day benefit periods.
• Cardiac rehabilitation, pulmonary rehabilitation and respiratory rehabilitation are covered at 100% of the in-network allowed amount.
• All in-network and out-of-network outpatient behavioral health visits are covered at 100% of the allowed amount. Services rendered by nonparticipating providers aren’t covered.

For Medicare Plus Blue PPO:

Cost share changes

• The in-network deductible is reduced to $150.
• The in-network out-of-pocket maximum is reduced to $500.

Note: This change excludes Protected plans as the current in-network deductible and out-of-pocket maximum is $0.

Benefit changes

(Protected plans are not subject to cost share. Therefore, they’re excluded from the following cost share changes. All other benefit changes apply unless otherwise stated.)

• This plan is now a Medicare Advantage Prescription Drug Plan, effective Jan. 1, 2023. Members will have prescription drug coverage through Blue Cross Blue Shield of Michigan (Optum Rx).
• In-network medical drugs (Part B)
• Outpatient — Subject to 10% coinsurance after deductible
• Office — Subject to $10 primary care provider copay and $20 specialist copay
• Home — Covered at 100% of the allowed amount and follows the home health care benefit
• Skilled nursing facility, or SNF, benefit
• Members will be allowed unlimited SNF days.
• Days 1-20 are subject to in-network deductible, then services are covered at 100% of the allowed amount. Days 21 and over are subject to 10% coinsurance.
• Members will be allowed unlimited days for partial hospitalization.
• Allergy testing and treatment
• Allergy testing, therapy and administration services are covered in-network at 100% of the allowed amount.
• Additional professional services provided during the visit are subject to in-network office visit and outpatient care cost share.
• In-network virtual/telehealth visits rendered by a specialist are subject to a $10 copay.
• Blood, blood storage and administration services are covered in-network at 100% of the allowed amount.
• Foot care — podiatry services
• Allows six visits in-network, subject to a $20 copay for General Members and $0 copay for Protected members. These visits are in addition to podiatry services that are covered under the standard Medicare benefit.
• Services related to wigs are covered without diagnosis restrictions.

As always, be sure to check online for benefits and eligibility.

Management of medical benefit drugs moving from Accredo to Blue Cross for URMBT Blue Cross non-Medicare members

Starting Jan. 1, 2023, Blue Cross Blue Shield of Michigan will manage prior authorizations for additional medical benefit drugs for which Accredo previously managed prior authorizations. You’ll find a list of these drugs later in this article.

This change affects UAW Retiree Medical Benefits Trust Blue Cross non-Medicare members.

These requirements don’t apply:

• When these drugs are administered in an inpatient setting
• To the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714)

How will this change be rolled out?

• For members for whom Accredo approved authorization requests on or before Aug. 31, 2022: Blue Cross will automatically issue a new authorization. These authorizations will be in effect indefinitely. We’ll send letters to notify affected members.
• For members who begin therapies from Sept. 1 through Dec. 31, 2022: Providers don’t need to submit authorization requests. Blue Cross will automatically issue authorizations for the drugs. These authorizations will be in effect indefinitely. We’ll send letters to notify affected members.
• For members who begin therapies on or after Jan. 1, 2023: Providers must submit prior authorization requests to AIM Specialty Health^® or through the NovoLogix^® online tool, as specified in the table below.

How will I submit prior authorization requests starting Jan. 1?

Note: If you need access to Availity^®, follow the instructions on the Register for web tools webpage at bcbsm.com/providers.

What drugs will be affected by this change?

See the list below. For information about additional requirements, such as site of care and quantity limits, see the appropriate drug lists. Access the drug list using the links in the "More about the authorization requirements" section later in this article.

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 these changes 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.

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.

Additional medical benefit drugs will require prior authorization for URMBT members with Blue Cross non-Medicare plans starting Jan. 1

For dates of service on or after Jan. 1, 2023, Blue Cross Blue Shield of Michigan will manage prior authorizations for additional medical benefit drugs for UAW Retiree Medical Benefits Trust members with Blue Cross non‑Medicare plans.

You’ll find a list of these drugs later in this article. You’ll need to submit prior authorization requests either to AIM Specialty Health^® or through the NovoLogix^® online tool.

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

The following requirements don’t apply:

• When these drugs are administered in an inpatient setting
• To the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714)

How to submit prior authorization requests

Note: If you need access to Availity^®, follow the instructions on the Register for web tools webpage at bcbsm.com/providers.

Which drugs will be affected by this change?

The drugs in the following table will be affected by this change.

For information about additional requirements, such as site of care and quantity limits, see the appropriate drug lists. Access the drug list using the links in the "More about the authorization requirements" section later in this article.

⁽¹⁾Prior to Jan. 1, 2023, this drug is a covered benefit but doesn’t require prior authorization.
⁽²⁾Prior to Jan. 1, 2023, this drug isn’t a covered benefit.

More about prior 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.

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.

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.

Coding update coming next year for Medicare Plus Blue pathology claims

To promote correct coding and assist with payment accuracy, Blue Cross Blue Shield of Michigan will enhance its claim editing process next year for pathology services on Medicare Plus Blue℠ outpatient facility and professional claims.

This coding update focuses on:

• Professional claims for pathology services when an ICD-10 code beginning with R is billed in the primary diagnosis position.
• Outpatient facility claims for pathology services when an R ICD-10 code is the only submitted diagnosis on the claim.

This coding update will exclude claim lines with modifier TC appended.

ICD-10-CM guidance indicates R codes are used for signs and symptoms instead of diagnoses. ICD-10-CM allows these codes in a primary spot when a diagnosis hasn’t been established by the provider. However, if the patient is receiving diagnostic services only (particularly those needing interpretation by a physician), the confirmed or definitive diagnosis should be coded.

In these cases, related signs and symptoms should not be coded as diagnoses. In the pathology realm, once pathology codes are submitted, a definitive diagnosis is typically determined. Therefore, the defined diagnosis should be provided in the first position, as opposed to a symptom-based diagnosis.

Based on the CPT, ICD-10-CM and guidelines from the Centers for Disease Control and Prevention, the pathologist should report a first-listed diagnosis based on the gross/microscopic examination.

The 2022 edition of the ICD-10-CM coding manual, Chapter 18, section B, under “Use of a symptom code with a definitive diagnosis code,” states: “Codes for signs and symptoms may be reported in addition to a related definitive diagnosis when the sign or symptom is not routinely associated with that diagnosis, such as the various signs and symptoms associated with complex syndromes. The definitive diagnosis code should be sequenced before the symptom code.”

Notes:

• If a claim is rejected due to edits that are needed, submit a corrected claim.
• If it’s necessary to submit an appeal, keep in mind that 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.

Avsola to require prior authorization for Blue Cross and Blue Shield Federal Employee Program non-Medicare members starting Jan. 1

For dates of service on or after Jan. 1, 2023, we're adding a prior authorization requirement for Blue Cross and Blue Shield FEP^® non-Medicare members for the following drug covered under the medical benefit:

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

For members who begin therapies prior to Dec. 31, 2022

Providers won’t need to submit prior authorization requests. Blue Cross will automatically issue authorizations for the drugs; these authorizations will be valid for six months.

For members who begin therapies on or after Jan. 1

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

If you have access to our provider portal (availity.com**), you already have access to NovoLogix. If you need access to Availity^®, follow the instructions on the Register for webtools webpage on bcbsm.com/providers.

After you’ve logged in to Availity, click on Payer Spaces and then on the BCBSM and BCN logo. Then you’ll see  links to the NovoLogix tools on the Applications tab.

List of requirements

For a full list of requirements related to drugs covered under the medical benefit, see the Utilization management medical drug list for Blue Cross and Blue Shield Federal Employee Program^® non-Medicare members. We’ll update this list prior to the effective date of the change.

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.

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

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

Follow these guidelines for billing genetic testing

When billing for genetic testing, keep the following policy guidelines in mind:

• Individual carrier screening procedure codes may receive a denial when a single comprehensive code is more appropriate.
• BRCA1 and BRCA2 genetic testing should be billed with the appropriate diagnosis and for the appropriate patient age.
• Lynch syndrome genetic testing may receive a denial when microsatellite instability analysis or immunohistochemistry testing hasn’t been billed in the previous 30 days.
• BRCA gene variant combinations should be billed with appropriate diagnosis codes.
• Cystic fibrosis transmembrane conductance regulator, or CFTR, gene variant combinations should be billed with appropriate diagnosis codes.
• Genetic analysis for non-invasive prenatal screening testing for fetal aneuploidy should be billed with appropriate diagnosis codes.
• Gap junction beta 2, or GJB2, gene variant combinations should be billed with appropriate diagnosis codes.

If you think the services rendered warrant an exception, follow the current clinical editing appeals process.

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.

Requirements changed for some commercial medical benefit drugs

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

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

**Will become a unique code

For additional details, see the Blue Cross and BCN utilization management medical drug list. This list is available on the following pages of the ereferrals.bcbsm.com website:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

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

Additional information

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

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

Cimerli now requires prior authorization for Medicare Advantage members

For dates of service on or after Oct. 3, 2022, we’ve added a prior authorization requirement for Medicare Plus Blue℠ and BCN Advantage℠ members for the following drug:

• Cimerli™ (ranibizumab-eqrn), HCPCS code J3590

For Lucentis^®, Cimerli is the second biosimilar and the first interchangeable biosimilar.

Both Cimerli and Lucentis will continue to require the member to first try and fail Avastin^® (bevacizumab).

The HCPCS codes for Avastin are J3590 for Medicare Plus Blue and J9035 for BCN Advantage.

As a reminder, Lucentis already requires prior authorization. Avastin doesn’t require prior authorization when used for retinal conditions.

All these drugs are part of members’ medical benefits, not their pharmacy benefits.

When prior authorization is required

Cimerli requires prior authorization when it’s administered by a health care provider in an outpatient facility or a physician’s office and billed in one of the following ways:

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

Submit prior authorization requests through the NovoLogix tool

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

After you’ve logged in to Availity, click on Payer Spaces and then 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. 

Reminder about requirements for other retinal drugs

As a reminder, all other intravitreal medications for retinal conditions continue to have Avastin as a step therapy requirement. These are:

• Eylea^® (aflibercept), HCPCS code J0178
• Beovu^® (rolucizumab-dbll), HCPCS code J0179
• Vabysmo^® (facricimab-svoa), HCPCS codes C9097 and J3590
• Byooviz^® (ranibizumab-nuna) HCPCS code Q5124
• Susvimo™ (ranibizumab injection, for ocular implant), HCPCS code J2779

List of requirements

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

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.

Prior authorization required for Spevigo for Medicare Advantage members

A prior authorization requirement has been added for Medicare Plus Blue℠ and BCN Advantage℠ members for dates of service on or after Sept. 26, 2022, for the following medication:

• Spevigo^® (spesolimab-sbzo), HCPCS code J3590

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

This medication is part of members’ medical benefits, not their pharmacy benefits.

When prior authorization is required

This medication requires prior authorization when it’s administered by a health care provider in an outpatient facility or a physician’s office and billed in one of the following ways:

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

Submit prior authorization requests through the NovoLogix tool

If you have access to the Availity Essentials provider portal (availity.com**), you already have access to NovoLogix. If you need to request access to Availity^®, follow the instructions on the Register for webtools 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 the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members.

We updated the list to reflect this change.

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 website don’t own or control this website.

Starting Jan. 1, we’ll change how we cover some prescription drugs

As we’ve stated before, our goal at Blue Cross Blue Shield of Michigan and Blue Care Network is to provide our members with safe, high-quality prescription drug therapies. We continually review our practices regarding prescription drugs to provide the best value for our members, control costs and make sure our members are using the right drug for the right situation.

Starting Jan. 1, 2023, we’ll change how we cover some medications on the drug lists associated with our prescription drug plans. We’ll send letters to notify affected members, their groups and their health care providers about these changes.

Read the following for an explanation of these changes:

Drugs that won’t be covered
We’ll no longer cover the following drugs. Unless noted, both the brand-name and available generic equivalents won’t be covered. For drugs with a generic equivalent available, the example brand names are listed for reference. If members fill a prescription for one of these drugs on or after Jan. 1, 2023, they’ll be responsible for the full cost.

The drugs that won’t be covered are listed along with suggested covered preferred alternatives that have similar effectiveness, quality and safety. When pharmacies fill prescriptions with preferred alternatives, the generic equivalents are dispensed, if available. Additional coverage requirements may apply for preferred alternatives, such as prior authorization.

Drugs that will have a higher copayment

The brand-name drugs that will have a higher copayment are listed along with suggested covered preferred alternatives that have similar effectiveness, quality and safety. When pharmacies fill prescriptions with preferred alternatives, the generic equivalents are dispensed, if available. Additional coverage requirements may apply for preferred alternatives.

**Nonpreferred brand-name drugs aren’t covered for members with a closed benefit.
***Applies to Blue Care Network only

Drugs that will have quantity limit changes
These drugs will have changes to the amount that can be filled.

Preventive drug coverage updates

Under the Affordable Care Act, most health plans must cover certain preventive services and prescription drugs with no out-of-pocket costs, based on recommendations by the U.S. Preventive Services Task Force.

The USPSTF is a panel of national experts in prevention and evidence-based medicine. The panel works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services, such as screenings, counseling services and preventive medications.

The USPSTF no longer recommends the use of aspirin for prevention of cardiovascular disease or colorectal cancer, so we’re no longer covering aspirin 325mg. Aspirin 81mg will remain covered for members at high risk of preeclampsia per the USPSTF’s recommendations.

If members fill a prescription for aspirin 325 mg on or after Jan. 1, 2023, they’ll be responsible for the full cost. Aspirin 325 mg is available for purchase over the counter.

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

We’re changing how we manage biologic asthma therapies, starting Jan. 1

Starting Jan. 1, 2023, Blue Cross Blue Shield of Michigan and Blue Care Network are changing how we manage some biologic asthma medications for all Blue Cross and BCN group and individual commercial members.

The following biologic asthma therapies will be affected by this change:

• Fasenra^® (benralizumab), HCPCS code J0517
• Nucala^® (mepolizumab), HCPCS code J2182

Fasenra and Nucala will continue to be covered under the medical benefit when administered by a health care professional. They’ll be managed under the pharmacy benefit when self-administered.

Starting Jan. 1, these drugs will no longer be covered under the medical benefit when they’re self-administered by a member.

Note: We’ve updated the medical policies for these drugs to reflect this change. You can view the medical policies through the Medical Policy Router Search page of bcbsm.com.

How to submit prior authorization requests

When Fasenra or Nucala will be self-administered, submit the request using an electronic prior authorization, or ePA, tool such as CoverMyMeds^® or Surescripts^®.

When Fasenra or Nucala needs to be administered by a health care professional, submit the request through the NovoLogix^® online tool.

What you need to do for members who self-administer these drugs

For members who self-administer these drugs and don’t have pharmacy benefits through Blue Cross or BCN, providers need to work with the member’s pharmacy vendor to ensure that the drug is covered.

For members who self-administer these drugs and do have pharmacy benefits through Blue Cross or BCN, providers will need to submit a prior authorization request under the member’s pharmacy benefit.

Members can obtain these drugs through an AllianceRx Walgreens Pharmacy.

Why we’re making this change

We’re making this change as part of our continued effort to provide members with access to the best health care at the lowest cost. The management changes for this drug class ensure that we’re taking the most cost-effective approach by reducing the cost to our members and to the plan. In addition, these changes ensure that patient health and outcomes aren’t affected while delivering value to members.

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.

For a full list of requirements related to drugs covered under the pharmacy benefit, see the Prior authorization and step therapy coverage criteria.

We'll update these lists to reflect the changes related to these drugs prior to the effective dates.

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

Management of medical benefit drugs moving from Accredo to Blue Cross for URMBT Blue Cross non-Medicare members

Starting Jan. 1, 2023, Blue Cross Blue Shield of Michigan will manage prior authorizations for additional medical benefit drugs for which Accredo previously managed prior authorizations. You’ll find a list of these drugs later in this article.

This change affects UAW Retiree Medical Benefits Trust Blue Cross non-Medicare members.

These requirements don’t apply:

• When these drugs are administered in an inpatient setting
• To the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714)

How will this change be rolled out?

• For members for whom Accredo approved authorization requests on or before Aug. 31, 2022: Blue Cross will automatically issue a new authorization. These authorizations will be in effect indefinitely. We’ll send letters to notify affected members.
• For members who begin therapies from Sept. 1 through Dec. 31, 2022: Providers don’t need to submit authorization requests. Blue Cross will automatically issue authorizations for the drugs. These authorizations will be in effect indefinitely. We’ll send letters to notify affected members.
• For members who begin therapies on or after Jan. 1, 2023: Providers must submit prior authorization requests to AIM Specialty Health^® or through the NovoLogix^® online tool, as specified in the table below.

How will I submit prior authorization requests starting Jan. 1?

Note: If you need access to Availity^®, follow the instructions on the Register for web tools webpage at bcbsm.com/providers.

What drugs will be affected by this change?

See the list below. For information about additional requirements, such as site of care and quantity limits, see the appropriate drug lists. Access the drug list using the links in the "More about the authorization requirements" section later in this article.

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 these changes 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.

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.

Additional medical benefit drugs will require prior authorization for URMBT members with Blue Cross non-Medicare plans starting Jan. 1

For dates of service on or after Jan. 1, 2023, Blue Cross Blue Shield of Michigan will manage prior authorizations for additional medical benefit drugs for UAW Retiree Medical Benefits Trust members with Blue Cross non‑Medicare plans.

You’ll find a list of these drugs later in this article. You’ll need to submit prior authorization requests either to AIM Specialty Health^® or through the NovoLogix^® online tool.

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

The following requirements don’t apply:

• When these drugs are administered in an inpatient setting
• To the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714)

How to submit prior authorization requests

Note: If you need access to Availity^®, follow the instructions on the Register for web tools webpage at bcbsm.com/providers.

Which drugs will be affected by this change?

The drugs in the following table will be affected by this change.

For information about additional requirements, such as site of care and quantity limits, see the appropriate drug lists. Access the drug list using the links in the "More about the authorization requirements" section later in this article.

⁽¹⁾Prior to Jan. 1, 2023, this drug is a covered benefit but doesn’t require prior authorization.
⁽²⁾Prior to Jan. 1, 2023, this drug isn’t a covered benefit.

More about prior 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.

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.

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.

Avsola to require prior authorization for Blue Cross and Blue Shield Federal Employee Program non-Medicare members starting Jan. 1

For dates of service on or after Jan. 1, 2023, we're adding a prior authorization requirement for Blue Cross and Blue Shield FEP^® non-Medicare members for the following drug covered under the medical benefit:

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

For members who begin therapies prior to Dec. 31, 2022

Providers won’t need to submit prior authorization requests. Blue Cross will automatically issue authorizations for the drugs; these authorizations will be valid for six months.

For members who begin therapies on or after Jan. 1

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

If you have access to our provider portal (availity.com**), you already have access to NovoLogix. If you need access to Availity^®, follow the instructions on the Register for webtools webpage on bcbsm.com/providers.

After you’ve logged in to Availity, click on Payer Spaces and then on the BCBSM and BCN logo. Then you’ll see  links to the NovoLogix tools on the Applications tab.

List of requirements

For a full list of requirements related to drugs covered under the medical benefit, see the Utilization management medical drug list for Blue Cross and Blue Shield Federal Employee Program^® non-Medicare members. We’ll update this list prior to the effective date of the change.

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.

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.

Clarification: DME/P&O and telehealth visits

The July 2022 issue of The Record included an article that referenced a Blue Cross Blue Shield of Michigan medical policy, updated in 2018 and indicating that health care providers can’t prescribe or issue durable medical equipment and prosthetics, orthotics and medical supplies during telehealth visits. The article should have indicated that exceptions are in place that allow telehealth visits for these purposes due to the COVID-19 public health emergency.

Blue Cross and Blue Care Network follow the Centers for Medicare & Medicaid Services COVID-19 PHE Interim Final Rules for DME/P&O items that allow exceptions to requirements for face-to-face encounters to avoid exposure of vulnerable populations. Telehealth visits can be used to prescribe DME/P&O items and medical supplies, effective March 18, 2020, until the end of the public health emergency, as indicated in our Temporary changes due to the COVID-19 pandemic document. For more information, see the CMS Medicare Learning Network guidance.**

We apologize for any confusion caused by the July article. We’ll communicate updated telehealth requirements for DME/P&O and medical supplies after the PHE has ended.

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