Next phase of Provider Secured Services and web-DENIS retirement to occur Oct. 25

On Oct. 25, Blue Cross Blue Shield of Michigan and Blue Care Network will enter the third phase of retirement for Provider Secured Services and web-DENIS. This phase will include the removal of:

• The HCPCS lookup tool
• All links to applications for submitting referral and prior authorization requests

Beginning Oct. 25, the HCPCS lookup tool and links for referral and prior authorization requests will be available only on our new provider portal – availity.com.** 

TIP: Use the Authorization Request tool or the Referral Request tool if you’re not sure whether a prior authorization or referral is required. If you know that a prior authorization or referral is required and where to submit the request, you can link directly to the specific application through the BCBSM and BCN Payer Space Applications tab.

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

Use our new provider portal

We continue to enhance the information you’ll find for Blue Cross and BCN in Availity Essentials. For help getting started with Availity Essentials, see the “Resources” section at the end of this article.

Watch for information on ‘final’ retirement

Continue to read this newsletter, as well as 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 at least one week before the final retirement.

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

• 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.

Blue Cross committed to coordination of care and exchange of information among practitioners

Blue Cross Blue Shield of Michigan collects and analyzes data each year to facilitate the coordination of care and exchange of information among specialists, behavioral health providers and primary care physicians following inpatient and outpatient visits.

Good two-way information exchange is especially important as we work to improve continuity and coordination of care within our network. For example, we not only need primary care providers to share information with specialists (including behavioral health specialists), but we need specialists to share patient information with the primary care providers as well.

Patient care that isn’t coordinated across care settings results in confusion for members, increased risks to patient safety and unnecessary costs due to duplicate testing or procedures. Collaboration among health care providers can also greatly improve member satisfaction.

We can work together to accomplish our goal of 100% coordination of care among all providers by:

• Ensuring that specialists and behavioral health care providers have the correct contact information about the patient’s primary care provider at the time of the visit
• Requesting that specialists and behavioral health providers forward post-visit information to the patient’s primary care provider
• Ensuring that primary care providers forward a patient’s medical information to any specialists or behavioral health providers who are treating the patient, as  needed
• Asking behavioral health patients to sign an authorization for release of information or including a note of refusal in their chart if a patient declines to share information

We encourage all heath care providers to continue to take steps to enhance the coordination of care and information exchange across the continuum of care to improve member satisfaction and care quality.

Announcing our PCMH and Collaborative Care designations

There we had two big developments in the Value Partnerships arena in September:

• We announced Patient-Centered Medical Home designations, which will be in effect for the next two years.
• We announced, for the first time, primary care practices that have been designated through our new Collaborative Care Designation Program — designations that will be in effect for the next year.

Why this is important

These two developments are significant for two reasons:

• They can help improve the behavioral health — addressing mental health and substance use disorder issues — of Michigan residents. The U.S. currently faces a national behavioral health emergency, according to Mental Health America.
• They can help improve the overall health of Michiganders, by providing value-based care that helps avoid emergency room visits and duplicative services — two key factors in high health care costs.

“The Collaborative Care designation program — the first of its kind in the nation — builds on our award-winning Patient-Centered Medical Home foundation, which is part of our Value Partnerships program, to provide additional support to members who are struggling with behavioral health issues,” said Dr. Amy McKenzie, vice president for clinical partnerships and associate chief medical officer. “We’re hopeful it will help address the current behavioral health emergency facing our country and state.”

A primary care practice must have PCMH designation and meet certain criteria to receive the Collaborative Care designation. The criteria, which consist of a set of capabilities, reflect elements that a practice needs to have to effectively deliver care using the Collaborative Care Model.

What is Collaborative Care?

Collaborative Care adds a behavioral health component to the partnership between a patient and his or her PCMH-designated physician. The Collaborative Care team consists of a doctor, who is the head of a care team, a behavioral health care manager and a consulting psychiatrist. These individuals work collaboratively to ensure patients get the care they need.

“We’re pleased to announce that 213 PCP practices earned the one-year designation on Sept. 1, 2022,” said Tom Leyden, director, Value Partnerships. “These practices are located in 33 counties throughout the state, including the Upper Peninsula.”

The largest concentration of Collaborative Care practices is in Southeast Michigan and the west side of the state.

PCMH designations

A total of 1,666 primary care practices have been designated as Patient-Centered Medical Homes. These practices represent 4,604 primary care physicians, caring for more than 2.9 million members across 78 counties in Michigan.

PCMH: A closer look

With the Patient-Centered Medical Home program, a doctor leads a team of health care professionals to meet a patient’s individual needs. The team may include nurses, pharmacists, a nutritionist and care coordinators, among others.

The successes of the PCMH approach are truly impressive. For example, in this designation cycle, our PCMH-designated practices, compared to non-PCMH practices, had a:

• 37.5% lower rate of adult ambulatory care-sensitive** inpatient discharges
• 22.5% lower rate of adult emergency department visits
• 26.1% lower rate of adult primary care-sensitive*** emergency department visits
• 25% lower rate of adult readmissions to the hospital
• 10.5% lower rate of high-tech radiology services for adults
• 40% lower rate of pediatric primary care-sensitive*** emergency department visits
• 28.5% lower rate of overall pediatric emergency department visits
• 5.7% lower rate of low-tech radiology services for children

“Having long-standing PCMH-designated practices available across Michigan is important in ensuring that our members have access to high-quality care,” Leyden said. “Over the past decade, Blue Cross data has repeatedly shown that patients in PCMH practices receive preventive care at higher rates and have fewer ER visits and inpatient hospital stays. This has resulted — and continues to result — in prevented costs and helps patients save money on copays and coinsurance.”

Collaborative Care: A closer look

The Collaborative Care Model has been in use by early adopters in Michigan since 2015. After reviewing preliminary results from those early adopters, Blue Cross Blue Shield of Michigan launched a formal training program for primary care practices seeking to implement Collaborative Care in 2020, along with an incentive structure for learning about and using the model.

“The Collaborative Care Model has been shown to be twice as effective for treating depression and anxiety than traditional care, according to research published in the Journal of the American Medical Association,” said Dr. William Beecroft, medical director of behavioral health. “It’s also been shown that effectively integrating physical and mental health care through a model such as CoCM reduces overall health care spend.”

Practices that would like to earn PCMH or Collaborative Care designation are encouraged to reach out to their physician organization for details. As a reminder, designated PCMH practices receive value-based reimbursement. And eligible practices receive value-based reimbursement for providing Collaborative Care.

**Ambulatory care-sensitive conditions are those that shouldn’t require inpatient hospitalization if appropriately managed by a primary care physician.

***Primary care-sensitive conditions are those that should be managed by a primary care physician so that an emergency department visit isn’t necessary.

2022 CPT 3rd-quarter PLA code update

Medicine vaccines
Toxoids code

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

Billing chart: Blue Cross highlights medical, benefit policy changes

You’ll find the latest information about procedure codes and Blue Cross Blue Shield of Michigan billing guidelines in the following chart.

This billing chart is organized numerically by procedure code. Newly approved procedures will appear under the New Payable Procedures heading. Procedures for which we have changed a billing guideline or added a new payable group will appear under Updates to Payable Procedures. Procedures for which we are clarifying our guidelines will appear under Policy Clarifications. New procedures that are not covered will appear under Experimental Procedures.

You will also see that descriptions for the codes are no longer included. This is a result of recent negotiations with the AMA on use of the codes.

We will publish information about new BCBS groups or changes to group benefits under the Group Benefit Changes heading.

For more detailed descriptions of the BCBSM policies for these procedures, please check under the Medical/Payment Policy tab in Explainer on web-DENIS. To access this online information:

• Log in to web-DENIS.
• Click on BCBSM Provider Publications & Resources.
• Click on Benefit Policy for a Code.
• Click on Topic.
• Under Topic Criteria, click on the drop-down arrow next to Choose Identifier Type and then click on HCPCS Code.
• Enter the procedure code.
• Click on Finish.
• Click on Search.

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

Medicare Advantage plans transitioning to Optum Rx pharmacy benefit manager

We notified providers earlier this year that the pharmacy benefit manager for our Medicare Advantage individual and group members would transition from Express Scripts, Inc. to Optum Rx^® beginning on Jan. 1, 2023. This applies to all our Medicare members with pharmacy coverage, including Medicare Plus Blue℠ and BCN Advantage℠ members. Our commercial plans transitioned on Jan. 1, 2022, as detailed in this January 2022 article in The Record.

As we indicated previously, the transition should be seamless for our participating health care providers and pharmacists. However, the major change is that Optum Home Delivery will provide mail-order drugs for preferred cost sharing, starting Jan. 1, 2023. You can expect that patients using our current mail-order pharmacy will be asking for new prescriptions for controlled substances, expired prescriptions or prescriptions without refills so they can be filled by Optum Home Delivery.

We’ll mail new ID cards to our members with Medicare Advantage prescription drug plans. They must show their new cards at the pharmacy starting Jan. 1, 2023, to help ensure that their prescriptions are covered correctly under their benefits.

You should continue to submit electronic prior authorizations for Medicare Plus Blue and BCN Advantage members using your current electronic medical record system or CoverMyMeds^® through Availity. Keep in mind that the BIN number changes to 610011, effective Jan. 1, 2023, for all Medicare Plus Blue and BCN Advantage members.

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

Starting Dec. 1, new prior authorizations are required for opioid medications exceeding 90 MMEs

Blue Cross Blue Shield of Michigan and Blue Care Network remain committed to battling our country’s opioid crisis through various programs and initiatives. Starting Dec. 1, 2022, health care providers must submit a new prior authorization to extend prescriptions for members who are taking opioids with a dosage exceeding 90 morphine milligram equivalents, or MMEs, if these members don’t have a current prior authorization in place.

Providers use MMEs to measure and compare different drugs, using morphine as the standard. Blue Cross requires a prior authorization for opioid dosages that exceed 90 MMEs per day.

Prescription opioids are powerful pain-reducing medications. Examples include prescription medications containing oxycodone, hydrocodone or codeine, and may go by the brand names of Vicodin^®, Norco^® and Tylenol^® No. 3, among others.

We’ll notify affected members and recommend they reach out to their providers.

TurningPoint to review site of care for select hip and knee surgeries for Blue Cross commercial members, starting Jan. 2

For dates of service on or after Jan. 2, 2023, TurningPoint Healthcare Solutions LLC will review the site of care for select hip and knee surgeries as part of each prior authorization determination.

Based on medical necessity review, TurningPoint may approve prior authorization requests for select hip and knee surgeries only when scheduled in an outpatient setting.

This change applies to the following Blue Cross Blue Shield of Michigan commercial groups and members:

• All fully insured groups
• Select self-funded groups, including UAW Retiree Medical Benefits Trust non-Medicare members
• All members with individual coverage

Note: Review the “Action item” at the top of this article to learn how to determine whether a Blue Cross commercial member requires prior authorization for a musculoskeletal procedure.

You must submit an authorization request for an inpatient admission (procedure code *99222) through the e‑referral system if both of these statements apply:

• TurningPoint approves a prior authorization request for a hip or knee surgery in an outpatient setting.
• The member experiences a change in condition that requires an inpatient admission.

Blue Cross or BCN will review the request using InterQual^® criteria. See the “Submit an inpatient authorization” section of the e-referral User Guide for more information.

Performing select hip and knee surgeries in outpatient settings is supported by evidence-based guidelines and the Centers for Medicare & Medicaid Services.

Reminder

TurningPoint already reviews the site of care for select hip and knee surgeries for Medicare Plus Blue℠, Blue Care Network commercial and BCN Advantage℠ members. We started reviewing the site of care in January 2022.

Additional information

• We updated the Musculoskeletal procedure authorizations: Frequently asked questions for providers document to reflect this change.

For more information about the TurningPoint musculoskeletal surgical quality and safety management program, see these pages on the ereferrals.bcbsm.com website:

• BCN Musculoskeletal Services
• Blue Cross Musculoskeletal Services

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

TurningPoint Healthcare Solutions LLC is an independent company that manages authorizations for musculoskeletal surgical and related procedures for Blue Cross Blue Shield of Michigan and Blue Care Network.

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

New family building and maternity support solution for commercial members

Blue Cross Blue Shield of Michigan and Blue Care Network are working with Maven, an independent company, to provide a family building and maternity solution that supports all backgrounds, lifestyles and phases of starting or growing a family and helps improve clinical outcomes for parents and babies.

This solution includes three programs, which will be available starting Jan. 1, 2023. The programs include access to:

• A dedicated care advocate who can provide personalized, one-on-one care and benefits navigation, answer questions, recommend practitioners for specific needs and refer members to high-quality, in-network health care providers.

• Personalized resources, including content related to prenatal health, postpartum depression and returning to work with more confidence. Resources include clinical-based articles, community forums, groups, live classes and quizzes.

• Clinical virtual support through 24/7 on-demand video appointments available within one hour. Members can speak with providers from more than 30 specialties, including OB-GYNs, mental health specialists, lactation consultants, nutritionists, and career and sleep coaches. Appointments are available in more than 35 languages.

Keep reading to learn more, including which members have access to each program.

• Family Building program — Provides support and information for different paths to parenthood, such as fertility treatments, surrogacy and adoption. This program will be available to members who have coverage through Blue Cross and BCN commercial self-funded groups that purchase this program.

In addition, Maven Wallet is an optional add-on to the Family Building program. It enables self-funded groups to help their employees with reimbursement of adoption and surrogacy costs.

• Maternity program — Offers support during the nine months of pregnancy and for three months postpartum. This program will be available to all members who have coverage through Blue Cross and BCN commercial fully insured groups and to all members who have individual coverage. It’s also available to members who have coverage through self-funded groups that purchase this program.

• Parenting & Pediatrics program — Supports parents as they raise their children from ages 1 to 10. This 12-month, renewable program will be available to members who have coverage through Blue Cross and BCN commercial self-funded groups that purchase this program.

These programs won’t change your patients’ current fertility and maternity benefits or replace their health care providers or coverage. Rather, they provide supplemental support and education between regularly scheduled, in-person prenatal and postpartum appointments when support is often needed most.

Look for additional information about this solution in upcoming issues of this newsletter.

Maven is an independent company supporting Blue Cross Blue Shield of Michigan and Blue Care Network by providing family building and maternity support services.

Sexually transmitted infection testing to be bundled

In support of correct coding and payment accuracy, Blue Cross Blue Shield of Michigan will be updating its payment policy for sexually transmitted infection, or STI, testing. The exact date of the update is yet to be determined. We’ll notify you of the effective date in a future Record article or provider alert.   

When two or more single test codes are billed separately for the same member, health care provider and same date of service, we’ll reimburse these services based on the rate for a single more comprehensive multiple organism code (CPT *87801 — Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique.)

The following are examples of single codes that would be bundled into *87801 if two or more are billed.

This isn’t an all-inclusive list:

• *87491 — Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique
• *87591 — Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique.
• *87661 — Infectious agent detection by nucleic acid (DNA or RNA); Trichomonas vaginalis, amplified probe technique

Blue Cross and BCN commercial will use Audaire Health provider portal to capture clinical outcomes on select therapies

Blue Cross Blue Shield of Michigan and Blue Care Network will use the Audaire Health™ provider portal to track and capture clinical outcomes for all Blue Cross commercial and BCN commercial members for select gene and cellular therapies, starting Oct. 1, 2022.

The data that health care providers enter in the Audaire provider portal will enable Blue Cross and BCN to capture and assess the clinical benefit of these therapies. The goal of collecting this data is to ensure member access to therapies while maintaining affordability.

Which therapies are affected?

Starting Oct. 1, Blue Cross and BCN commercial will capture clinical outcomes for the following therapies in the Audaire provider portal:

Note: Current requirements will continue to apply to these drugs, including prior authorization requirements.

What will change?

Starting Oct. 1:

• The first time Blue Cross or BCN approves a prior authorization request you submitted for one of these therapies, you (the requesting provider) must attest that you’ll enter clinical outcome information in the Audaire provider portal as requested by Blue Cross or BCN. Attestation is required for the therapies to be covered by a member’s benefit. (See “How should you prepare for this change?” below to learn more about attestation.)

Note: If you have patients for whom we approved an authorization request for one of these therapies prior to Oct. 1 and who currently have active coverage with Blue Cross or BCN, you’ll also be required to attest.

• For any member who is approved for one of these therapies, we’ll automatically add their basic information to the Audaire provider portal. We’ll also add basic information for any members who were approved for one of these therapies prior to Oct. 1.
• Providers will receive email reminders from Audaire on a regular basis to remind them to submit clinical information. The email messages will be sent by hello@audaire.com, and they’ll include a direct link to the portal for easy access.
• Providers can use either of these submission methods:
• Entering clinical information in the Audaire provider portal.
• Calling 512-643-5099. After stating your name, you’ll be connected to an Audaire representative, who can enter the clinical information on your behalf.

  Note: To get help entering information in the Audaire provider portal, call 512‑643‑5099 to schedule an appointment with an Audaire representative.

How should you prepare for this change?

You don’t need to take action.

The first time Blue Cross or BCN approves a prior authorization request you submitted for one of these therapies, an Audaire representative will reach out to you to set up a 30-minute phone call, during which they’ll:

• Create your Audaire Health profile, which will complete your attestation.
• Provide training on how to use the Audaire provider portal. 
• Answer your questions about the Audaire provider portal.

Note: An Audaire representative will also reach out to you if you have patients for whom we approved an authorization request for one of these therapies prior to Oct. 1 and have active coverage with Blue Cross or BCN.

Why are we making this change?

Blue Cross and BCN continually evaluate strategies to help manage drug costs.

Gene and cellular therapies hold significant promise for managing a wide range of diseases, but these therapies have high costs. Our goal is to ensure member access to therapies while maintaining affordability.

Questions?

If you have questions about this change, send them to Allison Olmsted, Pharm.D., at aolmsted@bcbsm.com.

Audaire Health is an independent company that provides select services to Blue Cross and BCN commercial members.

Prior authorization will be required for Opdualag, starting Dec. 1

Most Blue Cross Blue Shield of Michigan and Blue Care Network members will need prior authorization for Opdualag™ for dates of service on or after Dec. 1, 2022. Prior authorization requests must be submitted to AIM Specialty Health^®.

Opdualag (nivolumab and relatlimab-rmbw), HCPCS code J9298, is part of members’ medical benefits, not their pharmacy benefits.

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

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

More about the authorization requirements

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

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

• Blue Cross and BCN commercial:
• Medical oncology prior authorization list for Blue Cross commercial fully insured and BCN commercial members
• Blue Cross and BCN utilization management medical drug list
• URMBT members with Blue Cross commercial, non-Medicare plans:
• Medical oncology prior authorization list for UAW Retiree Medical Benefits Trust PPO non-Medicare members
• Medical Drug Management with Blue Cross for UAW Retiree Medical Benefit Trust PPO non-Medicare Members
• Medicare Plus Blue and BCN Advantage members:
• Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members

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

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

AIM Specialty Health is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage authorizations for select services. For more information, go to our ereferrals.bcbsm.com website.

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

Reminder: Additional edits coming soon for Blue Cross commercial claims, including medical record requests from Optum

In support of our commitment to payment integrity solutions that support payment accuracy and encourage correct coding, Blue Cross Blue Shield of Michigan is working with Optum, an independent company, to identify claims that may require additional review.

In previous articles, we let you know about edits that will occur through our new relationship with Optum. You may occasionally receive a letter directly from Optum requesting medical records before claim payment. We expect this to happen for no more that 1% of claims.

Here are some answers to frequently asked questions:

Q: How does Optum decide which claims require medical record review?

A: Optum has developed customized analytics to identify claims that need additional review. These analytics are developed using Blue Cross’ internal payment policies and the policies of external agencies (e.g., the Centers for Medicare & Medicaid Services).

Q: How do I submit my medical records and what should I include?

A: The Optum medical record request letters will be sent within two business days of the claim being selected for review (referred to as tagging). The request letters will provide instructions of how and where to submit your medical records and what to include with your submission. This includes:

• A list of affected claims
• An itemized list of required documents
• A page of instructions on how to submit through a secure internet portal (or by hard copy), plus a cover sheet with a bar code to identify your case number and pertinent information for Optum.  

Medical records should be submitted within 60 calendar days of the request. Once received, records will be reviewed within 12 business days and an outcome letter will be sent to you.  

If no records are received within 60 days, a technical denial letter will be sent as final communication and Blue Cross will be notified that Optum has closed the case.     

Q: When the program starts, who do I contact at Optum for assistance with medical record submission?

A: Contact Optum directly at the phone number listed in the medical record request letter.        

Q: What options do I have if I don’t agree with a denial?

A: Optum’s initial findings denial letter will include information you’ll need to request a reconsideration. Your information should include:

• The cover sheet provided with the denial letter with a bar code
• Explanation of why you don’t agree with the denial
• Supporting documentation, such as additional medical records or source information

Optum will conduct its review and send a resolution letter within 12 business days from date of receipt. Timely filing rules will apply.

Blue Cross, BCN covering additional vaccine

To increase access to vaccines and decrease the risk of vaccine-preventable disease outbreaks, Blue Cross Blue Shield of Michigan and Blue Care Network added the following vaccine to our list of vaccines covered under the pharmacy benefit:

The following table lists all the vaccines covered under eligible members’ prescription drug plans. Most Blue Cross and BCN commercial (non-Medicare) members with prescription drug coverage are eligible. If a member meets the coverage criteria, the vaccine is covered with no out-of-pocket cost.

If a member doesn’t meet the age requirement for a vaccine, Blue Cross and BCN won’t cover the vaccine under the prescription drug plan and the claim will reject.

Vaccines must be administered by certified, trained and qualified registered pharmacists.

We’ve changed how we manage Skyrizi SC, Stelara SC

For dates of service on or after Aug. 15, 2022, Blue Cross Blue Shield of Michigan and Blue Care Network changed how we manage the following medications for our Medicare Advantage members:

• Skyrizi^® SC (risankizumab-rzaa), HCPCS code J3590
• Stelara^® SC (ustekinumab), HCPCS code J3357

This change applies to our Medicare Plus Blue℠ and BCN Advantage℠ members.

Note: This change doesn’t affect Skyrizi IV, HCPCS code J3590, and Stelara IV, HCPCS code J3358, which will continue to be managed as part of members’ Part B medical benefits.

What changed

For dates of service on or after Aug. 15, Medicare Plus Blue and BCN Advantage members who previously received Skyrizi SC or Stelara SC under the Part B medical benefit are required to continue their treatment under their Part D pharmacy benefits.

We made this change because these therapies can be safely and conveniently self-administered at home. The Centers for Medicare and Medicaid Services added these medications to the Self-Administered Drug Exclusion List: (SAD List).**

As a result:

• These drugs are no longer covered when administered by a doctor or other health care professional under the Part B medical benefit.
• Skyrizi SC isn’t included in our Medicare Advantage Part D formularies, but health care providers can request prior authorization for it as an exception. (See the “How to submit prior authorization requests for Skyrizi SC and Stelara SC” section of this article.)
• Note: Skyrizi IV still requires prior authorization through the Part B medical benefit, using the NovoLogix^® web tool.
• Stelara SC is now covered only through Medicare Advantage members’ Part D prescription drug plans. Prior authorization continues to be required through members’ Part D benefits. (See the “How to submit prior authorization requests for Skyrizi SC and Stelara SC ” section of this article.)

Note: Stelara IV still requires prior authorization through the Part B medical benefit, using the NovoLogix web tool. 

• Your patients can obtain these medications at pharmacies that dispense specialty drugs. They can also obtain these drugs through an AllianceRx Walgreens Pharmacy.

Note: For members who don’t have Part D pharmacy benefits through Blue Cross or BCN, health care providers need to work with the independent pharmacy company that provides the member’s Part D coverage.

How to submit prior authorization requests for Skyrizi SC and Stelara SC

For members who have Part D pharmacy benefits through Medicare Plus Blue or BCN Advantage, providers need to submit prior authorization requests for Skyrizi SC and Stelara SC as follows: 

• Electronically: Through CoverMyMeds^® or another free ePA tool, such as Surescripts^® or ExpressPAth^®. See Save time and submit your prior authorization requests electronically for pharmacy benefit drugs (PDF) for more information.
• By phone: Call 1-800-437-3803 and follow the prompts for medications billed through the pharmacy benefit.
• By fax: 
• For Medicare Plus Blue requests, fax to 1-866-601-4428.
• For BCN Advantage requests, fax to 1-800-459-8027.

List of requirements

For a full list of requirements related to drugs covered under the medical benefit, see the Blue Cross and BCN utilization management medical drug list for Blue Cross commercial and BCN commercial members. We’ve updated this list to reflect the changes related to these drugs.

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

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

Skyrizi IV to have site-of-care requirement for most commercial members, starting Dec. 1

For dates of service on or after Dec. 1, 2022, we’re adding a site-of-care requirement for Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members for the following drug covered under the medical benefit:

• Skyrizi^® intravenous (risankizumab-rzaa), HCPCS code J3590

You’ll be prompted to select a site of care when you submit prior authorization requests for Skyrizi^® IV.
If the member meets clinical criteria for the drug, requests for the following sites of care will be approved automatically:

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

Additional information or documentation may be required for requests to administer Skyrizi IV in an outpatient hospital setting.

As a reminder, this drug already requires prior authorization; providers can submit prior authorization requests using the NovoLogix^® online tool. The new site-of-care requirement is in addition to the current prior authorization requirement.

Members who start courses of treatment with Skyrizi IV before Dec. 1, 2022, will be able to continue receiving the drug in their current location until their existing authorization expires. If those members then continue treatment under a new prior authorization, the site-of-care requirements outlined above will apply.

Reminder: Skyrizi SC is covered under the pharmacy benefit

Skyrizi^® SC (risankizumab-rzaa), HCPCS code J3590, isn’t covered under members’ medical benefits. Subcutaneous injections are self-administered and covered under members’ pharmacy benefits.

Some Blue Cross commercial groups not subject to these requirements

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

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

List of requirements

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

You can access this list and other information about requesting prior authorization on 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.

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.

Blood pressure coding can reduce HEDIS medical record requests

The Controlling High Blood Pressure, or CBP, HEDIS^® measure — also a Medicare Star Ratings measure — assesses patients ages 18 to 85 who had a diagnosis of hypertension reported on an outpatient claim and whose blood pressure was adequately controlled (<140/90 mm Hg) as of Dec. 31 of the measurement year.

Per HEDIS specifications, blood pressure CPT^® II codes can now establish patient compliance with the CBP measure. We’ll no longer need to review medical records to confirm blood pressure values when you add the CPT II codes to your patients’ claims that are billed as an office visit, including telehealth, telephone, e-visit and virtual visits.

Blood pressure readings can be captured during a telehealth, telephone, e-visit or virtual visit. Keep the following in mind:

• Patient-reported readings taken with a digital device are acceptable and should be documented in the medical record.
• Providers don’t need to see the reading on the digital device; the patient can verbally report the digital reading.

Read the tip sheet to learn more about the measure and view a chart with blood pressure CPT II codes.

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

We’re continuing our yearly flu shot campaign

Each year Blue Cross Blue Shield of Michigan and Blue Care Network launch a flu shot campaign geared toward members, group customers, the public and health care providers. This year is no different.

Throughout the entire flu season, we’re using our various communication channels to encourage everyone to get their annual flu shot. You may see flu shot content on Blue Cross social media channels, blogs, news articles and more.

Messages for our members

We’re sending emails and direct mail from October to January to our members who haven’t yet received a flu shot. Here are some of our key messages for members:

• Don’t wait, check the flu shot off your to-do list today. It’s a service that can take five minutes and can save you five days.
• A flu shot is a safe, quick and convenient way to keep you healthier this season.
• Flu strains vary from year to year, and flu shots are proven to be one of the most effective measures against the virus.
• Get your flu shot at your next scheduled doctor’s appointment.
• If you’ve already received your flu shot this year, encourage your friends and family to get one as well to better protect themselves.
• It’s not too late to get one at any point during peak season.

Our campaign is expected to reach people of all ages.

What you can do

We encourage you to continue discussions with your patients about the importance of a yearly flu shot and suggest they get one as soon as possible when they’re at your office or at their next scheduled appointment.

More information on flu and pneumonia shots for members with Blue Cross or BCN coverage is available at bcbsm.com/preventflu and bcbsm.com/medicareflushot. You’re welcome to share the information on these sites with your patients.

HEDIS tips for prenatal care and well-child visits

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

Encouraging prenatal visits for pregnant patients, especially during the first trimester, increases the likelihood of a positive outcome during delivery and start to life. And encouraging regular well-child visits after delivery is a big part of keeping the momentum of a positive start going.

Blue Cross Blue Shield of Michigan developed the following HEDIS^® tip sheets to assist health care providers and their staff in efforts to improve overall health care quality:

• Prenatal Care (PPC)
• Well-child Visits in the First 30 months of Life (W30)

Blue Cross and Blue Shield Federal Employee Program^® Standard and Basic Option pregnant members can also participate in the Pregnancy Care Incentive Program and be eligible to earn a free Pregnancy Care Box. All FEP members who are pregnant or nursing can receive one free breast pump kit per calendar year.  

For information on FEP benefits and incentive programs, members and providers 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.

Inpatient rehabilitation providers: Sign up for October training on e-referral system

We’ve scheduled webinars in October 2022 for inpatient rehabilitation, or IPR, providers to teach them how to use the e-referral system. In the training, we’ll also review the basic requirements for rehabilitation admissions and discuss discharge planning.

How to register for a webinar

To register for a session through our provider training site, follow these steps:

1. Open the registration page.
2. Complete the registration. We recommend using the same email you use to communicate with Blue Cross Blue Shield of Michigan for provider-related needs. This will become your login ID.
3. Follow the link to log in.
4. On the main page, click on the webinar event you want to attend. The webinar sessions are listed under Upcoming Events on the right side of the page.
5. Click on the Register button to complete your registration.
6. To add the event to your email calendar, either click on the Add to your calendar button on the confirmation page or open the calendar attachment on your confirmation email.

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

Why you should learn how to use the e-referral system

Beginning Jan. 1, 2023, we’ll require IPR providers located in Michigan to submit prior authorization requests through the e-referral system and not by fax. This applies to requests for both Blue Cross Blue Shield of Michigan and Blue Care Network commercial members for:

• Initial admissions
• Additional days (extensions)

Currently, many IPR providers are faxing the Blue Cross and BCN SNF/acute IPR assessment form to submit their prior authorization requests for inpatient rehabilitation services.

What's changing

Starting Jan. 1, 2023:

• We'll stop accepting faxed requests as a general practice.
• We'll accept faxes only for urgent requests when the e-referral system isn’t available. In those instances, fax the form using the instructions on the PDF document titled e-referral system planned downtimes and what to do.

If we receive a faxed form for an admission or extension when the e-referral system is available, we won't accept the request. We'll notify IPR providers by fax or phone that they must submit the request through the e-referral system.

Additional information

For additional details about the upcoming changes, refer to the articles we published in the September 2022 Record or the September-October 2022 BCN Provider News.

Update: Prepayment Laboratory Claim Edits implementation

In a July Record article, we wrote about the proposed implementation of a laboratory benefits management program through Avalon Healthcare Solutions and asked for input from our facilities. Based on that input, we’re providing some additional information about the program below:

• Blue Cross Blue Shield of Michigan will continue to share the science, policies and policy summaries to assist in the development of “test menus,” the order forms sent to health care providers with a list of tests.
• Educational sessions have been provided since June and will continued to be scheduled throughout the year. These sessions are intended to educate providers on Blue Cross’ Lab Benefit Management program and polices.
• The Office of Inspector General believes laboratories have a duty to modify their practices, as well as notifying physicians or other authorized individuals of their concerns and recommending corrective action to aid in ensuring appropriate ordering and execution.
• Inappropriate ordering of labs can be addressed through understanding and adherence to Blue Cross policies as outlined through coverage criteria and diagnosis codes. 
• Blue Cross has taken all lab policies through our review process, including several facility representatives who supported the adoption of these new policies. Any future enhancement and adjustments to Blue Cross lab policies will also be fully vetted before assimilation into practice.
• Claims can be appealed through the standard clinical editing process. Medical records from the ordering physician must be included with the appeal.

Following Blue Cross’ review of facility input, we’ll be moving forward with this program in early October. Details about the lab benefits management program were also presented at the Aug. 24, 2022, Staff Liaison Group meeting, which included leadership from the Michigan Health and Hospital Association and Blue Cross, and at the Sept. 29, 2022, PHA Advisory Committee meeting.

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

Related outpatient services performed 24 hours prior to admission are included in inpatient claim

Blue Cross Blue Shield of Michigan payment policy requires that certain outpatient services performed within 24 hours prior to an admission be included in the inpatient claim.

This payment policy applies when the outpatient and inpatient services are performed in the same facility. Services provided in the outpatient department within 24 hours prior to an inpatient admission are paid as part of the inpatient admission when the diagnosis is the same. 

Claims submitted for outpatient services within 24 hours prior to admission may receive a denial as they shouldn’t be billed separately.

Update: Multiple Therapies Services implementation

In a July Record article, we wrote about the proposed implementation of a new payment reduction policy for physical, occupational and speech therapy and asked for input from our participating facilities. Based on the input we received from professional providers, associations and facilities, the payment implementation policy is currently on hold. It will be reevaluated for future consideration and modifications.  

According to the provisions of the Participating Hospital Agreement, the Multiple Therapies Services proposal was presented at the Aug. 24, 2022, meeting of the Staff Liaison Group, which included leadership from the Michigan Health and Hospital Association and Blue Cross Blue Shield of Michigan, and at the Sept. 29, 2022, PHA Advisory Committee meeting.

TurningPoint to review site of care for select hip and knee surgeries for Blue Cross commercial members, starting Jan. 2

For dates of service on or after Jan. 2, 2023, TurningPoint Healthcare Solutions LLC will review the site of care for select hip and knee surgeries as part of each prior authorization determination.

Based on medical necessity review, TurningPoint may approve prior authorization requests for select hip and knee surgeries only when scheduled in an outpatient setting.

This change applies to the following Blue Cross Blue Shield of Michigan commercial groups and members:

• All fully insured groups
• Select self-funded groups, including UAW Retiree Medical Benefits Trust non-Medicare members
• All members with individual coverage

Note: Review the “Action item” at the top of this article to learn how to determine whether a Blue Cross commercial member requires prior authorization for a musculoskeletal procedure.

You must submit an authorization request for an inpatient admission (procedure code *99222) through the e‑referral system if both of these statements apply:

• TurningPoint approves a prior authorization request for a hip or knee surgery in an outpatient setting.
• The member experiences a change in condition that requires an inpatient admission.

Blue Cross or BCN will review the request using InterQual^® criteria. See the “Submit an inpatient authorization” section of the e-referral User Guide for more information.

Performing select hip and knee surgeries in outpatient settings is supported by evidence-based guidelines and the Centers for Medicare & Medicaid Services.

Reminder

TurningPoint already reviews the site of care for select hip and knee surgeries for Medicare Plus Blue℠, Blue Care Network commercial and BCN Advantage℠ members. We started reviewing the site of care in January 2022.

Additional information

• We updated the Musculoskeletal procedure authorizations: Frequently asked questions for providers document to reflect this change.

For more information about the TurningPoint musculoskeletal surgical quality and safety management program, see these pages on the ereferrals.bcbsm.com website:

• BCN Musculoskeletal Services
• Blue Cross Musculoskeletal Services

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

TurningPoint Healthcare Solutions LLC is an independent company that manages authorizations for musculoskeletal surgical and related procedures for Blue Cross Blue Shield of Michigan and Blue Care Network.

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

Sexually transmitted infection testing to be bundled

In support of correct coding and payment accuracy, Blue Cross Blue Shield of Michigan will be updating its payment policy for sexually transmitted infection, or STI, testing. The exact date of the update is yet to be determined. We’ll notify you of the effective date in a future Record article or provider alert.   

When two or more single test codes are billed separately for the same member, health care provider and same date of service, we’ll reimburse these services based on the rate for a single more comprehensive multiple organism code (CPT *87801 — Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; amplified probe(s) technique.)

The following are examples of single codes that would be bundled into *87801 if two or more are billed.

This isn’t an all-inclusive list:

• *87491 — Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis, amplified probe technique
• *87591 — Infectious agent detection by nucleic acid (DNA or RNA); Neisseria gonorrhoeae, amplified probe technique.
• *87661 — Infectious agent detection by nucleic acid (DNA or RNA); Trichomonas vaginalis, amplified probe technique

Prior authorization will be required for Opdualag, starting Dec. 1

Most Blue Cross Blue Shield of Michigan and Blue Care Network members will need prior authorization for Opdualag™ for dates of service on or after Dec. 1, 2022. Prior authorization requests must be submitted to AIM Specialty Health^®.

Opdualag (nivolumab and relatlimab-rmbw), HCPCS code J9298, is part of members’ medical benefits, not their pharmacy benefits.

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

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

More about the authorization requirements

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

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

• Blue Cross and BCN commercial:
• Medical oncology prior authorization list for Blue Cross commercial fully insured and BCN commercial members
• Blue Cross and BCN utilization management medical drug list
• URMBT members with Blue Cross commercial, non-Medicare plans:
• Medical oncology prior authorization list for UAW Retiree Medical Benefits Trust PPO non-Medicare members
• Medical Drug Management with Blue Cross for UAW Retiree Medical Benefit Trust PPO non-Medicare Members
• Medicare Plus Blue and BCN Advantage members:
• Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members

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

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

AIM Specialty Health is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage authorizations for select services. For more information, go to our ereferrals.bcbsm.com website.

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

Reminder: Additional edits coming soon for Blue Cross commercial claims, including medical record requests from Optum

In support of our commitment to payment integrity solutions that support payment accuracy and encourage correct coding, Blue Cross Blue Shield of Michigan is working with Optum, an independent company, to identify claims that may require additional review.

In previous articles, we let you know about edits that will occur through our new relationship with Optum. You may occasionally receive a letter directly from Optum requesting medical records before claim payment. We expect this to happen for no more that 1% of claims.

Here are some answers to frequently asked questions:

Q: How does Optum decide which claims require medical record review?

A: Optum has developed customized analytics to identify claims that need additional review. These analytics are developed using Blue Cross’ internal payment policies and the policies of external agencies (e.g., the Centers for Medicare & Medicaid Services).

Q: How do I submit my medical records and what should I include?

A: The Optum medical record request letters will be sent within two business days of the claim being selected for review (referred to as tagging). The request letters will provide instructions of how and where to submit your medical records and what to include with your submission. This includes:

• A list of affected claims
• An itemized list of required documents
• A page of instructions on how to submit through a secure internet portal (or by hard copy), plus a cover sheet with a bar code to identify your case number and pertinent information for Optum.  

Medical records should be submitted within 60 calendar days of the request. Once received, records will be reviewed within 12 business days and an outcome letter will be sent to you.  

If no records are received within 60 days, a technical denial letter will be sent as final communication and Blue Cross will be notified that Optum has closed the case.     

Q: When the program starts, who do I contact at Optum for assistance with medical record submission?

A: Contact Optum directly at the phone number listed in the medical record request letter.        

Q: What options do I have if I don’t agree with a denial?

A: Optum’s initial findings denial letter will include information you’ll need to request a reconsideration. Your information should include:

• The cover sheet provided with the denial letter with a bar code
• Explanation of why you don’t agree with the denial
• Supporting documentation, such as additional medical records or source information

Optum will conduct its review and send a resolution letter within 12 business days from date of receipt. Timely filing rules will apply.

We’ve changed how we manage Skyrizi SC, Stelara SC

For dates of service on or after Aug. 15, 2022, Blue Cross Blue Shield of Michigan and Blue Care Network changed how we manage the following medications for our Medicare Advantage members:

• Skyrizi^® SC (risankizumab-rzaa), HCPCS code J3590
• Stelara^® SC (ustekinumab), HCPCS code J3357

This change applies to our Medicare Plus Blue℠ and BCN Advantage℠ members.

Note: This change doesn’t affect Skyrizi IV, HCPCS code J3590, and Stelara IV, HCPCS code J3358, which will continue to be managed as part of members’ Part B medical benefits.

What changed

For dates of service on or after Aug. 15, Medicare Plus Blue and BCN Advantage members who previously received Skyrizi SC or Stelara SC under the Part B medical benefit are required to continue their treatment under their Part D pharmacy benefits.

We made this change because these therapies can be safely and conveniently self-administered at home. The Centers for Medicare and Medicaid Services added these medications to the Self-Administered Drug Exclusion List: (SAD List).**

As a result:

• These drugs are no longer covered when administered by a doctor or other health care professional under the Part B medical benefit.
• Skyrizi SC isn’t included in our Medicare Advantage Part D formularies, but health care providers can request prior authorization for it as an exception. (See the “How to submit prior authorization requests for Skyrizi SC and Stelara SC” section of this article.)
• Note: Skyrizi IV still requires prior authorization through the Part B medical benefit, using the NovoLogix^® web tool.
• Stelara SC is now covered only through Medicare Advantage members’ Part D prescription drug plans. Prior authorization continues to be required through members’ Part D benefits. (See the “How to submit prior authorization requests for Skyrizi SC and Stelara SC ” section of this article.)

Note: Stelara IV still requires prior authorization through the Part B medical benefit, using the NovoLogix web tool. 

• Your patients can obtain these medications at pharmacies that dispense specialty drugs. They can also obtain these drugs through an AllianceRx Walgreens Pharmacy.

Note: For members who don’t have Part D pharmacy benefits through Blue Cross or BCN, health care providers need to work with the independent pharmacy company that provides the member’s Part D coverage.

How to submit prior authorization requests for Skyrizi SC and Stelara SC

For members who have Part D pharmacy benefits through Medicare Plus Blue or BCN Advantage, providers need to submit prior authorization requests for Skyrizi SC and Stelara SC as follows: 

• Electronically: Through CoverMyMeds^® or another free ePA tool, such as Surescripts^® or ExpressPAth^®. See Save time and submit your prior authorization requests electronically for pharmacy benefit drugs (PDF) for more information.
• By phone: Call 1-800-437-3803 and follow the prompts for medications billed through the pharmacy benefit.
• By fax: 
• For Medicare Plus Blue requests, fax to 1-866-601-4428.
• For BCN Advantage requests, fax to 1-800-459-8027.

List of requirements

For a full list of requirements related to drugs covered under the medical benefit, see the Blue Cross and BCN utilization management medical drug list for Blue Cross commercial and BCN commercial members. We’ve updated this list to reflect the changes related to these drugs.

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

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

Skyrizi IV to have site-of-care requirement for most commercial members, starting Dec. 1

For dates of service on or after Dec. 1, 2022, we’re adding a site-of-care requirement for Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members for the following drug covered under the medical benefit:

• Skyrizi^® intravenous (risankizumab-rzaa), HCPCS code J3590

You’ll be prompted to select a site of care when you submit prior authorization requests for Skyrizi^® IV.
If the member meets clinical criteria for the drug, requests for the following sites of care will be approved automatically:

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

Additional information or documentation may be required for requests to administer Skyrizi IV in an outpatient hospital setting.

As a reminder, this drug already requires prior authorization; providers can submit prior authorization requests using the NovoLogix^® online tool. The new site-of-care requirement is in addition to the current prior authorization requirement.

Members who start courses of treatment with Skyrizi IV before Dec. 1, 2022, will be able to continue receiving the drug in their current location until their existing authorization expires. If those members then continue treatment under a new prior authorization, the site-of-care requirements outlined above will apply.

Reminder: Skyrizi SC is covered under the pharmacy benefit

Skyrizi^® SC (risankizumab-rzaa), HCPCS code J3590, isn’t covered under members’ medical benefits. Subcutaneous injections are self-administered and covered under members’ pharmacy benefits.

Some Blue Cross commercial groups not subject to these requirements

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

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

List of requirements

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

You can access this list and other information about requesting prior authorization on 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.

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 Advantage plans transitioning to Optum Rx pharmacy benefit manager

We notified providers earlier this year that the pharmacy benefit manager for our Medicare Advantage individual and group members would transition from Express Scripts, Inc. to Optum Rx^® beginning on Jan. 1, 2023. This applies to all our Medicare members with pharmacy coverage, including Medicare Plus Blue℠ and BCN Advantage℠ members. Our commercial plans transitioned on Jan. 1, 2022, as detailed in this January 2022 article in The Record.

As we indicated previously, the transition should be seamless for our participating health care providers and pharmacists. However, the major change is that Optum Home Delivery will provide mail-order drugs for preferred cost sharing, starting Jan. 1, 2023. You can expect that patients using our current mail-order pharmacy will be asking for new prescriptions for controlled substances, expired prescriptions or prescriptions without refills so they can be filled by Optum Home Delivery.

We’ll mail new ID cards to our members with Medicare Advantage prescription drug plans. They must show their new cards at the pharmacy starting Jan. 1, 2023, to help ensure that their prescriptions are covered correctly under their benefits.

You should continue to submit electronic prior authorizations for Medicare Plus Blue and BCN Advantage members using your current electronic medical record system or CoverMyMeds^® through Availity. Keep in mind that the BIN number changes to 610011, effective Jan. 1, 2023, for all Medicare Plus Blue and BCN Advantage members.

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

Starting Dec. 1, new prior authorizations are required for opioid medications exceeding 90 MMEs

Blue Cross Blue Shield of Michigan and Blue Care Network remain committed to battling our country’s opioid crisis through various programs and initiatives. Starting Dec. 1, 2022, health care providers must submit a new prior authorization to extend prescriptions for members who are taking opioids with a dosage exceeding 90 morphine milligram equivalents, or MMEs, if these members don’t have a current prior authorization in place.

Providers use MMEs to measure and compare different drugs, using morphine as the standard. Blue Cross requires a prior authorization for opioid dosages that exceed 90 MMEs per day.

Prescription opioids are powerful pain-reducing medications. Examples include prescription medications containing oxycodone, hydrocodone or codeine, and may go by the brand names of Vicodin^®, Norco^® and Tylenol^® No. 3, among others.

We’ll notify affected members and recommend they reach out to their providers.

Blue Cross and BCN commercial will use Audaire Health provider portal to capture clinical outcomes on select therapies

Blue Cross Blue Shield of Michigan and Blue Care Network will use the Audaire Health™ provider portal to track and capture clinical outcomes for all Blue Cross commercial and BCN commercial members for select gene and cellular therapies, starting Oct. 1, 2022.

The data that health care providers enter in the Audaire provider portal will enable Blue Cross and BCN to capture and assess the clinical benefit of these therapies. The goal of collecting this data is to ensure member access to therapies while maintaining affordability.

Which therapies are affected?

Starting Oct. 1, Blue Cross and BCN commercial will capture clinical outcomes for the following therapies in the Audaire provider portal:

Note: Current requirements will continue to apply to these drugs, including prior authorization requirements.

What will change?

Starting Oct. 1:

• The first time Blue Cross or BCN approves a prior authorization request you submitted for one of these therapies, you (the requesting provider) must attest that you’ll enter clinical outcome information in the Audaire provider portal as requested by Blue Cross or BCN. Attestation is required for the therapies to be covered by a member’s benefit. (See “How should you prepare for this change?” below to learn more about attestation.)

Note: If you have patients for whom we approved an authorization request for one of these therapies prior to Oct. 1 and who currently have active coverage with Blue Cross or BCN, you’ll also be required to attest.

• For any member who is approved for one of these therapies, we’ll automatically add their basic information to the Audaire provider portal. We’ll also add basic information for any members who were approved for one of these therapies prior to Oct. 1.
• Providers will receive email reminders from Audaire on a regular basis to remind them to submit clinical information. The email messages will be sent by hello@audaire.com, and they’ll include a direct link to the portal for easy access.
• Providers can use either of these submission methods:
• Entering clinical information in the Audaire provider portal.
• Calling 512-643-5099. After stating your name, you’ll be connected to an Audaire representative, who can enter the clinical information on your behalf.

  Note: To get help entering information in the Audaire provider portal, call 512‑643‑5099 to schedule an appointment with an Audaire representative.

How should you prepare for this change?

You don’t need to take action.

The first time Blue Cross or BCN approves a prior authorization request you submitted for one of these therapies, an Audaire representative will reach out to you to set up a 30-minute phone call, during which they’ll:

• Create your Audaire Health profile, which will complete your attestation.
• Provide training on how to use the Audaire provider portal. 
• Answer your questions about the Audaire provider portal.

Note: An Audaire representative will also reach out to you if you have patients for whom we approved an authorization request for one of these therapies prior to Oct. 1 and have active coverage with Blue Cross or BCN.

Why are we making this change?

Blue Cross and BCN continually evaluate strategies to help manage drug costs.

Gene and cellular therapies hold significant promise for managing a wide range of diseases, but these therapies have high costs. Our goal is to ensure member access to therapies while maintaining affordability.

Questions?

If you have questions about this change, send them to Allison Olmsted, Pharm.D., at aolmsted@bcbsm.com.

Audaire Health is an independent company that provides select services to Blue Cross and BCN commercial members.

Prior authorization will be required for Opdualag, starting Dec. 1

Most Blue Cross Blue Shield of Michigan and Blue Care Network members will need prior authorization for Opdualag™ for dates of service on or after Dec. 1, 2022. Prior authorization requests must be submitted to AIM Specialty Health^®.

Opdualag (nivolumab and relatlimab-rmbw), HCPCS code J9298, is part of members’ medical benefits, not their pharmacy benefits.

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

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

More about the authorization requirements

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

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

• Blue Cross and BCN commercial:
• Medical oncology prior authorization list for Blue Cross commercial fully insured and BCN commercial members
• Blue Cross and BCN utilization management medical drug list
• URMBT members with Blue Cross commercial, non-Medicare plans:
• Medical oncology prior authorization list for UAW Retiree Medical Benefits Trust PPO non-Medicare members
• Medical Drug Management with Blue Cross for UAW Retiree Medical Benefit Trust PPO non-Medicare Members
• Medicare Plus Blue and BCN Advantage members:
• Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members

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

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

AIM Specialty Health is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage authorizations for select services. For more information, go to our ereferrals.bcbsm.com website.

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

Blue Cross, BCN covering additional vaccine

To increase access to vaccines and decrease the risk of vaccine-preventable disease outbreaks, Blue Cross Blue Shield of Michigan and Blue Care Network added the following vaccine to our list of vaccines covered under the pharmacy benefit:

The following table lists all the vaccines covered under eligible members’ prescription drug plans. Most Blue Cross and BCN commercial (non-Medicare) members with prescription drug coverage are eligible. If a member meets the coverage criteria, the vaccine is covered with no out-of-pocket cost.

If a member doesn’t meet the age requirement for a vaccine, Blue Cross and BCN won’t cover the vaccine under the prescription drug plan and the claim will reject.

Vaccines must be administered by certified, trained and qualified registered pharmacists.

We’ve changed how we manage Skyrizi SC, Stelara SC

For dates of service on or after Aug. 15, 2022, Blue Cross Blue Shield of Michigan and Blue Care Network changed how we manage the following medications for our Medicare Advantage members:

• Skyrizi^® SC (risankizumab-rzaa), HCPCS code J3590
• Stelara^® SC (ustekinumab), HCPCS code J3357

This change applies to our Medicare Plus Blue℠ and BCN Advantage℠ members.

Note: This change doesn’t affect Skyrizi IV, HCPCS code J3590, and Stelara IV, HCPCS code J3358, which will continue to be managed as part of members’ Part B medical benefits.

What changed

For dates of service on or after Aug. 15, Medicare Plus Blue and BCN Advantage members who previously received Skyrizi SC or Stelara SC under the Part B medical benefit are required to continue their treatment under their Part D pharmacy benefits.

We made this change because these therapies can be safely and conveniently self-administered at home. The Centers for Medicare and Medicaid Services added these medications to the Self-Administered Drug Exclusion List: (SAD List).**

As a result:

• These drugs are no longer covered when administered by a doctor or other health care professional under the Part B medical benefit.
• Skyrizi SC isn’t included in our Medicare Advantage Part D formularies, but health care providers can request prior authorization for it as an exception. (See the “How to submit prior authorization requests for Skyrizi SC and Stelara SC” section of this article.)
• Note: Skyrizi IV still requires prior authorization through the Part B medical benefit, using the NovoLogix^® web tool.
• Stelara SC is now covered only through Medicare Advantage members’ Part D prescription drug plans. Prior authorization continues to be required through members’ Part D benefits. (See the “How to submit prior authorization requests for Skyrizi SC and Stelara SC ” section of this article.)

Note: Stelara IV still requires prior authorization through the Part B medical benefit, using the NovoLogix web tool. 

• Your patients can obtain these medications at pharmacies that dispense specialty drugs. They can also obtain these drugs through an AllianceRx Walgreens Pharmacy.

Note: For members who don’t have Part D pharmacy benefits through Blue Cross or BCN, health care providers need to work with the independent pharmacy company that provides the member’s Part D coverage.

How to submit prior authorization requests for Skyrizi SC and Stelara SC

For members who have Part D pharmacy benefits through Medicare Plus Blue or BCN Advantage, providers need to submit prior authorization requests for Skyrizi SC and Stelara SC as follows: 

• Electronically: Through CoverMyMeds^® or another free ePA tool, such as Surescripts^® or ExpressPAth^®. See Save time and submit your prior authorization requests electronically for pharmacy benefit drugs (PDF) for more information.
• By phone: Call 1-800-437-3803 and follow the prompts for medications billed through the pharmacy benefit.
• By fax: 
• For Medicare Plus Blue requests, fax to 1-866-601-4428.
• For BCN Advantage requests, fax to 1-800-459-8027.

List of requirements

For a full list of requirements related to drugs covered under the medical benefit, see the Blue Cross and BCN utilization management medical drug list for Blue Cross commercial and BCN commercial members. We’ve updated this list to reflect the changes related to these drugs.

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

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

Skyrizi IV to have site-of-care requirement for most commercial members, starting Dec. 1

For dates of service on or after Dec. 1, 2022, we’re adding a site-of-care requirement for Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members for the following drug covered under the medical benefit:

• Skyrizi^® intravenous (risankizumab-rzaa), HCPCS code J3590

You’ll be prompted to select a site of care when you submit prior authorization requests for Skyrizi^® IV.
If the member meets clinical criteria for the drug, requests for the following sites of care will be approved automatically:

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

Additional information or documentation may be required for requests to administer Skyrizi IV in an outpatient hospital setting.

As a reminder, this drug already requires prior authorization; providers can submit prior authorization requests using the NovoLogix^® online tool. The new site-of-care requirement is in addition to the current prior authorization requirement.

Members who start courses of treatment with Skyrizi IV before Dec. 1, 2022, will be able to continue receiving the drug in their current location until their existing authorization expires. If those members then continue treatment under a new prior authorization, the site-of-care requirements outlined above will apply.

Reminder: Skyrizi SC is covered under the pharmacy benefit

Skyrizi^® SC (risankizumab-rzaa), HCPCS code J3590, isn’t covered under members’ medical benefits. Subcutaneous injections are self-administered and covered under members’ pharmacy benefits.

Some Blue Cross commercial groups not subject to these requirements

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

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

List of requirements

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

You can access this list and other information about requesting prior authorization on 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.