Reminder: Private duty nursing services will require prior authorization

As previously communicated, Blue Cross Blue Shield of Michigan is expanding its health care provider network to include private duty nursing agencies — and agencies will need to get prior authorization before providing services to our members.

Private duty nursing services will require prior authorization for dates of service on or after Oct. 1, 2022. We’ll begin accepting prior authorization requests for these services through the e-referral system on Sept.  1.

Accessing the e-referral system

Here are instructions for accessing the system:

1. Log in to our provider portal (availity.com).
2. Click on Payer Spaces and then on the BCBSM and BCN logo.
3. Scroll down and click on the e-referral tile on the Applications tab.

Submitting claims and prior authorization requests

Here’s what you need to know about submitting claims and prior authorization requests:

• Enrolled private duty nursing agencies can electronically bill claims for dates of service on or after Oct. 1, 2022. For dates of service prior to Oct. 1, claims should be manually submitted by the member. Submit claims as soon as possible.
• For billing and authorization requests, agencies should use HCPCS code S9123 for registered nurses or S9124 for licensed practical nurses.
• Indicate total hours as units (one unit = one hour). Partial units aren’t accepted.

Note: Only the agency on the authorization will be approved for payment. 

• Only one authorization can be in place for a certain time period. On occasions when more than one agency is providing services to a member, only the primary agency will be able to seek authorization and submit a claim for services. The primary agency will need to coordinate the schedule and reimburse the partner agencies for their services.

Additional information

• On July 15, 2022, Blue Cross opened the Traditional and TRUST PPO (commercial) network to private duty nursing agencies for enrollment. As a Blue Cross provider:
• You’ll be paid directly for approved services.
• You’ll have access to member eligibility information.
• Your contact information will be accessible to millions of our members.

• To obtain a full list of selection standards and a copy of the agreement, send an email to PDN@bcbsm.com. This email will only be valid through Sept. 30, 2022.

• Our dedicated provider training site gives you easy access to recorded webinars, videos, e-learning modules and other training resources. Click here for instructions to register and log in. We recommend using the same email you use to communicate with Blue Cross for provider-related needs. This will become your user ID.