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September 2022
Update: Crisis services provide support for members with urgent behavioral health concernsSince we last wrote about our crisis services, a new facility joined our program: Pine Rest, located in Grand Rapids. The following provides additional details about all the facilities and other pertinent information. As you read in this newsletter previously, Blue Cross Blue Shield of Michigan and Blue Care Network recently launched new mobile crisis and crisis stabilization services to help members experiencing a mental health or substance use crisis get prompt and appropriate behavioral health treatment. The program is for our commercial members who are under age 65. Care options include:
These services are designed to ensure that members get the right care at the right time, in the right place. It can help them avoid emergency room visits for mental health concerns and substance use disorder, as well as unnecessary hospitalizations. About these services Psychiatric urgent care: Emergency and urgent walk-in and virtual service to address immediate assessment and treatment needs for patients who can’t wait for routine outpatient treatment and care Mobile crisis assessment: Emergency mobile mental health assessment Crisis stabilization: 24/7 recovery-oriented crisis center that offers emergency assessment, intervention and stabilization for urgent and emergent situations. Residential crisis treatment: Designed for short-term residential crisis treatment for adults ready to participate in recovery. Participating facilities The following facilities currently participate in the program, and may offer some or all these services: Common Ground Resources and Crisis Center
Hegira Health’s COPE (Community Outreach for Psychiatric Emergencies)
Pine Rest
Additional facilities will be added to the program in the near future. How to access these services Blue Cross or BCN members, health care providers and other individuals can contact these facilities by phone. They also accept walk-ins. Members who need help getting started can call the Mental Health and Substance Abuse number on the back of their member ID card. “The beauty of these services is they can meet the member where they are and be accessed any way you need to access them,” said Dr. William Beecroft, medical director of behavioral health for Blue Cross. Additional value Here are some additional benefits of mobile crisis and crisis stabilization services — all designed to provide a better member experience:
“These services help ensure our members get treated at the right place at the right time and that they’re linked to the appropriate level of care and available community resources,” Beecroft said. “However, as part of the evaluation and treatment process, some members may still require psychiatric hospitalization as part of their treatment plan.” New 988 crisis line: Another option In addition to contacting one of the facilities listed above or calling the number on the back of your member ID card, you can also call or text 988 if you or a loved one is struggling with a mental health or substance use crisis. The number is an easier-to-remember way to connect with the National Suicide Prevention Lifeline.
Announcing next phase of Provider Secured Services and web-DENIS retirement
The last day to use these applications on Blue Cross and BCN’s Provider Secured Services is Sept. 14, 2022. 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 in our new provider portal (availity.com**). You’re encouraged to learn about and use our new portal. However, Provider Secured Services will be available for a limited time. For help getting started with Availity Essentials, see the “Resources” section at the end of this article. Watch for information on ‘final’ retirement Read our provider alerts within Availity® 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’s how to find provider alerts within availity.com.**
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. Additional information for Internet Claims Submission Tool users If you currently use the Internet Claims Submission Tool, it’s important for you to know that the last day to use it is Sept. 14. If you need to keep lists and reports from the Internet Claims Submission Tool, you should obtain these before Sept. 14. Instructions for printing and downloading lists and reports are in the Knowledge Center. Here’s how to find them while in your Internet Claims Submission Tool dashboard:
Availity offers two options for providers who need a direct data entry claims submission tool:
Learn more about the Availity claims submission tool by viewing the DDE (direct data entry) claim submission for BCBSM providers webinar recording on the Availity Get Up to Speed with Training webpage.** Resources
**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.
We’ve enhanced Benefit Explainer to include new payability limitationBenefit Explainer users may have started seeing a new payability limitation regarding the National Provider Identifier, beginning Aug. 1, 2022. We first alerted users to the change in an Aug. 1 provider alert. The National Provider Identifier, available under the Medical/Payment Policy and Benefit Package Report tabs in Benefit Explainer, is a government ID issued to medical professionals and businesses. Assigned and managed through the National Plan and Provider Enumeration System, this 10-digit numeric number is used to verify valid values. The new limitation can appear as a stand-alone rule or as a combination rule with another limitation. It can appear in any of the following fields:
See screenshots below for examples of how the NPI may appear as a standalone rule or as a combination rule with a primary diagnosis.
When a user clicks on the link in the National Provider Identifier, Benefit Explainer will open a new tab. In the new tab, the user can view the specific National Provider Identifier code, as follows:
Note: Screenshots are provided for illustrative purposes only and may not represent actual data.
Fiscal year 2023 ICD-10-CM and PCS code updates now availableThe fiscal year 2023 ICD-10-CM and ICD-10-PCS code updates, which will be effective with dates of service on and after Oct. 1, 2022, are available on the Centers for Medicare & Medicaid Services’ website. This year’s updates include 1,842 new CM and PCS (diagnosis and inpatient procedure) codes, 35 CM and PCS code revisions, and 352 CM and PCS deletions. To view the code updates, visit the CMS website.** **Blue Cross Blue Shield of Michigan doesn’t own or control this website.
2023 early release CPT vaccine code addedMedicine vaccinesToxoids 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 changesYou’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:
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.
More Medicare Advantage members to become eligible for Landmark Health’s in-home care programStarting Jan. 1, 2023, Blue Cross Blue Shield of Michigan and Blue Care Network will expand the high-intensity, in-home care program provided by Landmark Health to include Medicare Advantage members with multiple chronic conditions who reside in any county in Michigan’s Lower Peninsula. For general information about the program, see this provider alert. For detailed information about the program, see the document titled High-intensity in-home care program: Frequently asked questions for providers. Landmark Health, L.L.C., is an independent company that provides select services for Blue Cross Blue Shield of Michigan and Blue Care Network members who have Medicare Advantage plans.
Medicare Advantage members with open gaps in care to receive in-home test kitsBlue Cross Blue Shield of Michigan and Blue Care Network are contracting with Everlywell, an independent company, to distribute in-home test kits to select Medicare Advantage members in September. Everlywell was previously named Home Access Health. If your patients receive an advance notice letter about the kits and have questions, encourage them to take advantage of this convenient, no-cost testing. Members who have an open gap in care for a colorectal cancer screening will receive a FIT™ kit, which allows them to screen for colorectal cancer at home. If a member also has an open gap in care for hemoglobin A1c, or HbA1c, testing, they will receive an HbA1c test kit. Members are encouraged to discuss test results with their primary care providers. In 2023, providers will be able to access their patient results in Everlywell’s portal. Test result notification:
New lab program for Blue Cross commercial and Medicare Plus Blue now liveAs previously communicated in the March, June and July issues of The Record, Blue Cross Blue Shield of Michigan has instituted a laboratory benefits management program supported by Avalon Healthcare Solutions, an independent company. This program uses enhanced editing to promote correct coding and assist with accurate claim payment. While the program’s original implementation date was delayed, you may have started receiving edits for laboratory services received in August for dates of service on or after June 1, 2022. Place of service exclusion Outpatient Blue Cross commercial and Medicare Plus Blue℠ claims won’t be subject to laboratory editing until further notice. What you need to know about appeals Should an edit occur on a claim, Blue Cross will continue to allow for an appeal submission using availity.com** or the Clinical Editing Appeal Form through fax or mail. Before you submit an appeal, we encourage you to review the Routine Laboratory Testing Policies, clinical documentation and claim information to determine whether a reconsideration or appeal is needed. Reconsideration can be used when updating ICD-10 codes and modifiers. To access the Blue Cross Blue Shield of Michigan Routine Laboratory Testing Policies, click here. If there are no updates to be made using a corrected claim for reconsideration, an appeal can be submitted when review of the clinical documentation will support payment using the policy criteria of the denied code. When submitting an appeal Include the clinical documentation to support the laboratory test. An appeal received with only the lab order and results won’t contain the necessary information for a proper review. Clinical documentation from the ordering health care provider is necessary and should be included with the appeal. Blue Cross won’t contact the ordering provider for this information. New tool The Trial Claim Advice Tool can assist providers by inputting codes for services, along with patients’ diagnoses, to determine possible edits in advance of submitting a new claim or reconsideration. To access the tool, follow these steps:
Note: Medicare NCDs and LCDs will supersede Avalon policies when applicable. On-demand training available To learn more about the program, view the Avalon Laboratory Services Overview under Claims or by entering Avalon in the search box on our provider training website. To request access to the provider training site, complete the following steps:
**Blue Cross Blue Shield of Michigan doesn’t own or control this website.
Some SecureCare clinical performance reports to be available later than expectedWhile the SecureCare® network performance management program went into effect on July 5, 2022, for Blue Cross Blue Shield of Michigan commercial and Medicare Plus Blue℠, the reports for some providers whose clinical performance is managed under this program will be available later than expected. SecureCare is an independent network performance management company that manages select services for Blue Cross. The providers whose reports won’t be immediately available are:
SecureCare decided to delay making the clinical performance reports for these providers available until the reports could be reformatted to:
SecureCare expects that the reformatted reports will provide more actionable and useful data for these providers. SecureCare to contact providers When the reformatted clinical performance reports are ready for viewing, SecureCare will distribute welcome packets to the affected providers and schedule a town hall meeting for those providers. SecureCare won’t reach out to providers until the reformatted clinical performance reports are available. Additional information You can find more information about SecureCare and its network performance management program by checking out the following resources:
All contracting, credentialing, eligibility, benefits, member services and claims processing will remain with Blue Cross. **Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.
We’ve made some questionnaire changes in e-referral systemIn July and August, we added, updated and removed questionnaires in the e-referral system. We also added, updated and removed 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 authorization requests. New questionnaire We added a Medicare implantable ambulatory event monitors questionnaire for pediatric and adult Medicare Plus Blue℠ and BCN Advantage℠ members. This questionnaire opens for procedure code *33285. Updated questionnaires We updated the following questionnaires:
Removed questionnaires We removed the questionnaires below, which currently open for procedure code *64568. These questionnaires will no longer open for any members, as this procedure code no longer requires prior authorization.
Accessing preview questionnaires, authorization criteria and medical policies You can access the preview questionnaires, authorization criteria and medical policies on the following pages of the ereferrals.bcbsm.com website:
Additional drugs to have requirements for URMBT members with Blue Cross non-Medicare plansFor dates of service on or after Nov. 1, 2022, the following drugs will require prior authorization through either the NovoLogix® online tool or AIM Specialty Health® and may also have site-of-care requirements, quantity limit requirements or both. These requirements will apply to UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans. The drugs are part of members’ medical benefits, not their pharmacy benefits. See the table for more information. When a cell is blank, the drug doesn’t have that requirement.
Note: These requirements don’t apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714). How to submit authorization requests Submit prior authorization requests through NovoLogix or AIM, as specified above. If you have access to our provider portal (availity.com**), log in to Availity®, click Payer Spaces and then click the BCBSM and BCN logo. This will take you to the Blue Cross and BCN payer space, where you can click the appropriate tile on the Applications tab. If you need to request access to Availity, follow the instructions on the Register for webtools webpage at bcbsm.com/providers. 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:
We’ll update the pertinent drug lists to reflect the information in this message prior to the effective date. Note: Accredo manages prior authorization requests for additional medical benefit drugs for these members. 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.
Payment policy for radiofrequency and laser treatment of varicose veins aligns with medical policyIn support of correct coding and payment accuracy, Blue Cross Blue Shield of Michigan’s payment policy for radiofrequency and laser treatment of varicose veins aligns with our medical policy. Our medical policy allows a lifetime limit of two per left leg and two per right leg for radiofrequency or laser treatment of varicose veins. In addition, the appropriate modifier must be appended to the procedure code billed to indicate which side of the body the service was performed on (e.g., LT, RT, 50). Claims submitted with CPT codes *36475 and *36478 will be evaluated to ensure that they don’t exceed the established limit and that they include the appropriate modifier. Claims that don’t meet the criteria may receive a denial. Also, keep in mind that if the related add-on codes are submitted without the required base codes, they’ll receive a denial. Following are the code descriptions and other information that coincide with the treatment and modifiers referenced in the policy: *36475 – Endovenous radiofrequency, first vein *36478 – Endovenous laser, first vein LT – left side
Training opportunities available to learn more about pharmacogenomicsAction item Consider taking advantage of educational opportunities to learn about pharmacogenomics, the study of how an individual’s genetic makeup affects how he or she responds to medications. As you’ve read in our provider publications previously, Blue Care Network is launching a new program, Blue Cross Personalized Medicine℠, to help physicians tailor the medication regimen of patients to their specific needs through pharmacogenomics, or PGx. BCN is currently testing the Blue Cross Personalized Medicine program with a limited number of eligible members. The full launch of a PGx program for all eligible BCN members will begin in January 2023. OneOme, an independent precision medicine company co-founded by the Mayo Clinic, has contracted with Blue Care Network to introduce this precision medicine program for eligible BCN members. The company is pleased to offer some educational opportunities for physicians, pharmacists and other clinicians who would like to learn more about pharmacogenomics. Training opportunities We encourage you to participate in the following educational opportunities if you’d like to learn more about pharmacogenomics. BCN Chief Medical Officer and Vice President of Strategy and Affordability Scott Betzelos, M.D., and OneOme Medical Director Julie England, M.D., will be panelists at the Orlando conference on Sept. 28. There is a cost to participate in these training opportunities.
If you’re unable to attend, visit oneome.com/bcbsm-webinar** to view previous educational webinars or for contact information to reach out to a member of OneOme’s clinical team. For more information You can read more about this program in these publications:
**Blue Care Network doesn’t own or control this website.
We’ve updated our e-learning videos on Medicare Star Ratings for 2022Action item Register for training on Medicare Star Ratings to receive continuing education credits. The Quality and Provider Education team has updated an important training resource for health care providers and staff. The 2022 CMS Star measures overview is now available on the provider training website. The video series discusses the importance of creating positive patient experiences as part of your efforts to close gaps in care. Topics include:
The video series has been approved for AMA PRA Category 1 Credit™. And we’ve made it even easier to earn continuing education credits this year. You can earn fractional credits for each of the five modules in the course, for a total of 2.25 credits. You don’t need to complete the entire course to earn credit. Provider training website Log in to the provider training website to access the modules. Look in the course catalog under “Quality management” or search for the lesson with the keyword “Star.” Don’t have access yet? To request access, follow these steps:
If you need assistance creating your login ID or navigating the site, contact ProviderTraining@bcbsm.com. HEDIS® is a registered trademark of the National Committee for Quality Assurance.
Lunch and learn webinars focus on risk adjustment, codingAction item Register now for webinars that can improve your coding processes. 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
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:
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.
New on-demand training availableAction item Check out our newest training opportunity and visit our provider training site Provider Experience continues to offer new training resources for health care providers and staff. Our on-demand courses are designed to help you work more efficiently with Blue Cross Blue Shield of Michigan and Blue Care Network. Here’s the newest learning opportunity:
Provider training site Our provider training site is available to enhance the training experience for health care providers and staff. To request access, follow these steps:
If you need assistance creating your login ID or navigating the site, email ProviderTraining@bcbsm.com.
Byooviz to be preferred ranibizumab drug for Medicare Advantage members, starting Oct. 4For dates of service on or after Oct. 4, 2022, for our Medicare Advantage (Medicare Plus Blue℠ and BCN Advantage℠) members, we’re designating preferred and nonpreferred ranibizumab products:
What’s changing? Providers will need to show they’ve tried Byooviz as a step therapy requirement before requesting authorization to use Lucentis. This change goes into effect for dates of service on or after Oct. 4, 2022. Both Byooviz and Lucentis will still require that the member first try and fail Avastin (bevacizumab), HCPCS code J3590 for Medicare Plus Blue and HCPCS code J9035 for BCN Advantage. Avastin doesn’t require prior authorization when used for retinal conditions. These drugs are covered under members’ medical benefits. Prior authorization still required Lucentis and Byooviz will continue to require prior authorization when administered in any site of care other than inpatient hospital (place of service code 21) and billed as follows:
Submitting prior authorization requests Submit prior authorization requests for Byooviz and Lucentis using the NovoLogix® online tool. It offers real-time status checks and immediate approvals for certain medications. If you have access to the AvailityEssentials 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 on 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 still have Avastin as a step therapy requirement. These are:
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'll update the list to reflect these changes prior to the effective date. **Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.
Here’s what you need to know about billing and requesting prior authorization for denosumabPart B specialty drugs Prolia® and Xgeva® have the same generic name (denosumab) and HCPCS code (J0897). Both drugs require authorization for Medicare Plus Blue℠ and BCN Advantage℠ members when administered by a health care provider in outpatient facilities or physicians’ offices. Here’s some important information about billing and requesting prior authorization for denosumab drugs. Include the NDC when billing for these drugs To ensure appropriate and timely reimbursement of claims, be sure to enter the following National Drug Code numbers along with HCPCS code J0897:
We can reimburse claims submitted for these drugs more quickly when you:
Submitting prior authorization requests To submit prior authorization requests for these drugs, log in to our provider portal (availity.com**). Click on Payer Spaces and then on the Blue Cross and BCN logo. On the Applications tab, do the following:
Reminders:
**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.
3 additional medications require prior authorization for Medicare Advantage membersFor dates of service on or after Aug. 8, 2022, the following drugs require prior authorization for Medicare Plus Blue℠ and BCN Advantage℠ members:
Submit prior authorization requests through the NovoLogix® online tool. These drugs are part of members’ medical benefits, not their pharmacy benefits. When prior authorization is required These medications require prior authorization when they’re administered by a health care provider in sites of care such as outpatient facilities or physicians’ offices and are billed in one of the following ways:
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. 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. **Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.
Importance of statin therapy for patients with cardiovascular disease, diabetesCardiovascular disease is the leading cause of death in the United States. It’s estimated that 92.1 million American adults have one or more types of cardiovascular disease.** People with diabetes also have elevated cardiovascular risk, thought to be due, in part, to elevations in unhealthy cholesterol levels. Having unhealthy cholesterol levels places people at significant risk for developing atherosclerotic cardiovascular disease, or ASCVD. American College of Cardiology and American Heart Association guidelines state that statins of moderate or high intensity are recommended for adults with established clinical ASCVD. American Diabetes Association and AHA guidelines also recommend statins for prevention of cardiovascular disease in patients with diabetes, based on age and other risk factors. Furthermore, guidelines state that adherence to statins will aid in ASCVD risk reduction in both populations (individuals with ASCVD and those with diabetes). Tip sheets The Centers for Medicare & Medicaid Services has two Medicare Star Ratings measures to support statin therapy’s importance. To learn more about these measures, read these tip sheets: Statin Therapy for Patients with Cardiovascular Disease (SPC) **Source: Statin Therapy for Patients With Cardiovascular Disease and Diabetes - NCQA (Blue Cross Blue Shield of Michigan doesn't own or control this website.)
Remind your eligible patients to get regular mammogramsIn the United States, 1 in 8 women will be diagnosed with invasive breast cancer in her lifetime, making it the second most common cancer in women, according to the American Cancer Society. Early detection is key to better outcomes for your patients — and you can play an integral role in helping ensure good outcomes by recommending regular screenings. The Breast Cancer Screening (BCS) HEDIS® measure (also a Medicare Star Ratings measure) assesses female patients ages 50 to 74 who had a mammogram to screen for breast cancer in the past two years. The National Committee for Quality Assurance now allows patients to be excluded from the measure due to advanced illness and frailty. NCQA acknowledges that breast cancer screening most likely wouldn’t benefit patients who are in declining health. Read the tip sheet to learn more about this measure, information to include in medical records, codes to include on patient claims to exclude for mastectomy and tips for 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.
Here are some resources to help patients manage chronic conditionsThis is part of an ongoing series of articles focusing on the tools and resources available to help FEP members manage their health. When patients can manage their chronic conditions, there’s a good chance emergency department visits, hospital admissions or hospital readmissions can be avoided. However, as you know, flare-ups sometimes occur and may require hospital services. By seeing your patients within seven days after a hospital discharge, chances of future emergency department visits, hospital admissions or hospital readmissions can be reduced. Here are some helpful resources to share with patients:
Federal Employee Program® members have additional support programs, incentives and health tools to help manage their chronic conditions. For more information on FEP programs or benefits, visit fepblue.org or call Customer Service at 1-800-482-3600. **Blue Cross Blue Shield of Michigan doesn’t own or control this website.
Reminder: Only certain modifiers payable for services provided in OPC facilities for Blue Cross commercial membersWhen billing for services provided in an outpatient psychiatric care facility, include the appropriate modifier to identify the licensure level of the servicing provider. Only the following modifiers should be reported on the claim when billing for services provided to Blue Cross Blue Shield of Michigan commercial members in OPC facilities:
For telemedicine visits that use both audio and visual technology, OPC facilities should include modifier GT or 95 on the claim. For more information, see the updated Requirements for providing behavioral health services to Blue Cross commercial members document. To view billing instructions for outpatient psychiatric care facilities, see the “Psychiatric Care Services” chapter of the Blue Cross commercial provider manual.
Reminder: Private duty nursing services will require prior authorizationAs 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:
Submitting claims and prior authorization requests Here’s what you need to know about submitting claims and prior authorization requests:
Note: Only the agency on the authorization will be approved for payment.
Additional information
Blue Cross AIC and HIT professional providers may see new rejection code when medical drug claims are incorrectly billedInstead of current rejection code P579, Ambulatory Infusion Center and Home Infusion Therapy professional providers who participate with Blue Cross Blue Shield of Michigan may receive a new rejection code when a National Drug Code is billed for a drug not payable to their provider type and specialty. This change will begin in October and apply to commercial members. The following message and code will appear on your provider voucher: THIS SERVICE IS NOT PAID. THE CLAIM IS FOR A PRODUCT WHICH IS NOT PAYABLE BASED ON YOUR PROVIDER INDENTIFICATION NUMBER. UNLESS A BILLING ERROR WAS MADE, WE OWE NO PAYMENT FOR THIS SERVICE, NOR DOES YOUR PATIENT. (P669)
Radiology code *71271 no longer requires prior authorization for Blue Cross commercial membersHere’s important information you should know:
We’ve updated the document titled Procedures that require prior authorization by AIM Specialty Health: Cardiology, radiology (high technology) and sleep studies (in lab) to reflect this change. As a reminder, the prior authorization requirement for this code for Medicare Plus Blue℠, Blue Care Network commercial and BCN Advantage℠ members was previously removed. AIM Specialty Health is an independent company that makes authorization determinations for select high-tech imaging services and other services performed in freestanding facilities, outpatient hospital settings, ambulatory surgery centers and physician offices. For additional information about submitting prior authorization requests to AIM, visit these webpages on ereferrals.bcbsm.com:
Submit requests for commercial inpatient rehabilitation admissions and extensions only through e-referralWhat you need to know Starting in January, we'll stop accepting faxed commercial inpatient rehabilitation requests as a general practice. We'll accept faxes only for urgent requests when the e-referral system isn’t available. For more details, see the “What’s changing” section of the article below. Beginning Jan. 1, 2023, we’ll require inpatient rehabilitation, or 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:
Currently, many inpatient rehabilitation providers are using 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:
If we receive a faxed form for an IPR 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. e-referral training In October, we’ll schedule webinars for IPR providers so they can learn how to use the e-referral system. Watch for upcoming communications about these webinars. Sign up for e-referral system
How to access the e-referral system Access the e-referral system through our provider portal by following these steps:
You’ll first need to register for access to our portal if you haven’t already done that. Refer to the Register for web tools webpage for instructions on how to:
Submit Medicare Advantage requests to naviHealth naviHealth manages prior authorization requests for post-acute care admissions for our Medicare Plus Blue℠ and BCN Advantage℠ members. **Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website. naviHealth is an independent company that manages authorizations for post-acute care services for Blue Cross Blue Shield of Michigan and Blue Care Network members who have Medicare Advantage plans.
Use updated forms for post-acute care prior authorization requests for commercial membersProviders should use our updated and aligned forms when submitting prior authorization requests for post-acute care for Blue Cross Blue Shield of Michigan and Blue Care Network commercial members. Among other changes, we combined the Blue Cross and BCN forms, which were previously separate, so providers can now use the same form to submit post-acute care requests for both Blue Cross and BCN commercial members. Follow the instructions on each form for completing and submitting it:
In July, we posted the forms in the following locations:
In addition to combining the Blue Cross and BCN forms, we updated the forms to make them easier to submit:
**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.
New lab program for Blue Cross commercial and Medicare Plus Blue now liveAs previously communicated in the March, June and July issues of The Record, Blue Cross Blue Shield of Michigan has instituted a laboratory benefits management program supported by Avalon Healthcare Solutions, an independent company. This program uses enhanced editing to promote correct coding and assist with accurate claim payment. While the program’s original implementation date was delayed, you may have started receiving edits for laboratory services received in August for dates of service on or after June 1, 2022. Place of service exclusion Outpatient Blue Cross commercial and Medicare Plus Blue℠ claims won’t be subject to laboratory editing until further notice. What you need to know about appeals Should an edit occur on a claim, Blue Cross will continue to allow for an appeal submission using availity.com** or the Clinical Editing Appeal Form through fax or mail. Before you submit an appeal, we encourage you to review the Routine Laboratory Testing Policies, clinical documentation and claim information to determine whether a reconsideration or appeal is needed. Reconsideration can be used when updating ICD-10 codes and modifiers. To access the Blue Cross Blue Shield of Michigan Routine Laboratory Testing Policies, click here. If there are no updates to be made using a corrected claim for reconsideration, an appeal can be submitted when review of the clinical documentation will support payment using the policy criteria of the denied code. When submitting an appeal Include the clinical documentation to support the laboratory test. An appeal received with only the lab order and results won’t contain the necessary information for a proper review. Clinical documentation from the ordering health care provider is necessary and should be included with the appeal. Blue Cross won’t contact the ordering provider for this information. New tool The Trial Claim Advice Tool can assist providers by inputting codes for services, along with patients’ diagnoses, to determine possible edits in advance of submitting a new claim or reconsideration. To access the tool, follow these steps:
Note: Medicare NCDs and LCDs will supersede Avalon policies when applicable. On-demand training available To learn more about the program, view the Avalon Laboratory Services Overview under Claims or by entering Avalon in the search box on our provider training website. To request access to the provider training site, complete the following steps:
**Blue Cross Blue Shield of Michigan doesn’t own or control this website.
Some SecureCare clinical performance reports to be available later than expectedWhile the SecureCare® network performance management program went into effect on July 5, 2022, for Blue Cross Blue Shield of Michigan commercial and Medicare Plus Blue℠, the reports for some providers whose clinical performance is managed under this program will be available later than expected. SecureCare is an independent network performance management company that manages select services for Blue Cross. The providers whose reports won’t be immediately available are:
SecureCare decided to delay making the clinical performance reports for these providers available until the reports could be reformatted to:
SecureCare expects that the reformatted reports will provide more actionable and useful data for these providers. SecureCare to contact providers When the reformatted clinical performance reports are ready for viewing, SecureCare will distribute welcome packets to the affected providers and schedule a town hall meeting for those providers. SecureCare won’t reach out to providers until the reformatted clinical performance reports are available. Additional information You can find more information about SecureCare and its network performance management program by checking out the following resources:
All contracting, credentialing, eligibility, benefits, member services and claims processing will remain with Blue Cross. **Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.
Additional drugs to have requirements for URMBT members with Blue Cross non-Medicare plansFor dates of service on or after Nov. 1, 2022, the following drugs will require prior authorization through either the NovoLogix® online tool or AIM Specialty Health® and may also have site-of-care requirements, quantity limit requirements or both. These requirements will apply to UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans. The drugs are part of members’ medical benefits, not their pharmacy benefits. See the table for more information. When a cell is blank, the drug doesn’t have that requirement.
Note: These requirements don’t apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714). How to submit authorization requests Submit prior authorization requests through NovoLogix or AIM, as specified above. If you have access to our provider portal (availity.com**), log in to Availity®, click Payer Spaces and then click the BCBSM and BCN logo. This will take you to the Blue Cross and BCN payer space, where you can click the appropriate tile on the Applications tab. If you need to request access to Availity, follow the instructions on the Register for webtools webpage at bcbsm.com/providers. 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:
We’ll update the pertinent drug lists to reflect the information in this message prior to the effective date. Note: Accredo manages prior authorization requests for additional medical benefit drugs for these members. 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.
Payment policy for radiofrequency and laser treatment of varicose veins aligns with medical policyIn support of correct coding and payment accuracy, Blue Cross Blue Shield of Michigan’s payment policy for radiofrequency and laser treatment of varicose veins aligns with our medical policy. Our medical policy allows a lifetime limit of two per left leg and two per right leg for radiofrequency or laser treatment of varicose veins. In addition, the appropriate modifier must be appended to the procedure code billed to indicate which side of the body the service was performed on (e.g., LT, RT, 50). Claims submitted with CPT codes *36475 and *36478 will be evaluated to ensure that they don’t exceed the established limit and that they include the appropriate modifier. Claims that don’t meet the criteria may receive a denial. Also, keep in mind that if the related add-on codes are submitted without the required base codes, they’ll receive a denial. Following are the code descriptions and other information that coincide with the treatment and modifiers referenced in the policy: *36475 – Endovenous radiofrequency, first vein *36478 – Endovenous laser, first vein LT – left side
Lunch and learn webinars focus on risk adjustment, codingAction item Register now for webinars that can improve your coding processes. 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
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:
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.
Byooviz to be preferred ranibizumab drug for Medicare Advantage members, starting Oct. 4For dates of service on or after Oct. 4, 2022, for our Medicare Advantage (Medicare Plus Blue℠ and BCN Advantage℠) members, we’re designating preferred and nonpreferred ranibizumab products:
What’s changing? Providers will need to show they’ve tried Byooviz as a step therapy requirement before requesting authorization to use Lucentis. This change goes into effect for dates of service on or after Oct. 4, 2022. Both Byooviz and Lucentis will still require that the member first try and fail Avastin (bevacizumab), HCPCS code J3590 for Medicare Plus Blue and HCPCS code J9035 for BCN Advantage. Avastin doesn’t require prior authorization when used for retinal conditions. These drugs are covered under members’ medical benefits. Prior authorization still required Lucentis and Byooviz will continue to require prior authorization when administered in any site of care other than inpatient hospital (place of service code 21) and billed as follows:
Submitting prior authorization requests Submit prior authorization requests for Byooviz and Lucentis using the NovoLogix® online tool. It offers real-time status checks and immediate approvals for certain medications. If you have access to the AvailityEssentials 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 on 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 still have Avastin as a step therapy requirement. These are:
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'll update the list to reflect these changes prior to the effective date. **Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.
Here’s what you need to know about billing and requesting prior authorization for denosumabPart B specialty drugs Prolia® and Xgeva® have the same generic name (denosumab) and HCPCS code (J0897). Both drugs require authorization for Medicare Plus Blue℠ and BCN Advantage℠ members when administered by a health care provider in outpatient facilities or physicians’ offices. Here’s some important information about billing and requesting prior authorization for denosumab drugs. Include the NDC when billing for these drugs To ensure appropriate and timely reimbursement of claims, be sure to enter the following National Drug Code numbers along with HCPCS code J0897:
We can reimburse claims submitted for these drugs more quickly when you:
Submitting prior authorization requests To submit prior authorization requests for these drugs, log in to our provider portal (availity.com**). Click on Payer Spaces and then on the Blue Cross and BCN logo. On the Applications tab, do the following:
Reminders:
**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.
3 additional medications require prior authorization for Medicare Advantage membersFor dates of service on or after Aug. 8, 2022, the following drugs require prior authorization for Medicare Plus Blue℠ and BCN Advantage℠ members:
Submit prior authorization requests through the NovoLogix® online tool. These drugs are part of members’ medical benefits, not their pharmacy benefits. When prior authorization is required These medications require prior authorization when they’re administered by a health care provider in sites of care such as outpatient facilities or physicians’ offices and are billed in one of the following ways:
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. 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. **Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.
Reminder: Only certain modifiers payable for services provided in OPC facilities for Blue Cross commercial membersWhen billing for services provided in an outpatient psychiatric care facility, include the appropriate modifier to identify the licensure level of the servicing provider. Only the following modifiers should be reported on the claim when billing for services provided to Blue Cross Blue Shield of Michigan commercial members in OPC facilities:
For telemedicine visits that use both audio and visual technology, OPC facilities should include modifier GT or 95 on the claim. For more information, see the updated Requirements for providing behavioral health services to Blue Cross commercial members document. To view billing instructions for outpatient psychiatric care facilities, see the “Psychiatric Care Services” chapter of the Blue Cross commercial provider manual.
Reminder: Private duty nursing services will require prior authorizationAs 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:
Submitting claims and prior authorization requests Here’s what you need to know about submitting claims and prior authorization requests:
Note: Only the agency on the authorization will be approved for payment.
Additional information
Radiology code *71271 no longer requires prior authorization for Blue Cross commercial membersHere’s important information you should know:
We’ve updated the document titled Procedures that require prior authorization by AIM Specialty Health: Cardiology, radiology (high technology) and sleep studies (in lab) to reflect this change. As a reminder, the prior authorization requirement for this code for Medicare Plus Blue℠, Blue Care Network commercial and BCN Advantage℠ members was previously removed. AIM Specialty Health is an independent company that makes authorization determinations for select high-tech imaging services and other services performed in freestanding facilities, outpatient hospital settings, ambulatory surgery centers and physician offices. For additional information about submitting prior authorization requests to AIM, visit these webpages on ereferrals.bcbsm.com: 
Additional drugs to have requirements for URMBT members with Blue Cross non-Medicare plansFor dates of service on or after Nov. 1, 2022, the following drugs will require prior authorization through either the NovoLogix® online tool or AIM Specialty Health® and may also have site-of-care requirements, quantity limit requirements or both. These requirements will apply to UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans. The drugs are part of members’ medical benefits, not their pharmacy benefits. See the table for more information. When a cell is blank, the drug doesn’t have that requirement.
Note: These requirements don’t apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714). How to submit authorization requests Submit prior authorization requests through NovoLogix or AIM, as specified above. If you have access to our provider portal (availity.com**), log in to Availity®, click Payer Spaces and then click the BCBSM and BCN logo. This will take you to the Blue Cross and BCN payer space, where you can click the appropriate tile on the Applications tab. If you need to request access to Availity, follow the instructions on the Register for webtools webpage at bcbsm.com/providers. 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:
We’ll update the pertinent drug lists to reflect the information in this message prior to the effective date. Note: Accredo manages prior authorization requests for additional medical benefit drugs for these members. 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.
Training opportunities available to learn more about pharmacogenomicsAction item Consider taking advantage of educational opportunities to learn about pharmacogenomics, the study of how an individual’s genetic makeup affects how he or she responds to medications. As you’ve read in our provider publications previously, Blue Care Network is launching a new program, Blue Cross Personalized Medicine℠, to help physicians tailor the medication regimen of patients to their specific needs through pharmacogenomics, or PGx. BCN is currently testing the Blue Cross Personalized Medicine program with a limited number of eligible members. The full launch of a PGx program for all eligible BCN members will begin in January 2023. OneOme, an independent precision medicine company co-founded by the Mayo Clinic, has contracted with Blue Care Network to introduce this precision medicine program for eligible BCN members. The company is pleased to offer some educational opportunities for physicians, pharmacists and other clinicians who would like to learn more about pharmacogenomics. Training opportunities We encourage you to participate in the following educational opportunities if you’d like to learn more about pharmacogenomics. BCN Chief Medical Officer and Vice President of Strategy and Affordability Scott Betzelos, M.D., and OneOme Medical Director Julie England, M.D., will be panelists at the Orlando conference on Sept. 28. There is a cost to participate in these training opportunities.
If you’re unable to attend, visit oneome.com/bcbsm-webinar** to view previous educational webinars or for contact information to reach out to a member of OneOme’s clinical team. For more information You can read more about this program in these publications:
**Blue Care Network doesn’t own or control this website.
Byooviz to be preferred ranibizumab drug for Medicare Advantage members, starting Oct. 4For dates of service on or after Oct. 4, 2022, for our Medicare Advantage (Medicare Plus Blue℠ and BCN Advantage℠) members, we’re designating preferred and nonpreferred ranibizumab products:
What’s changing? Providers will need to show they’ve tried Byooviz as a step therapy requirement before requesting authorization to use Lucentis. This change goes into effect for dates of service on or after Oct. 4, 2022. Both Byooviz and Lucentis will still require that the member first try and fail Avastin (bevacizumab), HCPCS code J3590 for Medicare Plus Blue and HCPCS code J9035 for BCN Advantage. Avastin doesn’t require prior authorization when used for retinal conditions. These drugs are covered under members’ medical benefits. Prior authorization still required Lucentis and Byooviz will continue to require prior authorization when administered in any site of care other than inpatient hospital (place of service code 21) and billed as follows:
Submitting prior authorization requests Submit prior authorization requests for Byooviz and Lucentis using the NovoLogix® online tool. It offers real-time status checks and immediate approvals for certain medications. If you have access to the AvailityEssentials 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 on 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 still have Avastin as a step therapy requirement. These are:
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'll update the list to reflect these changes prior to the effective date. **Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.
Here’s what you need to know about billing and requesting prior authorization for denosumabPart B specialty drugs Prolia® and Xgeva® have the same generic name (denosumab) and HCPCS code (J0897). Both drugs require authorization for Medicare Plus Blue℠ and BCN Advantage℠ members when administered by a health care provider in outpatient facilities or physicians’ offices. Here’s some important information about billing and requesting prior authorization for denosumab drugs. Include the NDC when billing for these drugs To ensure appropriate and timely reimbursement of claims, be sure to enter the following National Drug Code numbers along with HCPCS code J0897:
We can reimburse claims submitted for these drugs more quickly when you:
Submitting prior authorization requests To submit prior authorization requests for these drugs, log in to our provider portal (availity.com**). Click on Payer Spaces and then on the Blue Cross and BCN logo. On the Applications tab, do the following:
Reminders:
**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.
3 additional medications require prior authorization for Medicare Advantage membersFor dates of service on or after Aug. 8, 2022, the following drugs require prior authorization for Medicare Plus Blue℠ and BCN Advantage℠ members:
Submit prior authorization requests through the NovoLogix® online tool. These drugs are part of members’ medical benefits, not their pharmacy benefits. When prior authorization is required These medications require prior authorization when they’re administered by a health care provider in sites of care such as outpatient facilities or physicians’ offices and are billed in one of the following ways:
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. 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. **Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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On Sept. 15, 2022, Blue Cross Blue Shield of Michigan and Blue Care Network will enter the second phase of retirement for Provider Secured Services and web-DENIS. It will include removal of the Internet Claims Submission Tool and some other applications.
