Blue Cross works with Quartet to connect behavioral health providers with members, starting July 1, 2023

Blue Cross Blue Shield of Michigan has contracted with Quartet, an independent company that offers an online care navigation solution. The company connects behavioral health providers with new patients through an online platform at no cost to the provider or patient.

We know that some of our members struggle to find the behavioral health care they need. Our relationship with Quartet is designed to help our members who are having difficulty obtaining timely care from a behavioral health specialist in their area access outpatient behavioral health services with an appropriate provider more quickly.

Starting July 1, 2023, Quartet will begin referring members seeking outpatient treatment to behavioral health providers registered on Quartet’s platform, based on their clinical specialty and their availability.

Quartet’s services will be available to the following adult members (18 years of age or older) who reside in Michigan:

• Fully insured Blue Cross commercial members
• Fully insured Blue Care Network commercial members
• All BCN Advantage℠ members
• Select Medicare Plus Blue℠ members

Through Quartet, a behavioral health provider can receive referrals, accept new patients, track the patient’s progress and access clinical assessments and other resources.

Joining the Quartet online platform

Beginning April 2023, Quartet will begin reaching out to Blue Cross and BCN participating behavioral health providers to assist them with joining the Quartet online platform. Participation is voluntary. We hope our behavioral health providers are encouraged to join and will see the value in this tool for both practitioners and patients.

Here’s how Quartet works

1. Quartet works with the provider to create a profile and get added to the platform.
2. Quartet matches members seeking outpatient behavioral health care to a provider based on their geographic location, treatment needs and preferences. Quartet can refer members to both in-person and virtual care.
3. Quartet sends a referral to the selected provider through the platform for a specific member.
4. The provider reviews and accepts or declines the referral.
5. When the provider accepts the referral, the provider contacts the member to schedule an appointment.

Please visit quartethealth.com/mental-health-providers** for more information, to schedule a demo or if you would like to sign up.

Quartet is an independent company contracted by Blue Cross Blue Shield of Michigan to connect Blue Cross and BCN members seeking outpatient behavioral health services with the appropriate behavioral health providers.

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

What to do when voluntary prior authorization ends May 1

The February 2023 issue of The Record announced the end of voluntary prior authorization requests in the article “Voluntary prior authorization ends May 1.”

If you have a procedure coming up for a Blue Cross Blue Shield of Michigan patient after May 1 and you’re not sure whether it will be covered or not, here are some steps you should take:

1. Check eligibility and benefits — First, make sure the patient’s coverage is in effect and the procedure is a covered benefit. You can do this within our provider portal at availity.com** by clicking on Eligibility and Benefits Inquiry. If additional details are available within Benefit Explainer, you’ll see a link to Benefit Explainer near the logo toward the top of the member’s benefits screen.
2. Check if prior authorization is required — Within our provider portal, click on Authorization Request in the Patient Registration drop-down menu. Complete the information for the specific patient and procedure. This application will tell you if a prior authorization is required and, if so, where to submit the request.
3. Check medical policy — Check for further coverage details within the medical policy. Go to Medical Policy Router Search and type in a keyword or procedure code to learn more about medical policy coverage.
4. Contact Provider Inquiry — If coverage of the procedure is still not clear, contact Provider Inquiry for assistance:
• Professional: 1-800-344-8525
• Facility: 1-800-249-5103

Some procedures require prior authorization

Blue Cross requires prior authorization for some procedures. You can determine whether a procedure requires prior authorization for a specific patient by using the Authorization Request application described in Step 2 above. You can also reference the following resources for a summary of prior authorization requirements:

• Summary of utilization management programs for Michigan providers
• PPO Provider Preauthorization and Precertification Requirements

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

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

Prior authorization changes coming in June

Michigan’s prior authorization law requirements** go into effect on June 1, 2023. These requirements apply to health care insurers and providers in Michigan for members who have commercial coverage.

These requirements aim to give members and health care providers a clearer understanding of the services that require prior authorization and of the prior authorization criteria for medical and pharmacy benefits.

The areas that will be affected are:

These requirements also apply to the third-party vendors with which Blue Cross and BCN have contracted to manage prior authorizations for certain services. We’re working with these vendors to ensure compliance with the law.

As we make changes, we’ll publish provider alerts and newsletter articles with additional information. For example, we announced in the February issue of The Record that voluntary prior authorization ends on May 1.

Be sure to check member eligibility and benefits through our provider portal (availity.com)** or Provider Inquiry prior to performing services.

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.

***A request for medical care or services is considered urgent when the time frame for making determinations for routine or non-life-threatening care would do one of the following:

1. Seriously jeopardize the life or health of the member or the member’s ability to regain maximum function, based on a layperson’s judgment.
2. Seriously jeopardize the life, health or safety of others, due to the member’s psychological state.
3. Subject the member to adverse health consequences without the care or treatment that is the subject of the request, in the opinion of a practitioner who has knowledge of the member’s medical or behavioral condition.

We’re updating COVID-19 provider communications in preparation for end of public health emergency

On Jan. 30, 2023, the federal government announced it will end the public health emergency on May 11.

Blue Cross Blue Shield of Michigan and Blue Care Network enacted temporary measures to support health care providers and protect members during the COVID-19 pandemic. We’ve been updating the Temporary changes due to the COVID-19 pandemic document as we determine which temporary changes become permanent and which will end.

We’ll continue to update the document as we make policy decisions.

As a reminder, here’s how you can view our COVID-19 provider communications:

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

You can also access these communications on our public website on the COVID-19 webpage for health care providers.

Continue to look for additional communications as we prepare for the end of the public health emergency.

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.

Here’s how to determine prior authorization requirements for patients with non-Michigan Blue plans

Michigan providers can find information about prior authorization requirements for patients with non-Michigan Blue plans as follows:

• Specific information may be available through Availity^®. See the “Specific information” section below for details.
• General information is available through our Medical Policy & Pre-Cert/Pre-Auth Router. See the “General information” section later in this article for details.

Specific information

Specific information about prior authorization requirements may be available through Availity.

1. Log in to our provider portal at availity.com.**
2. Click on Patient Registration and then click on Authorizations & Referrals.

3. Click on Authorization Request.

4. In the Select a Payer screen, make these selections:

5. Click on Next.
6. In the Select a Patient field, choose any patient.
7. In the Member ID field, enter the subscriber ID from the non-Michigan member’s ID card. Be sure to include the three-character alpha prefix.
8. Complete the fields in the Requesting Provider section and click Next.
9. Based on what you see on the screen, complete the rest of the steps.

General information

For general information about services that require authorization, go to our Medical Policy & Pre-Cert/Pre-Auth Router. To access the router:

1. Go to bcbsm.com/providers.
2. Click on Resources.
3. Click on the out-of-area router link.
4. Click on the General pre-certification/pre-authorization information option.
5. Enter the three-character alpha prefix from the non-Michigan member’s subscriber ID in the Prefix field.
6. Click on Go.

Additional information

You can also find this information in the Determining prior authorization requirements for a member document. That document also explains how:

• Michigan providers can look up requirements for patients who have coverage through Blue Cross Blue Shield of Michigan or Blue Care Network plans.
• Non-Michigan providers can look up requirements for patients who have coverage through Blue Cross Blue Shield of Michigan or Blue Care Network plans.

You can access this document by clicking on the Determine prior authorization requirements for members tile on the left side of any page of our ereferrals.bcbsm.com website.

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

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

2023 CPT code update: New and deleted codes

Pathology and laboratory

Category III codes
Surgery

Category III codes
Radiology

Category III codes
Other medical services

Category III codes
Physical therapy

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.

We'll publish information about new Blue Cross groups or changes to group benefits under the Group Benefit Changes heading.

For more detailed descriptions of the Blue Cross' policies for these procedures, check under the Commercial Policy tab in Benefit Explainer on Availity^®. To access this online information:

1. Log in to availity.com.
2 .Click on Payer Spaces on the Availity menu bar.
3. Click on the BCBSM and BCN logo.
4. Click on Benefit Explainer on the Applications tab.
5. Click on the Commercial Policy tab.
6. Click on Topic.
7. Under Topic Criteria, click on the circle for Unique Identifier and click the drop-down arrow next to Choose Identifier Type, then click on HCPCS Code.
8. Enter the procedure code.
9. Click on Finish.
10. 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.

Blue Cross changing practitioner fees July 1

Blue Cross Blue Shield of Michigan will change practitioner fees for services with dates of service on or after July 1, 2023. This change applies to services provided to our Traditional, TRUST and Blue Preferred Plus℠ members, regardless of the customer group.

Blue Cross will use the 2023 Medicare resource-based relative value scale for most relative value unit priced procedures for dates of service on and after July 1. Most fees are currently priced using the 2022 values.

The Blue Cross overall fee update includes base fee adjustments and value-based reimbursement. Due to significant changes in relative value unit valuations, it’s best to review the fee schedule to view the effect on an individual code or group of codes.

Fee schedules effective July 1 will be available on the Provider Resources site through our provider portal on Availity^®. To find the fee schedules:

1. Log in to availity.com.**
2. Click on Payer Spaces on the menu bar.
3. Click on the BCBSM and BCN logo.
4. Scroll down and then click on Secure Provider Resources (Blue Cross and BCN).
5. Click on the Fee Schedules drop-down menu and then click on Blue Cross Professional Fee Schedules.

Only claims submitted with dates of service on or after July 1 will be reimbursed at the new rates.

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 doesn’t own or control this website.

Blueprint allocation amount of 1.5% to go into effect July 1, 2023

Over the past 18 years, Blue Cross Blue Shield of Michigan has evolved our payment processes to incentivize value over volume. We maintain specific base rates while offering new revenue opportunities through increased incentive payments to health care providers who demonstrate success in delivering care and managing patient health on a population basis. While this pay-for-value approach has improved quality and slowed the rising cost trend, there’s still much work to be done to ensure we can deliver high-quality care that’s affordable for all.

In support of the transition from the fee-for-service model to value-based care, we’ll be introducing a 1.5% allocation from Blue Cross commercial (PPO) professional fees to fund Blueprint risk arrangements for our Blue Cross commercial providers, starting July 1, 2023. These risk arrangements will be partially offset by our annual professional fee schedule update that will also take place starting July 1. 

The 1.5% allocation will be allotted to the Blueprint reward pool and used to reward eligible Risk Bearing Contracted Entities, or RBCEs, for improving the quality of patient care, transforming systems and practices, and reducing costs. Funding the commercial Blueprint incentives through the professional fee schedule is part of the mechanism we use to leverage customer dollars for provider-based incentive programs. 

Physician claim payment vouchers will reflect this change starting July 1, 2023. The vouchers will show the Blueprint allocation amount of 1.5% of the allowed amount, which is based on the Blue Cross commercial applicable fee schedule.

Here are some additional details:

• All funds from the Blueprint pool, including the allocation and any downside risk payments contributed back to the pool, are distributed to RBCEs that meet targeted commercial performance. 
• If the entire pool isn’t paid out in a calendar year due to variability in performance, the funds will be retained in the pool for distribution in the following year. If funds do carry over, the 1.5% Blueprint allocation may decrease to account for the retained funds in the Blueprint pool. 
• No funds in the Blueprint pool will be retained by Blue Cross for administrative costs.

A frequently asked questions document about the Blueprint allocation has been sent to physician organizations and RBCEs for their reference.

AIM changed its name to Carelon

In March 2023, AIM Specialty Health^® changed its name to Carelon Medical Benefits Management.
The name change doesn’t affect how the company works with providers. For example:

• Carelon still manages authorizations for the services they managed before the name change.
• The company’s provider portal web address didn’t change and providers can access it:
• Through our provider portal (availity.com)**
• Directly at providerportal.com**
• The call center numbers are the same:
• Blue Cross Blue Shield of Michigan: 1-800-728-8008
• Blue Care Network: 1-844-377-1278
  A recorded message tells callers of the name change to Carelon Medical Benefits Management.

• Visitors to the AIM Clinical Guidelines** site and corporate webpage** are automatically redirected to a Carelon web address.
• Clinical decision letters and other communications have transitioned to display the Carelon Medical Benefits Management name and logo.

Note: This is a change only to the AIM Specialty Health name; there are no changes to the way providers submit prior authorization requests.

Carelon Medical Benefits Management (formerly known as 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.

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 doesn’t own or control this website.

Changes to Carelon’s (formerly AIM’s) provider portal for medical oncology program

On May 14, 2023, Carelon Medical Benefits Management (formerly known as AIM Specialty Health^®) will release enhancements to the provider portal for the medical oncology program. The goal of the enhancements is to make the process of submitting prior authorization requests easier.

Starting May 14, the look and functionality of the clinical intake screens will change. Among other changes, you’ll notice:

• An improved look and feel in the case entry screens
• That biomarker questions are no longer presented for clinical scenarios to which the questions don’t apply
• That changes to the drug dosing screens make it easier to enter cycle ranges and dates of administration

Register for a webinar to learn more

To learn more about the changes you’ll see when submitting prior authorization requests for medical oncology drugs, register for one of the following webinars, which will be hosted by Carelon. (All times are Eastern time.)

Additional information

If you have questions about Carelon’s provider portal or about submitting prior authorization requests for medical oncology drugs, email Carelon at MedicalOncologySolution@aimspecialtyhealth.com.

For more information about the medical oncology program, see the following pages of our ereferrals.bcbsm.com website:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

Carelon Medical Benefits Management is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage authorizations for select services.

Reminder: Double-check Blue Cross commercial members’ coverage for COVID-19 vaccines

Some Blue Cross Blue Shield of Michigan commercial members have group plans that are exempt from complying with Affordable Care Act requirements. During much of the public health emergency, we covered 100% of the costs for administering COVID-19 vaccines to these members.

Effective April 1, 2023, these members will revert to their pre-pandemic vaccine coverage, unless their group requested otherwise. As a result, they may have out-of-pocket costs or may not have vaccine coverage.

Health care providers should check each Blue Cross commercial member’s eligibility and benefits to determine whether COVID-19 vaccines are a covered benefit.

Notes:

• When the public health emergency ends May 12, all Blue Cross and BCN members will continue to have COVID-19 vaccine coverage with no out-of-pocket costs if they meet the following criteria:
• Their plans comply with ACA requirements.
• Their vaccines are administered by in-network providers or at in‑network pharmacies.
• When the government-purchased supply of the COVID-19 vaccines runs out, providers should bill the member’s health plan for both administration and the vaccine product. We’ll process claims based on members’ immunization benefits.

Here’s how to check member eligibility and benefits for vaccines:

1. Log in to our provider portal (availity.com).**
2. Click on Patient Registration in the menu bar, then click on Eligibility and Benefits Inquiry.
3. Enter the necessary information in the Payer section and the Provider Information section.
4. In the Service Information section, enter Immunizations in the Benefit / Service Type field.
5. Enter the patient ID in the Patient Information section.
6. Click on Search.
7. Select the tile for the appropriate member, and click on Submit.
8. Do one of the following:

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.

The Pediatric Place: Creating a centralized hub to facilitate information exchange

Gathering at the start of their workday are, from left, Dr. Nichole Ellis, Jenny Spahr, pediatric nurse practitioner; Cindy Norton, practice manager; Kathy Petersen, family nurse practitioner, and Katie Allwardt, care manager.

This is the first article in a series highlighting some top performers in the Patient-Centered Medical Home Designation Program.

When The Pediatric Place of Hillsdale built a new facility two-and-a-half years ago, they added an island at the center of the exam rooms that the staff calls the “central brain.”

This feature facilitates real-time collaboration and enables the health care team to get a handle on what’s going on with a variety of patients. For example, when the team noticed that many of their patients had the flu recently, they were able to notify the school district promptly.

Pediatric Place, a designated Patient-Centered Medical Home, joined the Collaborative Care Designation Program last year. A nurse from the practice was trained to become the care manager, a position that plays a central role in the collaborative care model.

“As part of our efforts to develop strong relationships with the patients, we thought it was important to have a community and staff member already known by the patients to serve as the care manager,” said practice owner Nichole Ellis, D.O., a medical director with Integrated Health Partners. “Since our nurse began handling care management duties, we’ve seen a significant improvement in patients we’re treating for anxiety and depression.”

To receive CoCM designation, a primary care practice must already have PCMH designation and meet Collaborative Care-specific capabilities. The Pediatric Place has been a PCMH provider for the past 10 years.

Dr. Ellis believes the program has helped improve the value of health care the practice delivers. “The PCMH interpretive guidelines provide a great outline for how to deliver high-quality care, and hold us accountable to ensure we have standardized, documented processes. I really appreciate the way the PCMH program is set up because it allowed us to slowly add more capabilities as we grew, allowing us to see the positive impact this additional support creates for patients.”

Following are a few of the processes that she believes have had the most positive effect on the practice overall:

• Follow-up after specialist referrals — The staff makes monthly calls to families when a child has been referred to a specialist to ensure that they’ve made an appointment and that it was scheduled in an appropriate time frame.
• Lab and test tracking — The staff calls families to make sure routine lab testing and other tests were done.
• Follow-up after emergency department visits — The staff follows up with families when their child has been to the emergency department to schedule a follow-up appointment.
• Patient education — The staff educates parents about when they might want to make an after-hours call to the provider, helping to avoid unnecessary emergency department visits. Much of the focus is on letting new moms know what type of symptoms warrant an after-hours call.

Cindy Norton, the office manager, has been employed at the practice for nearly 30 years and has served as the office manager for five years. She’s worked closely with the practice’s physician organization, IHP, to implement data registries and other tools to help identify patients who need follow up, and then contacts them to close any gaps in care.

“Consistency and persistence are key to making sure patients get the care they need,” Norton said. “We work hard to ensure that none of our patients fall through the cracks.”

If you’d like to learn more about becoming a PCMH-designated practice, talk with your physician organization or send an email to valuepartnerships@bcbsm.com.

Nonclinical, transitional care program available to Medicare Advantage members outside of Michigan

In 2021, we announced that Blue Cross Blue Shield of Michigan and Blue Care Network had contracted with naviHealth, an independent company, to reduce avoidable inpatient readmissions through a nonclinical, transitional care program.

In March 2023, this program became available to Medicare Plus Blue℠ and BCN Advantage℠ members outside of Michigan when they’re admitted to an acute care hospital and are then discharged to their homes.

This program is currently available to Medicare Plus Blue and BCN Advantage members who are discharged from inpatient acute care facilities in Michigan directly to their homes or to certain post-acute care facilities. To view the list of participating post-acute care facilities, see our Dec. 9 provider alert.

To learn more about the nonclinical, transitional care program, see the November 2021 Record article or the November-December 2021 BCN Provider News article.

2023 brings changes to Total Care Program

Beginning April 7, 2023, Blue Cross Blue Shield of Michigan will be removing Organized Systems of Care from the national Total Care Program as the OSC program no longer offers the incentives required to meet Total Care’s current value-based reimbursement structure.

Total Care is a national designation program that recognizes doctors and hospitals for their efforts in coordinating total patient care, emphasizing prevention and wellness, and helping patients better manage chronic conditions to improve patient outcomes and cost-efficiency. Total Care providers are paid with value-based reimbursement rather than traditional fee-for-service, so they perform against both quality and cost outcome targets to receive incentives and rewards for better health outcomes.

About Organized Systems of Care

An OSC is a community of caregivers that has responsibility for a specific patient population. Blue Cross’ OSC program was initially introduced as an expansion of our Patient-Centered Medical Home program.

If you have any questions about this change, contact Lindsey Novach of National Programs at LNovach@bcbsm.com.

Reminder: New radiology-focused initiative aims to improve quality of care and member outcomes coming soon

As a reminder, Blue Cross Blue Shield of Michigan and Blue Care Network have contracted with Covera Health to launch a radiology-focused quality improvement program to help us better support radiologists and referring providers in their efforts to improve diagnostic quality, overall care and patient outcomes.

This program will start in the second quarter of 2023 for:

• Commercial members who have coverage through fully insured groups or individual coverage
• All Medicare Advantage members

For details about the program, see the January issue of The Record or Page 22 of the January-February issue of BCN Provider News.

Note: We previously stated that this program would start in April 2023.

Covera Health is an independent company that supports Blue Cross Blue Shield of Michigan and Blue Care Network by providing programs to help improve the diagnostic quality, quality of care and member outcomes related to radiology.

Reminder: Health care providers must confirm data every 90 days and attest in CAQH every 120 days

Have you confirmed data within the past 90 days and attested in CAQH within the past 120 days? If health care providers don’t re-attest with CAQH every 120 days, they won’t be included in Blue Cross Blue Shield of Michigan provider directories. This includes our Find a Doctor search tool. That’s why it’s so important to perform this task.

Here are some other reasons to re-attest with CAQH:

• Ensure that your affiliation with Blue Cross isn’t interrupted.
• Keep your contact information up to date.
• Make sure that claims payment isn’t interrupted.

Regardless of whether providers are practicing at an office location or practicing exclusively in an inpatient hospital setting, they need to perform this attestation.

If you’re practicing exclusively in an inpatient hospital setting, you must indicate it on your CAQH application. This information is used to determine whether full credentialing is required.

CAQH is a nonprofit alliance of health plans and trade associations focused on simplifying health care administration. Blue Cross uses CAQH to gather and coordinate our practitioner credentialing information. All health care practitioners, including hospital-based providers, need to be registered with CAQH.

If you have questions about CAQH, call the help desk at 1-888-599-1771, or go to CAQH.org.**

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

Star measure tip sheets updated for 2023

We’ve updated our series of Star Measure Tips  for 2023 and posted them on Availity^®. These tip sheets have been developed to assist health care providers and their staff in their efforts to improve overall health care quality for their patients and prevent or control diseases and chronic conditions.

The new tip sheets are current as of this publication. However, when the National Committee for Quality Assurance, or NCQA, publishes final updates to the 2023 HEDIS^® specifications, we may need to update the tip sheets again. As updated versions are produced, we’ll post the new ones and announce them in The Record.  

The Star Measure Tips highlight select measures in the Medicare Star Ratings program. Most of the measures featured in the tip sheets are HEDIS measures. HEDIS is one of the most widely used performance improvement tools in the U.S.

Accessing the tip sheets

The Star Measure Tip Sheets are housed on the Secure Provider Resources section of Availity. You can get there by following these steps:

1. Log in to our provider portal at availity.com.**
2. Click on Payer Spaces on the Availity menu bar.
3. Click on the BCBSM and BCN logo
4. Click on Secure Provider Resources (Blue Cross and BCN) on the Member Care tab and choose Tip Sheets from the drop-down menu.

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

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

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

Lunch and learn webinars for physicians and coders focus on risk adjustment, coding and documentation

Beginning this month, we’re offering webinars with updated information on documentation and coding common, challenging diagnoses. These live, educational lunchtime sessions also include the opportunity to ask questions. 

Below is our current schedule and the tentative topics for the sessions. All sessions start at noon Eastern time and generally last for 30 minutes.

Click here if you are already registered for the provider training website. Look in the Event Calendar on the provider training website or use the search feature with the keyword “lunch” to locate all 2023 sessions. Check out the screenshots below to see how the search feature works.

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 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 regarding a session or website registration, email ProviderTraining@bcbsm.com.

Reminder: Register now for 2023 virtual provider symposium sessions

As you may have read in the March Record, this year’s virtual provider symposiums run throughout May and June. Physicians, physician assistants, nurse practitioners, nurses and coders can receive continuing education credits for attending. You’re invited to register for any session listed below.

Click here to log in to the provider training website and register for sessions. If you don’t already have access, you can easily create an account by clicking here. We recommend you use the same email address you use to communicate with Blue Cross Blue Shield of Michigan when creating the account.

Once you’re logged in to the provider training site, open the event calendar to sign up for any of these sessions.

Reach for the Stars-HEDIS^®/Star Measure Overview: For physicians and office staff responsible for closing gaps in care related to quality adult measures.

Patient Experience: For physicians and office staff responsible for creating positive patient experiences. Learn how to ensure your practice has the knowledge and tools needed to set and meet patients’ expectations.

Coding Complex Cases: For physicians, coders, billers and administrative staff

Questions?

Contact Ellen Kraft at ekraft@bcbsm.com if you have questions about the sessions. Contact the provider training team at ProviderTraining@bcbsm.com if you have questions about registration or using the provider training website.

HEDIS^® is a registered trademark of the National Committee for Quality Assurance.

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

CME statement: The Minnesota Medical Association designates this internet this internet live activity for a maximum of 4 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

We’ve updated our provider training site and changed the platform we use for webinars

Provider Experience has made a few enhancements to its provider training site and how we host our webinars.

Moving forward, we’ll use the Microsoft Teams webinar platform to host all sessions. Participants with a Teams account will see their Teams ID tracked whenever they join a session. If you don’t have a Teams account, use your full name and email address to sign in.

All webinar events are posted on the provider training website. You can register for sessions as soon as they’re available.

Use the search feature to quickly locate the sessions that work with your schedule. Often, a keyword is all that’s needed to locate the event. For example, a search using the keyword “lunch” will locate the 2023 Lunch and Learn events, as illustrated below.

After the search completes, click on the Events tab to see the full list of sessions.

Click on the event title to register.

Click here if you’re already registered for the provider training website.

Click here to register for the provider training website. We recommend registering under the email you use to communicate with Blue Cross Blue Shield of Michigan and Blue Care Network for other provider-related needs. This will become your login ID.

Resources 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.

The Michigan Quality Improvement Consortium has prenatal care** and routine preventive services for infants and children** guidelines to support health care providers. Here are some additional resources you can use to help educate patients:

• Prenatal care
• The March of Dimes provides information on prenatal care checkups,** their importance and what to expect.
• Pregnancy Care Every Step of the Way and Your Pregnancy To-Do List flyers are available for Federal Employee Program^® members.  

• Routine preventive well-child visits
• The Centers for Disease Control and Prevention offers multiple resources,** including a Milestone Checklist.**
• The Healthy Families Program provides tools and resources to help support a healthy lifestyle for FEP members with children of all ages.

FEP member incentives and programs

• The Pregnancy Care Incentive Program offers expectant Basic and Standard Option members 18 years and older support and rewards during pregnancy.
• Pregnant FEP members can receive a free blood pressure monitor every two years as part of their maternity benefits. Members can fill out this form and mail it to the address listed.
• FEP members who are pregnant or nursing can choose from a selection of breast pumps with milk storage bags. FEP members can call 1-800-411-2583 to order a kit.

If you or an FEP member has questions about FEP incentive programs, support services and benefits, call Customer Service at 1-800-482-3600 or go online to fepblue.org.

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

Keep your EDI Provider Authorization form updated

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

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

Update the form when you:

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

Review the form when you:

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

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

How to change your EDI setup:

To make changes to your EDI setup log in to the Trading Partner Agreement webpage.

Or follow the navigation steps to arrive at the TPA login page at bcbsm.com/providers/help/edi:

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

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

Ambulatory surgery facilities can submit application to join Blue High Performance Network

As we informed you in the November 2022 Record article “Submit application to join Blue High Performance Network,” Blue Cross Blue Shield of Michigan has opened applications to hospital systems, their physician partners and other types of health care providers for the Detroit-area Blue High Performance Network℠, or BlueHPN. Criteria and participation status will be effective, starting Jan. 1, 2024.

Blue Cross has updated the criteria for ambulatory surgery facilities to participate in the Detroit-area BlueHPN. We’ll select health care providers based the criteria outlined in the BlueHPN Request for Applications.

To be eligible for the network, ambulatory surgery facilities must:

• Be located in and provide services to Blue Cross members in Genesee, Macomb, Oakland, St. Clair, Washtenaw and Wayne counties
• Meet all Blue Cross credentialing and privileging standards, and be in good standing in the TRUST PPO or Traditional network, depending on the provider type
• Agree to achieve and maintain quality performance measures as illustrated in the Request for Applications
• Not be affiliated with a non-Blue High Performance Network hospital system

To receive a copy of the full criteria and application instructions for the BlueHPN, email BlueHPN@bcbsm.com.

We’re updating our ambulatory surgery facility incentive model for CQI participation

In mid-2023, Blue Cross Blue Shield of Michigan and Blue Care Network will make updates to the ambulatory surgery facilities Collaborative Quality Initiatives model. We’ll introduce additional incentives for ASFs that participate in more than one CQI, as well as a performance-based incentive.

We introduced these changes to the participating ASFs in March 2023 and plan to roll out a portion of the new incentives in June 2023. Details of these changes will be updated in the ASF CQI Program guide by June 2023. 

Background

In late 2020, Blue Cross introduced the first incentive model for ambulatory surgery facilities participating in our CQIs. This incentive, introduced as a 1% facility fee increase, supports ASF’s clinical data abstraction and reporting, as well as the development of a quality initiatives infrastructure to support CQI operations and implementation of quality initiatives interventions. Qualifying ASFs participating in either the Michigan Arthroplasty Registry CQI, known as MARCQI, or the Michigan Spine Surgery Improvement Collaborative, known as MSSIC, are eligible to receive this incentive.

Additional information

For more information, refer to our provider manual or reach out to your provider consultant. To access the provider manual through our provider portal:

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

ASFs that are interested in participating in the CQI program can email CQIprograms@bcbsm.com for additional details.

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 doesn’t own or control this website.

Unconscious bias training needed to be eligible for designation as Blue Distinction Center for Maternity Care

As you’ve read in previous articles in our provider publications, Blue Cross Blue Shield of Michigan is adding an unconscious bias education requirement as part of our local plan criteria for the Blue Distinction^® Centers for Maternity Care program. 

This aligns with the Blue Cross and Blue Shield Association’s efforts to support maternal health equity actions, as well as Blue Cross Blue Shield of Michigan’s commitment to developing a robust maternal health strategy. Our strategy is intended to enhance the experience of members seeking to build families, improve clinical outcomes for mothers and babies, and eliminate maternal health disparities. 

To be eligible for designation, with a Jan. 1, 2024, effective date, all physicians and certified nurse midwives (both hospital-based and those with hospital privileges) who deliver babies at the applicant facility must have completed unconscious bias education by June 1, 2023. If training is completed after June 1, the effective date of designation may be delayed.

The following providers are excluded from this requirement:

• Physicians and CNMs who aren’t currently practicing at the applicant facility at the time of the application’s submission (for example, those who have retired or left employment at the facility)
• Physician assistants, nurse practitioners and medical or surgical residents in training
• Emergency room physicians
• Locum tenens physicians and temporary CNMs
• Obstetric hospitalists and laborists

Applying facilities must attest to completion of an education program through a Blue Cross Blue Shield of Michigan survey that will be administered by email. If a provider fails to complete unconscious bias education, then the provider will be considered “not eligible” for BDC status. This will result in the denial or loss of designation as a Blue Distinction Center for Maternity Care.

Unconscious bias education completed within the past 12 months will be accepted as satisfying this requirement. The recommended free online courses listed below are available to those who have not yet completed their training.

• Culturally and Linguistically Appropriate Services (CLAS) in Maternal Health Care:
  thinkculturalhealth.hhs.gov/maternal-health-care/**
• Dignity in Pregnancy and Childbirth:
  diversityscience.org/perinatal-care-equity/**

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

Change Healthcare portal created to help providers import medical records

Change Healthcare now offers eligible providers access to an online portal that allows the secure upload of requested medical records for the EquiClaim retrospective audits. EquiClaim is an independent company that provides auditing support for Blue Cross Blue Shield of Michigan and Blue Care Network conducting medical claim audits for our members.

As of January 2023, the portal allows for the submission of medical records only. Change Healthcare is working to expand the ability to upload other types of documents, such as appeals. The portal is protected health information-friendly and HIPPA compliant. It allows users to securely submit medical records to Change Healthcare at no cost to them.

Change Healthcare has an agreement with copy service vendor MRO that excludes providers from using the portal if they’re already in a contract with MRO.

How to register for the portal

Register for portal access using this link:**

• Select Medical Attachments when prompted on the Product & Services Selection page. Untick the solution on the left side.
• You’ll receive a confirmation page once you fill out the facility information; wait 5 to 6 business days for completion. You’ll receive a follow-up email with more steps to set a password for your secure account.

Portal instructions

You can access the Change Healthcare Attachments Solution at attachments.changehealthcare.com/payment-integrity.**

1. Enter the email address registered to account.
2. Click on the link for Payment Integrity on the bottom right corner of the page or select Payment Integrity from the Menu heading in the top left corner of the screen.
3. Enter the Case ID for the documents you’ll be uploading.
• Case ID can be found on the Medical Records Request letter.
• Case ID will be 12 characters in length.
4. Click on Add Files to select with documents to upload.
5. Click on Submit.

Questions?

If you have questions or need technical assistance, call 1-866-943-9579, option 1, from 8 a.m. to 4:30 p.m. Eastern time, Monday through Thursday. Please have your Tax Identification Number ready to provide to your support team member.

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

Submit prior authorization requests for human organ transplants through e-referral, not fax, starting June 1

Beginning June 1, 2023, we’ll require providers located in Michigan to submit prior authorization requests for human organ transplant procedures through the e-referral system and not by fax.

This applies to requests for Blue Cross Blue Shield of Michigan commercial, Blue Care Network commercial and BCN Advantage℠ members having bone marrow and specified solid organ transplant procedures.

This change doesn’t apply to Medicare Plus Blue℠ members.

Also, it doesn’t include kidney transplant procedures except for Blue Cross and Blue Shield Federal Employee Program^® members, for whom kidney transplant procedures require prior authorization.

Currently, most providers are faxing these requests to us.

Notice for hospital transplant financial coordinators

To prepare for this change, hospital transplant financial coordinators must contact their Availity^® administrator so the administrator can:

• Give the coordinator access to our provider portal (availity.com).**
• Set up the e-referral tool within Availity for the coordinator.

We’ll contact each coordinator by email to help them determine who their Availity administrator is. In addition, we’ll schedule webinars in May so the coordinators can learn how to use the e-referral system.

We’ll notify the coordinators directly about registering for the webinars.

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.

AIM changed its name to Carelon

In March 2023, AIM Specialty Health^® changed its name to Carelon Medical Benefits Management.
The name change doesn’t affect how the company works with providers. For example:

• Carelon still manages authorizations for the services they managed before the name change.
• The company’s provider portal web address didn’t change and providers can access it:
• Through our provider portal (availity.com)**
• Directly at providerportal.com**
• The call center numbers are the same:
• Blue Cross Blue Shield of Michigan: 1-800-728-8008
• Blue Care Network: 1-844-377-1278
  A recorded message tells callers of the name change to Carelon Medical Benefits Management.

• Visitors to the AIM Clinical Guidelines** site and corporate webpage** are automatically redirected to a Carelon web address.
• Clinical decision letters and other communications have transitioned to display the Carelon Medical Benefits Management name and logo.

Note: This is a change only to the AIM Specialty Health name; there are no changes to the way providers submit prior authorization requests.

Carelon Medical Benefits Management (formerly known as 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.

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 doesn’t own or control this website.

Changes to Carelon’s (formerly AIM’s) provider portal for medical oncology program

On May 14, 2023, Carelon Medical Benefits Management (formerly known as AIM Specialty Health^®) will release enhancements to the provider portal for the medical oncology program. The goal of the enhancements is to make the process of submitting prior authorization requests easier.

Starting May 14, the look and functionality of the clinical intake screens will change. Among other changes, you’ll notice:

• An improved look and feel in the case entry screens
• That biomarker questions are no longer presented for clinical scenarios to which the questions don’t apply
• That changes to the drug dosing screens make it easier to enter cycle ranges and dates of administration

Register for a webinar to learn more

To learn more about the changes you’ll see when submitting prior authorization requests for medical oncology drugs, register for one of the following webinars, which will be hosted by Carelon. (All times are Eastern time.)

Additional information

If you have questions about Carelon’s provider portal or about submitting prior authorization requests for medical oncology drugs, email Carelon at MedicalOncologySolution@aimspecialtyhealth.com.

For more information about the medical oncology program, see the following pages of our ereferrals.bcbsm.com website:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

Carelon Medical Benefits Management is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage authorizations for select services.

Reminder: Double-check Blue Cross commercial members’ coverage for COVID-19 vaccines

Some Blue Cross Blue Shield of Michigan commercial members have group plans that are exempt from complying with Affordable Care Act requirements. During much of the public health emergency, we covered 100% of the costs for administering COVID-19 vaccines to these members.

Effective April 1, 2023, these members will revert to their pre-pandemic vaccine coverage, unless their group requested otherwise. As a result, they may have out-of-pocket costs or may not have vaccine coverage.

Health care providers should check each Blue Cross commercial member’s eligibility and benefits to determine whether COVID-19 vaccines are a covered benefit.

Notes:

• When the public health emergency ends May 12, all Blue Cross and BCN members will continue to have COVID-19 vaccine coverage with no out-of-pocket costs if they meet the following criteria:
• Their plans comply with ACA requirements.
• Their vaccines are administered by in-network providers or at in‑network pharmacies.
• When the government-purchased supply of the COVID-19 vaccines runs out, providers should bill the member’s health plan for both administration and the vaccine product. We’ll process claims based on members’ immunization benefits.

Here’s how to check member eligibility and benefits for vaccines:

1. Log in to our provider portal (availity.com).**
2. Click on Patient Registration in the menu bar, then click on Eligibility and Benefits Inquiry.
3. Enter the necessary information in the Payer section and the Provider Information section.
4. In the Service Information section, enter Immunizations in the Benefit / Service Type field.
5. Enter the patient ID in the Patient Information section.
6. Click on Search.
7. Select the tile for the appropriate member, and click on Submit.
8. Do one of the following:

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.

Nonclinical, transitional care program available to Medicare Advantage members outside of Michigan

In 2021, we announced that Blue Cross Blue Shield of Michigan and Blue Care Network had contracted with naviHealth, an independent company, to reduce avoidable inpatient readmissions through a nonclinical, transitional care program.

In March 2023, this program became available to Medicare Plus Blue℠ and BCN Advantage℠ members outside of Michigan when they’re admitted to an acute care hospital and are then discharged to their homes.

This program is currently available to Medicare Plus Blue and BCN Advantage members who are discharged from inpatient acute care facilities in Michigan directly to their homes or to certain post-acute care facilities. To view the list of participating post-acute care facilities, see our Dec. 9 provider alert.

To learn more about the nonclinical, transitional care program, see the November 2021 Record article or the November-December 2021 BCN Provider News article.

Reminder: New radiology-focused initiative aims to improve quality of care and member outcomes coming soon

As a reminder, Blue Cross Blue Shield of Michigan and Blue Care Network have contracted with Covera Health to launch a radiology-focused quality improvement program to help us better support radiologists and referring providers in their efforts to improve diagnostic quality, overall care and patient outcomes.

This program will start in the second quarter of 2023 for:

• Commercial members who have coverage through fully insured groups or individual coverage
• All Medicare Advantage members

For details about the program, see the January issue of The Record or Page 22 of the January-February issue of BCN Provider News.

Note: We previously stated that this program would start in April 2023.

Covera Health is an independent company that supports Blue Cross Blue Shield of Michigan and Blue Care Network by providing programs to help improve the diagnostic quality, quality of care and member outcomes related to radiology.

Lunch and learn webinars for physicians and coders focus on risk adjustment, coding and documentation

Beginning this month, we’re offering webinars with updated information on documentation and coding common, challenging diagnoses. These live, educational lunchtime sessions also include the opportunity to ask questions. 

Below is our current schedule and the tentative topics for the sessions. All sessions start at noon Eastern time and generally last for 30 minutes.

Click here if you are already registered for the provider training website. Look in the Event Calendar on the provider training website or use the search feature with the keyword “lunch” to locate all 2023 sessions. Check out the screenshots below to see how the search feature works.

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 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 regarding a session or website registration, email ProviderTraining@bcbsm.com.

We’ve updated our provider training site and changed the platform we use for webinars

Provider Experience has made a few enhancements to its provider training site and how we host our webinars.

Moving forward, we’ll use the Microsoft Teams webinar platform to host all sessions. Participants with a Teams account will see their Teams ID tracked whenever they join a session. If you don’t have a Teams account, use your full name and email address to sign in.

All webinar events are posted on the provider training website. You can register for sessions as soon as they’re available.

Use the search feature to quickly locate the sessions that work with your schedule. Often, a keyword is all that’s needed to locate the event. For example, a search using the keyword “lunch” will locate the 2023 Lunch and Learn events, as illustrated below.

After the search completes, click on the Events tab to see the full list of sessions.

Click on the event title to register.

Click here if you’re already registered for the provider training website.

Click here to register for the provider training website. We recommend registering under the email you use to communicate with Blue Cross Blue Shield of Michigan and Blue Care Network for other provider-related needs. This will become your login ID.

Keep your EDI Provider Authorization form updated

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

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

Update the form when you:

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

Review the form when you:

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

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

How to change your EDI setup:

To make changes to your EDI setup log in to the Trading Partner Agreement webpage.

Or follow the navigation steps to arrive at the TPA login page at bcbsm.com/providers/help/edi:

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

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