Update: We’re migrating Medicare Plus Blue membership to NASCO beginning in 2024

In the March and October issues of The Record, we let you know that Blue Cross Blue Shield of Michigan is updating its internal processes in preparation for moving its Medicare Plus Blue℠ membership to the NASCO operating system, beginning next year. This reminder article includes some additional information and updates, as well as an example of what the new voucher will look like.

The migration of Medicare Plus Blue membership to the NASCO, which will affect the look of the Medicare Plus Blue provider vouchers and member ID cards, will take place in phases. In January 2024, members of groups that are new to Medicare Plus Blue will be loaded to the operating system. Then, in January 2025, individual members and those in other select group plans will migrate to NASCO. In 2026, key and large group membership will migrate.

The new Medicare Plus Blue provider voucher will look similar to the current Blue Cross commercial vouchers but will include a new field that indicates the provider network and new columns to identify the tax ID and electronic funds transfer dates. The sequestration and withhold amounts will appear in the remittance advice section. Inpatient, acute or rehabilitation diagnosis-related group claims will be listed on a single line on the remittance. Outpatient claims will continue to be listed on the claim line level.

Here’s a look at what the top portion of the new voucher will look like:

Access our training site from our provider portal; new learning path available

Starting Dec. 1, our provider training site will be accessible from our provider portal, availity.com.**

To access the training site, follow these steps:

1. Log in to the provider portal
2. Click on Payer Spaces on the menu bar and then click on the BCBSM and BCN logo.
3. Under Applications, click on the Provider Training Site tile
4. Click on Submit on the Select an Organization page
5. Existing users who used the same email address as their provider portal profile email will be directed to the training site. If you used a different email address, contact ProviderTraining@bcbsm.com to update your profile.

Note: If you’re a new training site user, complete the one-time registration by entering your role and creating a password. This allows you to access the training site outside of the provider portal if needed.

If you need assistance navigating the provider training site, email ProviderTraining@bcbsm.com.

New on-demand training available: Check out our new learning path

Provider Experience continues to offer 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. As part of our ongoing efforts, we recently added a new learning path.

Our newest learning path contains courses for medical coders, medical billing specialists and others who work with medical record documentation. This is our latest effort to help providers determine the right courses to take. We’ll keep updating the courses as new ones are created that cover coding and medical record documentation topics. This will ensure you have the latest information that’s easy to find in one spot.

Professional providers and facilities should encourage medical coders, billers and records technicians to view the new path. Simply open the Course Catalog on the provider training website and click on Learning paths.

And don’t forget to check the dashboard on our provider training site. It’s designed to enhance the training experience for providers and staff so watch for announcements as we add more courses, including those with CME offerings.

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.

Virtual Care replacing Blue Cross Online Visits in January

Beginning in 2024, eligible Blue Cross Blue Shield of Michigan and Blue Care Network members will no longer use Blue Cross Online Visits℠ for virtual urgent and mental health care. On Jan. 1, 2024, all members with this benefit will use Virtual Care by Teladoc Health^®.

Virtual Care will be available through the Teladoc Health app and website, and by phone. Members will still have access to virtual urgent care 24/7 and mental health care by appointment, including evenings and weekends. 

We understand that many health care providers offer virtual visits directly through their office. We encourage providers who don’t offer virtual visits to their patients to consider recommending Virtual Care to the Blue Cross and BCN members who express interest in it. Starting on Jan. 1, you can direct them to bcbsm.com/virtualcare or to call 1-800-835-2362, 24 hours a day, seven days a week.

View our Virtual Care FAQ for more information.   

Urgent care

With Virtual Care, members have care when they need it. They can talk to a U.S. board-certified doctor when their primary care provider isn’t available about conditions such as:

• Sinus and respiratory infections
• Cold and flu
• Painful urination
• Eye irritation or redness
• Sore throat

Members can select 24/7 Care in the Teladoc Health app or call the above phone number for assistance and to schedule an appointment.

Mental health care

Members can select Mental Health in the Teladoc Health app to find and get care from licensed therapists and U.S. board-certified psychiatrists. They can also call 1-800-835-2362 to schedule an appointment. Visits are private and confidential, and provide ongoing support for stressful situations or issues such as grief, anxiety and depression.

Members can start scheduling appointments on Jan. 1. Visits are available from 7 a.m. to 9 p.m. Eastern time, seven days a week. Psychotherapy with a psychologist or clinical social worker is available for members ages 13 and older, while members ages 18 and older can receive psychiatric services. Doctors don’t prescribe controlled substances.

We encourage mental health care providers to speak with their patients who have Blue Cross and BCN health coverage about this transition and assist them with mental health strategies and resources. Share with them the Blue Cross Behavioral Health website and let them know they can call the behavioral health phone number on the back of their member ID cards for more information or if they have a behavioral health need.

Members can also log in to their Blue Cross member account at bcbsm.com or through the mobile app to use Find Care and identify a mental health care provider they may want to see. Members can use Find Care to confirm if a Blue Cross provider offers virtual visits.

Virtual Care solutions

Virtual Care is part of an array of virtual care solutions Blue Cross Blue Shield of Michigan is offering to members. You can read about another solution, Virtual Primary Care, in this article that’s also in this issue of the newsletter. Virtual Primary Care is available to Blue Cross PPO members.

Teladoc Health^® is an independent company that provides Virtual Care Solutions for Blue Cross Blue Shield of Michigan and Blue Care Network.

Virtual Primary Care: An optional benefit for Blue Cross commercial members starting Jan. 1

As part of an array of virtual care solutions we’re offering our members, we’re introducing a program called Virtual Primary Care to select Blue Cross Blue Shield of Michigan members.

Starting Jan. 1, 2024, Virtual Primary Care will be available to all Blue Cross Blue Shield of Michigan fully insured commercial members (and family members on their plan who are 18 and older) and as a buy-up option for other groups. The offering will be supported by Teladoc Health^®, an independent company that has contracted with Blue Cross to provide virtual primary care solutions.

Unlike the Blue Care Network virtual primary care plan, which is considered a health plan product, the Blue Cross commercial solution is an optional benefit that some members may decide to use. Most of the members expected to use this benefit are those who aren’t attributed to a primary care physician and who aren’t seeking in-person care.

“Our customers, particularly the employer groups I work with, recognize the importance of a primary care relationship,” said Dr. Gretchen Goltz, medical director, Provider Engagement, in a column in the November-December issue of Hospital and Physician Update. “Many of them want all their employees to establish a care relationship with a primary care provider. At Blue Cross Blue Shield of Michigan, we agree with that line of thinking. We know that our members who have a primary care doctor they see regularly for preventive health care and appropriate screenings have better overall health outcomes.”

With Virtual Primary Care, members will be able to select a board-certified primary care physician by logging in to their member account, clicking on Your Choices for Care and following the prompts to the Virtual Care tab. Medical visits are with a board-certified physician and are primarily delivered by video.

Patients can also communicate with their care team by phone or in-app messaging. Those who register for Teladoc Health and schedule a first appointment will receive a blood pressure monitor and cuff.

When necessary, Teladoc Health will refer patients to specialists for in-person care. They won’t call primary care practices to refer patients to in-person care, but if a patient needs to see a PCP in person, Teladoc Health will work with the patient to find appropriate care using our Find a Doctor search tool.

For more information about our virtual care solutions

• To learn more about Virtual Primary Care, check out this flyer.
• To see how Virtual Primary Care will be reflected in Benefit Explainer, see this article, also in this issue.
• To read about the BCN virtual primary care plan, see this page of the November-December 2022 issue of BCN Provider News.
• To read about how we’re transitioning Blue Cross Online Visits℠ to Virtual Care, see this article, also in this issue.

Benefit changes coming in 2024 for UAW Retiree Medical Benefits Trust members

Starting Jan. 1, 2024, there will be several changes to the UAW Retiree Medical Benefits Trust members’ health plan benefits. We’re providing a summary of those changes below.

Enhanced Care Plan, known as ECP, and Traditional Care Network, or TCN, plans:

Cost share updates for General members

• The in-network deductible is reduced to $175 for individuals and $450 for families.
• In-network coinsurance has been removed; it’s now $0.
• The in-network out-of-pocket maximum is reduced to $175 for individuals and $450 for families.

Cost share updates for Protected members

• GM and Chrysler Protected members: In-network deductibles, coinsurance and out-of-pocket maximums have been removed; they are now $0.
• GM and Chrysler Protected members: Out-of-network coinsurance is reduced to 10%.
• Ford Protected members: Out-of-network out-of-pocket maximums will be capped at $3,000 for individuals and $5,500 for families to match GM and Chrysler Protected. Currently, the out-of-pocket maximum for out-of-network services is unlimited.



Note: In 2024, the ECP and TCN Protected class plans will be aligned for all Protected members.

Office visits

• ECP members:
• In-network primary care physician, or PCP, office visit copayment is removed; it’s now $0.
• In-network specialist office visit copayment is reduced to $10.
• TCN members: Office visits are now a benefit when performed by an in-network provider.
• In-network PCP office visit copayment is $0.
• In-network specialist office visit copayment is the lesser of $10 or 20% after coordinating with Medicare.
• Additional covered office-related services that are performed as part of an office visit are payable at 100%

These office copay changes also apply to the following services:

• Office/outpatient consultation
• Outpatient presurgical consultation
• Telemedicine visit (Blue Cross provider)
• Virtual Care by Teladoc® (replaces Blue Cross Online VisitsSM)
• Advance care planning
• Routine physical/annual exam
• Gynecological exam
• Routine vision exam
• Diabetic retinopathy exam
• Well-child visit

Note: Be sure to refer to the member’s eligibility and benefits for additional coverage details.

Urgent care and retail health clinic copays

• General members: Urgent care and retail health clinic copayments are reduced to $40.
• GM and Chrysler Protected members: Urgent care and retail health clinic copayments have been removed; they are now $0.

Note: Ford Protected members currently have $0 urgent care and retail health clinic copayments.

Acupuncture

Acupuncture is a benefit for the treatment of chronic lower back pain only for ECP members when an individual has been referred by their treating physician to a licensed acupuncturist. Coverage is subject to the new in-network cost share described above. Services rendered by an out-of-network provider are not covered.

Blue Care Network plans

Cost share updates

• General members: The in-network deductible is reduced to $250 for an individual and $525 for families.

Office visit copays

• General members: In-network primary care provider office visit copayment is reduced to $15; the specialist office visit copayment is reduced to $25.
• Protected members: In-network primary care provider and specialist office visit copayments are reduced to $15.

Urgent care and retail health clinic copays

• General members: In-network urgent care and retail health clinic copayments are reduced to $40.
• GM and Chrysler Protected members: In-network urgent care and retail health clinic copayments are reduced to $40.

BCN Advantage℠ plans

Cost share updates

• General members: In-network deductible is reduced to $250 for individuals and $525 for families.

Office visit copays

• General members: In-network primary care provider office visit copayment is reduced to $15; the specialist office visit copayment is reduced to $25.
• Protected members: In-network primary care provider and specialist office visit copayments are reduced to $15.

Urgent care and retail health clinic copays

• General members: In-network urgent care and retail health clinic copayments are reduced to $15.
• GM and Chrysler Protected members: In-network urgent care and retail health clinic copayments are reduced to $15.

Medicare Advantage Prescription Drug, or MAPD, plans:

Cost share updates

• General members: In-network deductible, coinsurance and out-of-pocket maximum (for deductible and coinsurance services only) have been removed; they are now $0. The in-network out-of-pocket maximum of $1,500 for copay-based services still applies.
• Coinsurance applies for Part B medical drugs dispensed at a retail pharmacy or through mail-order:
• 10% coinsurance up to dollar maximum equal to copay value ($33 or prorated for days’ supply of brand medications and generic medications are payable at 100%)

Note: The $500 out-of-pocket maximum remains in place for this benefit only.

Office visit copays

• General members: In-network primary care provider office visit copayment is reduced to $0, and the specialist office visit copayment is reduced to $10.

Urgent care and retail health clinic copays

• General and Protected members: In-network urgent care and retail health clinic copayments are reduced to $15.

As always, remember to check benefits and eligibility.

New MESSA medical plan takes effect Jan. 1

The Michigan Education Special Services Association, commonly known as MESSA, is launching a new medical plan, effective Jan. 1, 2024, called MESSA Balance+.

MESSA Balance+ is a high-deductible health plan featuring copayments for office visits and coinsurance for medical services. It also comes with a prescription plan that includes a mix of copayments and coinsurance, plus an extensive list of free preventive medications. It’s eligible for a health savings account and includes MESSA’s bundle of supplemental plans — accident, critical illness and hospital indemnity.

Because of the unique out-of-pocket cost structure of MESSA Balance+, be sure to check benefits before providing services to MESSA members.

Category I RSV vaccine codes added

The American Medical Association has added CPT Category I RSV vaccine codes. The codes, effective dates and Blue Cross Blue Shield of Michigan’s coverage decisions are below.

Medicine vaccines/Toxoids

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.

CPT Category III code update: New codes

The American Medical Association has added 45 new Category III codes as part of its CPT update. The codes, effective dates and Blue Cross Blue Shield of Michigan’s coverage decisions are below.

Radiology 

Surgery

Medicine

Cardiology

Medicine/Psychiatric services/Other Psychotherapy

Pathology and Laboratory

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.

The PGIP evolution: New and revised participation and quality expectations

As the Physician Group Incentive Program enters its 20^th year, we’re supporting the ongoing development of stronger systems of care, resulting in better clinical outcomes for Blue Cross Blue Shield of Michigan members and Michigan residents. The goals are to see our members in high-performing care relationships and our health care providers well-supported by their PGIP physician organizations, which will allow them to deliver the transformed models and improved quality outcomes we expect.

As we work toward raising the bar, Blue Cross will continue to review and elevate our expectations, PGIP physician organization eligibility requirements and associated incentives. We’re also working to ensure the program, POs and practices continue to excel so Blue Cross members and customers receive the highest quality and most cost-effective care possible.

Eligibility requirements

Here are the eligibility requirements for PGIP physician organizations as announced at the PGIP Quarterly on Sept. 8:

• POs must have 75 or more TRUST panel physicians or Traditional participating physicians, 50 of whom must be practicing as primary care providers in internal medicine, pediatrics, family practice or general practice and have at least 12,500 attributed combined commercial PPO and Medicare Advantage PPO members. 
• The board of the PGIP physician organization must be comprised of 51% or more Michigan-licensed practicing physicians who are members of the PPO TRUST or TRAD network and contribute to the PGIP Reward Pool.
• POs must have contractual authority to represent their physicians for this program and coordinate and facilitate practice improvements and program administration on behalf of the physicians.
• POs must continue to meet and comply with program standards, including Standards for Maintaining Quality Health Care, Standards for Health Information Privacy and Security, Standards for Controlling Health Care Costs, Standards for Assuring Appropriate Utilization of Health Care Services, and Standards for Assuring Reasonable Levels of Access to Health Care Services.
• POs must meet the minimum IT and analytic enablement requirements to actively and appropriately participate in our program. POs must meet the minimum requirements for the sharing of data between the PO and their practices, including a registry, data warehouse, Michigan Health Information Network connectivity and risk stratification tools. 

Note: All POs will be expected to comply with the new and enhanced requirements by the Fall 2024 PGIP Snapshot in preparation for the 2025 PGIP program year.

Quality expectations

PGIP Evolution focuses not only on PO eligibility requirements and the support that POs provide to their physician members, but also on ensuring appropriate levels of clinical quality performance. As shared during the PO collaboration call on Oct. 25, Blue Cross is continuing to focus on multiple components that contribute to the high performance of PGIP physician organizations, particularly as they relate to our Clinical Quality Initiative, or CLQI, which focuses on HEDIS^® and its stars metrics.

PGIP physician organizations are evaluated on their commercial PPO and Medicare Advantage PPO performance through this longstanding initiative.​ As part of PGIP Evolution, we’re addressing how POs are engaging and performing in CLQI. Beginning with the 2024 program year, Blue Cross will be engaging POs that have fallen into the bottom quartile of performance in four out of the past five years. We’ll work with these POs on quality improvement plans to increase their performance.​

For the 2024 program year, these POs will need to:​

• Submit action plans to Value Partnerships detailing efforts and planned resources to address performance issues and close gaps in care for each measure that falls below NCQA 75th percentile benchmark performance.
• Submit quarterly progress reports.
• Meet in person with Blue Cross leadership three times a year.
• Meet with an assigned mentor PGIP physician organization to address concerns and brainstorm solutions.

On an annual basis, we’ll be assessing all PGIP physician organizations to ensure no POs have multiple successive years of less-than-acceptable performance.

This information will be recirculated through PGIP communication channels as the Fall 2024 PGIP Snapshot nears. If you have questions, reach out to your field team representative or email valuepartnerships@bcbsm.com.

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

Reminder: Changes coming to prior authorization, case management functions for behavioral health services in January

Starting Jan. 1, 2024, Blue Cross Blue Shield of Michigan and Blue Care Network will consolidate the prior authorization and case management functions for behavioral health services, including treatment for autism.

We recently communicated these changes in The Record and BCN Provider News.  

Prior authorization and concurrent review requests will be managed through Blue Cross Behavioral Health℠ . Case management services will be handled through Blue Cross Coordinated Care℠ . These programs will align and standardize prior authorization and case management functions for members. The changes will affect most members covered by Blue Cross commercial, Medicare Plus Blue℠, BCN commercial and BCN Advantage℠ plans.

Find details in the FAQ

We updated the Blue Cross Behavioral Health: Frequently asked questions for providers document with the latest information. Here are the most recent changes:

• In the “Submitting prior authorization requests and concurrent review requests” section:
• We outlined how to submit requests electronically and by phone, before and after Jan. 1.
• We listed the medical necessity criteria we’ll use to make determinations on these requests.
• In the “Autism evaluation and treatment changes” section, we added information about:
• Additional opportunities for members to obtain a comprehensive diagnostic autism evaluation prior to starting treatment
• How to request a “bridge authorization,” which allows members to start applied behavior analysis, or ABA, treatment while they’re in the process of completing the components of the comprehensive evaluation
• In the “Appeals” section, we updated the information to show that you should follow the instructions in the determination letter to submit an appeal of a request that wasn’t approved.

You can access the FAQ at ereferrals.bcbsm.com on the:

• Blue Cross Behavioral Health and Autism pages
• BCN Behavioral Health and Autism pages

Watch for a recorded webinar

In December, we’ll publish a recorded webinar, which will provide:

• An overview of the changes
• Instructions on how to access and use the Blue Cross Behavioral Health provider portal
• Information about where to locate important resources
• Watch for upcoming communications on how to access the webinar.

Update: We’ve added extended fees for some external peer reviews

As previously communicated in a September 2023 Record article, we recently increased the cost for external reviews. The base cost of a standard clinical review is $378 per review. The base cost of a coding review is $334.

Extended fees will apply to the scenarios listed below and billed at the base rate plus $125 each hour after.

• Documentation exceeding 2,000 pages
• Diagnoses greater than or equal to three codes

According to Blue Cross Blue Shield of Michigan and Blue Care Network participation agreements with health care providers, the facility or practitioner’s office is responsible for paying the total cost of the appeal review if the peer review agency upholds Blue Cross’ decision regarding a claim.

We’ll use updated 2023 InterQual criteria, starting Feb. 1

On Feb. 1, 2024, Blue Cross Blue Shield of Michigan and Blue Care Network will start using updated 2023 InterQual^® criteria to make determinations on prior authorization requests for the services we manage.

Change Healthcare published updates to its 2023 InterQual criteria on Oct. 6, 2023. Refer to the table below to see which updated criteria we’re adopting. When you open the documents linked below, you’ll see the changes in red.

How we’ll use the updated criteria

We’ll use the updated criteria to make determinations on prior authorization requests for non-behavioral health services for the following members:

• Blue Cross commercial
• Medicare Plus Blue℠
• BCN commercial
• BCN Advantage℠

When clinical information is requested for a medical or surgical admission or for other services, we require providers to submit specific components of the medical record that show that the request meets the criteria. We review this information when making determinations on prior authorization requests.

This information:

• Applies to lines of business and members whose authorizations are managed by Blue Cross or BCN directly and not by independent companies that provide services to Blue Cross Blue Shield of Michigan
• Doesn’t apply to behavioral health services

No updates to our local rules

We’re not updating our local rules. We use InterQual criteria and our local rules when making determinations on prior authorization requests for Blue Cross and BCN commercial members for these types of post-acute care:

• Skilled nursing
• Inpatient rehabilitation
• Long-term acute care

You can access the local rules for post-acute care as follows:

• On the Blue Cross Authorization Requirements & Criteria page of ereferrals.bcbsm.com. Look in both the Blue Cross commercial and the Medicare Plus Blue sections of that page.
• On the BCN Authorization Requirements & Criteria page of ereferrals.bcbsm.com. Look under the Referral and authorization information heading.

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

Changes to preferred drug designations and prior authorization requirements for Medicare Advantage members

For dates of service on or after Jan. 1, 2024, Blue Cross Blue Shield of Michigan and Blue Care Network are making changes to the preferred and nonpreferred designations for some medical benefit drugs.

In addition, health care providers will need to submit prior authorization requests through different systems for some preferred and nonpreferred drugs.

These changes will affect most Medicare Plus Blue℠ members and BCN Advantage℠ members.

Preferred drug designations are changing

Starting Jan. 1, we’re changing preferred drug designations as shown in the following table.

Changes are in bold text.

How to submit prior authorization requests

Submit prior authorization requests as follows:

• Preferred oncology drugs will require prior authorization through Carelon Medical Benefits Management. All other preferred drugs will require prior authorization through the NovoLogix^® online tool.
• Nonpreferred drugs will require prior authorization through NovoLogix.

Note: Preferred infliximab and rituximab agents don’t require prior authorization.

Reminder: Bevacizumab agents don’t require prior authorization for use in retinal disorders.

To submit a prior authorization request, log in to our provider portal (availity.com),** click on Payer Spaces in the menu bar and then click on the BCBSM and BCN logo. Then click on the tile to access the appropriate NovoLogix tool or the Carelon ProviderPortal.

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

When prior authorization is required

These drugs will require prior authorization when they’re administered by a health care provider in sites of care such as outpatient facilities or physician offices and are billed in one of the following ways:

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

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 and BCN Advantage members.

We’ll update the list to reflect these changes prior to the effective date.

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

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

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

Blue Cross, BCN covering additional vaccines

Blue Cross Blue Shield of Michigan and Blue Care Network want to increase access to vaccines and decrease the risk of vaccine-preventable disease outbreaks. As a result, we’ve added the following vaccine to our list of vaccines covered under the pharmacy benefit:

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

Vaccines that have an age requirement

Vaccines that have no age requirement

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

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

Changes coming to infliximab step therapy requirements for Medicare Advantage members in January

For dates of service on or after Jan. 1, 2024, infliximab step therapy requirements are changing for Cimzia^®, Skyrizi^® IV and Ilumya^®. These changes apply to Medicare Plus Blue℠ and BCN Advantage℠ members.

Notes:

• These drugs are part of members’ medical benefits, not their pharmacy benefits.
• These drugs require prior authorization. Submit requests through the NovoLogix^® online tool.

Requirements added for Cimzia and Skyrizi

Starting Jan. 1, members will have to try and fail a preferred infliximab drug before a health care provider requests prior authorization for the following drugs:

• Cimzia (certolizumab pegol), HCPCS code J0717
• Skyrizi IV (risankizumab-rzaa), HCPCS code J2327

For information about preferred drug designations, see our provider alert, Update: Changes to preferred drug designations and prior authorization requirements for Medicare Advantage members.

Requirements removed for Ilumya

Starting Jan. 1, members won’t have to try and fail a preferred infliximab drug before using Ilumya.
Ilumya will continue to require prior authorization.

How to submit prior authorization requests

To submit a prior authorization request, log in to our provider portal, availity.com,** click on Payer Spaces in the menu bar and then click on the BCBSM and BCN logo. Then click on the tile to access the appropriate NovoLogix tool.

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

When prior authorization is required

The drugs mentioned above require prior authorization when they are administered by a provider in sites of care such as outpatient facilities or physician offices and are billed in one of the following ways:

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

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 and BCN Advantage members.

We’ll update the list to reflect these changes prior to the effective date.

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

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

Syfovre and Izervay must not be used with other geographic atrophy drugs for commercial members

For dates of service on or after Nov. 24, 2023, the following drugs must not be used in combination with each other or any other geographic atrophy, or GA, drug:

• Syfovre^® (pegcetacoplan), HCPCS codes J3490 and C9151
• Izervay™ (avacincaptad pegol), HCPCS code J3590

This change affects Blue Cross Blue Shield of Michigan commercial members and Blue Care Network commercial members.

Syfovre and Izervay will continue to require prior authorization through NovoLogix^®, as specified in the Blue Cross and BCN utilization management medical drug list for Blue Cross commercial and BCN commercial members.

Some Blue Cross commercial groups not subject to these requirements

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

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

Additional information

For additional information about drugs covered under the medical benefit, see the following pages of the ereferrals.bcbsm.com website:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

Prior authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

Tecvayli will have additional requirements for most commercial members, starting Dec. 7

Blue Cross Blue Shield of Michigan and Blue Care Network are updating the medical policy for Tecvayli^® (teclistamab-cqyv), HCPCS code J9380. The requirements in the updated medical policy will apply for most Blue Cross and BCN commercial members for dates of service on or after Dec. 7, 2023.

In keeping with the updated medical policy, members will have to meet the following additional requirements for treatment with Tecvayli to be considered medically necessary:

• Alanine aminotransferase, or ALT, and aspartate aminotransferase, or AST, less than or equal to three times the upper limit of normal, or ULN
• Creatinine clearance greater than or equal to 40 mL/min
• Left ventricular ejection fraction greater than or equal to 40%
• No active autoimmune disease except vitiligo, Type 1 diabetes mellitus or prior autoimmune thyroiditis

You can see the full list of requirements in the updated medical policy, which will be available by Dec. 7. To view the policy, go to the Medical Policy Router Search page, enter the name of the drug in the Policy/Topic Keyword field and press Enter. The search results will include links to both the current medical policy and the updated medical policy.

Note: To access the Medical Policy Router Search page, go to bcbsm.com/providers, click on Resources and then click on Search Medical Policies.

Some Blue Cross commercial groups aren’t subject to these requirements

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

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

Additional information

For additional information about drugs covered under the medical benefit, see the following pages of the ereferrals.bcbsm.com website:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

Prior authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

Vyvgart Hytrulo to have a site-of-care requirement for most commercial members, starting Jan. 1

For dates of service on or after Jan. 1, 2024, we’re adding a site-of-care requirement for Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members for the following drug covered under the medical benefit:

• Vyvgart^® Hytrulo (efgartigimod alfa and hyaluronidase-qvfc), HCPCS code J3590

The NovoLogix^® online tool will prompt you to select a site of care when you submit prior authorization requests for this drug. If the request meets clinical criteria for the drug and is for one of the following sites of care, it will be approved automatically:

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

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

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

Members who start courses of treatment with Vyvgart Hytrulo before Jan. 1, 2024, will be able to continue receiving the drug in their current location until their existing authorization expires. If those members then continue treatment under a new prior authorization, the site-of-care requirement outlined above will apply.

Some Blue Cross commercial groups not subject to these requirements

For Blue Cross commercial groups, the prior authorization and site-of-care requirements apply only to groups that participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List.

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

List of requirements

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

You can access this list and other information about requesting prior authorization at ereferrals.bcbsm.com, on these webpages:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

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

How to submit BCN, Medicare Plus Blue and BCN Advantage skin biopsy claims for payment

Procedure code *11102 is related to biopsy procedures on the skin. As of October 2023,  we pay Medicare Plus Blue℠, BCN Advantage℠ and Blue Care Network claims for this procedure code if the following statements apply:

• Procedure code *11102 is reported with other integumentary codes.
• Modifier 59 and related XE, XS, XP and XU modifiers are appended on the claims.

Reminder: Health care providers should continue following the guidelines communicated in our September 2021 article. This applies to appending modifier 59 and related XE, XS, XP and XU modifiers.

We no longer automatically pay for certain procedures that are billed with modifier 59 and related XE, XS, XP and XU modifiers, when they’re billed with a procedure code on the Centers for Medicare & Medicaid Services’ National Correct Coding Initiative Procedure-to-Procedure list.

Only select codes allow modifier 59 and related XE, XS, XP and XU modifiers to automatically bypass the National Council on Compensation Insurance code-pair edits.

The additional review assures that claims have been coded correctly for more complex situations where an overriding modifier has been appended.

Providers should:

• Code claims to the level of specificity for the services rendered.
• Appropriately append diagnosis codes and modifiers following the guidelines published by the American Medical Association and CMS.

The reported services should be supported in the patient’s medical record.

Note: Claims can be resubmitted for payment.

We’ve updated our chiropractic and osteopathic manipulation benefits

Blue Cross Blue Shield of Michigan has updated its chiropractic and osteopathic manipulation benefits to combine outpatient facility and professional member accumulation visit maximums and cost share. The updates were effective for all applicable groups for dates of service on and after Sept. 1, 2023.   

These changes apply to the following Blue Cross commercial groups that have chiropractic and osteopathic benefits:

• Fully insured
• Self-funded

When an outpatient facility and professional claim is reported in Place of Service 2 (outpatient hospital) for the same encounter on the same date of service, the accumulated service counts as only one visit toward the member’s benefit maximum. If a member receives an additional manipulation on the same date in a different POS 3 (office), the visit will be accumulated as a separate visit toward the member’s visit maximum.

Professional and facility existing group cost share won’t change. Services performed in a facility setting will apply facility cost share while services in an office setting will apply an office cost share.

Revenue code 0531 was turned on to accommodate the billing and reimbursement of osteopathic manipulations when reported with a valid CPT procedure code. This revenue code will apply fee-based reimbursement for the applicable codes.

The alignment of the benefits across both an outpatient facility and a provider’s office allows Blue Cross to adapt to the growing changes in provider billing practices. The changes will ensure compliance with benefit plan designs for our groups and will consistently apply benefit experiences regardless of where services are provided.

Note: Claims will continue to deny manipulation services when a group doesn’t have chiropractic or osteopathic benefits.

We’re making chiropractic, and sleeve gastrectomy and hernia repair payment policy updates

Chiropractic: Blue Cross Blue Shield of Michigan is updating its payment policy to no longer apply a bundling edit when procedure code *98943 is billed with other specified chiropractic manipulative treatment codes. Procedure code *98943 will be eligible to receive separate reimbursement at 50% of the allowed amount when billed with *98940, *98941 and *98942. This update will apply to claims processed starting in January.

Sleeve gastrectomy and hernia repair: Starting in March 2024, Blue Cross will be updating its payment policy to apply bundling edits to internal hernia repair codes when billed with bariatric surgery codes. Hernia repair codes won’t receive separate reimbursement when billed with bariatric surgery codes as they are considered incidental or mutually exclusive to the bariatric procedure. The specified codes applicable to this policy are as follows:

• Internal hernia repair codes: *43280, *43281, *43282, *43283
• Bariatric surgery codes: *43770, *43771, *43772, *43773, *43774, *43775

Blue Cross increases number of procedure codes payable to podiatrists

Blue Cross Blue Shield of Michigan is now allowing additional Current Procedural Terminology and Health Care Procedure Coding System codes to be payable to podiatrists.

We’ve made this change to align with Medicare and make it easier for podiatrists to do business with us.

Procedure codes *11400, *11401, *11402, *20606, *76882, *76942, *93922 and *93923 are within the scope of practice for a podiatrist; therefore they’re reimbursable when reported by this provider specialty.

These codes are payable based on the dates of service below:

Group-specific rules and benefits still apply. Verify your patients’ benefits for coverage.

New payability limitation in Benefit Explainer: Rendering Provider Designation

We’ve enhanced Benefit Explainer to include a new payability limitation called Rendering Provider Designation.

This new designation will first be used to indicate whether a Blue Cross Blue Shield of Michigan member has access to our Virtual Primary Care program, which launches Jan. 1, 2024, and what the member’s cost share would be if they choose to use the program.

Here’s a screenshot** of what Benefit Explainer users can expect to see.

**This screenshot example is for illustrative purposes and may not reflect actual data.

New resources to support staff and improve patient experience

During the past year, Blue Cross Blue Shield of Michigan’s Patient Experience team incorporated member, doctor and physician organization feedback to shape the resources and support we provide to physician practices. Throughout 2023, we engaged with many practices and physician organizations across Michigan to improve patient interactions, access to care and care coordination.

New training for your staff

One of our newest all-staff training focuses on dealing with challenging patients. These sessions, available in person and virtually, provide strategies to remain calm and diffuse situations with upset patients and complement our Patient Communication session that offers best practices for a great patient experience.

Email PatientExperience@bcbsm.com for more information or to schedule a session.

Webinars on demand

Visit the on-demand page of our Patient Experience site for webinars and training. These sessions are created to fit into your schedule and can be accessed at any time. Current offerings include:

• Combatting Burnout in the Health Care Setting is a five-part series that helps health care workers manage stress and burnout by providing practical strategies to maintain their own well-being.
• A three-part series that focuses on the CG-CAHPS Care domains — Getting Care Quickly, Care Coordination and Getting Needed Care — provides tips to improve processes such as medication reconciliation, lab and other test result follow-up, managing in-office wait times, specialist referrals and getting routine appointments quickly.

See the Additional Resources page for more training opportunities.

Specialist referral tactic

Earlier this year, Blue Cross’ Patient Experience team released its specialist referral folder, a new tactic to help practices manage patient expectations when referred to specialists. The folder helps guide the conversation about the time it may take to get an appointment with common specialists, definitions, a spot for medication lists and the specialist’s contact information. Paperwork pertinent to the referral can be kept in the folder so everything the patient needs for a successful appointment is in one place.

Patient Experience resources include a variety of tactic materials that center around the CAHPS Care domains. Materials include handouts, signs, and other tools for patients and staff.

We’re updating our site to enable visitors to view tactic materials, including the specialist referral folder and many other materials, such as tactics to improve wait times, medication reconciliation, patient portal use and more. Check out the Patient Experience site for more information.

Coming soon

Visit our Patient Experience site to discover new content and register for upcoming webinars, including sessions on telehealth interactions and health equity.

For information or to request a patient experience consultation, email PatientExperience@bcbsm.com.

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

As a reminder, we’re offering live, 30-minute educational webinars that provide updated information on documentation and coding for common challenging diagnoses. Webinars include an opportunity to ask questions. 

Here’s our upcoming webinar schedule and topic tentatively scheduled. The session starts at noon Eastern time. Log in to the provider training website to register.

To access the training site, follow these steps:

1. Log in to the provider portal
2. Click on Payer Spaces on the menu bar and then click on the BCBSM and BCN logo.
3. Under Applications, click on the Provider Training Site tile
4. Click on Submit on the Select an Organization page
5. Existing users who used the same email address as their provider portal profile email will be directed to the training site. If you used a different email address, contact ProviderTraining@bcbsm.com to update your profile.

Note: If you’re a new training site user, complete the one-time registration by entering your role and creating a password. This allows you to access the training site outside of the provider portal if needed.
If you need assistance navigating the provider training site, email ProviderTraining@bcbsm.com.

Locating a session

Click here to log in if you’re already registered for the provider training website. On the provider training website, look in the Event Calendar or use the search feature with the keyword “lunch” to quickly locate the 2023 sessions.

See the screenshots below for more details.

Previous sessions

You can also listen to previously recorded sessions. Check out the following:

For more information

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 questionnaires in e-referral system

On Oct. 15, 2023, Blue Cross Blue Shield of Michigan and Blue Care Network updated questionnaires in the e-referral system. We’ve also updated the corresponding preview questionnaires on the ereferrals.bcbsm.com website.

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

Updated questionnaires

We’ve updated the following questionnaires in the e-referral system:

Preview questionnaires

Preview questionnaires show the questions you’ll need to answer in the e-referral system so you can prepare your answers ahead of time.

To find the preview questionnaires, go to ereferrals.bcbsm.com:

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

Authorization criteria and medical policies

The Authorization Requirements & Criteria pages explain how to access the pertinent authorization criteria and medical policies.

Reminder: Changes coming to prior authorization, case management functions for behavioral health services in January

Starting Jan. 1, 2024, Blue Cross Blue Shield of Michigan and Blue Care Network will consolidate the prior authorization and case management functions for behavioral health services, including treatment for autism.

We recently communicated these changes in The Record and BCN Provider News.  

Prior authorization and concurrent review requests will be managed through Blue Cross Behavioral Health℠ . Case management services will be handled through Blue Cross Coordinated Care℠ . These programs will align and standardize prior authorization and case management functions for members. The changes will affect most members covered by Blue Cross commercial, Medicare Plus Blue℠, BCN commercial and BCN Advantage℠ plans.

Find details in the FAQ

We updated the Blue Cross Behavioral Health: Frequently asked questions for providers document with the latest information. Here are the most recent changes:

• In the “Submitting prior authorization requests and concurrent review requests” section:
• We outlined how to submit requests electronically and by phone, before and after Jan. 1.
• We listed the medical necessity criteria we’ll use to make determinations on these requests.
• In the “Autism evaluation and treatment changes” section, we added information about:
• Additional opportunities for members to obtain a comprehensive diagnostic autism evaluation prior to starting treatment
• How to request a “bridge authorization,” which allows members to start applied behavior analysis, or ABA, treatment while they’re in the process of completing the components of the comprehensive evaluation
• In the “Appeals” section, we updated the information to show that you should follow the instructions in the determination letter to submit an appeal of a request that wasn’t approved.

You can access the FAQ at ereferrals.bcbsm.com on the:

• Blue Cross Behavioral Health and Autism pages
• BCN Behavioral Health and Autism pages

Watch for a recorded webinar

In December, we’ll publish a recorded webinar, which will provide:

• An overview of the changes
• Instructions on how to access and use the Blue Cross Behavioral Health provider portal
• Information about where to locate important resources
• Watch for upcoming communications on how to access the webinar.

For commercial LTACH requests, questionnaire opens in e-referral system

When submitting a prior authorization request for an admission to a long-term acute care hospital, or LTACH, you must complete a questionnaire about the three skilled nursing facilities, or SNFs, you have contacted.

These must be SNFs you believe may be able to provide care for the member but that have indicated they can’t provide the level of care the member requires.

This applies to LTACH placement requests for most Blue Cross Blue Shield of Michigan and Blue Care Network commercial members.

You must provide the following information:

• Whether you’ve contacted three SNFs (yes or no)
• Name and contact information for each SNF

Follow the prompts in the questionnaire to ensure you’ve provided the information that’s required.

If the required information isn’t included when you submit the prior authorization request, the request is considered incomplete and can’t be processed. We’ll reach out to you and ask that you resubmit the request when the information is available. This delays the processing of the request.

Be aware that:

• The three SNFs must be contracted with Blue Cross or BCN and located within 75 miles of the facility in which the member is currently a patient.
• Two of the three SNFs must be facilities that can accommodate members who need higher levels of care such as complex wound care or total parenteral nutrition.

You can read more about these and other requirements in the document Blue Cross and BCN Local Rules for 2023 for post-acute care: Modifications of InterQual^® criteria.

You can access this document at ereferrals.bcbsm.com, on these webpages:

• Blue Cross Authorization Requirements & Criteria
• BCN Authorization Requirements & Criteria

Blue Cross updating reimbursement policy for administering blood transfusions at inpatient facilities

Blue Cross Blue Shield of Michigan and Blue Care Network will no longer reimburse separate claims for administering blood transfusions at inpatient facilities, effective Feb. 1, 2024.

This policy applies to all inpatient facility claims submitted for Blue Cross and BCN commercial members.

A blood transfusion is a routine medical procedure generally administered by nursing staff. Nursing services should be included in the general cost of the room where services are being given; therefore this service is considered ineligible for separate reimbursement.

When billing blood administration on a UB-04 for inpatient services, use the correct revenue code 0391.

Additional information

A blood transfusion is prescribed by a physician or a nonphysician practitioner for many reasons, including, but not limited to, surgery, injury and bleeding disorders.

Our updated reimbursement policy isn’t intended to affect decision-making for patient care, and health care providers are expected to apply medical judgment when caring for all members.

Benefit Explainer has new payability limitation for Primary or Secondary Diagnosis

On Nov. 20, 2023, we added Primary or Secondary Diagnosis as a new payability limitation to Benefit Explainer. When users view standalone Primary or Secondary Diagnosis, Primary Diagnosis or Any Diagnosis rules, the information bubble icon they see will read Applies or Does not apply.  

When users hover over the icon, they’ll see how the different rules apply to an outpatient facility claim billed with the same HCPCS code. When the bubble reads Applies it means the following for each rule:

Standalone Primary Diagnosis – The diagnosis restriction on the outpatient facility claim will only be based on the primary diagnosis code billed.

Standalone Primary or Secondary Diagnosis – The diagnosis restriction on the outpatient facility claim will be based on the primary diagnosis or the second diagnosis code billed.

Standalone Any Diagnosis – The diagnosis restriction on the outpatient facility claim will be based on any diagnosis code billed.

When the icon reads Does not apply for any of the above standalone diagnosis limitations, a diagnosis restriction won’t be applied to the outpatient facility claim.

Below is an example of what users will see. The example is for procedure code J0185 on the Medical/Payment Policy tab under Coverage Limitations, Medical, Primary Diagnosis.

When a user hovers over the icon, information on the diagnosis type appears.

Background

Facility outpatient claims are required to be billed with a HCPCS code. During claims processing, the Medical Policy Primary Diagnosis rule for the HCPCS code is applied to the outpatient facility claim. Health care providers can submit up to 25 diagnoses on a facility claim.

The information in the icon defines the location of the diagnosis on the facility claim that should be read to apply the Medical Policy Diagnosis rule.

Note: Screenshot examples are for illustrative purposes and may not reflect actual data.

Update: We’ve added extended fees for some external peer reviews

As previously communicated in a September 2023 Record article, we recently increased the cost for external reviews. The base cost of a standard clinical review is $378 per review. The base cost of a coding review is $334.

Extended fees will apply to the scenarios listed below and billed at the base rate plus $125 each hour after.

• Documentation exceeding 2,000 pages
• Diagnoses greater than or equal to three codes

According to Blue Cross Blue Shield of Michigan and Blue Care Network participation agreements with health care providers, the facility or practitioner’s office is responsible for paying the total cost of the appeal review if the peer review agency upholds Blue Cross’ decision regarding a claim.

We’ll use updated 2023 InterQual criteria, starting Feb. 1

On Feb. 1, 2024, Blue Cross Blue Shield of Michigan and Blue Care Network will start using updated 2023 InterQual^® criteria to make determinations on prior authorization requests for the services we manage.

Change Healthcare published updates to its 2023 InterQual criteria on Oct. 6, 2023. Refer to the table below to see which updated criteria we’re adopting. When you open the documents linked below, you’ll see the changes in red.

How we’ll use the updated criteria

We’ll use the updated criteria to make determinations on prior authorization requests for non-behavioral health services for the following members:

• Blue Cross commercial
• Medicare Plus Blue℠
• BCN commercial
• BCN Advantage℠

When clinical information is requested for a medical or surgical admission or for other services, we require providers to submit specific components of the medical record that show that the request meets the criteria. We review this information when making determinations on prior authorization requests.

This information:

• Applies to lines of business and members whose authorizations are managed by Blue Cross or BCN directly and not by independent companies that provide services to Blue Cross Blue Shield of Michigan
• Doesn’t apply to behavioral health services

No updates to our local rules

We’re not updating our local rules. We use InterQual criteria and our local rules when making determinations on prior authorization requests for Blue Cross and BCN commercial members for these types of post-acute care:

• Skilled nursing
• Inpatient rehabilitation
• Long-term acute care

You can access the local rules for post-acute care as follows:

• On the Blue Cross Authorization Requirements & Criteria page of ereferrals.bcbsm.com. Look in both the Blue Cross commercial and the Medicare Plus Blue sections of that page.
• On the BCN Authorization Requirements & Criteria page of ereferrals.bcbsm.com. Look under the Referral and authorization information heading.

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

Changes to preferred drug designations and prior authorization requirements for Medicare Advantage members

For dates of service on or after Jan. 1, 2024, Blue Cross Blue Shield of Michigan and Blue Care Network are making changes to the preferred and nonpreferred designations for some medical benefit drugs.

In addition, health care providers will need to submit prior authorization requests through different systems for some preferred and nonpreferred drugs.

These changes will affect most Medicare Plus Blue℠ members and BCN Advantage℠ members.

Preferred drug designations are changing

Starting Jan. 1, we’re changing preferred drug designations as shown in the following table.

Changes are in bold text.

How to submit prior authorization requests

Submit prior authorization requests as follows:

• Preferred oncology drugs will require prior authorization through Carelon Medical Benefits Management. All other preferred drugs will require prior authorization through the NovoLogix^® online tool.
• Nonpreferred drugs will require prior authorization through NovoLogix.

Note: Preferred infliximab and rituximab agents don’t require prior authorization.

Reminder: Bevacizumab agents don’t require prior authorization for use in retinal disorders.

To submit a prior authorization request, log in to our provider portal (availity.com),** click on Payer Spaces in the menu bar and then click on the BCBSM and BCN logo. Then click on the tile to access the appropriate NovoLogix tool or the Carelon ProviderPortal.

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

When prior authorization is required

These drugs will require prior authorization when they’re administered by a health care provider in sites of care such as outpatient facilities or physician offices and are billed in one of the following ways:

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

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 and BCN Advantage members.

We’ll update the list to reflect these changes prior to the effective date.

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

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

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

Changes coming to infliximab step therapy requirements for Medicare Advantage members in January

For dates of service on or after Jan. 1, 2024, infliximab step therapy requirements are changing for Cimzia^®, Skyrizi^® IV and Ilumya^®. These changes apply to Medicare Plus Blue℠ and BCN Advantage℠ members.

Notes:

• These drugs are part of members’ medical benefits, not their pharmacy benefits.
• These drugs require prior authorization. Submit requests through the NovoLogix^® online tool.

Requirements added for Cimzia and Skyrizi

Starting Jan. 1, members will have to try and fail a preferred infliximab drug before a health care provider requests prior authorization for the following drugs:

• Cimzia (certolizumab pegol), HCPCS code J0717
• Skyrizi IV (risankizumab-rzaa), HCPCS code J2327

For information about preferred drug designations, see our provider alert, Update: Changes to preferred drug designations and prior authorization requirements for Medicare Advantage members.

Requirements removed for Ilumya

Starting Jan. 1, members won’t have to try and fail a preferred infliximab drug before using Ilumya.
Ilumya will continue to require prior authorization.

How to submit prior authorization requests

To submit a prior authorization request, log in to our provider portal, availity.com,** click on Payer Spaces in the menu bar and then click on the BCBSM and BCN logo. Then click on the tile to access the appropriate NovoLogix tool.

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

When prior authorization is required

The drugs mentioned above require prior authorization when they are administered by a provider in sites of care such as outpatient facilities or physician offices and are billed in one of the following ways:

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

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 and BCN Advantage members.

We’ll update the list to reflect these changes prior to the effective date.

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

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

Syfovre and Izervay must not be used with other geographic atrophy drugs for commercial members

For dates of service on or after Nov. 24, 2023, the following drugs must not be used in combination with each other or any other geographic atrophy, or GA, drug:

• Syfovre^® (pegcetacoplan), HCPCS codes J3490 and C9151
• Izervay™ (avacincaptad pegol), HCPCS code J3590

This change affects Blue Cross Blue Shield of Michigan commercial members and Blue Care Network commercial members.

Syfovre and Izervay will continue to require prior authorization through NovoLogix^®, as specified in the Blue Cross and BCN utilization management medical drug list for Blue Cross commercial and BCN commercial members.

Some Blue Cross commercial groups not subject to these requirements

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

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

Additional information

For additional information about drugs covered under the medical benefit, see the following pages of the ereferrals.bcbsm.com website:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

Prior authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

Tecvayli will have additional requirements for most commercial members, starting Dec. 7

Blue Cross Blue Shield of Michigan and Blue Care Network are updating the medical policy for Tecvayli^® (teclistamab-cqyv), HCPCS code J9380. The requirements in the updated medical policy will apply for most Blue Cross and BCN commercial members for dates of service on or after Dec. 7, 2023.

In keeping with the updated medical policy, members will have to meet the following additional requirements for treatment with Tecvayli to be considered medically necessary:

• Alanine aminotransferase, or ALT, and aspartate aminotransferase, or AST, less than or equal to three times the upper limit of normal, or ULN
• Creatinine clearance greater than or equal to 40 mL/min
• Left ventricular ejection fraction greater than or equal to 40%
• No active autoimmune disease except vitiligo, Type 1 diabetes mellitus or prior autoimmune thyroiditis

You can see the full list of requirements in the updated medical policy, which will be available by Dec. 7. To view the policy, go to the Medical Policy Router Search page, enter the name of the drug in the Policy/Topic Keyword field and press Enter. The search results will include links to both the current medical policy and the updated medical policy.

Note: To access the Medical Policy Router Search page, go to bcbsm.com/providers, click on Resources and then click on Search Medical Policies.

Some Blue Cross commercial groups aren’t subject to these requirements

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

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

Additional information

For additional information about drugs covered under the medical benefit, see the following pages of the ereferrals.bcbsm.com website:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

Prior authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

Vyvgart Hytrulo to have a site-of-care requirement for most commercial members, starting Jan. 1

For dates of service on or after Jan. 1, 2024, we’re adding a site-of-care requirement for Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members for the following drug covered under the medical benefit:

• Vyvgart^® Hytrulo (efgartigimod alfa and hyaluronidase-qvfc), HCPCS code J3590

The NovoLogix^® online tool will prompt you to select a site of care when you submit prior authorization requests for this drug. If the request meets clinical criteria for the drug and is for one of the following sites of care, it will be approved automatically:

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

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

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

Members who start courses of treatment with Vyvgart Hytrulo before Jan. 1, 2024, will be able to continue receiving the drug in their current location until their existing authorization expires. If those members then continue treatment under a new prior authorization, the site-of-care requirement outlined above will apply.

Some Blue Cross commercial groups not subject to these requirements

For Blue Cross commercial groups, the prior authorization and site-of-care requirements apply only to groups that participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List.

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

List of requirements

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

You can access this list and other information about requesting prior authorization at ereferrals.bcbsm.com, on these webpages:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

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

We’ve updated our chiropractic and osteopathic manipulation benefits

Blue Cross Blue Shield of Michigan has updated its chiropractic and osteopathic manipulation benefits to combine outpatient facility and professional member accumulation visit maximums and cost share. The updates were effective for all applicable groups for dates of service on and after Sept. 1, 2023.   

These changes apply to the following Blue Cross commercial groups that have chiropractic and osteopathic benefits:

• Fully insured
• Self-funded

When an outpatient facility and professional claim is reported in Place of Service 2 (outpatient hospital) for the same encounter on the same date of service, the accumulated service counts as only one visit toward the member’s benefit maximum. If a member receives an additional manipulation on the same date in a different POS 3 (office), the visit will be accumulated as a separate visit toward the member’s visit maximum.

Professional and facility existing group cost share won’t change. Services performed in a facility setting will apply facility cost share while services in an office setting will apply an office cost share.

Revenue code 0531 was turned on to accommodate the billing and reimbursement of osteopathic manipulations when reported with a valid CPT procedure code. This revenue code will apply fee-based reimbursement for the applicable codes.

The alignment of the benefits across both an outpatient facility and a provider’s office allows Blue Cross to adapt to the growing changes in provider billing practices. The changes will ensure compliance with benefit plan designs for our groups and will consistently apply benefit experiences regardless of where services are provided.

Note: Claims will continue to deny manipulation services when a group doesn’t have chiropractic or osteopathic benefits.

New resources to support staff and improve patient experience

During the past year, Blue Cross Blue Shield of Michigan’s Patient Experience team incorporated member, doctor and physician organization feedback to shape the resources and support we provide to physician practices. Throughout 2023, we engaged with many practices and physician organizations across Michigan to improve patient interactions, access to care and care coordination.

New training for your staff

One of our newest all-staff training focuses on dealing with challenging patients. These sessions, available in person and virtually, provide strategies to remain calm and diffuse situations with upset patients and complement our Patient Communication session that offers best practices for a great patient experience.

Email PatientExperience@bcbsm.com for more information or to schedule a session.

Webinars on demand

Visit the on-demand page of our Patient Experience site for webinars and training. These sessions are created to fit into your schedule and can be accessed at any time. Current offerings include:

• Combatting Burnout in the Health Care Setting is a five-part series that helps health care workers manage stress and burnout by providing practical strategies to maintain their own well-being.
• A three-part series that focuses on the CG-CAHPS Care domains — Getting Care Quickly, Care Coordination and Getting Needed Care — provides tips to improve processes such as medication reconciliation, lab and other test result follow-up, managing in-office wait times, specialist referrals and getting routine appointments quickly.

See the Additional Resources page for more training opportunities.

Specialist referral tactic

Earlier this year, Blue Cross’ Patient Experience team released its specialist referral folder, a new tactic to help practices manage patient expectations when referred to specialists. The folder helps guide the conversation about the time it may take to get an appointment with common specialists, definitions, a spot for medication lists and the specialist’s contact information. Paperwork pertinent to the referral can be kept in the folder so everything the patient needs for a successful appointment is in one place.

Patient Experience resources include a variety of tactic materials that center around the CAHPS Care domains. Materials include handouts, signs, and other tools for patients and staff.

We’re updating our site to enable visitors to view tactic materials, including the specialist referral folder and many other materials, such as tactics to improve wait times, medication reconciliation, patient portal use and more. Check out the Patient Experience site for more information.

Coming soon

Visit our Patient Experience site to discover new content and register for upcoming webinars, including sessions on telehealth interactions and health equity.

For information or to request a patient experience consultation, email PatientExperience@bcbsm.com.

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

As a reminder, we’re offering live, 30-minute educational webinars that provide updated information on documentation and coding for common challenging diagnoses. Webinars include an opportunity to ask questions. 

Here’s our upcoming webinar schedule and topic tentatively scheduled. The session starts at noon Eastern time. Log in to the provider training website to register.

To access the training site, follow these steps:

1. Log in to the provider portal
2. Click on Payer Spaces on the menu bar and then click on the BCBSM and BCN logo.
3. Under Applications, click on the Provider Training Site tile
4. Click on Submit on the Select an Organization page
5. Existing users who used the same email address as their provider portal profile email will be directed to the training site. If you used a different email address, contact ProviderTraining@bcbsm.com to update your profile.

Note: If you’re a new training site user, complete the one-time registration by entering your role and creating a password. This allows you to access the training site outside of the provider portal if needed.
If you need assistance navigating the provider training site, email ProviderTraining@bcbsm.com.

Locating a session

Click here to log in if you’re already registered for the provider training website. On the provider training website, look in the Event Calendar or use the search feature with the keyword “lunch” to quickly locate the 2023 sessions.

See the screenshots below for more details.

Previous sessions

You can also listen to previously recorded sessions. Check out the following:

For more information

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.

Bypass manual review requirement for medically necessary insulin pumps

As stated in a May 2020 Record article, health care providers must append the KX and TW modifiers to avoid the manual review process for a medically necessary replacement insulin pump. 

To avoid the manual review process, all the following must apply:

• Insulin pump malfunctioned.
• Manufacturer’s warranty has expired.
• Blue Cross Blue Shield of Michigan’s five-year reasonable useful lifetime, or RUL, hasn’t been reached.
• The above criteria are clearly documented in the beneficiary’s medical record.

By appending the KX and TW modifiers, you are certifying that the member’s insulin pump has malfunctioned after the manufacturer’s warranty period, but before the five-year RUL, and that the member meets Blue Cross medical criteria for an insulin pump. The KX or TW modifier can only be added to the claim if the malfunction is documented in the patient’s medical record.

As a reminder, the medical record isn’t limited to the treating practitioner’s office records, but may include records from hospitals, nursing facilities, home health agencies or other health care professionals. Records from suppliers or health care professionals with a financial interest in the claim outcome aren’t considered sufficient by themselves to determine that an item is reasonable and necessary.

Durable medical equipment prosthetic and orthotic suppliers are reminded that:

• Supplier-produced records, even if signed by the treating practitioner, and attestation letters (for example, letters of medical necessity) aren’t considered to be part of a medical record for Medicare payment purposes.
• Templates and forms, including Centers for Medicare & Medicaid Services certificates of medical necessity with a date of service before Jan. 1, 2023, must be corroborated with information in the medical record.
• A prescription isn’t considered to be part of the medical record. Medical information intended to demonstrate compliance with coverage criteria may be included on the prescription but must be corroborated by information in the medical record.
• The beneficiary’s medical record must contain sufficient documentation of his or her medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). The information should include the beneficiary’s diagnosis and other pertinent information including, but not limited to, duration of the beneficiary’s condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, and past experience with related items.