Health care providers in Blueprint for Affordability shared-risk program improve performance

We first published this article in the January-February issue of Hospital and Physician Update but are reprinting it here in case you missed it.

Nearly three years after the launch of the Blueprint for Affordability shared-risk payment model, we’re seeing some impressive results. Physicians in Blueprint arrangements improved affordability by more than $70 million, increased overall health care quality and improved patient outcomes.

“These results are especially impressive considering that the COVID-19 crisis disrupted most of health care over the past three years,” said Todd Van Tol, Blue Cross Blue Shield of Michigan’s executive vice president for Health Care Value. “Also noteworthy is that these results include commercial and Medicare Advantage members in our PPO plans.”

Currently, more than 50% of our total attributed Blue Cross commercial and Medicare Advantage Michigan-based membership is covered by physicians who participate in the shared-risk payment model. A total of 22 physician organizations have signed onto the Blueprint shared-risk program, making it one of the largest payment models of its kind nationally.

More details

Here are some additional results:

• In both 2020 and 2021, Blueprint providers outperformed their non-Blueprint peers in key measures related to affordability and quality. This corresponds to $52 million in lower Blue Cross commercial spend and $21 million in lower Medicare Plus Blue℠ spend.
• More than 60% of participating physician organizations outperformed their affordability targets for Blue Cross commercial members and earned a share of the savings generated by the program.
• Providers in the shared-risk Blueprint contract perform better than plan average on various quality metrics, including rate of breast cancer and colorectal screenings, childhood immunizations and diabetic control measures.
• In 2021, for Blue Cross commercial members, using a quality composite score made up of 14 different quality metrics, providers participating in a shared-risk Blueprint contract outperformed other providers by nearly five percentage points.

Announcing providers participating in full-risk arrangements

Blue Cross recently announced that six physician organizations have opted to participate in full-risk arrangements for treating their Medicare Advantage patients. As we wrote in an article in the November-December issue of Hospital and Physician Update, some physician organizations participating in shared- or full-risk arrangements are working with companies that will help them be more successful in value-based care models by offering “enablement solutions.”

The following table provides a list of physician organizations that have announced they’re signing full-risk agreements for their Medicare Advantage patients (both Medicare Plus Blue℠ and BCN Advantage℠), along with the enablement company they’re working with and their geographic coverage area.

Note: Some organizations are in both shared-risk and full-risk arrangements with Blue Cross.

Background

With Blueprint for Affordability’s shared-risk model, introduced in 2019, health care organizations agreed to put a portion of their payments from Blue Cross “at risk,” based on their success in managing their patients’ health, thereby lowering their total cost of care.

We recently expanded Blueprint for Affordability to include a broader range of value-based initiatives that include an increased level of accountability, combined with support and rewards for providers involved in risk-sharing relationships. Many of these programs focus on seniors with multiple chronic conditions who typically have increased health care needs that can lead to high costs when those conditions aren’t well managed.

We now consider Blueprint for Affordability to be an umbrella term to encompass all our shared- and full-risk provider partnerships.

“Blue Cross and provider partners have actually been pioneering the shift to value-based care in Michigan since 2005,” Van Tol said. “Through our many Value Partnerships initiatives, including the nation’s leading Patient-Centered Medical Home program, Blue Cross has saved $2.2 billion in medical costs.”

To read more

See the article, “Blueprint for Affordability expands to include wide range of value-based initiatives,” in the November-December 2022 issue of Hospital and Physician Update.

Voluntary prior authorization ends May 1

Effective May 1, 2023, Blue Cross Blue Shield of Michigan will no longer accept voluntary prior authorization requests. This change is a result of the new Michigan prior authorization legislation (referred to as Public Act 60), signed into law on April 7, 2022. Due to the new Michigan prior authorization requirements, Blue Cross will devote its resources to evaluating only those prior authorizations that are required by the patient’s benefit plan.

We encourage you to familiarize your team with the self-service tools available on our provider portal (availity.com**) to better determine whether a service will be covered. If you need assistance with navigating Availity^®, view a recorded webinar at Get Up to Speed with Training.**

Reminders

Before rendering services, make sure you check benefits, eligibility and medical policy coverage guidelines, using the self-service tools on our provider portal. Here are some reminders:

• Check benefits and eligibility at availity.com.**
• View benefit details through Benefit Explainer. This is available on the Applications tab within the Blue Cross and BCN Payer Space in availity.com.**
• Review medical policy through our Medical Policy Router Search.
• You can also check benefits and eligibility or request assistance by calling Provider Inquiry:
• Professional: 1-800-344-8525
• Facility: 1-800-249-5103

Additional information

The change related to voluntary prior authorizations only affects prior authorizations that are voluntary, sometimes referred to as “voluntary preapprovals.” The current process, which ends May 1, is described in the “Preapproval of Services Chapter” of the Blue Cross Commercial Provider Manual.

The ending of voluntary prior authorizations doesn’t affect any of the required Blue Cross prior authorization programs, which you can find by:

• Reviewing the Summary of utilization management programs for Michigan providers document
• Checking authorization requirements for a specific Blue Cross patient on our provider portal as follows:
1. Log in to our provider portal (availity.com**).
2. On the Patient Registration dropdown, click on Authorization & Referrals.
3. Click on Authorization Request and complete the requested information to determine if a certain procedure requires a prior authorization.

Watch for additional information in future issues of The Record.

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 and HCPCS Update now available

Each year, we publish our CPT and HCPCS Update document, containing new and deleted CPT and HCPCS codes, and post it on the Secure Provider Resources section of Availity^®. Our new document contains new and deleted codes, effective Jan. 1, 2023.

To access the 2023 CPT and HCPCS Update, follow these steps:

1. Log in to our provider portal at availity.com** and then click on Secure Provider Resources.
2. Click on Billing and Claims.
3. Click on Codes and Criteria.

You’ll want to use this document as a reference guide for new CPT and HCPCS codes for 2023. As future updates occur throughout the year, we’ll publish Record articles outlining the changes.

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 Shied of Michigan doesn’t own or control this website.

Billing chart: Blue Cross highlights medical, benefit policy changes

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

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

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

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

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

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

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

HEDIS medical record reviews begin in February

Each year from February through May, Blue Cross Blue Shield of Michigan and Blue Care Network conduct Healthcare Effectiveness Data and Information Set, or HEDIS^®, medical record reviews for members who live in Michigan. This year, Blue Cross’ HEDIS clinical consultants will conduct HEDIS reviews for services rendered in 2022 for members with:

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

As part of its efforts to support HEDIS and government-required programs, the Blue Cross and Blue Shield Association mandates which entities can retrieve medical records for patients living in Michigan but enrolled in another state’s Blue plan. Blue Cross is authorized to retrieve medical records for patients enrolled in a Blue Medicare Advantage plan in another state.

Inovalon, an independent data and analytics firm, is authorized to retrieve medical records for patients enrolled in all Blue Cross commercial and BCN commercial plans, as well as Blue Medicare Advantage private fee-for-service and HMO plans.

For the HEDIS reviews, Blue Cross looks for details that may not have been captured in claims data, such as blood pressure readings, HbA1c lab results and colorectal cancer screenings. This information helps us improve health care quality reporting for our members.

Blue Cross’ HEDIS clinical consultants will contact you to schedule an appointment for a HEDIS review or request that providers fax the necessary records. The HEDIS review also requires proof of service documentation for data collected from a medical record.

If you have questions or concerns, contact Ellen Kraft EKraft@bcbsm.com.

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

Nonclinical, transitional care program available to members discharged to additional post-acute care facilities

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.

This program is 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.

On Jan. 1, 2023, this program expanded to include members who are discharged to additional post-acute care facilities. To view the list of post-acute care facilities that participate in this program, see this provider alert.

For details about the nonclinical, transitional care program, see the November 2021 Record article.

Requirements changed for some commercial medical benefit drugs

Blue Cross Blue Shield of Michigan and Blue Care Network encourage proper utilization of high-cost medications that are covered under the medical benefit. As part of this effort, we maintain a comprehensive list of requirements for Blue Cross and BCN group and individual commercial members.

From October through December 2022, we added prior authorization requirements, site-of-care requirements, or both for Blue Cross commercial and BCN commercial members for the following medical benefit drugs:

For additional details, see the Blue Cross and BCN utilization management medical drug list. This list is available on the following pages of the ereferrals.bcbsm.com website:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

As a reminder, an authorization approval isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.

Additional information

For Blue Cross commercial groups, these 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. A link to this list is also available on the Blue Cross Medical Benefit Drugs page of ereferrals.bcbsm.com.

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.

We’re no longer requiring prior authorization for 29 medical oncology drugs

We’re no longer requiring prior authorization from AIM Specialty Health^® for dates of service on or after Jan. 1, 2023 for 29 medical oncology drugs. These drugs are part of members’ medical benefits.
This change applies to:

• Blue Cross Blue Shield of Michigan commercial groups
• Members with coverage through fully insured groups
• Members with coverage through self-funded groups that have opted into the medical oncology program (Refer to the AIM medical oncology prior authorization program opt-in list for Blue Cross commercial self-funded groups.)
• Members with individual coverage
• Medicare Plus Blue℠ members
• Blue Care Network commercial members
• BCN Advantage℠ members

Drugs affected by this change

The following drugs are affected by this change:

**The manufacturer is withdrawing this drug from the market.
***Requires prior authorization by AIM for Medicare Advantage members only, for dates of service through Dec. 31, 2022.

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

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

We’ve updated the appropriate drug lists to reflect the information in this article.

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.

Fylnetra and Rolvedon to require prior authorization for most commercial members starting March 13

Starting March 13, 2023, we're adding prior authorization requirements for most Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members for the following drugs covered under the medical benefit:

• Fylnetra^® (pegfilgrastim-pbbk), HCPCS codes J3590 and C9399
• Rolvedon™ (eflapegrastim-xnst), HCPCS codes J3590 and C9399

When submitting requests on or after March 13

Starting March 13, 2023, submit prior authorization requests for Fylnetra and Rolvedon through the NovoLogix^® online tool. It offers real-time status checks and immediate approvals for certain medications.

To access NovoLogix, log in to our provider portal at availity.com,** click on Payer Spaces in the menu bar and then click on the BCBSM and BCN logo. You’ll find links to the NovoLogix tools on the Applications tab.

Note: If you need to request access to our provider portal, follow the instructions on the Register for web tools webpage on bcbsm.com/providers.

When submitting requests before March 13

Before March 13, 2023, fax requests for preservice review as follows:

• For Blue Cross commercial members: Fax to Provider Inquiry at 1‑866‑311‑9603.
• For BCN commercial members: Fax to the Medical Drug Help Desk at 1‑877‑325‑5979.

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.

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 of the change.

You can access this list and other information about requesting prior authorization on the following pages of the ereferrals.bcbsm.com website:

• 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.

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.

Sign up for webinar about E/M code changes

We’ve scheduled informational webinars on the 2023 changes to the CPT code set for evaluation and management services. These live webinars include a scenario review and opportunity to ask questions. You’ll also have the opportunity to earn one AAPC CEU credit if you attend one of the live webinars.

We encourage physicians, coders, billers and administrative staff to attend one of the following four webinar sessions:

• 10 to 11:30 a.m. Tuesday, Feb. 7
• 2 to 3:30 p.m. Thursday, Feb. 9
• 2 to 3:30 p.m. Tuesday, Feb. 14
• 10 to 11:30 a.m. Wednesday, Feb. 15

To sign up for a webinar:

• Register for the provider training website if you have not already done so.

Note: We recommend using the same email as you use to communicate with Blue Cross Blue Shield of Michigan for other needs. This will become your login ID.

• Log in to the provider training website.
• Go to the Event Calendar (see the screenshot below) and sign up for the session that works best for your schedule.

Register now for 2023 virtual provider symposium sessions

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 welcome to register for any session listed below.

Click here to log in to the provider training website to register for sessions.

You can easily create an account if you don’t already have access: Click here to register. We recommend that 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 the following 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.

For Blue Cross commercial members, follow ICD-10-CM laterality policy

In support of correct coding and payment accuracy, Blue Cross Blue Shield of Michigan commercial plans will apply the ICD-10-CM laterality policy for diagnosis-to-modifier comparison and diagnosis-to-diagnosis comparison. This change will take effect in March 2023.
 
One of the unique attributes of the ICD-10-CM code set is that laterality has been built into code descriptions. Some ICD-10-CM codes specify whether the condition occurs on the left or right, or is bilateral. If no bilateral code is provided and the condition is bilateral, then codes for both left and right should be assigned. If the side isn’t identified in the medical record, then the unspecified code should be assigned.

Diagnosis-to-modifier comparison

The diagnosis-to-modifier comparison assesses the lateral diagnosis associated with the claim line to determine if the procedure modifier matches the lateral diagnosis.

For example: If a diagnosis code is submitted that shows a service was performed on the right ear, but the modifier submitted shows that it was performed on the left ear, the claim may be denied due to this conflict.

Diagnosis-to-diagnosis comparison

The diagnosis-to-diagnosis comparison assesses lateral diagnoses associated with the same claim line to determine if the combination is inappropriate.

For example: If a diagnosis code is submitted on Line 1 of a claim that shows a service was performed on the right ear, but a secondary diagnosis on the same claim, a diagnosis is submitted showing the service was performed bilaterally (on both ears), the claim may be denied due to the duplicative nature of the claim.

We’ve made changes to reimbursement policy for psychiatric residential treatment facilities

As you may have read in a provider alert in December, Blues Cross Blue Shield of Michigan has developed a new reimbursement policy for psychiatric residential treatment facilities, or PRTFs, effective Dec. 1, 2022. This new policy doesn’t affect facilities or hospital systems that are under contract with us for services through our Hospital Contracting area.

With this policy, Blue Cross recognizes diagnosis-specific pricing related to feeding disorders. If diagnosis code F50.9 is reported on a claim and is authorized by Blue Cross, then it will trigger a specialty rate as reflected on the PRTF fee schedule. 

This fee schedule change is only for outpatient psychiatric clinics.

Keep your 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 the Provider Authorization form as part of the electronic data interchange setup process. All EDI trading partners must complete the TPA and the Provider Authorization form before they can exchange PHI with Blue Cross.

It’s important to keep your Provider Authorization form updated. The terms of the TPA require you to notify Blue Cross of any changes in your trading partner information. 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 complete 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.

Patient resources for medication management

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

For patients with chronic conditions, such as diabetes, hypertension, asthma or hyperlipidemia, managing medications can be difficult. Here are resources to help your patients manage their medications:

• Blue Cross and Blue Shield Federal Employee Program^® and non-FEP patients can use the My Medication Record** from the National Council on Aging.
• FEP members can use the Personal Health Record found on the MyBlue^® member portal or in the fepblue app.

FEP also provides members the opportunity to speak with a registered nurse, day or night, if they have general questions about their medication or condition. They can call the 24/7 Nurse Line at 1-888-258-3432, go online to fepblue.org/myblue or use the fepblue app.

If health care providers or members have questions about FEP support services and benefits, they can call Customer Service at 1-800-482-3600 or go online to fepblue.org.

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

Blue Cross recognizes local health care facilities for demonstrating quality cardiac care

In the United States, one person dies every 34 seconds from a cardiovascular disease, according to the Centers for Disease Control and Prevention.** That’s why Blue Distinction^® Centers for Cardiac Care — part of the Blue Distinction Specialty Care program — are so important. Blue Distinction^® Centers for Cardiac Care empower patients with the information they need to choose quality, in-network cardiac care.

In February 2022, Blue Cross Blue Shield of Michigan, in coordination with the Blue Cross and Blue Shield Association, invited health care facilities in Michigan to participate in the application process for a nationwide designation as a Blue Distinction^® Center for Cardiac Care. To date, nearly 20 providers in the Blue Cross Blue Shield of Michigan commercial PPO network have completed the designation process.   

Blue Distinction Centers are nationally designated providers that have proven to deliver quality care with safe practices that lead to better health outcomes for patients. In order to provide meaningful quality and cost differentials to employers, employees and providers, the Association updates criteria for designation in each specialty area approximately every two years. Approved facilities must reapply for Blue Distinction Center designations during each reevaluation cycle to continue to be assessed for eligibility for the designation program. 

To receive a Blue Distinction Center for Cardiac Care designation, health care facilities must demonstrate expertise in delivering safe and effective cardiac care for: 

• Percutaneous coronary interventions
• Coronary artery bypass graft
• Aortic valve replacement
• Mitral valve replacement and repair

Health care facilities recognized as Blue Distinction Centers are assessed using quality information supplied by facilities and third-party data registries, which were developed with input from the medical community and leading accreditation and quality organizations. Blue Distinction Centers+ have also proven to provide more cost-efficient care and are evaluated using cost measures derived from Blue Cross and Blue Shield companies’ medical claims. Only those health care facilities that first meet the quality measures for Blue Distinction Centers are considered for designation as a Blue Distinction Center+.

Facilities that have been designated under the Blue Distinction Centers for Cardiac Care program can be found using the Find a Doctor search feature, available at bcbsm.com.

As part of the Blue Distinction Centers for Cardiac Care program, Blue Cross and Blue Shield companies across the nation have recognized hundreds of health care facilities for providing quality care for patients and for having lower in-hospital mortality rates and lower bleeding complication rates for angioplasty than non-Blue Distinction Centers. Designated facilities also meet additional national standards, with patients facing fewer readmissions and mortality rates for coronary artery bypass graft procedures and heart attacks, compared to facilities that don’t meet the criteria.

In addition to meeting the quality criteria, Blue Distinction Centers+ for Cardiac Care are 21% more cost-efficient, on average, than their non-Blue Distinction Centers+ peers.

Since 2006, the Blue Distinction Specialty Care program has helped patients find quality specialty care in the areas of bariatric surgery, cancer care, cardiac care, cellular immunotherapy, fertility care, gene therapy, knee and hip replacements, maternity care, spine surgery, substance use treatment and recovery, and transplants, while encouraging health care professionals to improve the care they deliver.

For more information

• To learn more about Blue Distinction Specialty Care and to find a Blue Distinction Center for a specific area of specialty care, including cardiac care, visit the Blue Distinction Specialty Care website.
• If you’re interested in applying for designation as a Blue Distinction Center for Cardiac Care, send an email to Michelle Williams at MWilliams3@bcbsm.com.

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

Nonclinical, transitional care program available to members discharged to additional post-acute care facilities

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.

This program is 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.

On Jan. 1, 2023, this program expanded to include members who are discharged to additional post-acute care facilities. To view the list of post-acute care facilities that participate in this program, see this provider alert.

For details about the nonclinical, transitional care program, see the November 2021 Record article.

Requirements changed for some commercial medical benefit drugs

Blue Cross Blue Shield of Michigan and Blue Care Network encourage proper utilization of high-cost medications that are covered under the medical benefit. As part of this effort, we maintain a comprehensive list of requirements for Blue Cross and BCN group and individual commercial members.

From October through December 2022, we added prior authorization requirements, site-of-care requirements, or both for Blue Cross commercial and BCN commercial members for the following medical benefit drugs:

For additional details, see the Blue Cross and BCN utilization management medical drug list. This list is available on the following pages of the ereferrals.bcbsm.com website:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

As a reminder, an authorization approval isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.

Additional information

For Blue Cross commercial groups, these 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. A link to this list is also available on the Blue Cross Medical Benefit Drugs page of ereferrals.bcbsm.com.

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.

We’re no longer requiring prior authorization for 29 medical oncology drugs

We’re no longer requiring prior authorization from AIM Specialty Health^® for dates of service on or after Jan. 1, 2023 for 29 medical oncology drugs. These drugs are part of members’ medical benefits.
This change applies to:

• Blue Cross Blue Shield of Michigan commercial groups
• Members with coverage through fully insured groups
• Members with coverage through self-funded groups that have opted into the medical oncology program (Refer to the AIM medical oncology prior authorization program opt-in list for Blue Cross commercial self-funded groups.)
• Members with individual coverage
• Medicare Plus Blue℠ members
• Blue Care Network commercial members
• BCN Advantage℠ members

Drugs affected by this change

The following drugs are affected by this change:

**The manufacturer is withdrawing this drug from the market.
***Requires prior authorization by AIM for Medicare Advantage members only, for dates of service through Dec. 31, 2022.

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

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

We’ve updated the appropriate drug lists to reflect the information in this article.

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.

Fylnetra and Rolvedon to require prior authorization for most commercial members starting March 13

Starting March 13, 2023, we're adding prior authorization requirements for most Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members for the following drugs covered under the medical benefit:

• Fylnetra^® (pegfilgrastim-pbbk), HCPCS codes J3590 and C9399
• Rolvedon™ (eflapegrastim-xnst), HCPCS codes J3590 and C9399

When submitting requests on or after March 13

Starting March 13, 2023, submit prior authorization requests for Fylnetra and Rolvedon through the NovoLogix^® online tool. It offers real-time status checks and immediate approvals for certain medications.

To access NovoLogix, log in to our provider portal at availity.com,** click on Payer Spaces in the menu bar and then click on the BCBSM and BCN logo. You’ll find links to the NovoLogix tools on the Applications tab.

Note: If you need to request access to our provider portal, follow the instructions on the Register for web tools webpage on bcbsm.com/providers.

When submitting requests before March 13

Before March 13, 2023, fax requests for preservice review as follows:

• For Blue Cross commercial members: Fax to Provider Inquiry at 1‑866‑311‑9603.
• For BCN commercial members: Fax to the Medical Drug Help Desk at 1‑877‑325‑5979.

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.

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 of the change.

You can access this list and other information about requesting prior authorization on the following pages of the ereferrals.bcbsm.com website:

• 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.

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.

Sign up for webinar about E/M code changes

We’ve scheduled informational webinars on the 2023 changes to the CPT code set for evaluation and management services. These live webinars include a scenario review and opportunity to ask questions. You’ll also have the opportunity to earn one AAPC CEU credit if you attend one of the live webinars.

We encourage physicians, coders, billers and administrative staff to attend one of the following four webinar sessions:

• 10 to 11:30 a.m. Tuesday, Feb. 7
• 2 to 3:30 p.m. Thursday, Feb. 9
• 2 to 3:30 p.m. Tuesday, Feb. 14
• 10 to 11:30 a.m. Wednesday, Feb. 15

To sign up for a webinar:

• Register for the provider training website if you have not already done so.

Note: We recommend using the same email as you use to communicate with Blue Cross Blue Shield of Michigan for other needs. This will become your login ID.

• Log in to the provider training website.
• Go to the Event Calendar (see the screenshot below) and sign up for the session that works best for your schedule.

We’ve made changes to reimbursement policy for psychiatric residential treatment facilities

As you may have read in a provider alert in December, Blues Cross Blue Shield of Michigan has developed a new reimbursement policy for psychiatric residential treatment facilities, or PRTFs, effective Dec. 1, 2022. This new policy doesn’t affect facilities or hospital systems that are under contract with us for services through our Hospital Contracting area.

With this policy, Blue Cross recognizes diagnosis-specific pricing related to feeding disorders. If diagnosis code F50.9 is reported on a claim and is authorized by Blue Cross, then it will trigger a specialty rate as reflected on the PRTF fee schedule. 

This fee schedule change is only for outpatient psychiatric clinics.

Keep your 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 the Provider Authorization form as part of the electronic data interchange setup process. All EDI trading partners must complete the TPA and the Provider Authorization form before they can exchange PHI with Blue Cross.

It’s important to keep your Provider Authorization form updated. The terms of the TPA require you to notify Blue Cross of any changes in your trading partner information. 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 complete 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.