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January 2023

All Providers

Follow these tips for checking claim status and viewing remittance advices and vouchers in Availity

Online provider toolsIf you’re still getting accustomed to using our new provider portal, Availity® Essentials, here are some tips that can help with claims-related activities.

Checking claim status

Click on Claims & Payments and then click on Claim Status. If you have more than one organization, select the appropriate one, then select BCBS MICHIGAN AND BLUE CARE NETWORK as the payer. Next, follow these steps:

  1. Use Member Search to select the patient.
  2. Once you find the patient, click the patient’s row. This opens the HIPAA Standard tab.
  3. Select the billing provider and complete the fields in the Claim Information section.
  4. Click on Submit.

Tip: Allow at least 72 hours for the claim to be processed before checking its status.

Tip: For Federal Employee Program® contracts or contracts from non-Michigan Blue plans, start with the HIPAA Standard tab.

Using the Remittance Viewer in Availity

Click on Claims & Payments and then click on Remittance Viewer twice.

Tip: When you open the Remittance Viewer, you’ll see a pop-up screen titled Welcome to Remittance Viewer with a link at the bottom to a demo for using the tool.

The Remittance Viewer screen has two tabs:

  • Check/EFT —This tab opens by default. Use this to search with payment information.
  • Claim Use this tab to search with claim information.

Tip: Make sure the date span is correct for the search option you use. With the Check/EFT tab, it’s best to search for a couple of days before and after the check date.

Tip: When you find results, you’ll see a row of data. On the right, there will be an Actions column. One of the items is labeled EOP/EOB when you hover your mouse over it. This is the voucher you’re used to seeing in Provider Secured Services/web-DENIS. Another item is labeled Download when you hover your mouse over it. This is the electronic remittance advice that you can download as a PDF.

Submitting claims through the Availity Claim Submission tool

If you use Availity’s Claims Submission tool to submit claims to Blue Cross Blue Shield of Michigan and Blue Care Network, you need to make sure the member prefix is included with the member contract number on your claim. The prefix is usually three alpha characters preceding the nine-digit contract number. Federal Employee Program contract numbers are an exception, with an R followed by an eight-digit contract number.

In some cases, when you search for a Blue Cross or BCN member within Availity, the results don’t display the contract prefix. If you submit a claim that doesn’t include the prefix, the claim will reject due to an incomplete or invalid contract number.

To find the prefix, look up the patient in Availity’s Eligibility and Benefits Inquiry tool (found under the Patient Registration dropdown) and click on View Member ID Card near the top of the results page. The ID card image will include the complete contract number (called the Subscriber ID), including the prefix.

Training assistance

Here’s where you can learn more.

  • Go to the Availity Learning Center. Here’s how:
    1. Within Availity, click on Help & Training
    2. Click on Get Trained.
    3. In the search bar, click the Catalog icon (which looks like a folder) and search for either:
      • Claim Status Training Demo
      • Availity Claim Status
      • Remittance Solutions Training Demo
      • Remittance Viewer: Tips for finding what you need. Fast.

Troubleshooting

If you’re having problems checking claim status or using the Remittance Viewer, ask your Availity administrator to make sure you have the claim status role assigned to you.

Contact Availity Client Services for one-on-one assistance by calling 1-800-AVAILITY (282-4548) from 8 a.m. to 8 p.m. Eastern time, Monday through Friday (excluding holidays). Request an ACS ticket number for reference in case this call doesn’t resolve your problem and you need follow-up assistance.

Still need to register?

Find out how at Register for Availity Essentials.** Learn more at Get Started with Availity Essentials.**

Have you been surprised by a paper check when you expected electronic payment?

If you submit a claim with a tax ID that doesn’t match what we have in our system for electronic funds transfer, or EFT, the claim will pay by paper check instead of EFT. Review your recent vouchers that were paid via EFT to note the tax ID.

If you need to revise your EFT information, check out EFT training within the Availity Learning Center or in the Get Up to Speed with Training** website, or call 1-800-AVAILITY (282-4548), from 8 a.m. to 8 p.m. Eastern time, Monday through Friday (excluding holidays). Request an ACS ticket number for reference in case this call doesn’t resolve your problem and you need follow-up assistance.

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.


We’re updating Benefit Explainer to include Medicare Plus Blue benefit information

We’re making updates to Benefit Explainer to improve the information available to you online and make it easier for you to do business with us. These changes will give you access to the same medical and benefit policy information for our Medicare Plus Blue℠ members as you already have for our commercial plan members.

Benefit Explainer will continue to have Blue Cross Blue Shield of Michigan benefit information only; Blue Care Network benefit information isn’t included.

What you need to know

As of Nov. 7, we added a new link and tab for Medicare Plus Blue benefits. The new tab and link are labeled “Medicare Advantage Policy.” Although the new link and tab are visible to you now, the data won’t be loaded until a later date. Once the Medicare information is loaded, the new tab and link will be available for use. We’ll share more information with you as we get closer to the data launch.

The tab and link previously titled “Medical/Payment Policy” are now labeled “Commercial Policy.”

These tabs and links, along with others, will continue to function as usual.

Other changes

  • The coverage limitation previously labeled “Facility Emergency” is now labeled “Outpatient Facility Emergency.”
  • The coverage limitation previously titled “Discharge Diagnosis” is now labeled “Admitting Diagnosis.”

The Communications tab has a new field called “Commercial/Medicare Advantage Identifier.”

If you have any questions or need additional information, call Provider Inquiry.


We’re making a change to Record article categories

As part of our ongoing efforts to streamline The Record, we’re eliminating the Pharmacy category. Record articles related to prescription drugs will typically appear in the Professional or Facility categories, or both, depending on which types of health care providers require the information. Prescription drugs include those covered under pharmacy benefits as well as those covered under medical benefits.

We’re doing this because most pharmacies don’t receive The Record, and we want the Record categories to better reflect the types of providers who need to read these articles. In addition, articles that previously appeared in the Pharmacy category tend to focus on prescription drugs and how professional and facility health care providers prescribe and administer those drugs.

Beginning with this issue, following are the categories that will be used:

  • Professional (e.g., doctor’s offices)
  • DME
  • Facility (e.g., hospitals)
  • Vision
  • All providers

If you have any questions, send an email to provcomm@bcbsm.com.


Members enrolled in Healthy Blue Choices POS don’t need referrals to specialists

What you need to know

We want to let specialists who participate with Blue Cross Blue Shield of Michigan know that members enrolled in Healthy Blue Choices℠ POS don’t need a referral to see them for covered services. However, some services are covered only from in-network providers, including office visits.

Healthy Blue Choices℠ POS is a new point-of-service plan, effective Jan. 1, 2023, for FCA non-bargaining employees and retirees** that allows the flexibility to receive covered health care services in or out of network without a referral. It’s administered by Blue Care Network and works similarly to our popular Blue Elect Plus℠ POS plan.

Members enrolled in Healthy Blue Choices POS or Blue Elect Plus POS don't need a referral for any covered service. They can refer themselves to any provider — even to providers who are considered out of network for this product.

The member ID card prefix for both plans is the same one that’s on the member ID card for HMO coverage. The difference is that the front of the ID card shows the name of the plan. (See image below.) In addition, there is wording on the back of the card noting that referrals aren’t required.

Healthy Blue Choices POS for employees
(Note: Retirees have an XYD prefix.)

Requirements for selecting a primary care provider

Healthy Blue Choices POS members with a Michigan address must select a BCN primary care physician; however, they also have the option to receive covered health care services in or out of network without a referral. Members who live outside of Michigan, with a non-Michigan address, don’t need an assigned primary care physician. They also don’t need a referral — they just need to see a BlueCard-participating provider if they want to pay the lower in-network out-of-pocket costs.

More key information

  • All members have lower costs when seeing in-network providers.
  • Authorization requirements apply for certain services provided by both in- and out-of-network providers.
  • Some services are covered by in-network providers only, including most preventive services defined by the Affordable Care Act, office visits, durable medical equipment, prosthetics and orthotics, diabetic supplies, routine prenatal care (for members with active employee coverage) and colonoscopy (for members with retiree coverage).
  • Some services aren’t handled through Blue Care Network, including behavioral health services, infertility treatment services and pharmacy.

For more information

Refer to the Healthy Blue Choices℠ POS webpage for more information. If you have questions about Healthy Blue Choices POS, call Provider Inquiry as follows:

  • Physicians and professional providers: 1-800-344-8525
  • Hospitals and facilities: 1-800-249-5103

**FCA bargaining employees are covered under a separate health plan administered by Blue Care Network.


2023 early-release CPT Category III code update: New codes added

Category III codes
Medicine

Code Change Coverage comments Effective date
0738T Added Not covered Jan. 1, 2023
0740T Added Not covered Jan. 1, 2023
0741T Added Not covered Jan. 1, 2023
0743T Added Not covered Jan. 1, 2023
0745T Added Not covered Jan. 1, 2023
0746T Added Not covered Jan. 1, 2023
0749T Added Not covered Jan. 1, 2023
0750T Added Not covered Jan. 1, 2023
0764T Added Not covered Jan. 1, 2023
0765T Added Not covered Jan. 1, 2023
0766T Added Not covered Jan. 1, 2023
0767T Added Not covered Jan. 1, 2023
0768T Added Not covered Jan. 1, 2023
0769T Added Not covered Jan. 1, 2023
0770T Added Not covered Jan. 1, 2023
0771T Added Not covered Jan. 1, 2023
0772T Added Not covered Jan. 1, 2023
0773T Added Not covered Jan. 1, 2023
0774T Added Not covered Jan. 1, 2023
0776T Added Not covered Jan. 1, 2023
0777T Added Not covered Jan. 1, 2023
0778T Added Not covered Jan. 1, 2023
0779T Added Not covered Jan. 1, 2023
0780T Added Not covered Jan. 1, 2023
0783T Added Not covered Jan. 1, 2023

Category III codes
Pathology and Laboratory

Code Change Coverage comments Effective date
0751T Added Not covered Jan. 1, 2023
0752T Added Not covered Jan. 1, 2023
0753T Added Not covered Jan. 1, 2023
0754T Added Not covered Jan. 1, 2023
0755T Added Not covered Jan. 1, 2023
0756T Added Not covered Jan. 1, 2023
0757T Added Not covered Jan. 1, 2023
0758T Added Not covered Jan. 1, 2023
0759T Added Not covered Jan. 1, 2023
0760T Added Not covered Jan. 1, 2023
0761T Added Not covered Jan. 1, 2023
0762T Added Not covered Jan. 1, 2023
0763T Added Not covered Jan. 1, 2023

Category III codes
Radiology

Code Change Coverage comments Effective date
0742T Added Not covered Jan. 1, 2023
0747T Added Not covered Jan. 1, 2023

Category III codes
Surgery

Code Change Coverage comments Effective date
0739T Added Not covered Jan. 1, 2023
0744T Added Not covered Jan. 1, 2023
0748T Added Not covered Jan. 1, 2023
0775T Added Not covered Jan. 1, 2023
0781T Added Not covered Jan. 1, 2023
0782T Added Not covered Jan. 1, 2023

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.

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.
Code* BCBSM changes to:
Basic Benefit and Medical Policy, Group
Variations Payment Policy, Guidelines
NEW PAYABLE PROCEDURES

89344

Basic benefit and medical policy

Assisted reproductive techniques

Selected assisted reproductive techniques, or ART, are established and may be considered useful therapeutic options in the treatment of infertility.

When infertility is due to an underlying medical condition (for example, chronic infection, uterine fibroids, etc.), the treatment of that disorder is medically necessary and is covered under basic medical-surgical benefits.** When no medically correctable underlying medical condition is found (for example, low sperm count, anovulation), other options may be pursued. One option is ART — specific services that may be used to establish pregnancy. Assisted reproductive techniques are only available to members when the employer group has chosen to offer the services as additional or extra benefits through certificate benefit language or riders.

The focus of this policy is the use of ART in heterosexual couples who are infertile. Eligibility of same-sex couples or single individuals for ART is based on benefit coverage (the certificate of coverage or rider) and is beyond the scope of this medical policy.

**See the medical policy “Infertility Diagnosis.”

Procedure code *89344 was added as a covered service when billed with a diagnosis related to azoospermia, effective Sept. 1, 2022. The criteria was also updated to include elective single embryo transfer.

Basic benefit policy group variations

Inclusions:

Assisted reproductive techniques, or ARTs, aren’t general medical or surgical benefits. While the procedures listed in the inclusions are considered established, these services are available only as additional benefits, offered by a group or employer. The covered services and limitations are defined by the group or employer. The benefit plan, including the certificate of coverage or rider, determines the available coverage.

To access benefits for assisted reproductive techniques, the definition of infertility*** must be met. A benefit document (certificate of coverage or rider) may specify that the definition of infertility isn’t a requirement for ART services; it’s only in this case that the requirement of meeting the definition of infertility waived.  

***Infertility: Failure to achieve pregnancy after 12 months of unprotected intercourse in women younger than 35 years of age, or after six months in women older than 35 years of age.

Inclusions:

  • Artificial insemination
  • Assisted reproductive technologies:
    • In vitro fertilization, or IVF
    • Gamete intrafallopian transfer, or GIFT
    • Transuterine fallopian transfer, or TUFT
    • Natural oocyte retrieval with intravaginal fertilization, or NORIF
    • Pronuclear state tubal transfer, or PROST
    • Tubal embryo transfer, or TET
    • Zygote intrafallopian transfer, or ZIFT
    • Embryo transfer
    • Blastocyst transfer
    • Intracytoplasmic sperm injection, or ICSI, for male factor infertility only
    • Cryopreservation of embryos and sperm****
    • Storage of embryos and sperm
    • Thawing of embryos and sperm
    • Assisted embryo hatching when one of the following criteria is met:
      • The individual is 38 years of age or older.
      • There have been two or more IVF failures related to failed implantation.
    • Elective single-embryo transfer, or eSET

Exclusions:

  • Intracytoplasmic sperm injection in the absence of male factor infertility
  • Co-culture of embryos
  • Cryopreservation of ovarian tissue or testicular tissue****
  • Storage of ovarian tissue or testicular tissue
  • Thawing of ovarian tissue or testicular tissue****
  • All services related to gestational surrogacy, gestational parent, gestational carrier
  • Time lapse monitoring or imaging of embryos (for example, EmbryoScope)
  • Endometrial receptivity testing (for example, ERA®, or Endometrial Receptivity Analysis)
  • ART services are excluded when there has been a voluntary sterilization procedure (for example, tubal ligation, vasectomy), including when there has been surgical reversal of the sterilization procedure, as this is not considered treatment of disease
  • Reversal of prior sterilization procedure is excluded

****Cryopreservation and thawing of testicular tissue in adult men with azoospermia is considered medically necessary as part of the intracytoplasmic sperm injection procedure.

POLICY CLARIFICATIONS

0002M, 0003M ,76391, 81596, 76981, 76982, 76983, 91200,

Experimental
0014M, 76498,** 81599,** 84999**

**Unlisted codes

Basic benefit and medical policy

Noninvasive techniques for patients with chronic liver disease

The policy has been updated to cover procedure codes *0002M and *0003M when criteria are met, effective Sept. 1, 2022.

The safety and effectiveness of ultrasonic transient elastography (FibroScan®) for the evaluation or monitoring of patients with chronic liver disease have been established. It may be considered a useful diagnostic option when indicated.

Magnetic resonance elastography for the diagnosis and management of advanced hepatic fibrosis or cirrhosis has been established. It may be considered a useful option when indicated.

The use of other noninvasive imaging, including, but not limited to, acoustic radiation force impulse imaging, or ARFI, or real-time tissue elastography, is considered experimental for the evaluation or monitoring of patients with chronic liver disease. While these services may be safe, their clinical utility for this clinical indication hasn’t been determined.

The use of FibroSURE™ multianalyte assays (HCV FibroSURE, ASH FibroSURE, NASH FibroSURE) in chronic liver disease has been established. It may be considered a useful diagnostic option when indicated.

The peer-reviewed medical literature hasn’t demonstrated the clinical utility of other multianalyte assays with algorithmic analyses (for example, FIBROSpect II, Enhanced Liver Fibrosis Test) for the evaluation or monitoring of patients with chronic liver disease. Therefore, these services are considered experimental.

Inclusions:

Noninvasive imaging techniques:

  • Ultrasound transient elastography (FibroSCAN®), using an FDA-approved probe (for example, S+ M+ or XL+ Probe), may be considered established for the evaluation or monitoring of chronic liver disease.
  • Magnetic resonance elastography may be considered established for the diagnosis or management of advanced hepatic fibrosis or cirrhosis for one of the following:
    • Individuals with nonalcoholic fatty liver disease who have high risk for cirrhosis due to advanced age, obesity, diabetes or alanine aminotransferase level more than twice the upper limit of normal
    • Individuals with other established chronic liver diseases when ultrasound elastography cannot be performed or is nondiagnostic

Multianalyte assays:
 

  • A FibroSURE™ multianalyte assay (either HCV FibroSURE™, ASH FibroSURE™ or NASH FibroSURE™) may be considered established for the evaluation or monitoring of chronic liver disease.

Exclusions:

Noninvasive imaging techniques:

  • Ultrasound transient elastography in individuals with ascites
  • Acoustic radiation force impulse imaging
  • Real-time tissue elastography
  • Use of ultrasound elastography to differentiate benign from malignant liver lesions

Multianalyte assays:

Multianalyte assays with algorithmic analyses for the evaluation or monitoring of patients with chronic liver disease not listed above (for example, Fibrospect, ELF, etc. — not a complete list)

0239U, 0242U, 81191-81194, 81210, 81235, 81275, 81276, 81404-81406, 81445, 81455, 81479,** 88346, 88350, 0179U

**Unlisted procedure code

Basic benefit and medical policy

Circulating tumor DNA for non-small cell lung cancer

Payment policy:

Modifiers 26 and TC (TOS P and K) don’t apply to procedure codes *0239U and *0242U.

Not payable in an office location or ambulatory surgical facility, or ASF.

Payable to an M.D., D.O., and independent laboratory only.

Medical policy statement:

The effectiveness and clinical utility of circulating tumor DNA of individual genes, listed multiple gene panels when more than five genes are tested and FDA-approved companion diagnostic tests for the management of non-small cell lung cancer (liquid biopsy) have been established. They may be considered a useful therapeutic option when indicated.

Inclusionary guidelines have been updated. Procedure codes *0239U and *0242U being changed from experimental to payable effective date of Sept. 1, 2022.

Inclusions:

Analyzing cell-free/circulating tumor DNA (ctDNA) alterations in the ALK, EGFR, BRAF V600E, KRAS, ROS1, NTRK, MET exon14 skipping, PD-L1, ERBB2 (HER-2) and RET gene using one of the following methods:

  1. Individual genes
  2. Targeted multi-gene panels
  3. FDA approved companion diagnostic tests (for example, Cobas® EGFR, or Epidermal Growth Factor Receptor Mutation Test v.2, FoundationOne® Liquid CDx, Guardant360® CDx) 

When all the following apply:

  • Advanced stage III or IV non-small cell lung cancer
  • Clinical circumstances reflect one of the following:
    1. Patient is medically unfit for invasive tissue sampling.
    2. Following pathologic (biopsy) confirmation of a NSCLC diagnosis there is insufficient material for molecular analysis and follow-up tissue-based analysis is planned for all patients in which an oncogenic driver isn’t identified.
  • Used to detect ctDNA for targeted therapy benefit or to identify patients who won’t benefit from further molecular testing.

Exclusions:

  • Use of circulating tumor DNA (ctDNA) for any indications not mentioned above
  • Cell-free testing when the patient already meets criteria for treatment based on known biomarker status.  (for example, patient has already had testing or testing isn’t required).

J0179

Basic benefit and medical policy

Beovu (brolucizumab-dbll)

The FDA has updated the payable indications for Beovu (brolucizumab-dbll) effective May 27, 2022. The payable indications include diabetic macular edema.

J9228

Basic benefit and medical policy

Yervoy (ipilimumab)

Yervoy (ipilimumab) is covered for the following updated FDA-approved indication, effective May 27, 2022:

  • Esophageal cancer: Treatment of adult patients with unresectable advanced or metastatic esophageal squamous cell carcinoma as first-line treatment in combination with nivolumab.

Dosing information:

Esophageal squamous cell carcinoma: Yervoy 1 mg/kg every six weeks with nivolumab 3 mg/kg every two weeks or 360 mg every three weeks.

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.

Professional

New radiology-focused initiative aims to improve quality of care and patient outcomes

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

Covera’s quality improvement programs support radiology facilities and radiologists in their efforts to:

  • Engage in continuous quality improvement. 
  • Identify peer-learning opportunities.
  • Improve quality of care provided to members.
  • Improve patient outcomes.

Participating practices and radiologists will:

  • Have access to Covera’s Diagnostic Intelligence Platform, which includes quality assurance tools that incorporate clinically validated artificial intelligence and data science.
  • Have access to confidential quality assurance analytics and quality insights, including study-level, provider-level and practice-level reporting. This includes actionable insights to target clinical areas where additional peer learning and educational activities may be beneficial.
  • Be eligible for a high-quality designation. This designation makes it easier for referring providers to refer patients to high-quality radiology centers, which will help to improve member outcomes.

Program participation and quality assurance insights

  • Participation in this program will be voluntary and will be available to all radiology providers and facilities. Neither reimbursement nor value-based arrangements will be affected if a practice or radiologist chooses not to participate in Covera’s quality improvement program.
  • To participate in the program, practices must apply and complete participation agreements with Covera.
  • As part of its certification by the Agency for Healthcare Research and Quality as a patient safety organization, Covera can’t share sensitive provider data with other parties, including Blue Cross and BCN. This includes data related to quality assurance analytics and insights.

Program availability

Starting in April 2023, the program will be available for the following groups and members:

  • BCN commercial — Members who have coverage through fully insured groups and members who have individual coverage
  • BCN Advantage℠ — All groups and all members who have individual coverage
  • Blue Cross commercial — Members who have coverage through fully insured groups and members who have individual coverage
  • Medicare Plus Blue℠ — All groups and all members who have individual coverage

Designations for quality and value

On prior authorization requests approved by AIM Specialty Health®, Covera designations will display as follows:

  • For BCN commercial, BCN Advantage and Medicare Plus Blue members, facilities will be identified as having high-quality designations and will be listed as recommended providers.
  • For Blue Cross commercial, facilities will be identified as having high-quality designations.

Providers that are designated as high quality and are also cost effective will receive an additional “high-value” designation on prior authorization requests approved by AIM. Cost efficiency is determined through cost factors including (but not limited to):

  • The cost of the diagnostic service being requested
  • The average cost of the service in the geographic area

Only radiology centers that have been designated as high-quality are eligible to receive the high-value designation.

Register for webinars to learn more

Blue Cross, BCN and Covera Health will host webinars throughout the program, starting in January 2023. The webinars will provide an overview of the Covera programs, how they improved outcomes for members and providers, and how they can enhance peer learning opportunities.

For more information on dates and clinical areas covered, go to coverahealth.com/webinar.**

Questions?

If you have questions about this program, contact Covera Health by calling 1-855-211-2272 or by sending an email message to bcbsmsupport@coverahealth.com.

Our commitment to quality

Blue Cross and BCN are proud to be leaders in advancing collaborative partnerships with our provider community to improve the quality, outcomes and value of care delivered to our members. This new radiology-focused initiative represents a significant step in fulfilling our commitment to our providers, our members and the communities we serve.

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

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. For more information, go to our ereferrals.bcbsm.com website.

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


Billing changes coming for COVID-19 treatment products

Since the development of COVID-19 treatment products, the U.S. government has provided these products at no cost to health care providers. Because of this, providers submitted claims to Blue Cross Blue Shield of Michigan or Blue Care Network only for the administration of the products.

As the remaining federal supply runs out, these products are transitioning to the commercial marketplace.After a product transitions, providers will need to purchase it and submit a claim to Blue Cross or BCN for both the product and the administration of the product. For Blue Cross commercial and BCN commercial members, out-of-pocket costs may apply for commercialized treatment products.

Notes:

  • For Medicare Advantage members, we’re waiving all out-of-pocket costs for monoclonal antibody products and administration until the end of the year in which the public health emergency ends, according to the Centers for Medicare & Medicaid Services. Read the Dec. 17, 2021, provider alert for information about billing Medicare Advantage plans for monoclonal antibody products and administration.
  • For information about billing for the vaccine product after the federal supply runs out, see this article.

Expected time frame for additional products to transition to commercial marketplace

According to the Administration for Strategic Preparedness & Response,** following is the expected time frame for these products to transition to the commercial marketplace:

  • Evusheld, pre-exposure prophylaxis — early 2023
  • Lagevrio, oral antiviral — first quarter 2023
  • Paxlovid, oral antiviral — mid-2023

Additional information

For more information on COVID-19 vaccines, treatment, billing, etc., refer to our Coronavirus webpage. To access this page, log in to our provider portal (availity.com**) and follow these steps:

  1. Click on Payer Spaces in the menu bar and then click on the BCBSM and BCN logo.
  2. Click on the Resources tab.
  3. Click on the Secure Provider Resources (Blue Cross and BCN) link.
  4. Click on the Coronavirus information link under Easy Access.

You can also view these documents on our public coronavirus webpage.

Note: The U.S. Department of Health and Human Services is assisting providers who treat uninsured or underinsured patients with commercially purchased bebtelovimab by offering to replace the dose for free. HHS expects the supply for this initiative** to last through September 2023.

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

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


Here’s what you need to know about COVID-19 vaccines

When the government-purchased supply of COVID-19 vaccines runs out, health care providers should bill members’ health plans for both administration and the vaccine. We’ll process claims based on members’ immunization benefits.

As a reminder, you can view our COVID-19 provider communications as follows:

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

    Tip: You can make the Provider Resources site a favorite by clicking the heart icon next to this link. Clicking the heart adds a Secure Provider Resources (Blue Cross and BCN) link to the My Favorites menu.

  5. Under Easy Access, click on Coronavirus information.

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

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

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


User guide created to assist providers with importing medical records

EXL Health has created a user guide to assist health care providers with importing medical records into their portal. EXL is an independent company that contracts with Blue Cross Blue Shield of Michigan to conduct medical claim audits for Medicare Plus Blue℠ and Blue Cross commercial members.

No need to register

Providers, hospitals and facilities don’t need to register for an account to use the portal. They can use their facility name, letter reference key or email address to begin importing the requested medical records at exlhealthproviderportal.exlservice.com.**

Some features of EXL provider portal:

  • Provides upload confirmation
  • Records uploaded in real time
  • Enables multiple document types and audits to be included in single upload
  • Allows users to check status of audits

Training

Providers can get instructions needed for training staff on using the portal at exlservice.com/how-to-send-medical-records.**

Questions?

EXL is available to assist during any step of the process. Contact EXL by calling 1‑833-717-0378 and pressing “0” from 8 a.m. to 5 p.m. Eastern time Monday through Friday.

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


Here are the 2023 FEP benefit changes

Blue Cross and Blue Shield Federal Employee Program® 2023 benefit changes will take effect Jan. 1, 2023. Below is an overview of the changes.

Acupuncture

  • Basic Option only
    • We now cover 12 acupuncture visits per calendar year.

Bariatric surgery

  • Standard Option, Basic Option and FEP Blue Focus
    • We now provide benefits for medically necessary bariatric surgery beginning at age 16.

Diagnostic services

  • Basic Option only
    • The coinsurance for laboratory tests (such as blood tests and urinalysis), pathology services and EKGs is now 15%.

Facility

  • Basic Option only
    • The copayment for an inpatient admission is now $250 per day for up to $1,500 per admission for unlimited days.
    • The copayment for outpatient surgical and treatment services performed and billed by a facility is now $150 per day per facility.
    • The copayment for outpatient observation services performed and billed by a hospital or freestanding ambulatory facility is now $250 per day up to $1,500.
    • The copayment for outpatient hospital emergency room services and supplies, including professional provider services, diagnostic studies, radiology services, laboratory tests and pathology services, when billed by the hospital is now $250 per day per facility.
    • The copayment for outpatient diagnostic testing and treatment services performed and billed by a facility is now $200 per day per facility.

Infertility

  • Standard Option, Basic Option and FEP Blue Focus
    • We now cover one year of sperm and egg storage for individuals facing iatrogenic infertility.

Maternity

  • Standard Option, Basic Option and FEP Blue Focus
    • We now provide eight visits per calendar year to treat depression associated with pregnancy with no member out-of-pocket costs when a Preferred provider is used.
    • We now provide individuals who are pregnant with a free blood pressure monitor when ordered through the FEP vendor.

Medical food

  • Standard Option, Basic Option and FEP Blue Focus
    • We now cover medical foods for the treatment of inborn errors of amino acid metabolism regardless of age.

Pharmacy

  • Standard Option, Basic Option and FEP Blue Focus
    • We now cover the generic naloxone nasal spray with zero out-of-pocket costs for the first purchase of up to a 90-day supply per calendar year.
    • We now provide coverage for weight loss medications to treat obesity when obtained through one of the FEP pharmacy drug programs.
    • We now cover over-the-counter condoms for all members with zero member out-of-pocket costs when they have a prescription from their physician and are purchased in a Preferred retail pharmacy.
  • Standard Option only
    • Preferred insulins are now covered with a $35 copayment for up to a 30-day supply or a $65 copayment for a 31 to 90-day supply, when dispensed by a Preferred retail pharmacy.
    • Updates have been made to the approved drug list.
  • Basic Option only
    • The copayment for Tier 1 (generic drugs) without Medicare Part B primary is now $15 for each purchase of up to a 30-day supply ($40 for a 31 to 90-day supply).
    • The copayment for Tier 2 (preferred brand-name) drugs without Medicare Part B primary is now $60 for each purchase of up to a 30-day supply ($180 for a 31 to 90-day supply).
    • Members are now responsible for up to a $90 minimum copayment for Tier 3 (non-preferred brand-name) drugs for up to a 30-day supply ($250 minimum for a 31 to 90-day supply) without Medicare Part B primary.
    • Updates have been made to the approved drug list.
  • FEP Blue Focus only

Preventive care

  • Standard Option, Basic Option and FEP Blue Focus
    • We now cover computed tomography colonography under the adult preventive benefit for colorectal cancer tests.
    • We now cover preventive low-dose CT screenings for lung cancer for members aged 50 to 80.
    • FEP will make changes as soon as possible and provide preventive benefits for the U.S. Preventive Services Task Force A and B, the Advisory Committee on Immunization Practices, Health Resources and Services Administration, and Bright Futures recommendations as they occur throughout the year.

New prior approval requirements

  • Standard Option, Basic Option and FEP Blue Focus
    • We now require prior approval for certain high-cost drugs obtained outside of a pharmacy setting.
    • We now require prior approval for proton beam therapy.
    • We now require prior approval for stereotactic radiosurgery and stereotactic body radiation therapy.

Transplants

  • Standard Option, Basic Option and FEP Blue Focus
    • We no longer limit the number of non-full sibling donor screening tests for transplants.

For complete 2023 Blue Cross and Blue Shield Service Benefit Plan benefit information, go to fepblue.org/brochure or call Customer Service at 1-800-482-3600.


Know how to access and use RC Claim Assist through Availity Essentials

What you need to know

RC Claim Assist is available to Blue Cross Blue Shield of Michigan and Blue Care Network contracted health care providers through Availity® Essentials to help them bill for drugs covered under the medical benefit.

This article was developed to provide information on how to access and use RC Claim Assist, a free web‑based resource. RC Claim Assist provides:

  • An overview of medical drug products
  • A calculation tool to identify the correct National Drug Code and CPT codes to bill
  • The correct NDC quantity to bill
  • The unit of measure and HCPCS billable units according to the package information

How to access RC Claim Assist

Here’s how to find RC Claim Assist within Availity Essentials:

  1. Go to availity.com** and log in to your provider portal.
  2. Select Payer Spaces on the menu bar.
  3. Click on the BCBSM and BCN logo.
  4. Go to the Applications tab.
  5. Click on RC Claim Assist medical drug coding tool
  6. Click on Select a Provider.
  7. Click on Submit.

Tips to help you use RC Claim Assist

You can use any of the following starting points to retrieve the conversion between HCPCS or CPT and NDC:

  • HCPCS or CPT code
  • NDC code
  • Drug name

Refer to the tool only as a general reference and in conjunction with other resources, such as applicable fee schedules.

Note: Average wholesale price displayed is for reference only and doesn’t reflect the actual reimbursement in claims processing.

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.


Pemfexy to require prior authorization for most members starting Feb. 9

For dates of service on or after Feb. 9, 2023, we’ll require prior authorization for Pemfexy® (pemetrexed), HCPCS code J9304, through AIM Specialty Health®. This drug is part of members’ medical benefits, not their pharmacy benefits.

Prior authorization requirements apply when this drug is administered in outpatient settings for:

  • Blue Cross Blue Shield of Michigan commercial members who have coverage through UAW Retiree Medical Benefits Trust non-Medicare plans or fully insured groups, or who have individual coverage. Note: This requirement doesn’t apply to members who have coverage through other Blue Cross commercial self-funded groups, including the Blue Cross and Blue Shield Federal Employee Program®.
  • Medicare Plus Blue℠ members
  • Blue Care Network commercial members
  • BCN Advantage℠ members

How to submit authorization requests

Submit authorization requests to AIM using one of the following methods:

  • Through the AIM ProviderPortal, which you can access by doing one of the following:
  • Logging in to our provider portal (availity.com**), clicking on Payer Spaces and then clicking on the BCBSM and BCN logo. This takes you to the Blue Cross and BCN payer space where you’ll click the AIM Provider Portal tile.
  • Logging in directly to the AIM ProviderPortal at providerportal.com.**
  • By calling the AIM Contact Center at 1-844-377-1278

More about the authorization requirements

Authorization isn’t a guarantee of payment. As always, health care providers need to verify eligibility and benefits for members.

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

We’ll update the pertinent drug lists to reflect the information in this message 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 services.

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


Xenpozyme and Spevigo to have site-of-care requirements for most commercial members, starting in March

For dates of service on or after March 1, 2023, we’re adding site-of-care requirements for Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members for the following drugs covered under the medical benefit:

  • Xenpozyme (olipudase alfa), HCPCS code J3590
  • Spevigo (spesolimab-sbzo), HCPCS code J3590

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

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

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

As a reminder, these drugs already require prior authorization; providers can submit prior authorization requests using NovoLogix. The new site-of-care requirements are in addition to the current prior authorization requirements.

Members who start courses of treatment with Xenpozyme or Spevigo before March 1, 2023, 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 requirements 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 March 1, 2023.

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

As a reminder, authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.


Fylnetra now requires prior authorization for Medicare Advantage members

For dates of service on or after Dec. 19, 2022, we require prior authorization for Fylnetra® (pegfilgrastim-pbbk), HCPCS code J3590, for our Medicare Advantage members (both Medicare Plus Blue℠ and BCN Advantage℠ members). This drug is part of members’ medical benefits, not their pharmacy benefits.

Submit prior authorization requests through the NovoLogix® online tool.

When prior authorization is required

This medication requires prior authorization when it’s administered by a health care provider in sites of care such as outpatient facilities or physicians’ offices, and is 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 by using the UB04 claim form for a hospital outpatient type of bill 013x

Submit prior authorization requests through the NovoLogix tool

To access NovoLogix, 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. 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.

List of requirements

For a list of requirements related to drugs covered under the medical benefit, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members.

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

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


Hemgenix and Tzield require prior authorization for Medicare Advantage members

For dates of service on or after Dec. 2, 2022, we require prior authorization for Medicare Plus Blue℠ and BCN Advantage℠ members for the following drugs covered under the medical benefit:

  • Hemgenix® (etranacogene dezaparvovec-drlb), HCPCS code J3590
  • Tzield™ (teplizumab-mzwv), HCPCS code J3590

A prior authorization requirement also applies to most Blue Cross Blue Shield of Michigan and Blue Care Network commercial members. See this provider alert for more information.

Submit prior authorization requests through NovoLogix®

Submit prior authorization requests for Hemgenix and Tzield 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 (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.

To request access to our provider portal, follow the instructions on the Register for web tools webpage at bcbsm.com/providers.

When prior authorization is required

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

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

List of requirements

For a full outline of requirements related to drugs covered under the medical benefit for our Medicare Advantage members, refer to the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members.

We’ve updated this list to reflect the change for Hemgenix and Tzield.

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

Authorization isn't a guarantee of payment. As always, 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.


Reminder: What you need to know about billing specialty pharmacy drugs

We want to remind you that specialty pharmacy drugs shouldn’t be billed by both the specialty pharmacy and physician. 

When physician-administered drugs are ordered from the specialty pharmacy and shipped to the physician for administration, the specialty pharmacy submits the claim for the drug under the medical benefit. The physician should only bill for the administration of the drug. 

If the specialty drug is billed by both the specialty pharmacy and physician, the physician’s claim may be denied.


We’re expanding specialty pharmacy claim editing for Medicare Plus Blue

In support of correct coding and payment accuracy, we’ll begin applying additional edits for specialty pharmacy claims in March 2023 for our Medicare Plus Blue℠ members. These edits apply to claims processed under the medical benefit, not the pharmacy benefit.

They’ll address various coding inaccuracies, including, but not limited to:

  • Invalid National Drug Codes, or NDCs
  • Improper diagnosis codes
  • Quantities
  • Prior authorizations
  • Wastage

These edits are supported by guidelines as approved by the Centers for Medicare & Medicaid Services and other nationally recognized governing bodies. 


We’ve updated fax forms for submitting prior authorization requests to TurningPoint

On Nov. 22, 2022, Blue Cross Blue Shield of Michigan and Blue Care Network posted updated fax forms on ereferrals.bcbsm.com for use when submitting prior authorization requests to TurningPoint Healthcare Solutions, LLC, for musculoskeletal procedures.

We updated the forms as follows:

Prior authorization request form

Updates

Joint and spine procedures

  • Added a “Case urgency” section (standard or expedited)
  • Specified that for procedures with policies that have smoking and BMI criteria, the requesting provider must include signed documentation stating that they have discussed the risks and benefits of the procedure related to smoking and elevated BMI, as appropriate

Pain management: Epidural steroid injections

Added a “Case urgency” section (standard or expedited)

Pain management: Facet joint injection

Added a “Case urgency” section (standard or expedited)

Pain management: Neuroablation procedures

  • Added a “Case urgency” section (standard or expedited)
  • Added the question: “Is this request for Iovera® (cryoabltion)?”

Pain management: Sacroiliac joint injections

Added a “Case urgency” section (standard or expedited)

If you use fax forms to submit prior authorization requests to TurningPoint, be sure to incorporate the updated forms into your process.

You can find these forms and other useful resources on these pages of our ereferrals.bcbsm.com website:

TurningPoint Healthcare Solutions LLC is an independent company that manages authorizations for musculoskeletal surgical and related procedures for Blue Cross Blue Shield of Michigan and Blue Care Network.


New, engaging patient experience e-learning course now available

Action item

Visit our provider training site to learn how to improve the overall experience of your patients.

Many of you have been asking for a self-directed, virtual approach to learning best practice tips, tools and techniques for improving the patient experience in personal and office interactions with patients. We’ve responded by developing a patient experience e-learning course, consisting of four modules.

The four modules include:

  • Understanding the patient experience
  • The changing expectations of consumers
  • The importance of clear communication in setting expectations and building relationships
  • The impact of the patient experience on health outcomes and tips for turning a good patient experience to a great one

The series is informative, engaging, fun and respectful of your busy schedules. It takes on average about 15 minutes to complete a module.

The modules have been reviewed and enthusiastically endorsed by a variety of our stakeholders, including physicians, physician organization staff and provider office staff.  They’re available for clinical and non-clinical staff on our provider training site. We encourage you to go through the modules individually or as part of a team in the office.

To register for and access provider training site

To request access to the site (if you haven’t already registered) or to link to the site, follow these steps:

  1. Open the registration page.
  2. Complete the registration. (We recommend using the same email you use to communicate with Blue Cross for provider-related needs. This will become your login ID.)
  3. Follow the link to log in.

If you need assistance creating your login ID or navigating the site, contact ProviderTraining@bcbsm.com.

Continuing education credits

The Minnesota Medical Association designates this activity for a maximum of 2 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Patient experience podcast series

As a reminder, be sure to check out our patient experience podcasts. For complete details, see the December Record article.


New on-demand training available

Action item

Visit our provider training site to find new resources on topics that are important to your role.

Provider Experience continues to offer new training resources for health care providers and staff. Our on-demand courses can help you work more efficiently with Blue Cross Blue Shield of Michigan and Blue Care Network.

We recently added the following learning opportunities:

  • HCPCS and revenue code combinations: This updated course shows you how to use reference tools to complete and troubleshoot Blue Cross commercial facility claims, addressing the transition to our new provider portal.
  • Patient experience eLearning: This new course reviews best practices for improving the overall experience of your patients. See this article, also in this issue of The Record, for complete details.

As a reminder, we also have courses available to physicians for continuing education credit. These include:

  • CMS Star measures overview
  • Patient experience podcast series called “Practice Up!” (See this article in the December Record for details.)

Check the dashboard on our provider training site for announcements of what’s available as we add more CME offerings to enhance the training experience for health care providers and staff.  

Complete the following steps to request access to the training site:

  1. Open the registration page
  2. Complete the registration. We recommend using the same email you use to communicate with Blue Cross for provider-related needs. This will become your login ID.
  3. Follow the link to log in.

If you need assistance creating your login ID or navigating the site, contact ProviderTraining@bcbsm.com.


Gastric stimulation questionnaire updated

On Nov. 14, 2022, we updated the Gastric stimulation questionnaire in the e-referral system for adult Medicare Plus Blue℠, Blue Care Network commercial and BCN Advantage℠ members.

We also updated the corresponding preview questionnaire on the ereferrals.bcbsm.com website.

As a reminder, we use our prior 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.

Preview questionnaires

You can access preview questionnaires at ereferrals.bcbsm.com. They show the questions you'll need to answer in the questionnaires that open in the e-referral system so you can prepare your answers ahead of time.

To find the preview questionnaires:

Authorization criteria and medical policies

The pertinent prior authorization criteria and medical policies are also available on the Authorization Requirements & Criteria page.


We won’t be bundling testing codes for sexually transmitted infections at this time

In an article in the October Record, we wrote that we planned to bundle STI testing codes in the near future. However, after additional consideration, we’ve decided not to move forward with this initiative at this time.

If a determination is made to pursue this initiative further, we’ll communicate about it in a future issue of The Record.

Facility

New radiology-focused initiative aims to improve quality of care and patient outcomes

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

Covera’s quality improvement programs support radiology facilities and radiologists in their efforts to:

  • Engage in continuous quality improvement. 
  • Identify peer-learning opportunities.
  • Improve quality of care provided to members.
  • Improve patient outcomes.

Participating practices and radiologists will:

  • Have access to Covera’s Diagnostic Intelligence Platform, which includes quality assurance tools that incorporate clinically validated artificial intelligence and data science.
  • Have access to confidential quality assurance analytics and quality insights, including study-level, provider-level and practice-level reporting. This includes actionable insights to target clinical areas where additional peer learning and educational activities may be beneficial.
  • Be eligible for a high-quality designation. This designation makes it easier for referring providers to refer patients to high-quality radiology centers, which will help to improve member outcomes.

Program participation and quality assurance insights

  • Participation in this program will be voluntary and will be available to all radiology providers and facilities. Neither reimbursement nor value-based arrangements will be affected if a practice or radiologist chooses not to participate in Covera’s quality improvement program.
  • To participate in the program, practices must apply and complete participation agreements with Covera.
  • As part of its certification by the Agency for Healthcare Research and Quality as a patient safety organization, Covera can’t share sensitive provider data with other parties, including Blue Cross and BCN. This includes data related to quality assurance analytics and insights.

Program availability

Starting in April 2023, the program will be available for the following groups and members:

  • BCN commercial — Members who have coverage through fully insured groups and members who have individual coverage
  • BCN Advantage℠ — All groups and all members who have individual coverage
  • Blue Cross commercial — Members who have coverage through fully insured groups and members who have individual coverage
  • Medicare Plus Blue℠ — All groups and all members who have individual coverage

Designations for quality and value

On prior authorization requests approved by AIM Specialty Health®, Covera designations will display as follows:

  • For BCN commercial, BCN Advantage and Medicare Plus Blue members, facilities will be identified as having high-quality designations and will be listed as recommended providers.
  • For Blue Cross commercial, facilities will be identified as having high-quality designations.

Providers that are designated as high quality and are also cost effective will receive an additional “high-value” designation on prior authorization requests approved by AIM. Cost efficiency is determined through cost factors including (but not limited to):

  • The cost of the diagnostic service being requested
  • The average cost of the service in the geographic area

Only radiology centers that have been designated as high-quality are eligible to receive the high-value designation.

Register for webinars to learn more

Blue Cross, BCN and Covera Health will host webinars throughout the program, starting in January 2023. The webinars will provide an overview of the Covera programs, how they improved outcomes for members and providers, and how they can enhance peer learning opportunities.

For more information on dates and clinical areas covered, go to coverahealth.com/webinar.**

Questions?

If you have questions about this program, contact Covera Health by calling 1-855-211-2272 or by sending an email message to bcbsmsupport@coverahealth.com.

Our commitment to quality

Blue Cross and BCN are proud to be leaders in advancing collaborative partnerships with our provider community to improve the quality, outcomes and value of care delivered to our members. This new radiology-focused initiative represents a significant step in fulfilling our commitment to our providers, our members and the communities we serve.

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

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. For more information, go to our ereferrals.bcbsm.com website.

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


Here’s what you need to know about COVID-19 vaccines

When the government-purchased supply of COVID-19 vaccines runs out, health care providers should bill members’ health plans for both administration and the vaccine. We’ll process claims based on members’ immunization benefits.

As a reminder, you can view our COVID-19 provider communications as follows:

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

    Tip: You can make the Provider Resources site a favorite by clicking the heart icon next to this link. Clicking the heart adds a Secure Provider Resources (Blue Cross and BCN) link to the My Favorites menu.

  5. Under Easy Access, click on Coronavirus information.

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

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

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


User guide created to assist providers with importing medical records

EXL Health has created a user guide to assist health care providers with importing medical records into their portal. EXL is an independent company that contracts with Blue Cross Blue Shield of Michigan to conduct medical claim audits for Medicare Plus Blue℠ and Blue Cross commercial members.

No need to register

Providers, hospitals and facilities don’t need to register for an account to use the portal. They can use their facility name, letter reference key or email address to begin importing the requested medical records at exlhealthproviderportal.exlservice.com.**

Some features of EXL provider portal:

  • Provides upload confirmation
  • Records uploaded in real time
  • Enables multiple document types and audits to be included in single upload
  • Allows users to check status of audits

Training

Providers can get instructions needed for training staff on using the portal at exlservice.com/how-to-send-medical-records.**

Questions?

EXL is available to assist during any step of the process. Contact EXL by calling 1‑833-717-0378 and pressing “0” from 8 a.m. to 5 p.m. Eastern time Monday through Friday.

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


Here are the 2023 FEP benefit changes

Blue Cross and Blue Shield Federal Employee Program® 2023 benefit changes will take effect Jan. 1, 2023. Below is an overview of the changes.

Acupuncture

  • Basic Option only
    • We now cover 12 acupuncture visits per calendar year.

Bariatric surgery

  • Standard Option, Basic Option and FEP Blue Focus
    • We now provide benefits for medically necessary bariatric surgery beginning at age 16.

Diagnostic services

  • Basic Option only
    • The coinsurance for laboratory tests (such as blood tests and urinalysis), pathology services and EKGs is now 15%.

Facility

  • Basic Option only
    • The copayment for an inpatient admission is now $250 per day for up to $1,500 per admission for unlimited days.
    • The copayment for outpatient surgical and treatment services performed and billed by a facility is now $150 per day per facility.
    • The copayment for outpatient observation services performed and billed by a hospital or freestanding ambulatory facility is now $250 per day up to $1,500.
    • The copayment for outpatient hospital emergency room services and supplies, including professional provider services, diagnostic studies, radiology services, laboratory tests and pathology services, when billed by the hospital is now $250 per day per facility.
    • The copayment for outpatient diagnostic testing and treatment services performed and billed by a facility is now $200 per day per facility.

Infertility

  • Standard Option, Basic Option and FEP Blue Focus
    • We now cover one year of sperm and egg storage for individuals facing iatrogenic infertility.

Maternity

  • Standard Option, Basic Option and FEP Blue Focus
    • We now provide eight visits per calendar year to treat depression associated with pregnancy with no member out-of-pocket costs when a Preferred provider is used.
    • We now provide individuals who are pregnant with a free blood pressure monitor when ordered through the FEP vendor.

Medical food

  • Standard Option, Basic Option and FEP Blue Focus
    • We now cover medical foods for the treatment of inborn errors of amino acid metabolism regardless of age.

Pharmacy

  • Standard Option, Basic Option and FEP Blue Focus
    • We now cover the generic naloxone nasal spray with zero out-of-pocket costs for the first purchase of up to a 90-day supply per calendar year.
    • We now provide coverage for weight loss medications to treat obesity when obtained through one of the FEP pharmacy drug programs.
    • We now cover over-the-counter condoms for all members with zero member out-of-pocket costs when they have a prescription from their physician and are purchased in a Preferred retail pharmacy.
  • Standard Option only
    • Preferred insulins are now covered with a $35 copayment for up to a 30-day supply or a $65 copayment for a 31 to 90-day supply, when dispensed by a Preferred retail pharmacy.
    • Updates have been made to the approved drug list.
  • Basic Option only
    • The copayment for Tier 1 (generic drugs) without Medicare Part B primary is now $15 for each purchase of up to a 30-day supply ($40 for a 31 to 90-day supply).
    • The copayment for Tier 2 (preferred brand-name) drugs without Medicare Part B primary is now $60 for each purchase of up to a 30-day supply ($180 for a 31 to 90-day supply).
    • Members are now responsible for up to a $90 minimum copayment for Tier 3 (non-preferred brand-name) drugs for up to a 30-day supply ($250 minimum for a 31 to 90-day supply) without Medicare Part B primary.
    • Updates have been made to the approved drug list.
  • FEP Blue Focus only

Preventive care

  • Standard Option, Basic Option and FEP Blue Focus
    • We now cover computed tomography colonography under the adult preventive benefit for colorectal cancer tests.
    • We now cover preventive low-dose CT screenings for lung cancer for members aged 50 to 80.
    • FEP will make changes as soon as possible and provide preventive benefits for the U.S. Preventive Services Task Force A and B, the Advisory Committee on Immunization Practices, Health Resources and Services Administration, and Bright Futures recommendations as they occur throughout the year.

New prior approval requirements

  • Standard Option, Basic Option and FEP Blue Focus
    • We now require prior approval for certain high-cost drugs obtained outside of a pharmacy setting.
    • We now require prior approval for proton beam therapy.
    • We now require prior approval for stereotactic radiosurgery and stereotactic body radiation therapy.

Transplants

  • Standard Option, Basic Option and FEP Blue Focus
    • We no longer limit the number of non-full sibling donor screening tests for transplants.

For complete 2023 Blue Cross and Blue Shield Service Benefit Plan benefit information, go to fepblue.org/brochure or call Customer Service at 1-800-482-3600.


Pemfexy to require prior authorization for most members starting Feb. 9

For dates of service on or after Feb. 9, 2023, we’ll require prior authorization for Pemfexy® (pemetrexed), HCPCS code J9304, through AIM Specialty Health®. This drug is part of members’ medical benefits, not their pharmacy benefits.

Prior authorization requirements apply when this drug is administered in outpatient settings for:

  • Blue Cross Blue Shield of Michigan commercial members who have coverage through UAW Retiree Medical Benefits Trust non-Medicare plans or fully insured groups, or who have individual coverage. Note: This requirement doesn’t apply to members who have coverage through other Blue Cross commercial self-funded groups, including the Blue Cross and Blue Shield Federal Employee Program®.
  • Medicare Plus Blue℠ members
  • Blue Care Network commercial members
  • BCN Advantage℠ members

How to submit authorization requests

Submit authorization requests to AIM using one of the following methods:

  • Through the AIM ProviderPortal, which you can access by doing one of the following:
  • Logging in to our provider portal (availity.com**), clicking on Payer Spaces and then clicking on the BCBSM and BCN logo. This takes you to the Blue Cross and BCN payer space where you’ll click the AIM Provider Portal tile.
  • Logging in directly to the AIM ProviderPortal at providerportal.com.**
  • By calling the AIM Contact Center at 1-844-377-1278

More about the authorization requirements

Authorization isn’t a guarantee of payment. As always, health care providers need to verify eligibility and benefits for members.

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

We’ll update the pertinent drug lists to reflect the information in this message 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 services.

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


Xenpozyme and Spevigo to have site-of-care requirements for most commercial members, starting in March

For dates of service on or after March 1, 2023, we’re adding site-of-care requirements for Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members for the following drugs covered under the medical benefit:

  • Xenpozyme (olipudase alfa), HCPCS code J3590
  • Spevigo (spesolimab-sbzo), HCPCS code J3590

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

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

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

As a reminder, these drugs already require prior authorization; providers can submit prior authorization requests using NovoLogix. The new site-of-care requirements are in addition to the current prior authorization requirements.

Members who start courses of treatment with Xenpozyme or Spevigo before March 1, 2023, 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 requirements 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 March 1, 2023.

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

As a reminder, authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.


Fylnetra now requires prior authorization for Medicare Advantage members

For dates of service on or after Dec. 19, 2022, we require prior authorization for Fylnetra® (pegfilgrastim-pbbk), HCPCS code J3590, for our Medicare Advantage members (both Medicare Plus Blue℠ and BCN Advantage℠ members). This drug is part of members’ medical benefits, not their pharmacy benefits.

Submit prior authorization requests through the NovoLogix® online tool.

When prior authorization is required

This medication requires prior authorization when it’s administered by a health care provider in sites of care such as outpatient facilities or physicians’ offices, and is 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 by using the UB04 claim form for a hospital outpatient type of bill 013x

Submit prior authorization requests through the NovoLogix tool

To access NovoLogix, 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. 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.

List of requirements

For a list of requirements related to drugs covered under the medical benefit, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members.

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

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


Hemgenix and Tzield require prior authorization for Medicare Advantage members

For dates of service on or after Dec. 2, 2022, we require prior authorization for Medicare Plus Blue℠ and BCN Advantage℠ members for the following drugs covered under the medical benefit:

  • Hemgenix® (etranacogene dezaparvovec-drlb), HCPCS code J3590
  • Tzield™ (teplizumab-mzwv), HCPCS code J3590

A prior authorization requirement also applies to most Blue Cross Blue Shield of Michigan and Blue Care Network commercial members. See this provider alert for more information.

Submit prior authorization requests through NovoLogix®

Submit prior authorization requests for Hemgenix and Tzield 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 (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.

To request access to our provider portal, follow the instructions on the Register for web tools webpage at bcbsm.com/providers.

When prior authorization is required

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

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

List of requirements

For a full outline of requirements related to drugs covered under the medical benefit for our Medicare Advantage members, refer to the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members.

We’ve updated this list to reflect the change for Hemgenix and Tzield.

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

Authorization isn't a guarantee of payment. As always, 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.


We’ve updated fax forms for submitting prior authorization requests to TurningPoint

On Nov. 22, 2022, Blue Cross Blue Shield of Michigan and Blue Care Network posted updated fax forms on ereferrals.bcbsm.com for use when submitting prior authorization requests to TurningPoint Healthcare Solutions, LLC, for musculoskeletal procedures.

We updated the forms as follows:

Prior authorization request form

Updates

Joint and spine procedures

  • Added a “Case urgency” section (standard or expedited)
  • Specified that for procedures with policies that have smoking and BMI criteria, the requesting provider must include signed documentation stating that they have discussed the risks and benefits of the procedure related to smoking and elevated BMI, as appropriate

Pain management: Epidural steroid injections

Added a “Case urgency” section (standard or expedited)

Pain management: Facet joint injection

Added a “Case urgency” section (standard or expedited)

Pain management: Neuroablation procedures

  • Added a “Case urgency” section (standard or expedited)
  • Added the question: “Is this request for Iovera® (cryoabltion)?”

Pain management: Sacroiliac joint injections

Added a “Case urgency” section (standard or expedited)

If you use fax forms to submit prior authorization requests to TurningPoint, be sure to incorporate the updated forms into your process.

You can find these forms and other useful resources on these pages of our ereferrals.bcbsm.com website:

TurningPoint Healthcare Solutions LLC is an independent company that manages authorizations for musculoskeletal surgical and related procedures for Blue Cross Blue Shield of Michigan and Blue Care Network.


New on-demand training available

Action item

Visit our provider training site to find new resources on topics that are important to your role.

Provider Experience continues to offer new training resources for health care providers and staff. Our on-demand courses can help you work more efficiently with Blue Cross Blue Shield of Michigan and Blue Care Network.

We recently added the following learning opportunities:

  • HCPCS and revenue code combinations: This updated course shows you how to use reference tools to complete and troubleshoot Blue Cross commercial facility claims, addressing the transition to our new provider portal.
  • Patient experience eLearning: This new course reviews best practices for improving the overall experience of your patients. See this article, also in this issue of The Record, for complete details.

As a reminder, we also have courses available to physicians for continuing education credit. These include:

  • CMS Star measures overview
  • Patient experience podcast series called “Practice Up!” (See this article in the December Record for details.)

Check the dashboard on our provider training site for announcements of what’s available as we add more CME offerings to enhance the training experience for health care providers and staff.  

Complete the following steps to request access to the training site:

  1. Open the registration page
  2. Complete the registration. We recommend using the same email you use to communicate with Blue Cross for provider-related needs. This will become your login ID.
  3. Follow the link to log in.

If you need assistance creating your login ID or navigating the site, contact ProviderTraining@bcbsm.com.

No portion of this publication may be copied without the express written permission of Blue Cross Blue Shield of Michigan, except that BCBSM participating health care providers may make copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCBSM.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2022 American Medical Association. All rights reserved.