Michigan Automated Prescription System may not capture all information about a patient’s experience with controlled substances

Health care providers using the Michigan Automated Prescription System should know that the database may not capture information about some controlled substances in a patient’s history.

Substances not captured by MAPS include:

• Controlled substances administered or dispensed to patients from opioid treatment programs, such as methadone and buprenorphine
• Samples of controlled substances provided to a patient
• Controlled substances dispensed by a doctor at a medical institution for a maximum of 48 hours

MAPS is an interactive database used to track controlled substances, schedule II through V, including gabapentin.

MAPS provides clinicians with important information about a patient’s controlled substance prescription history. It can be a valuable tool when considering treatment options and screening patients who may be at risk for abuse or diversion.

For more information on MAPS, visit the MI Automated Prescription System (MAPS)** website.

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

Reminder: Prior authorization changes start June 1

Michigan’s prior authorization law requirements** go into effect on June 1, 2023. These requirements apply to Michigan health care plans and providers whose members or patients have commercial coverage.

One of the requirements of the law is that providers must submit prior authorization requests electronically. If providers can’t submit requests electronically due to temporary technical problems, such as power or internet outages, they can submit via alternate methods, such as phone or fax. For alternate submission methods, see the appropriate page of our ereferrals.bcbsm.com website.

The law also requires health care plans to:

• Provide a list of services that require prior authorization and the clinical criteria used to make determinations on prior authorization requests. On June 1, this information will be available at bcbsm.com/priorauth.

• Make determinations on standard (non-urgent) preservice prior authorization requests within nine days of receiving a request. We’ll do this starting June 1.

We’re updating other communications to reflect these changes.

We previously communicated this information and more about the requirements of the law in our provider newsletters and in the provider alert titled “Update: Prior authorization changes coming in June.”

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

HCPCS 1st-quarter update: New and updated codes

The Centers for Medicare & Medicaid Services has added several new codes as part of its quarterly Health Care Procedure Coding System updates. The codes, effective dates and Blue Cross Blue Shield of Michigan’s coverage decisions are below.

Skin substitutes

Durable medical equipment/Prosthetics and orthotics/Medical supplies

Injections/administrative drug

Modifiers

Data gathering

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.

HCPCS replacement codes, effective April 1, 2023, established

Q5127 replaces C9399, J3490, J3590 and J9999 when billing for Stimufend (pegfilgrastim-fpgk), a biosimilar

The Centers for Medicare & Medicaid Services has established a permanent procedure code for specialty medical drug Stimufend (pegfilgrastim-fpgk), a biosimilar.

All services through March 31, 2023, will continue to be reported with codes C9399, J3490, J3590 and J9999. All services performed on and after April 1, 2023, must be reported with Q5127.       

Prior authorization is required through the Medical Benefit Drug program for Q5127 for all groups unless they’re opted out of the program.

For groups that have opted out of the prior authorization program, this code is covered for its FDA-approved indications.

Q5128 replaces C9399, J3490, J3590 and J9999 when billing for Cimerli (ranibizumab-eqrn), a biosimilar

CMS has established a permanent procedure code for specialty medical drug Cimerli (ranibizumab-eqrn), a biosimilar.

All services through March 31, 2023, will continue to be reported with codes C9399, J3490, J3590 and J9999. All services performed on and after April 1, 2023, must be reported with Q5128.       

Prior authorization is required through the Medical Benefit Drug program for Q5128 for all groups unless they’re opted out of the program.

For groups that have opted out of the prior authorization program, this code is covered for its FDA-approved indications.

Q5129 replaces C9399, J3490, J3590 and J9999 when billing for Vegzelma (bevacizumab-adcd), a biosimilar

CMS has established a permanent procedure code for specialty medical drug Vegzelma (bevacizumab-adcd), a biosimilar.

All services through March 31, 2023, will continue to be reported with codes C9399, J3490, J3590 and J9999. All services performed on and after April 1, 2023, must be reported with Q5129.       

Prior authorization is required through the Medical Benefit Drug program for Q5129 for all groups unless they’re opted out of the program.

For groups that have opted out of the prior authorization program, this code is covered for its FDA-approved indications.

Q5130 replaces C9399, J3490, J3590 and J9999 when billing for Fylnetra (pegfilgrastim-pbbk), a biosimilar

CMS has established a permanent procedure code for specialty medical drug Fylnetra (pegfilgrastim-pbbk), a biosimilar.

All services through March 31, 2023, will continue to be reported with codes C9399, J3490, J3590 and J9999. All services performed on and after April 1, 2023, must be reported with Q5130.

Prior authorization is required through the Medical Benefit Drug program for Q5130 for all groups unless they’re opted out of the program.

For groups that have opted out of the prior authorization program, this code is covered for its FDA-approved indications.

C9145 replaces J3490, J3590 when billing for Aponvie (aprepitant) for facility services only

CMS has established a permanent procedure code for specialty medical drug Aponvie (aprepitant).
All services through March 31, 2023, will continue to be reported with code J3490 and J3590. All facility services performed on and after April 1, 2023, must be reported with C9145, while all professional services will continue to be reported with J3490 and J3590.

C9146 replaces J9999 when billing for Elahere (mirvetuximab soravtansine-gynx) for facility services only

CMS has established a permanent procedure code for specialty medical drug Elahere.

All services through March 31, 2023, will continue to be reported with J9999.  All facility services performed on and after April 1, 2023, must be reported with C9146, while all professional services will continue to be reported with J9999.

C9147 replaces J9999 when billing for Imjudo (tremelimumab-actl) for facility services only

CMS has established a permanent procedure code for specialty medical drug Imjudo.

All services through March 31, 2023, will continue to be reported with J9999. All facility services performed on and after April 1, 2023, must be reported with C9147, while all professional services will continue to be reported with J9999.

C9148 replaces J3590 when billing for Tzield (teplizumab-mzwv) for facility services only

CMS has established a permanent procedure code for specialty medical drug Tzield.

All services through March 31, 2023, will continue to be reported with J3590. All facility services performed on and after April 1, 2023, must be reported with C9148, while all professional services will continue to be reported with J3590.

C9149 replaces C9399, J3490 and J3590, and when billing for Tzield (teplizumab-mzwv) for facility services only

CMS has established a permanent procedure code for specialty medical drug Tzield.

All services through March 31, 2023, will continue to be reported with J3590. All facility services performed on and after April 1, 2023, must be reported with C9149, while all professional services will continue to be reported with J3590.  

J0208 replaces J3490 when billing for Pedmark (sodium thiosulfate)

CMS has established a permanent procedure code for specialty medical drug Pedmark.

All services through March 31, 2023, will continue to be reported with J3490. All services performed on and after April 1, 2023, must be reported with J0208.

J0218 replaces J3490, J3590 and C9399 when billing for Xenpozyme (olipudase alfa-rpcp)

CMS has established a permanent procedure code for specialty medical drug Xenpozyme.

All services through March 31, 2023, will continue to be reported with J3490, J3590 and C9399. All services performed on and after April 1, 2023, must be reported with J0218.

Site-of-care prior authorization is required through the Medical Benefit Drug program for J0218 for all groups unless they’re opted out of the program.

For groups that have opted out of the Medical Benefit Drug program, this code is covered for its FDA-approved indications and requires manual review.

J1411 replaces C9399, J3490, J3590 and J9999 when billing for Hemgenix (etranacogene dezaparvovec-drlb)

CMS has established a permanent procedure code for specialty medical drug Hemgenix (etranacogene dezaparvovec-drlb), a gene/cellular therapy.

All services through March 31, 2023, will continue to be reported with codes C9399, J3490, J3590 and J9999. All services performed on and after April 1, 2023, must be reported with J1411.

Prior authorization is required through the Medical Benefit Drug program for J1411 for all groups unless they’re opted out of the program.

For groups that have opted out of the Medical Benefit Drug program, this code is covered for its FDA-approved indications and requires manual review.

J1449 replaces J3490, J3590, C9399 and J9999 when billing for Rolvedon (eflapegrastim-xnst)

CMS has established a permanent procedure code for specialty medical drug Rolvedon (eflapegrastim-xnst).

All services through March 31, 2023, will continue to be reported with codes J3490, J3590, C9399 and J9999.  All services performed on and after April 1, 2023, must be reported with J1449.

Prior authorization is required through the Medical Benefit Drug program for J1449 for all groups unless they’re opted out of the program.

For groups that have opted out of the prior authorization program, this code is covered for its FDA-approved indications.

J1747 replaces J3490, J3590, C9399 and J9999 when billing for Spevigo (spesolimab-sbzo)

CMS has established a permanent procedure code for specialty medical drug Spevigo (spesolimab-sbzo).
All services through March 31, 2023, will continue to be reported with codes J3490, J3590, C9399 and J9999. All services performed on and after April 1, 2023, must be reported with J1747.

Site-of-care prior authorization is required through the Medical Benefit Drug program for J1747 for all groups unless they’re opted out of the program.

For groups that have opted out of the Medical Benefit Drug program, this code is covered for its FDA-approved indications and requires manual review.

Billing chart: Blue Cross highlights medical, benefit policy changes

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

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

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

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

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

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

You’re invited to join PGIP as a physician organization

Blue Cross Blue Shield of Michigan will be accepting applications from new physician organizations for the Physician Group Incentive Program from June 1 through July 31, 2023. To request application materials, send an email to valuepartnerships@bcbsm.com.

About PGIP

The Physician Group Incentive Program was developed with input from providers across Michigan to help improve the quality and efficiency of health care in the state. PGIP facilitates change through a wide range of initiatives, including our nationally recognized Patient-Centered Medical Home program.

Through PGIP, we reward physician organizations for improving health care delivery to their attributed patient population. PGIP-participating physicians are eligible for value-based reimbursement consideration as a result of program efforts.

About physician organizations

A PGIP physician organization consists of physicians participating in our PPO or Traditional network, working together to:

• Transform systems of care to effectively manage patient populations.
• Build the infrastructure needed to optimize, measure and monitor quality of care.
• Promote collaborative relationships.
• Support the most cost-effective delivery of services to improve patient outcomes.

To learn more

• For more information on PGIP and its initiatives, visit the Physician Group Incentive Program section of valuepartnerships.com.
• If you’re interested in participating in PGIP as an individual practitioner, click here to learn more about PGIP physician organizations.

Some pre-COVID-19 utilization management requirements to resume July 1

With the end of the COVID-19 public health emergency, or PHE, Blue Cross Blue Shield of Michigan and Blue Care Network will reinstate certain utilization management requirements that were in effect before the PHE.

Below are the changes and when they’ll go into effect.

2 additional facilities join our crisis services program

In case you missed this article in the May-June issue of Hospital and Physician Update, we’re reprinting it here. To subscribe to Hospital and Physician Update, a newsletter designed for participating physicians and hospital executives — or to subscribe to other provider newsletters — click here.

We’re continuing to grow our crisis services program, offering members who are experiencing a mental health crisis a wider array of appropriate options. Since we last wrote about our crisis services in our provider newsletters earlier this year, two additional facilities — Network 180 and Integrated Services of Kalamazoo — have joined the program.

Our research with participating facilities has found that members who visit a crisis services location are directed to outpatient services, rather than an emergency department, most of the time and are receiving behavioral health services more quickly. For example, Common Ground is directing them to an outpatient facility 75% of the time.

“This is not only helping our members receive appropriate care but can help them save time and money,” said William Beecroft, M.D., medical director of behavioral health for Blue Cross Blue Shield of Michigan. “Emergency departments are among the most expensive care settings and an emergency department visit can be very time-consuming.”

See the table below for the current crisis locations, service areas and available care options.

If you’re a health care provider interested in joining this program, send an email to Dr. William Beecroft at wbeecroft@bcbsm.com or William Pompos at wpompos@bcbsm.com.

Changes to maternity support program include new name, menopause support

Last year, Blue Cross Blue Shield of Michigan and Blue Care Network began working with Maven, an independent company, to provide a Family Building and Maternity Support Solution.

We’ve renamed this solution the Family Building and Women’s Health Support Solution and enhanced it, as follows:

Maternity program

Starting in July 2023, members who have coverage through Blue Cross and BCN commercial self-funded groups that purchase this program will receive maternity support during the nine months of pregnancy and for one year postpartum.

The program will still end at three months postpartum for members who have individual coverage or coverage through Blue Cross and BCN commercial fully insured groups.

For additional details about this program, see the October 2022 Record and the November-December 2022 BCN Provider News.

Menopause program

In July, members who are experiencing physical and mental symptoms related to menopause can get access to expert advice and resources. This program will be available to all members who have individual coverage or coverage through Blue Cross and BCN commercial fully insured groups. It’s also available to members who have coverage through self-funded groups that purchase this program.
Menopause program support includes:

• Early identification of menopausal symptoms and treatment guidance
• 24/7 virtual access to a coaching care team that specializes in perimenopause, menopause and postmenopause
• Within the Maven mobile app, guided education and access to communities for connecting with others in the same stage of life
• One-on-one mental health support throughout the menopausal journey

Similar to other Maven solutions, the menopause program will include access to the following:

• A dedicated care advocate who can provide personalized, one-on-one support to answer questions, recommend the right types of care for specific needs, and help members find high-quality, in-network providers
• Personalized resources, including clinically approved articles, community forums to engage with others on similar journeys and classes led by clinical professionals
• Clinical virtual support through 24/7 on-demand video appointments available within one hour. Members can speak with top-rated clinical coaches,** including OB-GYNs, mental health specialists and career coaches. Appointments are available in more than 35 languages. A chat option is also available.

**Maven coaches don’t replace in-person care or relationships with established care teams and providers. They’re additional resources.

Maven is an independent company supporting Blue Cross Blue Shield of Michigan and Blue Care Network by providing family building and women’s health support services.

Bronson Internal Medicine: Embracing team-based care to support patients

Dr. Andrew Chen stands with medical assistants Sara Harmen, left, and Kristin Goff.

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

In addressing the needs of a wide variety of patients, Bronson Internal Medicine in Kalamazoo places a high value on the team-based approach — an integral part of the Patient-Centered Medical Home program.

A PCMH practice since 2016, Bronson has nine primary care providers and one nurse practitioner, supported by a social worker, nurse care manager and pharmacist. Having an extended care team is especially helpful when treating patients with chronic conditions or social factors that affect their health.

More recently, the practice also joined the Collaborative Care Designation Program, which builds on the PCMH foundation. The program uses the services of a behavioral health care manager and consulting psychiatrist in addition to a primary care provider, to help ensure that behavioral health needs are met.

“Patients are more complex today, with more challenging needs, and they’re living longer,” said Dr. Andrew Chen, who joined the practice in 2021 after completing his residency. “Team-based care will be a necessity moving forward.” 

PCMH successes

Dr. Chen pointed to the following processes as being the most instrumental in the practice’s success:

• Using a team-based care model
• Following evidence-based medicine
• Trusting the team to support patients in managing chronic conditions and behavioral health needs
• Providing same-day access to patients to avoid unnecessary emergency department and urgent care visits

Also, the practice uses the Epic medical records system, which provides real-time reminders of gaps in care and the services patients need. The system also provides the MyChart portal, allowing patients direct communication access to their health care providers.

Telemedicine is another factor that’s been crucial to the success of the practice, particularly during the COVID-19 pandemic. It’s allowed providers to meet with patients virtually for various medical needs, counseling related to medications, lab results and mental health needs, as well as for COVID-19 follow-up.

Bronson Internal Medicine is also part of the Provider-Delivered Care Management program in which care management is delivered in the physician’s office, provided by trained care team members who work in conjunction with the physician. “This has allowed providers to have access to quick communications about the patient’s plan of care and how care management could support them,” Dr. Chen said.
 
Advice for other practices

Asked if he had any advice for practices working to implement PCMH capabilities, Dr. Chen replied: “It’s important for providers to trust and utilize the ancillary staff such as social workers, complex care managers for chronic conditions, behavioral health care managers for mental health issues and pharmacy staff for medication issues. It’s also important to delegate follow-up when appropriate and refer patients with complex conditions who need support to care management.”

Other articles in the series

Check out the following two articles, which appeared in the April and May issues of The Record.

• “The Pediatric Place: Creating a centralized hub to facilitate information exchange”
• “MyMichigan Family Practice Center: Building a high-functioning team”

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

Providers to receive denial for incorrect coding of electroencephalogram and ultrasound screening for abdominal aortic aneurysm, starting in September

Electroencephalogram isn’t covered with a headache-only diagnosis. And the codes below shouldn’t be billed when the only diagnosis code on the claim is for headache or migraine. Beginning in September 2023, you may receive a denial when these codes are billed with a headache-only diagnoses:

• *95812 — Electroencephalogram (EEG) extended monitoring; 41 to 60 minutes
• *95813 —  Electroencephalogram (EEG) extended monitoring; 61 to 119 minutes
• *95816 —  Electroencephalogram (EEG); including recording awake and drowsy
• *95819 —  Electroencephalogram (EEG); including recording awake and asleep
• *95822 —  Electroencephalogram (EEG); recording in coma or sleep only

Abdominal aortic aneurysm screening

Blue Cross Blue Shield of Michigan payment policy for abdominal aortic aneurysm screening study aligns with Centers for Medicare & Medicaid Services guidelines. Beginning in September 2023, you may receive a denial when an abdominal aortic aneurysm (CPT *76706) is billed for a male patient 65 years or older, but younger than 76, when a family history of abdominal aortic aneurysm or history of smoking isn’t present on the claim.

Discuss health concerns addressed in Medicare Health Outcomes Survey with your patients

Beginning in July, some of your Blue Cross Blue Shield of Michigan and Blue Care Network patients with Medicare Advantage plans may receive the annual Health Outcomes Survey, or HOS, conducted by Centers for Medicare & Medicaid Services. The survey will ask them about the status of their physical and mental health, and whether they’ve been advised by their physician about fall prevention, managing urinary incontinence and physical activity.

How you can make a difference

The interactions you have with your patients directly affect the responses on the survey. Some patients may need your encouragement to discuss their concerns during their annual physical. Having discussions and advising them on the topics covered in the HOS improves your patients’ quality of life, engagement in their health and experience with your practice.

Here are some suggestions for topics to discuss at annual physicals:  

• Review and address any physical or emotional wellness concerns.
• Discuss and advise on appropriate exercise.
• Develop treatment plans with patients to address incontinence. 
• Discuss ways to prevent falls and improve balance.

How Blue Cross and BCN are supporting you

• Offering members incentives for annual wellness visits
• Sending members emails and letters to encourage them to have these conversations with you
• Providing health care providers with live and on-demand webinars to address incontinence, physical activity and fall prevention (See the “Find out more about HOS” section below for webinar information.)
• Providing members with the SilverSneakers^® program
• Providing informational resources

Find out more about HOS

Our CMS Star measures course has a module with more detail about the Health Outcomes Survey. Click here to log in to the provider training website and search for the course. Use the keyword “HOS.”

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

You can also check out our Health Outcomes Survey tip sheet for sample survey questions and tips for success.

Blue Cross and BCN to use Audaire Health provider portal to capture clinical outcomes for CAR-T cell therapy drugs

Starting July 1, 2023, Blue Cross Blue Shield of Michigan and Blue Care Network will use the Audaire Health™ provider portal to track and capture clinical outcomes for CAR-T cell therapy drugs for Blue Cross commercial and BCN commercial members.

The data entered in the portal will enable Blue Cross and BCN to capture and assess the clinical benefit of these therapies.

The Audaire portal will replace the manual reporting process for clinical outcomes for CAR-T cell therapy drugs, thereby reducing administrative burden. Blue Cross or BCN will no longer fax forms to prescribing health care providers on an annual basis for them to enter clinical outcome information and send back to us.

Which CAR-T cell therapy drugs are affected? 

Starting July 1, Blue Cross and BCN will require providers to enter clinical outcomes into the Audaire provider portal for the following CAR-T cell therapies, which are covered under members’ medical benefits.

Notes:

• Current requirements will continue to apply to these drugs. Continue to submit prior authorization requests through the NovoLogix^® online tool. (To access NovoLogix, log in to our provider portal, availity.com,** click on Payer Spaces and then click on the BCBSM and BCN logo; this will take you to the Blue Cross and BCN payer space, where you’ll find links to the NovoLogix tools on the Applications tab. If you don’t have access to Availity^®, see the Register for web tools page on bcbsm.com.)
• Providers must enter clinical information in the Audaire provider portal for any additional CAR-T cell therapy drugs approved by the Food and Drug Administration after July 1, 2023.

What will change on July 1?

• The first time Blue Cross or BCN approves your prior authorization request for one of these therapies, you (the requesting provider) must attest that you’ll enter clinical outcome information in the Audaire provider portal. Attestation is required for the therapies to be covered by a member’s benefit. (See How should you prepare for this change? below to learn more about attestation.)
• We’ll automatically add basic information to the Audaire provider portal for members approved for one of these therapies.
• We’ll also add basic information for members approved for one of these therapies from Jan. 1, 2022, through June 30, 2023. An Audaire representative will contact and ask requesting providers to enter clinical outcome information in its provider portal for these members.
• Audaire will send emails on a regular basis to remind providers to submit clinical information. Emails will come from hello@audaire.com, and they’ll include a direct link to the portal for easy access.

Providers can use either of these submission methods:

• Enter clinical information in the easy-to-use survey format in the Audaire provider portal.
• Call 512-643-5099. An Audaire representative will enter the clinical information on your behalf.

Note: Call 512‑643‑5099 to schedule an appointment with an Audaire representative to learn how to enter information in the portal.

How should you prepare for this change?

You don’t need to take action.

The first time Blue Cross or BCN approves your prior authorization request for one of these therapies, an Audaire representative will reach out to you to set up a 30-minute phone call during which they’ll:

• Create your Audaire Health profile, which will complete your attestation.
• Provide training on how to use the portal.
• Answer your questions.

An Audaire representative will also reach out to you if you have patients for whom we approved an authorization request for one of these therapies before July 1 and who have active coverage with Blue Cross or BCN.

Why are we making this change?

CAR-T cell therapies are high-cost treatments, and Blue Cross and BCN recognize the value and therapeutic promise these therapies hold. The goal of collecting this data is to ensure member access to therapies while maintaining affordability.

Do other drugs require tracking in the Audaire provider portal?

Blue Cross and BCN also require providers to track clinical outcomes for commercial members for the following high-cost spinal muscular atrophy therapies:

• Zolgensma^® (onasemnogene abeparvovec-xioi)
• Spinraza^® (nusinersen)
• Evrysdi^® (risdiplam)

For additional details, see the October 2022 Record article and the November-December 2022 BCN Provider News article.

Questions?

Email questions to Allison Olmsted, Pharm.D., at aolmsted@bcbsm.com.

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

Audaire Health is a contracted independent company that provides select services to Blue Cross and BCN commercial members.

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

Starting July 1, we’ll change how we pay for certain drugs that must be administered by a health care provider

Our goal at Blue Cross Blue Shield of Michigan and Blue Care Network is to provide our members with safe, high-quality prescription drug therapies. We continually review prescription drugs to help ensure we provide the best value for our members, control costs and make sure our members are using the right drug for the right situation. Starting July 1, 2023, we’ll change how we pay for certain drugs.

We’ll no longer pay for the drugs listed below with the member’s prescription drug benefit. Since these drugs should only be administered by a health care provider, we’ll pay for them under the member’s medical benefit. Our prescription drug benefits only pay for drugs that can be self-administered by the patient, per prescription labeling approved by the U.S. Food and Drug Administration.

This change affects all pharmacy drug lists where the drug is currently covered by the pharmacy benefit.

We’ll send letters to affected groups, members and their providers about this change. And we’ll advise members to talk with their doctor about continuing to receive their drug therapies and how certain drugs should be billed to their medical benefit, starting July 1.

Tzield to require prior authorization for URMBT members with Blue Cross non-Medicare plans

For dates of service on or after July 10, 2023, Tzield™ (teplizumab-mzwv), HCPCS codes J3590/C9149, will require prior authorization through the NovoLogix^® online tool for UAW Retiree Medical Benefits Trust members with Blue Cross Blue Shield of Michigan non-Medicare plans.

This drug is covered under the medical benefit.

The prior authorization requirement applies only when Tzield is administered in an outpatient setting.

Note: Prior authorization doesn’t apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714).

How to submit authorization requests

Submit prior authorization requests through NovoLogix. 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.

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

More about the authorization requirement

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

For additional information on requirements related to drugs covered under the medical benefit for URMBT members with Blue Cross non-Medicare plans, see:

• Medical Drug Management with Blue Cross for UAW Retiree Medical Benefit Trust PPO non-Medicare Members
• Medical oncology prior authorization list for UAW Retiree Medical Benefits Trust PPO non-Medicare members

We’ll update the pertinent drug lists to reflect the information in this message prior to the effective date.

**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.

Questionnaires in e-referral system have been updated

On April 24, 2023, we updated questionnaires in the e-referral system. We also updated the corresponding preview questionnaires on ereferrals.bcbsm.com.

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

Updated questionnaires

We updated the following questionnaires:

Preview questionnaires

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

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

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

Authorization criteria and medical policies

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

Blue Cross covers medically necessary care

As a reminder, Blue Cross Blue Shield of Michigan covers medically necessary care, defined in the Blue Cross Blue Shield of Michigan Commercial Provider Manual as procedures, treatments, supplies, devices, equipment, facilities or drugs (all services) that a medical practitioner, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms.

Medically necessary care must also be:

• In accordance with generally accepted standards of medical practice
• Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease
• Not primarily for the convenience of the patient, physician or other health care provider
• Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease

The provider manual further states that these standards are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician specialty society recommendations, the views of medical practitioners working in relevant clinical areas, and other factors.

Physical medicine services must be:

• Medically necessary and appropriate for the patient’s acute diagnosis due to recent illness, injury or distinct aggravation of a condition or surgery
• Given for a condition that can be significantly improved in a reasonable and generally predictable period of time
• Documented in the patient’s medical record

Providers with questions should call Provider Services at 313-225-9000 or 1-800-344-8525. Patients with questions should contact Customer Service at the number on the back of their member ID cards.

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

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

Here’s our current schedule and tentative topics for the webinars. Each session starts at noon Eastern time. Log in to the provider training website to register for sessions that work with your schedule.

If you haven’t already registered for the provider training website, follow these steps:

1. Click here to register.
2. Complete the registration. We recommend using the same email you use to communicate with Blue Cross Blue Shield of Michigan for other needs. This will become your login ID.

Locating a session

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

See screenshots below for more details.

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

For more information
If you have any questions about the sessions, contact April Boyce at aboyce@bcbsm.com. If you have questions regarding a session or website registration, email ProviderTraining@bcbsm.com.

Reminder: Register for 2023 virtual provider symposium sessions

This year’s virtual provider symposiums started in May and continue in 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.

To register:

1. Click here to log in to the provider training website. If you don’t already have access, click here to register. We recommend you use the same email address you use to communicate with Blue Cross Blue Shield of Michigan for other needs when creating the account.
2. Open the Event Calendar to sign up for any of the following upcoming sessions.

Here’s a look at the upcoming sessions, who they’ve been designed for and the dates and times.

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

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

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

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

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

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

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

Resources for cancer screening and prevention available

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

The Michigan Quality Improvement Consortium provides guidelines for preventive services for adults ages 18 through 49** and 50 and older.** These guidelines include information on screenings for colorectal, cervical and breast cancers.

Here are some resources from the American Cancer Society, Centers for Disease Control and Prevention, Department of Health and Human Services, and American Lung Association:

• Cancer screening saves lives.**
• Breast cancer: Things you should know**
• Cervical cancer**
• Colorectal cancer screening**
• Guidelines for diet**  and physical activity.**
• Quitting smoking guide**

Blue Cross and Blue Shield Federal Employee Program^® benefits have no out-of-pocket cost for colorectal, cervical and breast cancer screenings when done by a Preferred provider.

FEP members also have benefits for smoking and tobacco cessation treatment.

Providers and members can call Customer Service at 1-800-482-3600 or go online to fepblue.org if they have questions about FEP benefits.

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

Some pre-COVID-19 utilization management requirements to resume July 1

With the end of the COVID-19 public health emergency, or PHE, Blue Cross Blue Shield of Michigan and Blue Care Network will reinstate certain utilization management requirements that were in effect before the PHE.

Below are the changes and when they’ll go into effect.

2 additional facilities join our crisis services program

In case you missed this article in the May-June issue of Hospital and Physician Update, we’re reprinting it here. To subscribe to Hospital and Physician Update, a newsletter designed for participating physicians and hospital executives — or to subscribe to other provider newsletters — click here.

We’re continuing to grow our crisis services program, offering members who are experiencing a mental health crisis a wider array of appropriate options. Since we last wrote about our crisis services in our provider newsletters earlier this year, two additional facilities — Network 180 and Integrated Services of Kalamazoo — have joined the program.

Our research with participating facilities has found that members who visit a crisis services location are directed to outpatient services, rather than an emergency department, most of the time and are receiving behavioral health services more quickly. For example, Common Ground is directing them to an outpatient facility 75% of the time.

“This is not only helping our members receive appropriate care but can help them save time and money,” said William Beecroft, M.D., medical director of behavioral health for Blue Cross Blue Shield of Michigan. “Emergency departments are among the most expensive care settings and an emergency department visit can be very time-consuming.”

See the table below for the current crisis locations, service areas and available care options.

If you’re a health care provider interested in joining this program, send an email to Dr. William Beecroft at wbeecroft@bcbsm.com or William Pompos at wpompos@bcbsm.com.

Providers to receive denial for incorrect coding of electroencephalogram and ultrasound screening for abdominal aortic aneurysm, starting in September

Electroencephalogram isn’t covered with a headache-only diagnosis. And the codes below shouldn’t be billed when the only diagnosis code on the claim is for headache or migraine. Beginning in September 2023, you may receive a denial when these codes are billed with a headache-only diagnoses:

• *95812 — Electroencephalogram (EEG) extended monitoring; 41 to 60 minutes
• *95813 —  Electroencephalogram (EEG) extended monitoring; 61 to 119 minutes
• *95816 —  Electroencephalogram (EEG); including recording awake and drowsy
• *95819 —  Electroencephalogram (EEG); including recording awake and asleep
• *95822 —  Electroencephalogram (EEG); recording in coma or sleep only

Abdominal aortic aneurysm screening

Blue Cross Blue Shield of Michigan payment policy for abdominal aortic aneurysm screening study aligns with Centers for Medicare & Medicaid Services guidelines. Beginning in September 2023, you may receive a denial when an abdominal aortic aneurysm (CPT *76706) is billed for a male patient 65 years or older, but younger than 76, when a family history of abdominal aortic aneurysm or history of smoking isn’t present on the claim.

Starting July 1, we’ll change how we pay for certain drugs that must be administered by a health care provider

Our goal at Blue Cross Blue Shield of Michigan and Blue Care Network is to provide our members with safe, high-quality prescription drug therapies. We continually review prescription drugs to help ensure we provide the best value for our members, control costs and make sure our members are using the right drug for the right situation. Starting July 1, 2023, we’ll change how we pay for certain drugs.

We’ll no longer pay for the drugs listed below with the member’s prescription drug benefit. Since these drugs should only be administered by a health care provider, we’ll pay for them under the member’s medical benefit. Our prescription drug benefits only pay for drugs that can be self-administered by the patient, per prescription labeling approved by the U.S. Food and Drug Administration.

This change affects all pharmacy drug lists where the drug is currently covered by the pharmacy benefit.

We’ll send letters to affected groups, members and their providers about this change. And we’ll advise members to talk with their doctor about continuing to receive their drug therapies and how certain drugs should be billed to their medical benefit, starting July 1.

Tzield to require prior authorization for URMBT members with Blue Cross non-Medicare plans

For dates of service on or after July 10, 2023, Tzield™ (teplizumab-mzwv), HCPCS codes J3590/C9149, will require prior authorization through the NovoLogix^® online tool for UAW Retiree Medical Benefits Trust members with Blue Cross Blue Shield of Michigan non-Medicare plans.

This drug is covered under the medical benefit.

The prior authorization requirement applies only when Tzield is administered in an outpatient setting.

Note: Prior authorization doesn’t apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714).

How to submit authorization requests

Submit prior authorization requests through NovoLogix. 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.

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

More about the authorization requirement

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

For additional information on requirements related to drugs covered under the medical benefit for URMBT members with Blue Cross non-Medicare plans, see:

• Medical Drug Management with Blue Cross for UAW Retiree Medical Benefit Trust PPO non-Medicare Members
• Medical oncology prior authorization list for UAW Retiree Medical Benefits Trust PPO non-Medicare members

We’ll update the pertinent drug lists to reflect the information in this message prior to the effective date.

**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.

Blue Cross covers medically necessary care

As a reminder, Blue Cross Blue Shield of Michigan covers medically necessary care, defined in the Blue Cross Blue Shield of Michigan Commercial Provider Manual as procedures, treatments, supplies, devices, equipment, facilities or drugs (all services) that a medical practitioner, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms.

Medically necessary care must also be:

• In accordance with generally accepted standards of medical practice
• Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease
• Not primarily for the convenience of the patient, physician or other health care provider
• Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease

The provider manual further states that these standards are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician specialty society recommendations, the views of medical practitioners working in relevant clinical areas, and other factors.

Physical medicine services must be:

• Medically necessary and appropriate for the patient’s acute diagnosis due to recent illness, injury or distinct aggravation of a condition or surgery
• Given for a condition that can be significantly improved in a reasonable and generally predictable period of time
• Documented in the patient’s medical record

Providers with questions should call Provider Services at 313-225-9000 or 1-800-344-8525. Patients with questions should contact Customer Service at the number on the back of their member ID cards.

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

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

Here’s our current schedule and tentative topics for the webinars. Each session starts at noon Eastern time. Log in to the provider training website to register for sessions that work with your schedule.

If you haven’t already registered for the provider training website, follow these steps:

1. Click here to register.
2. Complete the registration. We recommend using the same email you use to communicate with Blue Cross Blue Shield of Michigan for other needs. This will become your login ID.

Locating a session

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

See screenshots below for more details.

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

For more information
If you have any questions about the sessions, contact April Boyce at aboyce@bcbsm.com. If you have questions regarding a session or website registration, email ProviderTraining@bcbsm.com.