Starting Jan. 1, new cancer support program will be available for some commercial members

Blue Cross Blue Shield of Michigan and Blue Care Network are working with OncoHealth^® to provide a cancer support program (Iris by OncoHealth) for adult members ages 18 and older who have a cancer diagnosis or who are cancer survivors.

Starting Jan. 1, 2024, this program will help members navigate the emotional, physical and financial challenges caused by cancer diagnosis and treatment. It also aims to lower the burden on health care providers and complement — not replace or interfere with — the care they provide. It’s meant to provide supplemental support and education between regularly scheduled, in-person appointments.

Iris by OncoHealth will be available to:

• Members who have coverage through Blue Cross and BCN commercial fully insured groups
• Commercial members who have individual coverage
• Members who have coverage through self-funded groups that purchase the program

There will be no cost to eligible members. With permission from the member, it will also be available to their caregivers.

Through the Iris mobile app or by phone, the program will include access to:

• 24/7 support from oncology nurses — Members can discuss symptoms and side effects with oncology nurses. The Iris nurses report new or worsening symptoms to the member’s primary oncology team by fax or phone. The Iris nursing team is supported by medical oncologists and advanced practice providers who are available for case escalation.
  
  

  Note: The Iris nurses use OncoHealth Medical Group’s symptom management pathways to help members manage symptoms. The pathways are based on standards of care established by the National Comprehensive Cancer Network, the American Society of Clinical Oncology and the Oncology Nursing Society, adapted for use in virtual care.

  Symptom management pathways won’t include prescription medications, but may include over-the-counter medications.

• Oncology-specific mental health support — Members can schedule virtual care appointments with licensed therapists. The Iris therapists offer members support for cancer-specific concerns, including adjusting to illness, coping with anxiety, depression and uncertainty, and communicating with their care teams. Members are often able to meet with a therapist within 24 to 48 hours of scheduling an appointment.
  
• Registered dietitian nutritionists with cancer expertise — The Iris dietitians offer personalized support to address high-impact nutritional symptoms and provide diagnosis-specific guidance related to food and nutrition.
  
• Peer mentors — A trained team of cancer patients, caregivers and survivors are available to support and advise members based on their own experiences navigating a cancer diagnosis.
  
• Customized educational information — This includes a library of clinically approved videos, articles and other self-guided content curated for each member.
  
• A symptom tracker — Members can report symptoms and side effects through the tracker in the mobile app. Iris nurses remotely monitor the information members enter, which enables them to intervene early when necessary.
  
• Advance care planning assistance
  
• Navigation to financial and community resources — These resources reduce barriers to care.
  
• Interpreters — If English isn’t the member’s first language, interpreters are available.

To learn more, view this Iris by OncoHealth video** or go to IrisOncology.com.**

OncoHealth is an independent company supporting Blue Cross Blue Shield of Michigan and Blue Care Network by providing cancer support services.

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

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

In a March 2023 Record article, we notified you that Blue Cross Blue Shield of Michigan is updating its internal processes in preparation for moving its Medicare Plus Blue℠ membership to the NASCO operating system beginning next year. The migration only affects Medicare Plus Blue provider vouchers and will take place in phases.

In January 2024, groups that are new to Medicare Plus Blue will be loaded to the operating system. Then, in January 2025, individual members and select non-key groups (smaller groups) will migrate to NASCO. In 2026, key and large groups will migrate.

The new Medicare Plus Blue provider voucher will look similar to the current Blue Cross commercial vouchers but will include a new field that indicates the provider network. The voucher will also include new columns to identify the tax ID and electronic funds transfer dates. In addition, it will have descriptions regarding the sequestration and withhold amounts in the remittance advice section.

Additional Information

When providers receive payments from the NASCO platform, the check or EFT number series on the voucher will be updated as follows:

• Paper checks — Check numbers will begin with “4;” currently they begin with “1.”
• EFT payments — Numbers will begin with “7;” currently they begin with “6.”

Also, all Medicare Advantage claims will be finalized on a Tuesday and either a check or EFT will be issued at that time. EFT funds will be received on Friday of the same week unless that day is a federal holiday.

These changes only apply to members being migrated to NASCO.

Member ID cards

We’ll also issue new Medicare Plus Blue member ID cards with a new alphanumeric prefix, deidentified ID number and nine-digit group number for those on the NASCO system. Members will receive the new cards according to their migration time frame indicated above. The image below provides an example of what the new group ID card will look like.

Example of a Medicare Plus Blue Group PPO ID card with Medicare Rx:

Note: Groups without prescription drug coverage won’t have the Medicare Rx symbol.

We’ll be providing more information about the migration in a future issue of The Record.

Next Drug Take Back Day scheduled for Oct. 28

The U.S. Drug Enforcement Agency’s next National Prescription Drug Take Back Day is from 10 a.m. to 2 p.m. Oct. 28. These twice-yearly events (held in April and October) provide your patients with a safe, convenient and responsible way to dispose of prescription drugs. They also help educate people about the potential for abuse of medications, including opioids.

At the most recent Drug Take Back Day in April, communities across the country removed nearly 664,000 pounds of unneeded prescriptions to help prevent drug misuse.

Resources

Blue Cross Blue Shield of Michigan supports Drug Take Back events as part of its ongoing efforts to combat the opioid epidemic. We offer a range of materials you can share with your patients and employees. For example:

• Our Opioid Resources Employer Toolkit contains an opioid resources guide and educational materials on topics such as how to safely store and dispose of medicine.
• Our Opioids website provides information about the opioid epidemic, opioid dependence and using opioids safely.
• We’ll publish a blog on mibluesperspectives.com in October.

Finding a drug disposal facility

Let your patients know they can find a drug disposal facility near them by checking out the DEA’s search tool.** For more information on Drug Take Back Day or the appropriate disposal of prescription drugs, visit the DEA Diversion Control Division website.**

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

We’re working to create awareness of fraudulent schemes and resources to report fraud

Our Corporate and Financial Investigations Unit conducts an annual fraud awareness campaign for employees each October — and this year, the unit is broadening its approach by reaching out to members and health care providers as well.

The goal of the campaign is to create awareness of fraud schemes and educate all stakeholders on how to recognize and report potential fraud, waste and abuse. Both our members and participating providers may become victims of fraud. For example, a member’s medical records may be affected by fraudulent claims activity.

DME fraud

One of the largest health care fraud schemes of the past year involves durable medical equipment fraud, costing the health care industry tens of millions of dollars a year. Since providers can be a victim of DME fraud, we reach out to providers whose NPIs are used without their knowledge. Providers may be approving DME without knowing the true cost charged to private insurers by DME companies.

“This is just one of the many ways we’re working to protect providers from becoming a victim of this and other fraud schemes,” said Daniel Crowell, senior director, Corporate and Financial Investigations.

Here’s an important guideline to keep in mind:

• DME is best suited for in-person visits, where devices can be properly fitted and assessed by the member’s provider.

Risk to members

Telemarketers sometimes market “free” DME to members, which results in high costs to insurers. Our Medicare members can be particularly susceptible to these schemes. Fraudulent telemarketers may reach out to seniors, intentionally confuse them and then get Medicare to pay for equipment that isn’t actually vetted by a medical professional.

Resources

• Contact CFI if you have concerns or recognize possible fraudulent activity. Call 1-844-STOP-FWA (1-844-786-7392) or send an email to StopFraud@bcbsm.com.
• Check out the Victimized Provider Project section** of the Centers for Medicare & Medicaid Services' website. The Victimized Provider Project helps keep providers from being held liable for overpayment for claims paid that are the result of identity theft.

By working together, we can help eliminate fraud, an effort that will improve patient safety and reduce costs.

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

CPT 3rd-quarter update: New and deleted codes

Laboratory and Pathology/Proprietary Laboratory Analyses

Pathology and Laboratory/MAAA Administrative Code

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

CPT code update: New immunization vaccine codes

Medicine Vaccines/Toxoids

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

HCPCS update: New code

The Centers for Medicare & Medicaid Services has added a new code as part of its Health Care Procedure Coding System update. The code, effective date and Blue Cross Blue Shield of Michigan’s coverage decision are below.

Injections

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 July 6, 2023, established

J0174 replaces C9399 J3490, J3590 and J9999 when billing for Leqembi (lecanemab-irmb)

Effective July 6, 2023, the Centers for Medicare & Medicaid Services established a permanent procedure code for the specialty medical drug Leqembi (lecanemab-irmb).

Report all services through July 5, 2023, with J3490, J3590, C9399 and J9999. All services performed on and after July 6, 2023, must be reported with J0174.

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

Billing chart: Blue Cross highlights medical, benefit policy changes

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

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

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

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

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

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

Blue Cross, BCN covering additional vaccines

To increase access to vaccines and decrease the risk of vaccine-preventable disease outbreaks, Blue Cross Blue Shield of Michigan and Blue Care Network will add the following vaccines to our list of vaccines covered under the pharmacy benefit:

Following are all the vaccines that are covered under eligible members’ prescription drug plans. Most Blue Cross and BCN commercial (non-Medicare) members with prescription drug coverage are eligible. If a member meets the coverage criteria, the vaccine is covered with no out-of-pocket costs.

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

Vaccines that are covered and have no age requirement

Covid vaccines

• Pfizer-BioNTech COVID-19 vaccine, bivalent
• Moderna COVID-19 vaccine, bivalent
• Novavax COVID-19 vaccine

Vaccines with age requirements

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

Accurate billing and coding reminders

To ensure accurate coding and billing, Blue Cross Blue Shield of Michigan would like to offer these reminders about laser treatments for psoriasis and anesthesia medication modifiers.

Laser treatment for psoriasis

The following procedure codes should only be reported for the treatment of psoriasis:

• *96920  ̶  Laser treatment for inflammatory skin disease (psoriasis); total area less than 250 sq cm
• *96921  ̶  Laser treatment for inflammatory skin disease (psoriasis); 250 sq cm to 500 sq cm
• *96922  ̶  Laser treatment for inflammatory skin disease (psoriasis); over 500 sq cm

Claims submitted with a diagnosis other than the treatment of psoriasis may receive a denial.

Medical direction modifiers for anesthesia

Blue Cross’ payment policy also requires accurate reporting of anesthesia medical direction modifiers. Please make sure the appropriate medical direction modifier is added to the anesthesia procedure code to indicate the level of service the physician or the non-physician practitioner provides.

Conflicts in the reporting of anesthesia medical direction modifiers may result in a claim denial.

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.

We’ve announced our Collaborative Care designations

We recently announced that 239 primary care practices and five OB/GYN practices have been designated for our Collaborative Care Designation Program for the September 2023 through August 2024 designation cycle. This was the first year that OB/GYN practices were included in the program.

Designated practices deliver care using the highly effective Collaborative Care Model. Collaborative Care adds a behavioral health component to the partnership between a patient and their PCMH-designated physician.

The Collaborative Care team consists of a doctor, who is the head of a care team, a behavioral health care manager and a consulting psychiatrist. These individuals work collaboratively to ensure patients get the care they need.

This approach can help improve the behavioral health of Michigan residents, addressing both mental health and substance use disorder conditions. Collaborative Care can also improve the overall health of Michiganders by providing value-based care that helps avoid emergency room visits and duplicative services.

As we explained in a Hospital and Physician Update article on Collaborative Care, a primary care practice must have a Patient-Centered Medical Home designation and meet certain criteria to receive the Collaborative Care designation. The criteria, which consist of a set of capabilities, reflect elements that a practice needs to have to effectively deliver care using the Collaborative Care Model.

The largest concentration of Collaborative Care practices is in Southeast Michigan and the west side of the state.

The Collaborative Care Model has been in use by early adopters in Michigan since 2015. After reviewing preliminary results from those early adopters, Blue Cross Blue Shield of Michigan launched a formal training program for primary care practices seeking to implement Collaborative Care in 2020, along with an incentive structure for learning about and using the model.

Practices that would like to earn a PCMH or Collaborative Care designation are encouraged to reach out to their physician organization for details.

We’ll require prior authorization for some diabetes drugs prescribed to Medicare Advantage members, starting Jan. 1

We continually review prescription drugs to provide the best value for our members, control costs and make sure members are using the right drug for the right situation.

As part of our process, certain diabetes medications will require prior authorization if they’re prescribed for Medicare Plus Blue℠ and BCN Advantage℠ members who don’t have a supporting prescription or medical record with a diabetes diagnosis, beginning Jan. 1, 2024. Original Medicare prohibits Part D plans from covering drugs used for weight loss.

The drugs that will require prior authorization are listed below:

Health care providers prescribing any of the medications listed above for our Medicare Plus Blue and BCN Advantage members will need to request a prior authorization for the medication to be covered for their patients. For information on how to submit the request electronically, click here.

We’ll let your affected patients know about this change and encourage them to speak with you about any concerns.

For a complete list of drugs and associated requirements, go to 2023 Drug Lists.

Kidney-only transplants to require prior authorization, starting Jan. 1

For dates of service on or after Jan. 1, 2024, hospital transplant financial coordinators must submit prior authorization requests for kidney-only transplants through the e-referral system for:

• Blue Cross Blue Shield of Michigan fully insured group and individual commercial members
• Blue Care Network fully insured group and individual commercial members
• All BCN Advantage℠ members

As with other transplants that already require prior authorization — including simultaneous pancreas-kidney, or SPK — it’s a two-step process in the e-referral system:

1. Submit an outpatient prior authorization request that includes:
• Procedure codes *50360 and *50365
• The facility
• For commercial members, enter a Blue Distinction^® Center for Transplants.
• For BCN Advantage members, enter a facility that’s accredited by the Centers for Medicare & Medicaid Services for kidney transplants.
• The completed questionnaire — The questionnaire automatically opens in the e-referral system for you to fill out.
• Clinical information — Include the history and physical, the letter of intent and clinical documentation to support the need for the transplant.

The request will pend for clinical review. In addition, the request will require medical director review if the facility isn’t a Blue Distinction Center for Transplants (for commercial members), the facility isn’t accredited by CMS for kidney transplants (for BCN Advantage members) or the member doesn’t meet medical policy criteria. 

If the authorization is approved, it will be valid for one year.

2. When a kidney becomes available, submit a prior authorization request for the inpatient stay. Include the outpatient authorization number for the transplant procedure codes in the Case Communication field. This will enable us to issue an approval quickly as it makes the connection between the inpatient request and the already-approved outpatient authorization.

You’ll be able to start submitting requests through the e-referral system for kidney-only transplants on Jan. 1, 2024.

We’ll update the e-referral User Guide for kidney-only transplants before Jan. 1. The pertinent information will be in “Section IV: Referrals and Authorizations,” in the subsection titled “5. Submit an Outpatient Authorization.” (The e-referral User Guide also includes information about submitting a re-authorization request, if the authorization obtained through Step 1, mentioned above, expires before a kidney becomes available.)

Notes:

• For more information about Blue Distinction Centers, see the Blue Distinction Centers webpage on our ereferrals.bcbsm.com website.
• If the e-referral system isn’t available or isn’t performing as expected, see the document titled e-referral system maintenance times and what to do.
• This prior authorization requirement for kidney-only transplants is already in place for the Blue Cross and Blue Shield Federal Employee Program^® members.

Here are some key guidelines for NICU billing

When billing room and board services for pediatric patients outside of the defined newborn age of 28 days or less for new admissions, health care providers should use the appropriate corresponding pediatric room and board revenue codes. 

According to ICD-10-CM classification guidelines, a newborn is defined as a baby who is in the first 28 days of life. Critical care services for the newborn take place in a nursery or neonatal intensive care unit, also called NICU, and are represented by revenue codes 0170-0174. If a medical condition presents after the first 28 days of life, it’s no longer considered a newborn medical condition.

Exclusions to this billing guideline are when the patient is transferred from the birth hospital to another hospital for non-routine care, with services beginning during the newborn period.

Newborn and pediatric revenue codes and descriptions:

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.

Review requirements for prior authorization of Omisirge

Omisirge^® is a new-to-market cellular therapy that was recently approved by Blue Cross Blue Shield of Michigan’s and Blue Care Network’s Pharmacy and Therapeutics committee.

On May 23, 2023, we published a provider alert stating that Omisirge will require prior authorization for most commercial members for dates of service on or after June 8, 2023. The member must have an approval for a stem cell transplant on file through Blue Cross’ and BCN’s Human Organ Transplant Program before a prior authorization request for Omisirge can be approved.

You can view the complete requirements in our Omisirge medical policy. To access the medical policy:

1. Go to bcbsm.com/providers.
2. Click on Resources.
3. Click on Search Medical Policies.
4. In the Medical Policy Router Search page, type “Omisirge” in the Policy/Topic Keyword field and press Enter.
5. Click on the link to open the Omisirge medical policy.

Select Medicare Advantage members received in-home test kits in September

Blue Cross Blue Shield of Michigan and Blue Care Network contracted with Everlywell, an independent company, to distribute in-home test kits in September to select Medicare Advantage members.

Some members may have received the following tests:

• Members who had a gap in care for colorectal cancer screening received a fecal immunochemical test, or FIT, kit.
• Members who had a gap in care for hemoglobin A1c, or HbA1c, testing, received an HbA1c testing kit.

If your patients reach out to you about these tests, you may want to encourage them to take advantage of this convenient, no-cost testing.

Members who were sent the tests were encouraged to discuss test results with their primary care providers. Here’s how the test result notification process works:
 

We’ve added and updated questionnaires in e-referral system

On Aug. 27, 2023, Blue Cross Blue Shield of Michigan and Blue Care Network added and updated questionnaires in the e-referral system. We also updated the corresponding authorization criteria and preview questionnaires on the ereferrals.bcbsm.com website.

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

New questionnaire

We added the following questionnaire to the e-referral system:

Updated questionnaires

We updated the following questionnaires:

Preview questionnaires

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

To find the preview questionnaires, go to ereferrals.bcbsm.com 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 Authorization Requirements & Criteria pages explain how to access the pertinent authorization criteria and medical policies.

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

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

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

Here’s our upcoming 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’re 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 the screenshots below for more details.

Previous sessions

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

For more information

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

Reminder: Resources, on-demand courses available on our training website

Take advantage of the training resources we offer to health care providers and their staff. Resources include on-demand courses designed to help you work more efficiently with Blue Cross Blue Shield of Michigan and Blue Care Network.

See the information below to find out about some of the learning opportunities we launched earlier this year that we think you’ll find worthwhile.

Blue Cross Personalized Medicine℠ presentations: We hosted a series of webinars discussing this new program, which is based on pharmacogenomics, a subgroup of precision medicine. The presentations are specific to primary care physicians, behavioral health providers, cardiologists and oncologists. Search “personalized” on the training website to quickly locate the four presentations.

CMS Star measures overview for 2023: This course is an overview of HEDIS^® quality measures that are also Medicare Star Ratings measures. Updated for 2023, the course has a new section on the CAHPS^® survey, tips for closing gaps in care, clarifications on quality measure requirements and assistance with coding and documentation. You can earn continuing education credits for completing these courses. Search “star” to locate the series.

HEDIS^® measures scenarios for 2023: This course shows you how to close quality gaps using the HEDIS^® tip sheets. Learn the tips and tricks through a series of scenarios where you’ll help figure out why an office is seeing gaps in specific measures. The course has been updated for 2023 and is also eligible for continuing education credits. Search “HEDIS” to locate the course.

To log in to the provider training site, click here.

To request access to our training site:

1. Visit the registration page and provide the requested information. We recommend using the same email you use to communicate with Blue Cross for provider-related needs. This will become your login ID.
2. Click on Register, and follow the prompts to log in.

If you need assistance registering or navigating the site, contact providertraining@bcbsm.com.

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

Resources for prenatal care, well-child visits and childhood immunizations

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

Early prenatal care, regular well-child visits and routine immunizations support a healthy pregnancy and healthy start to a child’s life. Blue Cross Blue Shield of Michigan developed the following HEDIS^® tip sheets on prenatal care, well-child visits and immunizations to assist health care providers and their staff in treating their patients:

• Prenatal Care (PPC)
• Well-child Visits in the First 30 months of Life (W30)
• Childhood Immunizations Status (CIS)

Blue Cross and Blue Shield Federal Employee Program^® members have access to resources and programs to support growing families. Here are some helpful resources:

• The Your Pregnancy To-Do-List promotes good health and preparation for the arrival of the newborn.
• For information on maternal health, such as urgent maternal warning signs and mental health during and after pregnancy, patients should visit fepblue.org.
• The Well-Child Quick Reference Guide includes the recommended well-child visit and immunization schedule.

The Blue Cross and Blue Shield Service Benefit Plan provides benefit coverage for members at no out-of-pocket cost for prenatal care, well-child visits and most immunizations when serviced by a Preferred provider.

For more information on FEP benefits and resources, members and providers should call Customer Service at 1-800-482-3600 or go to fepblue.org.

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

Look for status note in e-referral system when we pend prior authorization requests for some services

In the Blue Cross Blue Shield of Michigan and Blue Care Network e-referral system, we’re adding a status note to let health care providers know when we’ve pended prior authorization requests for initial admissions to and extensions of stays in:

• Acute (non-behavioral health) inpatient hospitals
• Skilled nursing facilities, acute inpatient rehabilitation facilities and long-term acute care hospitals — for commercial members only
  Note: As a reminder, naviHealth manages these requests for Medicare Plus Blue℠ and BCN Advantage℠ members.

We recently implemented this function to make it easier for providers to see the status of their requests. Here’s how it works:

When a Blue Cross or BCN Utilization Management staff member pends a prior authorization request for review by a medical director, a status note appears in the upper-left portion of the Inpatient Authorization Details screen.

The status note says, “Request is being reviewed by physician,” as shown below.

The status note is displayed for Blue Cross commercial, Medicare Plus Blue, BCN commercial and BCN Advantage requests that are managed by the Blue Cross and BCN Utilization Management department.

When we make a determination on the request — whether an approval or a denial — you’ll no longer see the status note.

Previously, when we pended a request, we added a statement to that effect in the Case Communication field.

naviHealth is an independent company that manages authorizations for post-acute care services for Blue Cross Blue Shield of Michigan and Blue Care Network members who have a Medicare Advantage plan.

Reminder: Include preadmission testing services on inpatient claim

Blue Cross Blue Shield of Michigan payment policy requires that health care providers include all preadmission testing services, rendered up to seven days prior to admission, on the inpatient claim. These services shouldn’t be considered for separate reimbursement.

Claims submitted for preadmission testing services within seven days of a related inpatient stay may be denied if billed separately.

Kidney-only transplants to require prior authorization, starting Jan. 1

For dates of service on or after Jan. 1, 2024, hospital transplant financial coordinators must submit prior authorization requests for kidney-only transplants through the e-referral system for:

• Blue Cross Blue Shield of Michigan fully insured group and individual commercial members
• Blue Care Network fully insured group and individual commercial members
• All BCN Advantage℠ members

As with other transplants that already require prior authorization — including simultaneous pancreas-kidney, or SPK — it’s a two-step process in the e-referral system:

1. Submit an outpatient prior authorization request that includes:
• Procedure codes *50360 and *50365
• The facility
• For commercial members, enter a Blue Distinction^® Center for Transplants.
• For BCN Advantage members, enter a facility that’s accredited by the Centers for Medicare & Medicaid Services for kidney transplants.
• The completed questionnaire — The questionnaire automatically opens in the e-referral system for you to fill out.
• Clinical information — Include the history and physical, the letter of intent and clinical documentation to support the need for the transplant.

The request will pend for clinical review. In addition, the request will require medical director review if the facility isn’t a Blue Distinction Center for Transplants (for commercial members), the facility isn’t accredited by CMS for kidney transplants (for BCN Advantage members) or the member doesn’t meet medical policy criteria. 

If the authorization is approved, it will be valid for one year.

2. When a kidney becomes available, submit a prior authorization request for the inpatient stay. Include the outpatient authorization number for the transplant procedure codes in the Case Communication field. This will enable us to issue an approval quickly as it makes the connection between the inpatient request and the already-approved outpatient authorization.

You’ll be able to start submitting requests through the e-referral system for kidney-only transplants on Jan. 1, 2024.

We’ll update the e-referral User Guide for kidney-only transplants before Jan. 1. The pertinent information will be in “Section IV: Referrals and Authorizations,” in the subsection titled “5. Submit an Outpatient Authorization.” (The e-referral User Guide also includes information about submitting a re-authorization request, if the authorization obtained through Step 1, mentioned above, expires before a kidney becomes available.)

Notes:

• For more information about Blue Distinction Centers, see the Blue Distinction Centers webpage on our ereferrals.bcbsm.com website.
• If the e-referral system isn’t available or isn’t performing as expected, see the document titled e-referral system maintenance times and what to do.
• This prior authorization requirement for kidney-only transplants is already in place for the Blue Cross and Blue Shield Federal Employee Program^® members.

Here are some key guidelines for NICU billing

When billing room and board services for pediatric patients outside of the defined newborn age of 28 days or less for new admissions, health care providers should use the appropriate corresponding pediatric room and board revenue codes. 

According to ICD-10-CM classification guidelines, a newborn is defined as a baby who is in the first 28 days of life. Critical care services for the newborn take place in a nursery or neonatal intensive care unit, also called NICU, and are represented by revenue codes 0170-0174. If a medical condition presents after the first 28 days of life, it’s no longer considered a newborn medical condition.

Exclusions to this billing guideline are when the patient is transferred from the birth hospital to another hospital for non-routine care, with services beginning during the newborn period.

Newborn and pediatric revenue codes and descriptions:

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.

Review requirements for prior authorization of Omisirge

Omisirge^® is a new-to-market cellular therapy that was recently approved by Blue Cross Blue Shield of Michigan’s and Blue Care Network’s Pharmacy and Therapeutics committee.

On May 23, 2023, we published a provider alert stating that Omisirge will require prior authorization for most commercial members for dates of service on or after June 8, 2023. The member must have an approval for a stem cell transplant on file through Blue Cross’ and BCN’s Human Organ Transplant Program before a prior authorization request for Omisirge can be approved.

You can view the complete requirements in our Omisirge medical policy. To access the medical policy:

1. Go to bcbsm.com/providers.
2. Click on Resources.
3. Click on Search Medical Policies.
4. In the Medical Policy Router Search page, type “Omisirge” in the Policy/Topic Keyword field and press Enter.
5. Click on the link to open the Omisirge medical policy.

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

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

Here’s our upcoming 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’re 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 the screenshots below for more details.

Previous sessions

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

For more information

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