Attribution will be expanded to advanced practice providers in April

Starting in April, physician organizations and Blueprint risk-bearing contracted entities will be able to align advanced practice health care providers (certified nurse practitioners and physician assistants) to their provider entities through the Provider Enrollment and Change Self-Service tool in our provider portal (availity.com).**

To access the Provider Enrollment and Change Self-Service tool in our provider portal:

1. Log in to availity.com.**
2. Under Payer Spaces, click on the BCBSM and BCN logo.
3. Click on the Applications tab.
4. Scroll down and then click on the tile for Provider Enrollment and Change Self-Service.

Note: Users need to be registered in one of the following roles to access the tool:

• Provider data management
• Provider enrollment and contracting

Advanced practice providers can identify as primary care providers

Advanced practice providers will also be able to identify as primary care providers for our Blue Cross Blue Shield of Michigan commercial PPO and Medicare Plus Blue℠ PPO products during enrollment, which will allow them to be included in Blue Cross’ primary care attribution process used by our Physician Group Incentive Program, Blueprint and other provider value-based programs. Details on advanced practice provider opportunities in our provider value-based programs will be announced at a later date. 

When eligible certified nurse practitioners or physician assistants choose to enroll as primary care providers, this will enable Blue Cross members to search for them as primary care providers on the Find a Doctor directory on bcbsm.com. Eligible CNP primary care provider specialties for Blue Cross PPO and Medicare Plus Blue PPO include:

• Acute care nurse practitioner
• Adult care nurse practitioner
• Certified nurse practitioner
• Family nurse practitioner
• Adult care nurse practitioner
• Pediatric nurse practitioner
• Gerontology 

Physician assistants will be considered primary care providers based on the specialty of their supervising physicians (also known as the participating physicians) during enrollment. The participating physicians must be M.D.s or D.O.s, actively enrolled with Blue Cross, and fully credentialed and in good standing with the company. Non-Blue Cross M.D.s and D.O.s, or those with an active disciplinary status, can’t be the participating physicians for physician assistants. Eligible physician subspecialties include:

• Adolescent medicine
• Family practice (medicine)
• Family medicine and osteopathic manipulative therapy, or OMT
• General practice
• Geriatric practice
• Internal medicine
• Pediatrics
• Preventive medicine
• Public/health/general

Participating physician data maintenance (for example, changing participating physician) will be managed through the same process used for all other practitioner demographic changes. Physician assistant primary care provider eligibility will be limited to Blue Cross PPO and Medicare Plus Blue PPO at this time. PAs will be eligible to be a Blue Care Network primary care provider at a future date to be determined.

CNPs and PAs identified as primary care providers will be included in our primary care member attribution process for Blue Cross PPO and Medicare Plus Blue PPO. M.D.s and D.O.s will take precedence over the CNPs and PAs in the attribution algorithm. A CNP or PA will never reduce M.D. or D.O. attribution. CNPs and PAs will only receive attributed members when those members haven’t seen an M.D. or D.O. primary care provider for at least 24 months.

Contact Provider Inquiry if you have any questions related to advanced practice providers’ primary care provider eligibility or member attribution implications.

**Blue Cross Blue Shield of Michigan doesn’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 and electronic data interchange services.

Reminder: How to check the status of prior authorization requests to share with your patients

As a reminder, if a patient who has coverage through Blue Cross Blue Shield of Michigan or Blue Care Network asks about the status of a prior authorization request, you can check it by following these steps:

1. Log in to our provider portal at availity.com.**
2. Click on Payer Spaces in the menu bar, and then click on the BCBSM and BCN logo.
3. Click on the applicable tile in the Applications tab through which you submitted the authorization request.

Additional information available for providers

Providers can also find a summary of services that require prior authorization through our Summary of utilization management programs for Michigan providers document on ereferrals.bcbsm.com.

Note: For help using the e-referral tool, go to ereferrals.bcbsm.com and, under Access & Training, click on Training Tools.

**Blue Cross Blue Shield of Michigan doesn’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 and electronic data interchange services.

Starting June 1, Blue Cross will no longer cover Sajazir injection

Starting June 1, 2024, Blue Cross Blue Shield of Michigan and Blue Care Network will no longer cover Sajazir™ injection as a pharmacy benefit. Instead, we’ll cover generic icatibant acetate subcutaneous injection. Sajazir is a medication commonly used to treat acute attacks of hereditary angioedema. 

Both Sajazir and icatibant acetate subcutaneous injection are generic icatibant acetate products for brand name Firazyr^® and are FDA-approved. However, Sajazir is more expensive than other available generic products. It also requires limited distribution through LeMed Specialty Pharmacy^©, a nonpreferred specialty pharmacy, whereas the other generic products are available through specialty pharmacies. Our preferred specialty pharmacy is AllianceRx Walgreens Pharmacy.

If your patient requires treatment with Sajazir rather than another generic product after June 1, a medical necessity review will be required.

We’ll notify affected members of these changes and encourage them to talk with you to address any concerns and get a new prescription, if needed.

If you have questions, call the Pharmacy Services Clinical Help Desk at 1-800-437-3803.

We added new on-demand training to provider training site

Provider Experience continues to offer training resources for health care providers and staff. Our on-demand courses are designed to help you work more efficiently with Blue Cross Blue Shield of Michigan and Blue Care Network. We recently started publishing short courses that providers and staff can complete in just a few minutes. Find a quick introduction to our mini module concept.

We also added the following learning opportunity:

• Submitting appeals and peer-to-peer review requests in e-referral: The recording for the March 13, 2024, webinar for inpatient hospital providers is now available on the provider training website. You can also take the e-learning course that includes a simulation of the steps you take to submit requests. Search “e-referral” to find these courses along with others about the e-referral tool.

The goal of our provider training site is to enhance the training experience for providers and staff. Check out the dashboard regularly for announcements as we add more courses, including those with CME offerings.

To access the training site, follow these steps:

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

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

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

**Blue Cross Blue Shield of Michigan doesn’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 and electronic data interchange services.

2024 CPT 2nd-quarter update: New codes

The American Medical Association has added 34 new Category III codes and two vaccine codes as part of its CPT second-quarter update. The codes, effective dates and Blue Cross Blue Shield of Michigan’s coverage decisions are below.

Category III
Anesthesia Delivery

Category III
Surgery

Category III
Medicine

Category III
Medicine/Behavioral Health

Category III
Radiology

Category III
Radiology/Diagnostic Radiology

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 is 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 changing practitioner fees July 1

Blue Cross Blue Shield of Michigan will change practitioner fees for services with dates of service on or after July 1, 2024. This change applies to services provided to our Traditional, TRUST and Blue Preferred Plus℠ members, regardless of the customer group.

Blue Cross will use the 2024 Medicare resource-based relative value scale for most relative value unit priced procedures for dates of service on and after July 1. Most fees are currently priced using the 2023 values.

The Blue Cross overall fee update includes base fee adjustments and value-based reimbursement. Due to significant changes in relative value unit valuations, it’s best to review the fee schedule to view the effect on an individual code or group of codes.

Fee schedules effective July 1 will be available on the Provider Resources site through our provider portal on Availity^® Essentials. To find the fee schedules:

1. Log in to availity.com.**
2. Click on Payer Spaces on the menu bar.
3. Click on the BCBSM and BCN logo.
4. Scroll down and then click on Secure Provider Resources (Blue Cross and BCN).
5. Click on the Fee Schedule drop-down menu and then click on Blue Cross Professional Fee Schedules.

Only claims submitted with dates of service on or after July 1 will be reimbursed at the new fees.

**Blue Cross Blue Shield of Michigan doesn’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.

Reminder: Confirm data every 90 days, attest in CAQH every 120 days

Have you confirmed your data within the past 90 days and attested in CAQH within the past 120 days? Health care providers are required to confirm the following data elements every 90 days: name, specialty, address, phone number and digital contact information. Providers are also required to re-attest every 120 days for all other data elements, including credentialing, licensing and demographics.

If providers don’t re-attest with CAQH every 120 days, they won’t be included in Blue Cross Blue Shield of Michigan’s provider directories, including our Find a Doctor search tool. Your credentialing status will end if you fail to re-attest, and you’ll need to reapply.

It’s important to attest with CAQH to:

• Ensure your affiliation with Blue Cross isn’t interrupted.
• Keep your contact information up to date.
• Make sure claims payments aren’t interrupted.

Providers who practice at an office location or practice exclusively in an inpatient hospital setting also need to perform this attestation. If you’re practicing exclusively in an inpatient hospital setting, you must indicate that on your CAQH application. This information is used to determine whether full credentialing is required.
CAQH is a nonprofit alliance of health plans and trade associations focused on simplifying health care administration. Blue Cross uses CAQH to gather and coordinate our practitioner credentialing information.

All health care practitioners, including hospital-based providers, need to be registered with CAQH.

If you have questions about CAQH, call the help desk at 1-888-599-1771, or go to CAQH.org.**

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

Blue Cross enhances Medicare Plus Blue attribution model by adding PCP Select option

Blue Cross Blue Shield of Michigan is adding a new option to the retrospective claims-based Medicare Plus Blue℠ attribution model. PCP Select will give Medicare Plus Blue members the option to select primary care providers in their member portal or mobile phone applications. Members who select primary care providers in the portal will be attributed based on the primary care providers they selected, rather than on the standard claims model.

PCP Select should be available to members beginning May 1, 2024. Medicare Plus Blue members who choose not to select a primary care provider will continue to be attributed based on the standard claims model. Selecting a primary care provider in the member portal won’t limit which providers a member can see for care, nor will it affect a member’s benefits or claims payments. Instead, it will allow for quicker and more efficient attribution, which will improve data sharing and financial operations.

What you need to know

• Members will be notified of this option when they log in to their member portal accounts after PCP Select is available.
• Instructions on the portal will advise members to select a primary care provider only after they’ve established care with that provider (for example, have had visits with the provider and plan to continue seeing the provider for primary care). We encourage this, but it’s not a requirement.
• If members need help with the selection process, they can call the Customer Service number on the back of their member ID card.

If providers have questions about this Medicare Plus Blue attribution enhancement, call Provider Inquiry at 1-866-309-1719.

New patient experience resources for practices

Blue Cross Blue Shield of Michigan has added new patient experience resources that focus on strategies for communicating with patients to provide a great patient experience. They include webinars and additional content to our on-demand library.

In April, we’ll be presenting a three-part webinar series, “Improving health outcomes for older adults,” to help physicians and clinical staff navigate the complexities of discussing potentially sensitive issues with older patients. It’ll include topics such as urinary incontinence, fall risk and mental health — concerns that can have a significant effect on patients’ health, longevity and well-being. Each session will give strategies to enhance patient communication and foster open dialog that can lead to improved care and outcomes for older adults.

Register for these virtual webinars by visiting the Upcoming Webinars page of the Blue Cross Patient Experience site. All sessions will be from noon to 12:45 p.m.

Part 1: April 16, 2024 — We’ll focus on ensuring effective care through conversations with patients about urinary incontinence, physical activity and fall risk, along with a brief background on the Health Outcomes Survey.

Part 2: April 18, 2024 — Participants will learn strategies to discuss mental and physical health with older adults. The session will also discuss using patient-centered planning to improve or maintain patients’ health.

Part 3: April 23, 2024 —  Learn about the barriers and anxiety older patients have to broaching discussions about sensitive topics, such as memory problems and advanced care planning. We’ll explore providers’ apprehension to bring up sensitive topics, and share tips to relieve patients’ anxiety, ways to build trust and strategies providers can use to overcome their own anxieties toward sensitive conversations.

Recordings will be available on demand at the Patient Experience site after the live sessions. Physicians who attend this 90-minute total workshop can receive CME credits. CEU’s are also available for medical assistants.

Check out our on-demand library

Visit the On-Demand Content page of the Patient Experience site to view the latest educational resources.

• The “Managing Challenging Patient Interactions” webinar provides strategies for health care professionals to manage upset or frustrated patients or caregivers. It covers tactics to prevent challenging situations, tips to stay calm and de-escalation strategies. “Managing Challenging Patient Interactions” is also available as an in-office training session.
• Over the past few years, many physician practices have adopted the use of telehealth to increase access for patients and provide greater flexibility in scheduling. To help practices ensure their virtual visits provide the same patient experience as in-office visits, we’ve developed the e-learning series titled “Telehealth – Processes to maintain a great patient experience.” Two modules are available:
• A module for clinicians focused on patient-centered care and communication tips (15 minutes)
• A module for office managers or leads with tips to ensure telehealth appointments are successful (15 minutes)

For these and other on-demand resources, CME credits are available for physicians and CEU’s are available for medical assistants.

For more information, email PatientExperience@bcbsm.com.

Reminder: How billing works for care authorized by VA at non-VA facilities for FEP members

Veteran Administration benefits are coordinated with Blue Cross and Blue Shield Federal Employee Program^® benefits.

When a VA facility authorizes care by a non-VA health care provider, the VA facility is considered the billing provider, and the non-VA provider is considered the performing provider. The VA, as the billing provider, is responsible for filing the member’s claim for the FEP^® benefit to the local plan. The non-VA provider is reimbursed by the VA facility.

Ambulance providers should use appropriate modifiers for transportation to or from crisis stabilization units

Blue Cross Blue Shield of Michigan and Blue Care Network recognize crisis stabilization units as therapeutic sites. Crisis stabilization units provide immediate behavioral health support and treatment services in a therapeutic setting to individuals in acute behavioral health distress who require urgent care beyond what an outpatient behavioral health provider can provide. Crisis stabilization units can help to deescalate a person’s level of distress, prevent, or treat a behavioral health crisis, and reduce acute symptoms of a behavioral health condition.

Diagnostic or therapeutic sites are recognized by the origin or destination with a “D.” Effective April 1, 2024, ambulance providers should report the following modifiers for Basic Life Support, or BLS, emergency ambulance services with an origin or destination for a crisis stabilization unit:

• DH  ̶  From the crisis stabilization unit to the hospital
• HD  ̶  From the hospital to the crisis stabilization unit
• RD  ̶  From the residence to the crisis stabilization unit
• SD  ̶  From scene of an accident to the crisis stabilization unit

Starting April 1, additional preferred product required for Soliris, Ultomiris for most commercial members

For dates of service on or after April 1, 2024, step therapy requirements will change for Soliris^® (eculizumab), HCPCS code J1300, and Ultomiris^® (ravulizumab), HCPCS code J1303.

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

By April 1, we’ll update the Blue Cross and BCN utilization management medical drug list to reflect the new preferred drugs.

The drugs discussed above continue to require prior authorization through the NovoLogix^® online tool.

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

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

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

Additional information

For more information about medical benefit drugs, see the following pages on ereferrals.bcbsm.com:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

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

We’ve changed how we manage Entyvio SC, Omvoh SC

On March 1, 2024, Blue Cross Blue Shield of Michigan and Blue Care Network changed how we manage the following drugs for our Medicare Plus Blue℠ and BCN Advantage℠ members:

• Entyvio^® SC (vedolizumab), HCPCS code J3590
• Omvoh™ SC (mirikizumab-mrkz), HCPCS code J3590

Note: This change doesn’t affect Entyvio IV, HCPCS code J3380, or Omvoh IV, HCPCS code J3590, which will continue to be managed as part of members’ Part B medical benefits. These drugs continue to require prior authorization through the NovoLogix^® web tool.

What changed on March 1

On March 1, Medicare Plus Blue and BCN Advantage members who previously received Entyvio SC or Omvoh SC under the Part B medical benefit were required to continue their treatments under their Part D pharmacy benefits.

We made this change because these therapies can be safely and conveniently self-administered in the home; the Centers for Medicare & Medicaid Services, or CMS, has added these drugs to the Self-Administered Drug Exclusion List: (SAD List).**

As a result:

• These drugs are no longer covered when administered by a doctor or other health care professional under the Part B medical benefit.
• Entyvio SC and Omvoh SC aren’t included in our Medicare Advantage Part D formularies, but providers can request prior authorization for them as exceptions. (See the “How to submit prior authorization requests for Entyvio SC and Omvoh SC” section below.)
• Your patients can obtain these medications at pharmacies that dispense specialty drugs. They can also obtain these drugs from AllianceRx Walgreens Pharmacy through mail order or pickup at a Walgreens retail pharmacy.
• For members who don’t have Part D pharmacy benefits through Blue Cross or BCN, providers need to work with the pharmacy vendor that provides each member’s Part D coverage.

How to submit prior authorization requests for Entyvio SC and Omvoh SC

For members who have Part D pharmacy benefits through Medicare Plus Blue or BCN Advantage, providers need to submit prior authorization requests for Entyvio SC and Omvoh SC as follows: 

• Electronically: Through CoverMyMeds^® or another free ePA tool, such as Surescripts^® or ExpressPAth^®. See Save time and submit your prior authorization requests electronically for pharmacy benefit drugs for more information.
• By phone: Call 1-800-437-3803 and follow the prompts for medications billed through the pharmacy benefit.
• By fax: 
• For Medicare Plus Blue requests, fax to 1-866-601-4428.
• For BCN Advantage requests, fax to 1-800-459-8027.

List of requirements

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

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

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

Additional cardiology codes will require prior authorization for commercial members, starting May 11

For dates of service on or after May 11, 2024, these additional cardiology codes will require prior authorization by Carelon Medical Benefits Management for Blue Cross Blue Shield of Michigan and Blue Care Network commercial members:

• *0795T
• *0796T
• *0797T

Starting May 11, Carelon will use the Blue Cross and BCN medical policy titled Leadless Cardiac Pacemakers as the criteria for making determinations on prior authorization requests. To access this policy, open the Medical Policy Router Search page on bcbsm.com, enter the name of the policy in the Policy/Topic Keyword field and press Enter.

You’ll be able to access Carelon’s clinical criteria for these procedures, when available, on the Current Cardiology Guidelines** page of the Carelon website.

Additional information

By May 11, we’ll update this document to include the previously mentioned codes.

For more resources related to the cardiology procedures that require prior authorization, refer to these webpages at ereferrals.bcbsm.com:

• Blue Cross Cardiology Services
• BCN Cardiology Services

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

Carelon Medical Benefits Management is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage prior authorizations for select services.

We’ve posted our 2024 HEDIS tip sheets

Our 2024 HEDIS^® tip sheets are posted in the Clinical Quality section of Secure Provider Resources on our provider portal. Each year, we update and post our HEDIS and Star measure tip sheets. The Star measure tip sheets were posted earlier this year. 

About our tip sheets

• HEDIS tip sheets are developed to assist health care providers and their staff in efforts to improve overall health care quality and prevent or control diseases and chronic conditions. HEDIS is one of the most widely used performance improvement tools in the U.S.
• Star tip sheetshighlight select measures in the Medicare Star Ratings program. Most of the measures highlighted in our Star tip sheetsare also HEDIS measures.

Accessing the tip sheets

To access our tip sheets:

1. Log in to our provider portal at availity.com.**
2. Under Payer Spaces, click on the BCBSM and BCN logo.
3. Click on Secure Provider Resources (Blue Cross and BCN) under the Resources tab.
4. Under the Member Care tab, click on Clinical Quality Tip Sheets.

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

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

Webinars for physicians, coders focus on risk adjustment, coding

Beginning in April 2024, we’ll offer webinars about documentation and coding of common challenging diagnoses. These live, lunchtime educational sessions will also include an opportunity to ask questions. 

Below is our schedule and the tentative topics for the sessions. All sessions start at noon Eastern time and generally last for 30 minutes. Register for the session that best works with your schedule on the provider training website.

Provider training website access

Provider portal users with an Availity^® Essentials account can access the provider training website by logging in to availity.com,** clicking on Payer Space in the top menu bar and then clicking on the BCBSM and BCN logo. Then click on the Applications tab, scroll down to the Provider Training Site tile and click on it.

You can also directly access the training website if you don’t have a provider portal account: Provider training website.

After logging in to the provider training website, look in Event Calendar to sign up for your desired session. You can also quickly search for all the sessions with the keyword “lunchtime" and then look under the results for Events.

Questions?

• For more information about the sessions, contact April Boyce at aboyce@bcbsm.com.
• For more information about registration or using the provider training website, contact the provider training team at ProviderTraining@bcbsm.com.
• For more information on accessing the provider training website through the provider portal see the “Access our training site from our provider portal; new learning path available” article in the December 2023 Record.

**Blue Cross Blue Shield of Michigan doesn’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 and electronic data interchange services.

Register now for 2024 virtual provider symposium sessions

This year’s virtual provider symposiums focusing on quality measures, documentation and coding guidelines will start in May. Registration is now open on the provider training website. Physicians, physician assistants, nurse practitioners, nurses and coders can receive continuing education credits for attending.

Once you’re logged in to the provider training site, open the event calendar to sign up for any of the sessions listed below. You can also quickly search for all the sessions with the keyword “symposium” and then look under the results for Events.

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

Coding and Documentation Tips for 2024 and Beyond: For physicians, coders, billers and administrative staff

Provider training website access

Provider portal users with an Availity^® Essentials account can access the provider training website by logging in to availity.com,** clicking on Payer Space in the top menu bar and then clicking on the BCBSM and BCN logo. Then click on the Applications tab, scroll down to the Provider Training Site tile and click on it.

You can also directly access the training website if you don’t have a provider portal account.

Questions?

• For more information about the sessions, contact Ellen Kraft at ekraft@bcbsm.com.
• For more information about registration or using the provider training website, contact the provider training team at ProviderTraining@bcbsm.com.
• For more information on accessing the provider training website through the provider portal see the “Access our training site from our provider portal; new learning path available” article in the December 2023 Record.

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

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

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

Changes to Gastric stimulation and Breast reconstruction questionnaires in e-referral system

On Feb. 25, 2024, we updated questionnaires in the e-referral system.

We also updated the corresponding preview questionnaires in the Authorization criteria and preview questionnaires document on the ereferrals.bcbsm.com website.

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

Updated questionnaires

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

Preview questionnaires

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

To find the preview questionnaires, see the document titled Authorization criteria and preview questionnaires.

You can access this document by going to ereferrals.bcbsm.com and doing the following:

• For Medicare Plus Blue: Click on Blue Cross and then click on Prior Authorization. Scroll down and look under the Authorization information for Medicare Plus Blue members heading.
• For BCN: Click on BCN and then click on Prior Authorization & Plan Notification. Scroll down and look under the Authorization criteria and preview questionnaires for select services heading.

Authorization criteria and medical policies

The Authorization criteria and preview questionnaires document explains how to access the pertinent authorization criteria and medical policies.

Resources for prenatal care, 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 and childhood immunizations support a healthy pregnancy and start to a child’s life. Here are some resources for prenatal care and childhood immunizations.

Prenatal care

Because of the importance of early prenatal care, the National Committee for Quality Assurance created a Healthcare Effectiveness Data and Information Set, or HEDIS^®, measure. To help health care providers understand the measure and how to report compliance, Blue Cross Blue Shield of Michigan created a prenatal care HEDIS tip sheet.

The Blue Cross and Blue Shield Federal Employee Program^® developed the Your Pregnancy To-Do List flyer to help its members prepare for a healthy and safe pregnancy. 

Childhood immunizations

To help babies have a healthy start to life, the American Academy of Pediatrics recommends specific vaccines before the age of 2. The Childhood Immunizations Status (CIS) HEDIS measure helps support childhood immunizations, and Blue Cross Blue Shield of Michigan created a CIS tip sheet to help providers understand the measure and report compliance.

The Federal Employee Program also developed the Good Health Starts Early Well-Child Quick Reference Guide for its members. It includes the recommended vaccine schedule from birth to 18, along with other health information.

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

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

New patient experience resources for practices

Blue Cross Blue Shield of Michigan has added new patient experience resources that focus on strategies for communicating with patients to provide a great patient experience. They include webinars and additional content to our on-demand library.

In April, we’ll be presenting a three-part webinar series, “Improving health outcomes for older adults,” to help physicians and clinical staff navigate the complexities of discussing potentially sensitive issues with older patients. It’ll include topics such as urinary incontinence, fall risk and mental health — concerns that can have a significant effect on patients’ health, longevity and well-being. Each session will give strategies to enhance patient communication and foster open dialog that can lead to improved care and outcomes for older adults.

Register for these virtual webinars by visiting the Upcoming Webinars page of the Blue Cross Patient Experience site. All sessions will be from noon to 12:45 p.m.

Part 1: April 16, 2024 — We’ll focus on ensuring effective care through conversations with patients about urinary incontinence, physical activity and fall risk, along with a brief background on the Health Outcomes Survey.

Part 2: April 18, 2024 — Participants will learn strategies to discuss mental and physical health with older adults. The session will also discuss using patient-centered planning to improve or maintain patients’ health.

Part 3: April 23, 2024 —  Learn about the barriers and anxiety older patients have to broaching discussions about sensitive topics, such as memory problems and advanced care planning. We’ll explore providers’ apprehension to bring up sensitive topics, and share tips to relieve patients’ anxiety, ways to build trust and strategies providers can use to overcome their own anxieties toward sensitive conversations.

Recordings will be available on demand at the Patient Experience site after the live sessions. Physicians who attend this 90-minute total workshop can receive CME credits. CEU’s are also available for medical assistants.

Check out our on-demand library

Visit the On-Demand Content page of the Patient Experience site to view the latest educational resources.

• The “Managing Challenging Patient Interactions” webinar provides strategies for health care professionals to manage upset or frustrated patients or caregivers. It covers tactics to prevent challenging situations, tips to stay calm and de-escalation strategies. “Managing Challenging Patient Interactions” is also available as an in-office training session.
• Over the past few years, many physician practices have adopted the use of telehealth to increase access for patients and provide greater flexibility in scheduling. To help practices ensure their virtual visits provide the same patient experience as in-office visits, we’ve developed the e-learning series titled “Telehealth – Processes to maintain a great patient experience.” Two modules are available:
• A module for clinicians focused on patient-centered care and communication tips (15 minutes)
• A module for office managers or leads with tips to ensure telehealth appointments are successful (15 minutes)

For these and other on-demand resources, CME credits are available for physicians and CEU’s are available for medical assistants.

For more information, email PatientExperience@bcbsm.com.

Reminder: How billing works for care authorized by VA at non-VA facilities for FEP members

Veteran Administration benefits are coordinated with Blue Cross and Blue Shield Federal Employee Program^® benefits.

When a VA facility authorizes care by a non-VA health care provider, the VA facility is considered the billing provider, and the non-VA provider is considered the performing provider. The VA, as the billing provider, is responsible for filing the member’s claim for the FEP^® benefit to the local plan. The non-VA provider is reimbursed by the VA facility.

Starting April 1, additional preferred product required for Soliris, Ultomiris for most commercial members

For dates of service on or after April 1, 2024, step therapy requirements will change for Soliris^® (eculizumab), HCPCS code J1300, and Ultomiris^® (ravulizumab), HCPCS code J1303.

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

By April 1, we’ll update the Blue Cross and BCN utilization management medical drug list to reflect the new preferred drugs.

The drugs discussed above continue to require prior authorization through the NovoLogix^® online tool.

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

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

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

Additional information

For more information about medical benefit drugs, see the following pages on ereferrals.bcbsm.com:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

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

We’ve changed how we manage Entyvio SC, Omvoh SC

On March 1, 2024, Blue Cross Blue Shield of Michigan and Blue Care Network changed how we manage the following drugs for our Medicare Plus Blue℠ and BCN Advantage℠ members:

• Entyvio^® SC (vedolizumab), HCPCS code J3590
• Omvoh™ SC (mirikizumab-mrkz), HCPCS code J3590

Note: This change doesn’t affect Entyvio IV, HCPCS code J3380, or Omvoh IV, HCPCS code J3590, which will continue to be managed as part of members’ Part B medical benefits. These drugs continue to require prior authorization through the NovoLogix^® web tool.

What changed on March 1

On March 1, Medicare Plus Blue and BCN Advantage members who previously received Entyvio SC or Omvoh SC under the Part B medical benefit were required to continue their treatments under their Part D pharmacy benefits.

We made this change because these therapies can be safely and conveniently self-administered in the home; the Centers for Medicare & Medicaid Services, or CMS, has added these drugs to the Self-Administered Drug Exclusion List: (SAD List).**

As a result:

• These drugs are no longer covered when administered by a doctor or other health care professional under the Part B medical benefit.
• Entyvio SC and Omvoh SC aren’t included in our Medicare Advantage Part D formularies, but providers can request prior authorization for them as exceptions. (See the “How to submit prior authorization requests for Entyvio SC and Omvoh SC” section below.)
• Your patients can obtain these medications at pharmacies that dispense specialty drugs. They can also obtain these drugs from AllianceRx Walgreens Pharmacy through mail order or pickup at a Walgreens retail pharmacy.
• For members who don’t have Part D pharmacy benefits through Blue Cross or BCN, providers need to work with the pharmacy vendor that provides each member’s Part D coverage.

How to submit prior authorization requests for Entyvio SC and Omvoh SC

For members who have Part D pharmacy benefits through Medicare Plus Blue or BCN Advantage, providers need to submit prior authorization requests for Entyvio SC and Omvoh SC as follows: 

• Electronically: Through CoverMyMeds^® or another free ePA tool, such as Surescripts^® or ExpressPAth^®. See Save time and submit your prior authorization requests electronically for pharmacy benefit drugs for more information.
• By phone: Call 1-800-437-3803 and follow the prompts for medications billed through the pharmacy benefit.
• By fax: 
• For Medicare Plus Blue requests, fax to 1-866-601-4428.
• For BCN Advantage requests, fax to 1-800-459-8027.

List of requirements

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

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

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

Additional cardiology codes will require prior authorization for commercial members, starting May 11

For dates of service on or after May 11, 2024, these additional cardiology codes will require prior authorization by Carelon Medical Benefits Management for Blue Cross Blue Shield of Michigan and Blue Care Network commercial members:

• *0795T
• *0796T
• *0797T

Starting May 11, Carelon will use the Blue Cross and BCN medical policy titled Leadless Cardiac Pacemakers as the criteria for making determinations on prior authorization requests. To access this policy, open the Medical Policy Router Search page on bcbsm.com, enter the name of the policy in the Policy/Topic Keyword field and press Enter.

You’ll be able to access Carelon’s clinical criteria for these procedures, when available, on the Current Cardiology Guidelines** page of the Carelon website.

Additional information

By May 11, we’ll update this document to include the previously mentioned codes.

For more resources related to the cardiology procedures that require prior authorization, refer to these webpages at ereferrals.bcbsm.com:

• Blue Cross Cardiology Services
• BCN Cardiology Services

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

Carelon Medical Benefits Management is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage prior authorizations for select services.

Webinars for physicians, coders focus on risk adjustment, coding

Beginning in April 2024, we’ll offer webinars about documentation and coding of common challenging diagnoses. These live, lunchtime educational sessions will also include an opportunity to ask questions. 

Below is our schedule and the tentative topics for the sessions. All sessions start at noon Eastern time and generally last for 30 minutes. Register for the session that best works with your schedule on the provider training website.

Provider training website access

Provider portal users with an Availity^® Essentials account can access the provider training website by logging in to availity.com,** clicking on Payer Space in the top menu bar and then clicking on the BCBSM and BCN logo. Then click on the Applications tab, scroll down to the Provider Training Site tile and click on it.

You can also directly access the training website if you don’t have a provider portal account: Provider training website.

After logging in to the provider training website, look in Event Calendar to sign up for your desired session. You can also quickly search for all the sessions with the keyword “lunchtime" and then look under the results for Events.

Questions?

• For more information about the sessions, contact April Boyce at aboyce@bcbsm.com.
• For more information about registration or using the provider training website, contact the provider training team at ProviderTraining@bcbsm.com.
• For more information on accessing the provider training website through the provider portal see the “Access our training site from our provider portal; new learning path available” article in the December 2023 Record.

**Blue Cross Blue Shield of Michigan doesn’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 and electronic data interchange services.