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August 2024
Change Healthcare’s incident and its potential effect on membersEarlier this year, Change Healthcare experienced a cybersecurity incident that affected the ability of many of our health care provider partners to handle daily transactions. Change Healthcare is an independent company that serves as a clearing house, supporting core transactions for health care providers, such as eligibility and benefit checks and claims submission. On June 20, 2024, Change Healthcare issued a public notice formally declaring a breach of protected health information. Change Healthcare indicated that it will take full responsibility for all required breach notifications and will begin notifying individuals. If your office was affected by the incident, it is likely that some of your patients may receive a letter from Change Healthcare in the coming months notifying them that their personal or health information may have been involved. Change Healthcare will offer them two years of free credit monitoring and identity theft protection. More information can be found on Change Healthcare’s website** or the Change Healthcare Cyberattack webpage** set up for individuals whose data may have been affected. Questions can be directed to the Change Healthcare call center at 1-866-262-5342. Here are provider alerts related to the Change Healthcare incident:
**Blue Cross Blue Shield of Michigan and Blue Care Network don’t own or control this website.
New training opportunities available on provider training siteAction item Visit our provider training site to find short and new courses about working with our processes. 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 added the following learning opportunities for August:
How to access provider training To access the training site, follow these steps:
Those who don’t have a provider portal account can directly access the training through the Provider training website. Questions? For more information about using the provider training website, contact the provider training team at ProviderTraining@bcbsm.com. **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 and electronic data interchange services.
2024 HCPCS 2nd-quarter update: New codes added, deletedThe 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. Injections/chemotherapy
Injections
Medicine/oral and other drugs
Surgery/skin substitutes
Procedures/professional services (temporary)
Procedures/professional services (temporary)
Procedures/professional services (temporary)
Outpatient Prospective Payment System
OPPS
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 established, effective July 1J9361 replaces C9399, J3490, J3590, J9999 when billing for efbemalenograstim alfa-vuxw The Centers for Medicare & Medicaid Services has established a permanent procedure code for specialty medical drug efbemalenograstim alfa-vuxw. All services through June 30, 2024, will continue to be reported with codes C9399, J3490, J3590 and J9999. All services performed on and after July 1, 2024, must be reported with J9361. Prior authorization is required through the Medical Benefit Drug Program for J9361 for all groups unless they are opted out of the program. Q5137 replaces C9399, J3490, J3590, J9999 when billing for ustekinumab-auub (Wezlana), biosimilar, subcutaneous CMS has established a permanent procedure code for specialty medical drug ustekinumab-auub (Wezlana™), biosimilar, subcutaneous, 1 mg. All services through June 30, 2024, will continue to be reported with codes C9399, J3490, J3590 and J9999. All services performed on and after July 1, 2024, must be reported with Q5137. Prior authorization is required through the Medical Benefit Drug Program for Q5137 for all groups unless they are opted out of the program. For groups that have opted out of the prior authorization program, this code is covered for its U.S. Food and Drug Administration-approved indications. Q5138 replaces C9399, J3490, J3590, J9999 when billing for ustekinumab-auub (Wezlana), biosimilar, intravenous CMS has established a permanent procedure code for specialty medical drug ustekinumab-auub (Wezlana), biosimilar, intravenous, 1 mg. All services through June 30, 2024, will continue to be reported with codes C9399, J3490, J3590 and J9999. All services performed on and after July 1, 2024, must be reported with Q5138. Prior authorization is required through the Medical Benefit Drug Program for Q5138 for all groups unless they are 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. J3393 replaces C9399, J3490, J3590, J9999 when billing for Zynteglo (betibeglogene autotemcel) CMS has established a permanent procedure code for specialty medical drug Zynteglo™ (betibeglogene autotemcel). All services through June 30, 2024, will continue to be reported with codes C9399, J3490, J3590 and J9999. All services performed on and after July 1, 2024, must be reported with J3393. Prior authorization is required through the Medical Benefit Drug Program for J3393 for all groups unless they are 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. J3394 replaces C9399, J3490, J3590, J9999 when billing for Lyfgenia (lovotibeglogene autotemcel) CMS has established a permanent procedure code for specialty medical drug Lyfgenia™ (lovotibeglogene autotemcel). All services through June 30, 2024, will continue to be reported with codes C9399, J3490, J3590 and J9999. All services performed on and after July 1, 2024, must be reported with J3394. Prior authorization is required through the Medical Benefit Drug Program for J3394 for all groups unless they are 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. J7171 replaces C9167, C9399, J3490, J3590, J9999 when billing for ADAMTS13 (recombinant-krhn) CMS has established a permanent procedure code for specialty medical drug ADAMTS13 (recombinant-krhn). All services through June 30, 2024, will continue to be reported with codes C9167, C9399, J3490, J3590 and J9999. All services performed on and after July 1, 2024, must be reported with J7171. Procedure code C9167 was deleted effective June 30, 2024, and replaced with J7171. Prior authorization is required through the Medical Benefit Drug Program for J7171 for all groups unless they are 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. J3247 replaces C9166 when billing for Cosentyx (secukinumab) CMS has established a permanent procedure code for specialty medical drug Cosentyx® (secukinumab). All services through June 30, 2024, will continue to be reported with C9166. All services performed on and after July 1, 2024, must be reported with J3247. Prior authorization is required through the Medical Benefit Drug Program for J3247 for all groups unless they are 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. J2470 replaces C9113 when billing for pantoprazole sodium, injection CMS has established a permanent procedure code for specialty medical drug pantoprazole sodium, injection. All services through June 30, 2024, will continue to be reported with C9113. All services performed on and after July 1, 2024, must be reported with J2470. Procedure code C9113 was deleted June 30, 2024, and replaced with J2470. J2471 replaces C9113 when billing for pantoprazole (hikma), injection, not therapeutically equivalent to J2470 CMS has established a permanent procedure code for specialty medical drug pantoprazole (hikma), injection, not therapeutically equivalent to J2470. All services through June 30, 2024, will continue to be reported with C9113. All services performed on and after July 1, 2024, must be reported with J2471. Procedure code C9113 was deleted June 30, 2024, and replaced with J2471. J2267 replaces C9168 when billing for Omvoh CMS has established a permanent procedure code for specialty medical drug Omvoh™. All services through June 30, 2024, will continue to be reported with code C9168. All services performed on and after July 1, 2024, must be reported with J2267. Procedure code C9168 was deleted June 30, 2024, and replaced with J2267.
Billing chart: Blue Cross highlights medical, benefit policy changesYou’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:
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. To view the “August 2024 Billing chart,” click here.
**Blue Cross Blue Shield of Michigan doesn’t own or control this website.
Clinical editing polices updatedIn support of correct coding and payment accuracy, we are providing the information below to keep you informed about payment policy updates, new policies and coding reminders. Medicare Plus Blue℠ Reminder: Alpha-1 proteinase inhibitors To promote correct coding and assist with payment accuracy, Blue Cross Blue Shield of Michigan will enhance its claim editing process effective Nov. 1, 2024, for Part B medical drugs for Medicare Plus Blue claims. To receive timely and appropriate payment of the Part B drugs listed below when billed with HCPCS code J0256 or J0257, health care providers must include both a diagnosis code that supports an Alpha-1 antitrypsin deficiency and symptomatic emphysema. Per our medical policy, coverage for Alpha-1 proteinase inhibitors is provided when all the following are met:
Drug names
Note: The appeal process won’t change. Continue to submit appeals on the Clinical Editing Appeal Form or through Availity® with the necessary documentation that supports the service billed. Also, continue to fax one appeal at a time to avoid processing delays. BCN Advantage℠ G2211 G2211 is payable for BCN Advantage and won’t be payable for Blue Care Network commercial. This configuration was updated at the end of June 2024. G2211 description — Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient's single, serious condition or a complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established.) QN6 Enhanced benefits that were denying QN6 inappropriately have been corrected. This configuration was updated at the end of June 2024. QN6 description — Not a covered service. G0136 G0136 must be reported with a qualified visit to be payable. If a qualified service isn’t found on the same claim, then G0136 will deny. G0136 description — Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5 to 15 minutes. BCN commercial and BCN Advantage Pain management When pain management is reported with anesthesia or moderate sedation currently, the pain management codes are denying requiring providers to submit appeals on codes that were previously authorized by TurningPoint. We have updated the configuration to allow the pain management codes and deny the anesthesia or moderate sedation as of the end of June. Per our payment policy we don’t allow anesthesia or moderate sedation with pain management codes. Availity® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal services. TurningPoint Healthcare Solutions LLC is an independent company provides care review services for Blue Cross Blue Shield of Michigan and Blue Care Network.
Home health care services won’t require prior authorization for Medicare Advantage members, starting Oct. 1For dates of service on or after Oct. 1, 2024, home health care services for Medicare Plus Blue℠ and BCN Advantage℠ members won’t require prior authorization. For dates of service before Oct. 1, 2024, continue to submit prior authorization requests to CareCentrix® for our Medicare Advantage members. As part of our commitment to deliver care in line with standards set by the Centers for Medicare & Medicaid Services, we’ll continue to monitor compliance with these standards through claims review, post-payment audits and strategic collaboration with health care providers who are in shared- and full-risk arrangements. Watch for provider alerts and articles in The Record and BCN Provider News with additional information about this change. CareCentrix is an independent company that manages the prior authorization of home health care services for Blue Cross Blue Shield of Michigan and Blue Care Network members who have Medicare Advantage plans.
Reminder: Requirements for billing DME, prosthetic, orthotics, medical suppliesBlue Cross Blue Shield of Michigan requires all durable medical equipment and medical supply providers who bill for custom prosthetic and orthotic services to have a Provider Transaction Access Number, or PTAN. This requirement includes all professional providers, including those who meet the Centers for Medicare & Medicaid Services exemption criteria. Providers must obtain American Board for Certification accreditation for orthotics, prosthetics and pedorthics from a CMS-approved source and then request the PTAN from CMS to bill for custom P&O services. Once you have your 10-digit PTAN, you’ll need to enroll in the Blue Cross network with the ABC certification and the PTAN. Blue Cross may require a separate P&O provider identification number for billing custom P&O services and a DME provider PIN for billing DME and off-the-shelf P&O services. Visit the Enrollment page at bcbsm.com or contact Provider Enrollment and Data Management at 1-800-822-2761 to request registration as a P&O provider. If your provider specialty isn’t updated, services billed to Blue Cross for custom P&O services will reject as not payable to your provider specialty and you’ll be liable for the charge and can’t bill the member. Contact Provider Enrollment and Data Management for additional information to update your provider enrollment status.
We’re changing our reimbursement policy for select proceduresBlue Cross Blue Shield of Michigan is ending a 15% professional fee incentive that we’ve been paying when certain procedures are performed in an ambulatory surgical center instead of a hospital. This is effective for Blue Cross Blue Shield of Michigan commercial claims. The incentive is ending for claims submitted and received after July 31, 2024, regardless of date of service. A preliminary list of CPT codes covered by the incentive was published in the January 2021 issue of The Record.
We’re changing how we manage immunoglobulin therapies for most commercial members, starting Oct. 1For dates of service on or after Oct. 1, 2024, the drugs listed below will be the preferred immunoglobulin products for most Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members:
Here’s how these products are covered:
How this will affect members Here’s important information you’ll need to know:
How to submit prior authorization requests You’ll submit prior authorization requests differently depending on how the medication is administered, as follows:
Some Blue Cross commercial groups aren’t subject to this requirement For Blue Cross commercial, this requirement applies only to groups that participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under medical benefits. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List. Notes:
List of requirements For more information about the requirements related to drugs covered under medical benefits, see these lists:
For a full list of requirements related to drugs covered under the pharmacy benefit, see the Prior authorization and step therapy coverage criteria. We’ll update these lists to reflect the changes related to these drugs before the effective dates. Authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.
Reminder: Bill HCPCS code J3590 for off-label intravitreal use of Avastin for Blue Cross commercial membersWhen submitting claims for Avastin® (bevacizumab), bill as follows:
For a full list of requirements related to Avastin and other drugs covered under medical benefits, see the Blue Cross and BCN utilization management medical drug list for Blue Cross commercial and BCN commercial members. You can access this list and other information about requesting prior authorization on the following pages of the ereferrals.bcbsm.com website:
Starting Aug. 1, we’ll change how we cover brand-name Copaxone 40 mgStarting Aug. 1, 2024, Blue Cross Blue Shield of Michigan and Blue Care Network will change how we cover brand-name Copaxone® (glatiramer acetate) 40 mg, a medication commonly used to treat relapsing forms of multiple sclerosis. Members can continue to fill their prescription with generic glatiramer acetate (Copaxone®, Glatopa®). A new prescription may be needed. The following table summarizes the changes for members if they continue to fill their prescription with brand-name Copaxone® 40 mg.
We’ve been sending letters to notify affected members, their groups and their health care providers about these changes.
Blue Cross, BCN cover additional vaccineTo increase access to vaccines and decrease the risk of vaccine-preventable disease outbreaks, Blue Cross Blue Shield of Michigan and Blue Care Network has added the following to our list of vaccines covered under the pharmacy benefit:
The following lists 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 cost sharing. Vaccines with age requirements
Vaccines with no age requirements
If a member doesn’t meet the age requirement for a vaccine, Blue Cross and BCN won’t cover the vaccine under the prescription drug plan, and the claim will reject. Vaccines must be administered by certified, trained and qualified registered pharmacists.
Step therapy requirements added for Soliris, Ultomiris for Medicare Advantage members with PNH, starting Sept. 16For dates of service on or after Sept. 16, 2024, providers will have to show that our Medicare Plus Blue℠ and BCN Advantage℠ members have tried and failed Empaveli® (pegcetacoplan), HCPCS code J3490, when requesting prior authorization for the following drugs for the diagnosis of paroxysmal nocturnal hemoglobinuria, or PNH:
Empaveli will continue to require prior authorization. Here’s other important information:
When prior authorization is required These drugs require prior authorization, as applicable, when they are administered by a health care provider in sites of care such as outpatient facilities or physician offices and are billed in one of the following ways:
How to access NovoLogix To access NovoLogix, log in to our provider portal (availity.com),** click on Payer Spaces in the menu bar and then click on the BCBSM and BCN logo. You’ll find links to the NovoLogix tools on the Applications tab. Note: If you need to request access to our provider portal, follow the instructions on the Register for web tools webpage at bcbsm.com/providers. List of requirements For a list of requirements related to drugs covered under medical benefits, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members. We’ll update this list before 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 and electronic data interchange services.
Vyjuvek has additional requirements for most commercial membersBlue Cross Blue Shield of Michigan and Blue Care Network have updated the medical policy for Vyjuvek® (beremagene geperpavec-svdt). The requirements in the medical policy apply for most Blue Cross and BCN commercial members for dates of service on or after July 22, 2024. In keeping with the updated medical policy, the following additional requirements must be met for treatment with Vyjuvek to be considered medically necessary:
To see the full list of requirements in the updated medical policy, go to the Medical Policy Router Search page, enter the name of the drug in the Policy/Topic Keyword field and press Enter. Tip: To access the Medical Policy Router Search page, go to bcbsm.com/providers, click on Resources and then click on Search Medical Policies. Some Blue Cross commercial groups aren’t subject to these requirements For Blue Cross commercial, these requirements apply only to groups that participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under medical benefits. 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 members with Blue Cross non-Medicare plans don’t participate in the standard prior authorization program. Additional information For additional information about drugs covered under medical benefits, see the following pages of the ereferrals.bcbsm.com website: Prior authorization isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.
We’re adding requirements for Lamzede, Vyjuvek for URMBT members with Blue Cross non-Medicare plansFor dates of service on or after Sept. 12, 2024, Lamzede® and Vyjuvek® will have the requirements outlined below for UAW Retiree Medical Benefits Trust members with Blue Cross Blue Shield of Michigan non‑Medicare plans.
Submit prior authorization requests through the NovoLogix® online tool when these drugs will be billed as a medical benefit. Note: The requirements don’t apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714). How to access NovoLogix 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, see the Register for web tools webpage on bcbsm.com. For drugs that have a site-of-care requirement, the NovoLogix online tool will prompt you to select a site of care when you submit prior authorization requests. If the request meets clinical criteria for the drug and is for one of the following sites of care, it will be approved automatically:
More about requirements for medical benefit drugs For additional information on requirements related to drugs covered under medical benefits for URMBT members with Blue Cross non-Medicare plans, see:
We’ll update the drug lists to reflect the information in this article before the effective date. As a reminder, prior authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members. **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 to offer provider portal services.
New Alyglo requirements for Federal Employee Program non-Medicare membersFor dates of service on or after June 1, 2024, the drug listed below has a prior authorization requirement and a site-of-care requirement for Blue Cross and Blue Shield Federal Employee Program® non‑Medicare members:
For members who began therapies before June 1 Authorizations approved for therapies that began before June 1, 2024, will be valid for up to 12 months. For members beginning therapy on or after June 1 For members beginning therapy on or after June 1, submit prior authorization requests through the NovoLogix® online tool. It offers real-time status checks and immediate approvals for certain medications. To access NovoLogix, log in to our provider portal (availity.com),** click on Payer Spaces in the menu bar and then click on the BCBSM and BCN logo. You’ll find links to the NovoLogix tools on the Applications tab. Note: If you need to request access to our provider portal, see the Register for web tools webpage on bcbsm.com. The NovoLogix online tool will prompt you to select a site of care when you submit prior authorization requests for this drug. If the request meets clinical criteria for the drug and is for one of the following sites of care, it will be approved automatically:
Additional information or documentation may be required for requests to administer Alyglo in an outpatient hospital setting. List of requirements For a full list of requirements related to drugs covered under medical benefits, see the Utilization management medical drug list for Blue Cross and Blue Shield Federal Employee Program® non-Medicare members. We’ve updated this list to reflect the new requirements. You can access this list and other information about submitting prior authorization requests on the following pages of ereferrals.bcbsm.com: Prior authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members. **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 to offer provider portal services.
Mental health HEDIS resources to help close gaps in careThis is part of an ongoing series of articles focusing on the tools and resources available to help FEP® members manage their health. Resources are available to help health care providers close gaps in care for the following Healthcare Effectiveness Data and Information Set, or HEDIS®, measures. Antidepressant Medication Management (AMM) Antidepressants are commonly used in the treatment of moderate to severe depression. However, about half of all patients taking antidepressants discontinue medications prematurely, according to the National Institute of Mental Health. The AMM HEDIS measure assesses adults with a diagnosis of major depression who are newly treated with antidepressant medication and remained on their antidepressant medications. Use of Opioids from Multiple Providers (UOP) People who receive opioids from four or more prescribers or pharmacies have a higher likelihood of opioid-related overdose death than those who receive opioids from one prescriber or one physician, according to the Journal of the American Medical Association. The UOP HEDIS measure assesses adults receiving prescription opioids for more than 15 days from multiple prescribers, multiple pharmacies or both. Follow-up care after an emergency department visit for a behavioral health or substance use condition has been shown to improve mental health and reduce substance use, according to the National Committee for Quality Assurance. The FUA and FUM measures assess people who had an emergency department visit with diagnosis of substance use disorder or mental illness and had a follow-up visit within seven and 30 days of discharge with a provider. The following webpages provide additional information on follow-up care measures from the NCQA:
Resources for FEP members The Blue Cross and Blue Shield Federal Employee Program® offers additional resources to help members manage their conditions at home.
**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.
Do you have time for a Quality Minute on statins?This is an ongoing series of quick tips designed to be read in 60 seconds or less and provide your practice with information about performance in key areas. Statins
For more information, refer to the Statin Therapy for Patients with Cardiovascular Disease (SPC), Statin Use in Persons with Diabetes (SUPD) and Statin Therapy for Patients with Diabetes (SPD) tip sheets. You can also find them by:
**Blue Cross Blue Shield of Michigan and BCN don’t own or control this website. OptumRx is an independent company that processes prescription claims and prior authorizations for services provided under the pharmacy benefit for Blue Cross Blue Shield of Michigan and Blue Care Network members. 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.
Webinars for physicians, coders focus on risk adjustment, codingWe’re offering 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 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 here if you don’t have a provider portal account. 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 sessions with the keyword “lunchtime" and then look under the results for Events. You can listen to the previously recorded sessions, too. Check out the following:
Questions?
**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 and electronic data interchange services.
Clinical editing polices updatedIn support of correct coding and payment accuracy, we are providing the information below to keep you informed about payment policy updates, new policies and coding reminders. Medicare Plus Blue℠ Reminder: Alpha-1 proteinase inhibitors To promote correct coding and assist with payment accuracy, Blue Cross Blue Shield of Michigan will enhance its claim editing process effective Nov. 1, 2024, for Part B medical drugs for Medicare Plus Blue claims. To receive timely and appropriate payment of the Part B drugs listed below when billed with HCPCS code J0256 or J0257, health care providers must include both a diagnosis code that supports an Alpha-1 antitrypsin deficiency and symptomatic emphysema. Per our medical policy, coverage for Alpha-1 proteinase inhibitors is provided when all the following are met:
Drug names
Note: The appeal process won’t change. Continue to submit appeals on the Clinical Editing Appeal Form or through Availity® with the necessary documentation that supports the service billed. Also, continue to fax one appeal at a time to avoid processing delays. BCN Advantage℠ G2211 G2211 is payable for BCN Advantage and won’t be payable for Blue Care Network commercial. This configuration was updated at the end of June 2024. G2211 description — Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient's single, serious condition or a complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established.) QN6 Enhanced benefits that were denying QN6 inappropriately have been corrected. This configuration was updated at the end of June 2024. QN6 description — Not a covered service. G0136 G0136 must be reported with a qualified visit to be payable. If a qualified service isn’t found on the same claim, then G0136 will deny. G0136 description — Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5 to 15 minutes. BCN commercial and BCN Advantage Pain management When pain management is reported with anesthesia or moderate sedation currently, the pain management codes are denying requiring providers to submit appeals on codes that were previously authorized by TurningPoint. We have updated the configuration to allow the pain management codes and deny the anesthesia or moderate sedation as of the end of June. Per our payment policy we don’t allow anesthesia or moderate sedation with pain management codes. Availity® is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to offer provider portal services. TurningPoint Healthcare Solutions LLC is an independent company provides care review services for Blue Cross Blue Shield of Michigan and Blue Care Network.
Clarification: Emergency Department Claim Analyzer program’s hospitals reimbursed by fee schedule informationIn the June 2024 issue of The Record, we let you know that the Emergency Department Claim Analyzer program was re-implemented June 1, 2024. We need to clarify information from that article. The section titled “Hospitals reimbursed by fee schedule” should read as follows: For hospitals reimbursed by the fee schedule, claims recommended for adjustment will be adjusted to the appropriate level. These claims will be paid according to the fee schedule and require no additional action by the hospitals. You will see the change on the provider voucher and 835 electronic transaction. The adjusted level will be included in the replacement line, and the adjudication information will also be displayed with a CO45 adjustment code, along with the difference between the initially reported amount for the emergency visit and the new emergency visit listed on the replacement line. Other clarifications For dates of service on or after June 1, 2024, Blue Cross Blue Shield of Michigan is reviewing claims that are billed with a level four or five evaluation and management code (*99284 or *99285) for the appropriate level of care on a prepayment basis. Claims that don't meet the policy criteria will be adjusted and reimbursed at the appropriate level. At this time, claims that are two or more levels higher than the Blue Cross reimbursement policy will be adjusted. Claims that are one level higher won't be adjusted. For dates of service before June 1, 2024, Blue Cross is reviewing claims that are billed with a level four or five E/M code (*99284 or *99285) for the appropriate level of care on a prepayment basis. Claims that don't meet the policy criteria will be adjusted and reimbursed at the appropriate level. Blue Cross will continue to monitor all emergency department claims submitted. We reserve the right to modify the scope if adherence and adjustments don't align with the reimbursement policy. Watch for provider alerts and articles in The Record and BCN Provider News with additional information about this change.
Home health care services won’t require prior authorization for Medicare Advantage members, starting Oct. 1For dates of service on or after Oct. 1, 2024, home health care services for Medicare Plus Blue℠ and BCN Advantage℠ members won’t require prior authorization. For dates of service before Oct. 1, 2024, continue to submit prior authorization requests to CareCentrix® for our Medicare Advantage members. As part of our commitment to deliver care in line with standards set by the Centers for Medicare & Medicaid Services, we’ll continue to monitor compliance with these standards through claims review, post-payment audits and strategic collaboration with health care providers who are in shared- and full-risk arrangements. Watch for provider alerts and articles in The Record and BCN Provider News with additional information about this change. CareCentrix is an independent company that manages the prior authorization of home health care services for Blue Cross Blue Shield of Michigan and Blue Care Network members who have Medicare Advantage plans.
We’re changing our reimbursement policy for select proceduresBlue Cross Blue Shield of Michigan is ending a 15% professional fee incentive that we’ve been paying when certain procedures are performed in an ambulatory surgical center instead of a hospital. This is effective for Blue Cross Blue Shield of Michigan commercial claims. The incentive is ending for claims submitted and received after July 31, 2024, regardless of date of service. A preliminary list of CPT codes covered by the incentive was published in the January 2021 issue of The Record.
We’re changing how we manage immunoglobulin therapies for most commercial members, starting Oct. 1For dates of service on or after Oct. 1, 2024, the drugs listed below will be the preferred immunoglobulin products for most Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members:
Here’s how these products are covered:
How this will affect members Here’s important information you’ll need to know:
How to submit prior authorization requests You’ll submit prior authorization requests differently depending on how the medication is administered, as follows:
Some Blue Cross commercial groups aren’t subject to this requirement For Blue Cross commercial, this requirement applies only to groups that participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under medical benefits. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List. Notes:
List of requirements For more information about the requirements related to drugs covered under medical benefits, see these lists:
For a full list of requirements related to drugs covered under the pharmacy benefit, see the Prior authorization and step therapy coverage criteria. We’ll update these lists to reflect the changes related to these drugs before the effective dates. Authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.
Reminder: Bill HCPCS code J3590 for off-label intravitreal use of Avastin for Blue Cross commercial membersWhen submitting claims for Avastin® (bevacizumab), bill as follows:
For a full list of requirements related to Avastin and other drugs covered under medical benefits, see the Blue Cross and BCN utilization management medical drug list for Blue Cross commercial and BCN commercial members. You can access this list and other information about requesting prior authorization on the following pages of the ereferrals.bcbsm.com website:
Starting Aug. 1, we’ll change how we cover brand-name Copaxone 40 mgStarting Aug. 1, 2024, Blue Cross Blue Shield of Michigan and Blue Care Network will change how we cover brand-name Copaxone® (glatiramer acetate) 40 mg, a medication commonly used to treat relapsing forms of multiple sclerosis. Members can continue to fill their prescription with generic glatiramer acetate (Copaxone®, Glatopa®). A new prescription may be needed. The following table summarizes the changes for members if they continue to fill their prescription with brand-name Copaxone® 40 mg.
We’ve been sending letters to notify affected members, their groups and their health care providers about these changes.
Blue Cross, BCN cover additional vaccineTo increase access to vaccines and decrease the risk of vaccine-preventable disease outbreaks, Blue Cross Blue Shield of Michigan and Blue Care Network has added the following to our list of vaccines covered under the pharmacy benefit:
The following lists 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 cost sharing. Vaccines with age requirements
Vaccines with no age requirements
If a member doesn’t meet the age requirement for a vaccine, Blue Cross and BCN won’t cover the vaccine under the prescription drug plan, and the claim will reject. Vaccines must be administered by certified, trained and qualified registered pharmacists.
Step therapy requirements added for Soliris, Ultomiris for Medicare Advantage members with PNH, starting Sept. 16For dates of service on or after Sept. 16, 2024, providers will have to show that our Medicare Plus Blue℠ and BCN Advantage℠ members have tried and failed Empaveli® (pegcetacoplan), HCPCS code J3490, when requesting prior authorization for the following drugs for the diagnosis of paroxysmal nocturnal hemoglobinuria, or PNH:
Empaveli will continue to require prior authorization. Here’s other important information:
When prior authorization is required These drugs require prior authorization, as applicable, when they are administered by a health care provider in sites of care such as outpatient facilities or physician offices and are billed in one of the following ways:
How to access NovoLogix To access NovoLogix, log in to our provider portal (availity.com),** click on Payer Spaces in the menu bar and then click on the BCBSM and BCN logo. You’ll find links to the NovoLogix tools on the Applications tab. Note: If you need to request access to our provider portal, follow the instructions on the Register for web tools webpage at bcbsm.com/providers. List of requirements For a list of requirements related to drugs covered under medical benefits, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members. We’ll update this list before 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 and electronic data interchange services.
Vyjuvek has additional requirements for most commercial membersBlue Cross Blue Shield of Michigan and Blue Care Network have updated the medical policy for Vyjuvek® (beremagene geperpavec-svdt). The requirements in the medical policy apply for most Blue Cross and BCN commercial members for dates of service on or after July 22, 2024. In keeping with the updated medical policy, the following additional requirements must be met for treatment with Vyjuvek to be considered medically necessary:
To see the full list of requirements in the updated medical policy, go to the Medical Policy Router Search page, enter the name of the drug in the Policy/Topic Keyword field and press Enter. Tip: To access the Medical Policy Router Search page, go to bcbsm.com/providers, click on Resources and then click on Search Medical Policies. Some Blue Cross commercial groups aren’t subject to these requirements For Blue Cross commercial, these requirements apply only to groups that participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under medical benefits. 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 members with Blue Cross non-Medicare plans don’t participate in the standard prior authorization program. Additional information For additional information about drugs covered under medical benefits, see the following pages of the ereferrals.bcbsm.com website: Prior authorization isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.
We’re adding requirements for Lamzede, Vyjuvek for URMBT members with Blue Cross non-Medicare plansFor dates of service on or after Sept. 12, 2024, Lamzede® and Vyjuvek® will have the requirements outlined below for UAW Retiree Medical Benefits Trust members with Blue Cross Blue Shield of Michigan non‑Medicare plans.
Submit prior authorization requests through the NovoLogix® online tool when these drugs will be billed as a medical benefit. Note: The requirements don’t apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714). How to access NovoLogix 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, see the Register for web tools webpage on bcbsm.com. For drugs that have a site-of-care requirement, the NovoLogix online tool will prompt you to select a site of care when you submit prior authorization requests. If the request meets clinical criteria for the drug and is for one of the following sites of care, it will be approved automatically:
More about requirements for medical benefit drugs For additional information on requirements related to drugs covered under medical benefits for URMBT members with Blue Cross non-Medicare plans, see:
We’ll update the drug lists to reflect the information in this article before the effective date. As a reminder, prior authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members. **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 to offer provider portal services.
New Alyglo requirements for Federal Employee Program non-Medicare membersFor dates of service on or after June 1, 2024, the drug listed below has a prior authorization requirement and a site-of-care requirement for Blue Cross and Blue Shield Federal Employee Program® non‑Medicare members:
For members who began therapies before June 1 Authorizations approved for therapies that began before June 1, 2024, will be valid for up to 12 months. For members beginning therapy on or after June 1 For members beginning therapy on or after June 1, submit prior authorization requests through the NovoLogix® online tool. It offers real-time status checks and immediate approvals for certain medications. To access NovoLogix, log in to our provider portal (availity.com),** click on Payer Spaces in the menu bar and then click on the BCBSM and BCN logo. You’ll find links to the NovoLogix tools on the Applications tab. Note: If you need to request access to our provider portal, see the Register for web tools webpage on bcbsm.com. The NovoLogix online tool will prompt you to select a site of care when you submit prior authorization requests for this drug. If the request meets clinical criteria for the drug and is for one of the following sites of care, it will be approved automatically:
Additional information or documentation may be required for requests to administer Alyglo in an outpatient hospital setting. List of requirements For a full list of requirements related to drugs covered under medical benefits, see the Utilization management medical drug list for Blue Cross and Blue Shield Federal Employee Program® non-Medicare members. We’ve updated this list to reflect the new requirements. You can access this list and other information about submitting prior authorization requests on the following pages of ereferrals.bcbsm.com: Prior authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members. **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 to offer provider portal services.
Webinars for physicians, coders focus on risk adjustment, codingWe’re offering 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 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 here if you don’t have a provider portal account. 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 sessions with the keyword “lunchtime" and then look under the results for Events. You can listen to the previously recorded sessions, too. Check out the following:
Questions?
**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 and electronic data interchange services.
Reminder: Requirements for billing DME, prosthetic, orthotics, medical suppliesBlue Cross Blue Shield of Michigan requires all durable medical equipment and medical supply providers who bill for custom prosthetic and orthotic services to have a Provider Transaction Access Number, or PTAN. This requirement includes all professional providers, including those who meet the Centers for Medicare & Medicaid Services exemption criteria. Providers must obtain American Board for Certification accreditation for orthotics, prosthetics and pedorthics from a CMS-approved source and then request the PTAN from CMS to bill for custom P&O services. Once you have your 10-digit PTAN, you’ll need to enroll in the Blue Cross network with the ABC certification and the PTAN. Blue Cross may require a separate P&O provider identification number for billing custom P&O services and a DME provider PIN for billing DME and off-the-shelf P&O services. Visit the Enrollment page at bcbsm.com or contact Provider Enrollment and Data Management at 1-800-822-2761 to request registration as a P&O provider. If your provider specialty isn’t updated, services billed to Blue Cross for custom P&O services will reject as not payable to your provider specialty and you’ll be liable for the charge and can’t bill the member. Contact Provider Enrollment and Data Management for additional information to update your provider enrollment status. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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