Reminder: Supporting documentation required for certain claim types

Specific documentation should be attached to the Medical Record Routing Form when health care providers bill certain claim types for Blue Cross Blue Shield of Michigan commercial (non-Medicare) members. The form is used to submit required documentation for a previously submitted claim or to link required documentation to an electronically submitted original claim.

The supporting documentation is necessary to ensure the claim can be reviewed in a timely manner to determine a procedure’s medical appropriateness and service payment amount. When the necessary documentation isn’t attached, claims will be denied.

Blue Cross requires providers to send additional documentation in medical records supporting the treatment provided to the patient for these claim types:

• Individual consideration procedure codes – Send records such as surgical notes or detailed descriptions.
• Not-otherwise-classified procedure codes – Provide additional documentation when the procedure code description data element (Loop 2400 SV202-7) of the electronic claim only provides a partial explanation of the procedure performed.
• Procedure code with modifier 22 – Requires documentation to describe increased procedural services when the work performed is substantially greater than typically required.
• Procedure code with modifier 62 – Requires documentation to describe when two surgeons work together as primary surgeons performing distinct parts of a procedure.
• Procedure code with modifier 66 – Requires documentation in a surgical report to describe the collaboration of more than two surgeons for team surgery.
• Air ambulance – Includes procedure codes A0424, A0430, A0431, A0435 and A0436; requires the ambulance run report and medical records, including the “Medical Transport Justification” documentation, that support the need for air transport versus ground transport.
• Hearing claims with modifier SC – Requires documentation to show medical necessity for the service.
• Cosmetic service claims – Some procedures may be considered either cosmetic or reconstructive based on the indications for surgery; therefore, additional documentation is required to support the statement of medical necessity that justifies the surgery as reconstructive.

The Medical Record Routing form should not be used for secondary claims and timely filing requests. Instead, these should be discussed with Provider Inquiry. Claim denials not related to medical record requests should also be discussed with Provider Inquiry.

If you have any questions or need to speak with Provider Inquiry, call:

• Professional: 1-800-344-8525
• Facility: 1-800-249-5103

Practice caution with requests for patient information

Our Corporate and Financial Investigations Unit has been made aware of provider offices receiving fraudulent requests for patient information, national provider identifier numbers and provider signatures. These requests, which may come to you by standard mail, email or fax, often include clues that indicate they are not legitimate; for example:

• Use of a generic “BlueCross BlueShield” logo; that is not the official Blue Cross Blue Shield of Michigan, Blue Care Network or Blue Cross and Blue Shield Association logo
• Obvious grammatical errors (wrong tense, misspelled words, random or inconsistent capitalization)
• Phone numbers that don’t match

DME fraud is becoming more common

One of the largest health care fraud schemes of the past few years involves durable medical equipment, costing the health care industry tens of millions of dollars a year. Our Medicare members can be particularly susceptible to these schemes. For example, fraudulent telemarketers may reach out to seniors offering “free” DME equipment to members, intentionally trying to confuse them to get Medicare to pay for equipment that isn’t actually vetted by a medical professional (and that the member often never receives).

If you suspect a request may be fraudulent, don’t respond to it

When we conduct mass requests for medical records or patient information, we often notify you through a provider newsletter article or a provider alert. If you’re suspicious of a request that you receive, you can contact our Fraud Hotline at 1-844-STOP-FWA (1-844-786-7392) or send an email to StopFraud@bcbsm.com. We may ask you to share the request so we can check its legitimacy.

For more useful information, check out the Victimized Provider Project section** of the Centers for Medicare & Medicaid website. The Victimized Provider Project helps keep providers from being held liable for overpayment for claims paid that are the result of identity theft.

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

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

Register now for Prior Authorization Programs with Carelon webinar

Provider office personnel responsible for obtaining prior authorizations are encouraged to register now for a webinar about Blue Cross Blue Shield of Michigan’s utilization management program with Carelon Medical Benefits Management (formerly AIM Specialty Health).

Carelon performs medical appropriateness reviews on for the following services: high-tech radiology, cardiology, radiation oncology, medical oncology and in-lab sleep studies. Prior authorization programs vary based on the member group contract and benefits.

This live session will present an educational overview of all the programs, as well as a demonstration of how to navigate the Carelon portal to submit, view and manage a prior authorization request. The presentation is followed by a question and answer period. You can register for this webinar on our provider training website.

Provider training website access

Provider portal users with an Availity Essentials account can access the provider training website on the Applications tab in the BCBSM/BCN Payer Space. Log in through availity.com.**

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. Or quickly search for the session with the keyword “Carelon” and then look under the results for Events.

Questions?

• 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.

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.

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.

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

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.

High-level professional emergency department claims must be supported in medical records

Optum is requesting medical records on behalf of Blue Cross Blue Shield of Michigan for the pre-pay program. Medical records for professional emergency department PPO claims will be requested to verify that documentation supports a high-level of medical decision making for claims billed with CPT code *99285.

CPT code *99285 is used to report emergency department visits requiring a medically appropriate history and/or examination and high medical decision-making.

Here are some key documentation reminders to support CPT code *99285:

• While history and physical examination is important, it won’t be a determining factor for code selection.
• The MDM complexity should be well-documented and meet the criteria for high-level decision-making.
• High-level MDM involves reviewing and analyzing a significant amount of data, including tests, imaging studies, and coordination with other health care providers and must be clearly documented.
• High-level risk addresses situations with a high risk of complications, severe morbidity, or mortality, requiring high-level decision-making and management.

Remember, per CPT guidelines, “Time is not a descriptive component for the emergency department levels of E/M services because emergency department services are typically provided on a variable intensity basis, often involving multiple encounters with several patients over an extended period of time.”

Refer to the American College of Emergency Physicians MDM Grid** for leveling guidelines.

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

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” by looking 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.

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

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

Register now for our Behavioral Health Summit

Professional behavioral health providers and billers are invited to our upcoming Behavioral Health Summit. Attendees can interact with Provider Engagement & Transformation consultants, receive tailored presentations from various behavioral health-specific departments and network with peers and industry leaders. The summit will be held in person on Thursday, May 9, and Thursday, June 6, and virtually Thursday, Aug. 8.

For more information about the summit, contact providerengagement@bcbsm.com.

Resources can help educate patients about flu vaccine, acute bronchitis

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

Half of U.S. adults hospitalized for the flu have heart disease, and the risk of having a first heart attack is six times greater following a flu infection, according to the American Heart Association.** That risk can be substantially lowered by receiving the flu vaccine, but less than half of U.S. adults do so.

The Centers for Disease Control and Prevention developed a flyer, Treating Influenza: Information for People at High Risk for Serious Flu Complications,** to help health care providers educate patients with chronic conditions on the importance of flu vaccinations.

Preventing and treating bronchitis

If a patient develops acute bronchitis or bronchiolitis, the CDC also developed a patient education flyer, Preventing and Treating Bronchitis,** you can distribute. The flyer provides information on what acute bronchitis is, symptoms, when to seek medical care and treatment recommendations, including why antibiotics aren’t used.

Information about FEP

For information on Blue Cross and Blue Shield Federal Employee Program^® benefits, providers and members can visit fepblue.org or call Customer Service at 1-800-482-3600.

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

Do you have time for a Quality Minute?

Quality Minute will be 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.

Medicare wellness visits

• An annual wellness visit, or AWV, is the most crucial visit for your Medicare Advantage members’ quality of care, and it’s a component of contracts and incentive programs.
• AWVs can be scheduled anytime during the calendar year, regardless of the member’s previous AWV. This means you do not have to wait 365 days from the previous AWV. Every Medicare Plus Blue℠ and BCN Advantage℠ member is eligible for an AWV starting Jan. 1 of the new year.
• AWVs can be completed and billed on the same day as an annual physical exam (*99385-*99387, *99395-*99397) or an evaluation and management service (*99202-*99215) if all components of both visits are met, including all medical record documentation guidelines. Add modifier 25 to the physical or E/M code. Members should be informed that there may be costs associated with services billed in addition to the AWV.
• When an AWV is completed virtually with an E/M code, both video and audio are required.

For more information

Refer to the Medicare Wellness Visits tip sheet. Here’s how to find it:

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

Review medications at every patient visit

• Remind patients to bring their medications to each visit. You can add this to your messaging for appointment reminders.
• Use a standard phrase, such as “I’m going to review your medications.” This will help patients remember the review if they receive a CAHPS survey asking about this later.
• The medical record must include the name of the person who reviewed the medications with the patient and the date of review.

Cost, side effects and barriers to pharmacy pickup may affect medication adherence

• Remind patients to use their pharmacy benefits when paying for medications.
• Prescription drug prices under a patient’s pharmacy coverage is typically more cost-effective than discount programs, especially for generic medications.
• Use of discount programs will not count toward pharmacy quality gaps, such as medication adherence.
• Ninety-day mail order prescriptions are the gold standard to ensure patients adhere to their medication regimens.
• All active diagnoses should be submitted on claims annually to exclude members from quality measures for which their diagnoses make medications intolerable.

By following these simple tips, you’ll improve patients’ experience measured by several Medicare Star measures.

For more information, refer to the Medication Adherence Star measure tip sheet.

CAHPS^®, Consumer Assessment of Healthcare Providers and Systems, is a registered trademark of the Agency for Healthcare Quality and Research.

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.

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

Changes coming to coverage of some prescription drugs

Starting July 1, 2024, we’re changing how we cover some medications on the drug lists associated with our prescription drug plans. The following list detail these changes.

We’ll notify affected members, their groups and their health care providers in writing about the changes, see below for more information.

Drugs that will have a higher copayment

Unless noted, both the brand name and available generic equivalents of the following drugs won’t be covered. If a member fills a prescription for one of these drugs on or after July 1, 2024, they’ll be responsible for the full cost.

The brand-name drug that will have a higher copayment is listed along with suggested, covered preferred alternatives that have similar effectiveness, quality and safety. When pharmacies fill prescriptions with preferred alternatives, the generic equivalents are dispensed, if available. Additional coverage requirements may apply for preferred alternatives.

**Nonpreferred brand drugs are not covered for members with a closed benefit.

Webinars for physicians, coders focus on risk adjustment, coding

We’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 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. You can listen to the previously recorded sessions too. Check out the following:  

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 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.

We’re reminding members about important preventive cancer screenings

Blue Cross Blue Shield of Michigan and Blue Care Network want to help members live their healthiest lives and help providers close gaps in care. We’ll begin sending targeted communications throughout May and in to early June to members who haven’t had recommended cancer screenings to encourage them to discuss their cancer risk and testing options with their physicians. Health care providers can help members by scheduling time to discuss the importance of cervical, breast and colorectal cancer screenings.

Providers play an important role in this preventive care by discussing lifestyle, family history and a screening schedule that’s right for each patient.

Effective cancer screening and early detection has led to declining death rates from cancer.

The Healthcare Effectiveness Data, or HEDIS^®, measures for screening are below:

Colorectal cancer

The Colorectal Cancer Screening HEDIS^® Star Measure assesses patients ages 45 to 75 who had appropriate screenings for colorectal cancer. Colonoscopy is the gold standard for colorectal cancer screening. Providers can discuss alternative options for patients who are reluctant to have one.

Providers can discuss lifestyle modifications for members. More than half of all cases and deaths are attributable to modifiable risk factors, such as smoking, an unhealthy diet, high alcohol consumption, physical inactivity and excess body weight.

Breast cancer

Breast cancer is the second most common cancer in women, according to the American Cancer Society.
The Breast Cancer Screening HEDIS^® Star Measure assesses female patients ages 50 to 74 who had a mammogram to screen for breast cancer in the past two years.

Cervical cancer

Cervical cancer is the fourth most common cancer in women globally, according to the World Health Organization.

The HEDIS measure for cervical cancer screening uses the following criteria for those who were recommended for routine screening:

• Women 21 to 64 years of age who had cervical cytology performed within the last three years
• Women 30 to 64 years of age who had cervical high-risk human papillomavirus (hrHPV) testing performed within the last five years
• Women 30 to 64 years of age who had cervical cytology/high-risk human papillomavirus (hrHPV) cotesting within the last five years

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

**Blue Cross and BCN don’t own or control this website.

Register now for the virtual series: Equitable Care for Older Adults

This May, Blue Cross Blue Shield of Michigan will present a three-part webinar series highlighting some of the conditions commonly experienced by older patients and how each of these conditions presents barriers to obtaining care. This “Equitable Care for Older Adults” series will explore the effects that hearing loss, vision impairments and cognitive decline can have on patient care. We’ll also discuss best practices that can make care more equitable for those experiencing these impairments.

Register below for each session in this series:

Part 1: May 21, 2024, from noon to 12:45 p.m.
We’ll discuss the current challenges faced in health care settings by those who have hearing impairments and include strategies to ensure accessibility. We’ll also present resources for practices and their patients who experience hearing loss.

Part 2: May 23, 2024, from noon to 12:45 p.m.
Participants will learn about the barriers faced in health care settings by patients experiencing vision impairment. We’ll discuss best practices that help maintain equitable care and present additional resources for providers and their patients.

Part 3: May 30, 2024, from noon to 12:45 p.m.
We’ll review the impacts age-related cognitive decline can have on older adults and their caregivers when accessing health care. We’ll present tips to communicate effectively with older patients and their caregivers, while ensuring equitable access to care.

Register by visiting the Upcoming Webinars page of the Blue Cross Patient Experience site. Recordings will be available on-demand at the Patient Experience site after the live sessions. Continuing medical education, or CME, credits are available for physicians. Continuing education units, or CEU, are available for medical assistants and other health care professionals.

Strategies to care for older patients and manage challenging patients

Visit the on-demand page of the Patient Experience site to view recently added educational resources.

Our April series, “Improving Health Outcomes for Older Adults,” is now available on demand.

• Part 1: “Ensuring Effective Care Through Conversations” focuses on effectively communicating with patients about urinary incontinence, physical activity and fall risk, along with a brief background on the Health Outcomes Survey. (45 minutes)
• Part 2: “Discussions to Help Older Patients Maintain Their Mental and Physical Health” discusses strategies to discuss the risks associated with poor mental and physical health for older adults and the use of patient-centered planning. (45 minutes)
• Part 3: “Overcoming Barriers to Sensitive Conversations with Patients” reviews the barriers and anxieties older patients may have when discussing sensitive topics, such as memory problems or advanced care planning. It also includes tips to relieve patients’ anxiety and build trust, plus strategies to overcome providers’ own apprehensions. (45 minutes)

The “Managing Challenging Patient Interactions” webinar, which is also available on demand, provides strategies for health care professionals to manage upset or frustrated patients or caregivers in the office setting. It covers tactics to prevent challenging situations, tips to stay calm and de-escalation strategies. This session is also available as an in-office lunch-and-learn meeting for practices. (1 hour)

For these and other on-demand resources, CME credits are available for physicians and CEUs are available for medical assistants and other health care professionals.

For more information, email PatientExperience@bcbsm.com or visit the Blue Cross Patient Experience site.

Requirements and codes changed for some medical benefit drugs

Blue Cross Blue Shield of Michigan and Blue Care Network encourage proper utilization of high-cost medications that are covered under the medical benefit. As part of this effort, we maintain comprehensive lists of requirements for our members.

In January, February and March 2024, we added requirements for some medical benefit drugs. These requirements went into effect on various dates. In addition, some drugs were assigned new HCPCS codes.

Changes in requirements

For Blue Cross commercial and BCN commercial members, we added prior authorization requirements, site-of-care requirements or both for the following drugs:

For Medicare Plus Blue℠ and BCN Advantage℠ members, we added prior authorization requirements for the following drugs:

Code changes

The table below shows HCPCS code changes that were effective January 2024 for the medical benefit drugs managed by Blue Cross and BCN.

Drug lists

For additional details, see the following drug lists:

• Commercial members: Blue Cross and BCN utilization management medical drug list
• Medicare Advantage members: Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members.

These lists are also available on the following pages of the ereferrals.bcbsm.com website:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

Additional information about these requirements

We communicated these changes previously through provider alerts, which contain additional details.

You can view the provider alerts on ereferrals.bcbsm.com and on our Provider Resources site, which is accessible through our provider portal, availity.com.***

Additional information for Blue Cross commercial groups

For Blue Cross commercial groups, authorization requirements apply only to groups that participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List. A link to this list is also available on the Blue Cross Medical Benefit Drugs page of the ereferrals.bcbsm.com website.

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.

Reminder

An authorization approval isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.

**May be assigned a unique code in the future.

***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.

Prior authorization requirements changing for musculoskeletal pain management, spinal procedure codes

For dates of service on or after June 3, 2024, we’re adding prior authorization requirements for several pain management and spinal procedure codes that are managed through TurningPoint Healthcare Solutions LLC’s Musculoskeletal Surgical Quality and Safety Management program.

The tables below outline the changes. In the tables:

• Some of the procedure codes represent specific procedures that have been separated out from more general procedures already managed by TurningPoint.
• Other procedure codes replaced codes that were retired by the American Medical Association.

Note: This change doesn’t affect MESSA members. For additional information about which members are affected, see the Musculoskeletal Services and Pain Management Services pages on ereferrals.bcbsm.com.

Pain management procedure codes

Spinal procedure codes

Additional information

We updated the document titled Musculoskeletal procedure codes that require authorization by TurningPoint to reflect these changes.

For more information about TurningPoint’s Musculoskeletal Surgical Quality and Safety Management program, see the following pages on the ereferrals.bcbsm.com website:

• Blue Cross Musculoskeletal Services
• Blue Cross Pain Management Services
• BCN Musculoskeletal Services
• BCN Pain Management Services

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

Step therapy requirement to be added for VPRIV, Elelyso for Medicare Advantage members, starting June 1

For dates of service on or after June 1, 2024, health care providers must show that Medicare Plus Blue℠ and BCN Advantage℠ members tried and failed Cerezyme^® (imiglucerase) when requesting prior authorization for the following drugs:

• VPRIV^® (velaglucerase alfa), HCPCS code J3385
• Elelyso^® (taliglucerase alfa), HCPCS code J3060

Cerezyme is Blue Cross Blue Shield of Michigan and Blue Care Network’s preferred enzyme replacement therapy for Gaucher disease.

These drugs are covered under members’ medical benefits, not their pharmacy benefits.

Providers should submit prior authorization requests for VPRIV and Elelyso through the NovoLogix^® online tool.

As a reminder, Cerezyme doesn’t require prior authorization for dates of service on or after Jan. 1, 2024.

When prior authorization is required

VPRIV and Elelyso require prior authorization when they are administered by a provider in sites of care such as outpatient facilities or physician offices and are billed in one of the following ways:

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

Submit prior authorization requests through NovoLogix

To access NovoLogix, log in to our provider portal at availity.com,** click Payer Spaces in the menu bar and then click the BCBSM and BCN logo. You’ll find links to the NovoLogix tools on the Applications tab. 

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

List of requirements

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

We’ll update this list prior to the effective date.

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

NovoLogix is an independent company that provides an online prescription drug prior authorization tool for Blue Cross Blue Shield of Michigan and Blue Care Network.

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 policies updated

To ensure correct coding and payment accuracy, we’re sharing the below information about forthcoming payment policy updates, new policies and coding reminders. 

Blue Cross Blue Shield of Michigan commercial

Modifier “AS” is required for assistant at surgery billing

The modifier “AS” is used to indicate that the assistant at the time of surgery was a physician's assistant, certified nurse practitioner, clinical nurse specialist or doctor of podiatric medicine.

Claims submitted without the modifier may be denied when major surgical procedures have also been billed by a physician. In August, we plan to add a new line appending modifier AS to ensure services are reimbursed at the correct rate.

Don’t bill multiple anesthesia codes

Only one anesthesia code should be reported per anesthesia administration encounter and when multiple surgical procedures are performed during a single anesthesia administration. Claims submitted for more than one anesthesia code may receive a denial.

Blue Care Network commercial

Preadmission testing

Testing that is related to an inpatient admission is considered inclusive to the inpatient stay. Claims submitted for preadmission testing when related to inpatient admission may receive a denial.

BCN Advantage℠

Frequency limit for subsequent visits
In alignment with the Centers for Medicare & Medicaid Services, BCN Advantage has removed frequency limits for subsequent inpatient visits, subsequent nursing facility visits and critical care consultation when reported with modifiers 93, 95, FQ, GT and GQ. This applies to telehealth place of service (02 and 10).

BCN commercial and BCN Advantage

Reporting multiple visits

Both BCN commercial and BCN Advantage don’t reimburse more than one emergency room visit on the same day. Multiple visits reported on the same day, with same revenue code, without condition code GO aren’t allowed.

Elrexfio, Talvey to require prior authorization for most members, starting June 20

For dates of service on or after June 20, 2024, the following drugs will require prior authorization through the Oncology Value Management program:

• Elrexfio™ (elranatamab-bcmm), HCPCS code J1323
• Talvey™ (talquetamab-tgvs), HCPCS code J3055

The Oncology Value Management program is administered by Carelon Medical Benefits Management. These drugs are part of members’ medical benefits, not their pharmacy benefits. 

Prior authorization requirements apply when these drugs are administered in outpatient settings for:

• Blue Cross Blue Shield of Michigan commercial:
• All fully insured members (group and individual)
• Members who have coverage through self-funded groups that have opted in to the Oncology Value Management program.
• Although UAW Retiree Medical Benefits Trust non-Medicare plans have opted into this program, these requirements may not apply. Refer to their medical oncology drug list, which is linked below.
• This requirement doesn’t apply to members who have coverage through the Blue Cross and Blue Shield Federal Employee Program^®.
• Medicare Plus Blue℠ members
• Blue Care Network commercial members
• BCN Advantage℠ members

How to submit prior authorization requests

Submit prior authorization requests to Carelon using one of the following methods:

• Go through the Carelon provider portal, which you can access by doing one of the following:
• Logging in to our provider portal (availity.com),** clicking Payer Spaces and then clicking the BCBSM and BCN logo. This takes you to the Blue Cross and BCN payer space, where you’ll click the Carelon ProviderPortal tile.

Note: If you need to request access to our provider portal, see the Register for web tools webpage on bcbsm.com.

• Logging in directly to the Carelon provider portal at providerportal.com.**
• Call the Carelon Contact Center at 1-844-377-1278.

Drug lists

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

• Blue Cross commercial and BCN commercial:
• Oncology Value Management program prior authorization list for Blue Cross and BCN commercial members
• Blue Cross and BCN utilization management medical drug list
• URMBT members with Blue Cross non-Medicare plans:
• Oncology Value Management program prior authorization list for UAW Retiree Medical Benefits Trust PPO non-Medicare members
• Medical Drug Management with Blue Cross for UAW Retiree Medical Benefits Trust PPO non-Medicare Members
• Medicare Plus Blue and BCN Advantage members:
• Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members

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

Columvi, Daxxify, Qalsody to require prior authorization for URMBT members with Blue Cross non-Medicare plans

For dates of service on or after July 1, 2024, the drugs listed below will require prior authorization for UAW Retiree Medical Benefits Trust members with Blue Cross Blue Shield of Michigan non‑Medicare plans.

These drugs are part of members’ medical benefits, not their pharmacy benefits.

See the table below for:

• Drug names and HCPCS codes
• Where to submit prior authorization requests

The prior authorization requirement applies apply only when these drugs are administered in an outpatient setting.

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

How to submit prior authorization requests

To access the Carelon provider portal or the NovoLogix online tool, log in to our provider portal (availity.com),** click Payer Spaces in the menu bar and then click the BCBSM and BCN logo. On the Applications tab, click the tile for the Carelon provider portal or the appropriate NovoLogix tool.

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

You can also log in directly to the Carelon provider portal at providerportal.com.**

More about requirements for medical benefit drugs

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

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

We’ll update the drug lists to reflect the information in this message prior to 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 and Blue Care Network to offer provider portal and electronic data interchange services.

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

Cinryze, Elfabrio, Evkeeza to have site-of-care requirement for most commercial members, starting July 1

For dates of service on or after July 1, 2024, we’re adding a site-of-care requirement for Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members for the following drugs covered under the medical benefit:

• Cinryze^® (c-1 esterase), HCPCS code J0598
• Elfabrio^® (pegunigalsidase alfaiwxj), HCPCS code J2508
• Evkeeza^® (evinacumab-dgnb), HCPCS code J1305

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

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

Additional information or documentation may be required for requests to administer Cinryze, Elfabrio and Evkeeza in an outpatient hospital setting.

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

Members who start courses of treatment with Cinryze, Elfabrio or Evkeeza before July 1, 2024, will be able to continue receiving the drug in their current location until their existing authorization expires. If these members then continue treatment under a new prior authorization, the site-of-care requirement outlined above will apply.

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

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

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

List of requirements

For a full list of requirements related to drugs covered under the medical benefit, see the Blue Cross and BCN utilization management medical drug list for Blue Cross commercial and BCN commercial members.

We’ll update this list prior to the effective date.

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

• Blue Cross Medical Benefit Drugs page
• BCN Medical Benefit Drugs page

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

NovoLogix is an independent company that provides an online prescription drug prior authorization tool for Blue Cross Blue Shield of Michigan and Blue Care Network.

Udenyca Onbody to require prior authorization for most commercial members effective immediately

For dates of service on or after March 5, 2024, we’ve added a prior authorization requirement for most Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members for the following drug covered under the medical benefit:

• Udenyca^® Onbody (pegfilgrastim-cbqv), HCPCS code Q5111

Note: This change applies to UAW Retiree Medical Benefits Trust (non-Medicare) members.

How to submit prior authorization requests

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 at availity.com,** click Payer Spaces in the menu bar, and then click 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.

Some Blue Cross commercial groups aren’t subject to this requirement

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 don’t participate in the standard prior authorization program.

List of requirements

For a full list of requirements related to drugs covered under the medical benefit, see the Blue Cross and BCN utilization management medical drug list for Blue Cross commercial and BCN commercial members.
You can access this list and other information about requesting prior authorization on the following pages of the ereferrals.bcbsm.com website:

• 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.

** 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.

Questionnaire changes in e-referral system

On March 31, 2024, we added one questionnaire and updated other questionnaires in the e-referral system.

We’ve updated the Authorization criteria and preview questionnaires document on the ereferrals.bcbsm.com website to reflect these changes.

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

New questionnaire

We’ve added the following questionnaire to the e-referral system.

Updated questionnaires

We’ve 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.

Most commercial members must try preferred product for Zynteglo

For dates of service on or after April 19, 2024, we’ve added a step therapy requirement for Zynteglo™ (betibeglogene autotemcel), HCPCS code J3590.

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

We’ve updated the Blue Cross and BCN utilization management medical drug list to reflect the preferred drug.

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.

NovoLogix is an independent company that provides an online prescription drug prior authorization tool for Blue Cross Blue Shield of Michigan and Blue Care Network.

Changes coming to coverage of some prescription drugs

Starting July 1, 2024, we’re changing how we cover some medications on the drug lists associated with our prescription drug plans. The following list detail these changes.

We’ll notify affected members, their groups and their health care providers in writing about the changes, see below for more information.

Drugs that will have a higher copayment

Unless noted, both the brand name and available generic equivalents of the following drugs won’t be covered. If a member fills a prescription for one of these drugs on or after July 1, 2024, they’ll be responsible for the full cost.

The brand-name drug that will have a higher copayment is listed along with suggested, covered preferred alternatives that have similar effectiveness, quality and safety. When pharmacies fill prescriptions with preferred alternatives, the generic equivalents are dispensed, if available. Additional coverage requirements may apply for preferred alternatives.

**Nonpreferred brand drugs are not covered for members with a closed benefit.

Webinars for physicians, coders focus on risk adjustment, coding

We’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 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. You can listen to the previously recorded sessions too. Check out the following:  

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 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.

We’re reminding members about important preventive cancer screenings

Blue Cross Blue Shield of Michigan and Blue Care Network want to help members live their healthiest lives and help providers close gaps in care. We’ll begin sending targeted communications throughout May and in to early June to members who haven’t had recommended cancer screenings to encourage them to discuss their cancer risk and testing options with their physicians. Health care providers can help members by scheduling time to discuss the importance of cervical, breast and colorectal cancer screenings.

Providers play an important role in this preventive care by discussing lifestyle, family history and a screening schedule that’s right for each patient.

Effective cancer screening and early detection has led to declining death rates from cancer.

The Healthcare Effectiveness Data, or HEDIS^®, measures for screening are below:

Colorectal cancer

The Colorectal Cancer Screening HEDIS^® Star Measure assesses patients ages 45 to 75 who had appropriate screenings for colorectal cancer. Colonoscopy is the gold standard for colorectal cancer screening. Providers can discuss alternative options for patients who are reluctant to have one.

Providers can discuss lifestyle modifications for members. More than half of all cases and deaths are attributable to modifiable risk factors, such as smoking, an unhealthy diet, high alcohol consumption, physical inactivity and excess body weight.

Breast cancer

Breast cancer is the second most common cancer in women, according to the American Cancer Society.
The Breast Cancer Screening HEDIS^® Star Measure assesses female patients ages 50 to 74 who had a mammogram to screen for breast cancer in the past two years.

Cervical cancer

Cervical cancer is the fourth most common cancer in women globally, according to the World Health Organization.

The HEDIS measure for cervical cancer screening uses the following criteria for those who were recommended for routine screening:

• Women 21 to 64 years of age who had cervical cytology performed within the last three years
• Women 30 to 64 years of age who had cervical high-risk human papillomavirus (hrHPV) testing performed within the last five years
• Women 30 to 64 years of age who had cervical cytology/high-risk human papillomavirus (hrHPV) cotesting within the last five years

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

**Blue Cross and BCN don’t own or control this website.

Register now for the virtual series: Equitable Care for Older Adults

This May, Blue Cross Blue Shield of Michigan will present a three-part webinar series highlighting some of the conditions commonly experienced by older patients and how each of these conditions presents barriers to obtaining care. This “Equitable Care for Older Adults” series will explore the effects that hearing loss, vision impairments and cognitive decline can have on patient care. We’ll also discuss best practices that can make care more equitable for those experiencing these impairments.

Register below for each session in this series:

Part 1: May 21, 2024, from noon to 12:45 p.m.
We’ll discuss the current challenges faced in health care settings by those who have hearing impairments and include strategies to ensure accessibility. We’ll also present resources for practices and their patients who experience hearing loss.

Part 2: May 23, 2024, from noon to 12:45 p.m.
Participants will learn about the barriers faced in health care settings by patients experiencing vision impairment. We’ll discuss best practices that help maintain equitable care and present additional resources for providers and their patients.

Part 3: May 30, 2024, from noon to 12:45 p.m.
We’ll review the impacts age-related cognitive decline can have on older adults and their caregivers when accessing health care. We’ll present tips to communicate effectively with older patients and their caregivers, while ensuring equitable access to care.

Register by visiting the Upcoming Webinars page of the Blue Cross Patient Experience site. Recordings will be available on-demand at the Patient Experience site after the live sessions. Continuing medical education, or CME, credits are available for physicians. Continuing education units, or CEU, are available for medical assistants and other health care professionals.

Strategies to care for older patients and manage challenging patients

Visit the on-demand page of the Patient Experience site to view recently added educational resources.

Our April series, “Improving Health Outcomes for Older Adults,” is now available on demand.

• Part 1: “Ensuring Effective Care Through Conversations” focuses on effectively communicating with patients about urinary incontinence, physical activity and fall risk, along with a brief background on the Health Outcomes Survey. (45 minutes)
• Part 2: “Discussions to Help Older Patients Maintain Their Mental and Physical Health” discusses strategies to discuss the risks associated with poor mental and physical health for older adults and the use of patient-centered planning. (45 minutes)
• Part 3: “Overcoming Barriers to Sensitive Conversations with Patients” reviews the barriers and anxieties older patients may have when discussing sensitive topics, such as memory problems or advanced care planning. It also includes tips to relieve patients’ anxiety and build trust, plus strategies to overcome providers’ own apprehensions. (45 minutes)

The “Managing Challenging Patient Interactions” webinar, which is also available on demand, provides strategies for health care professionals to manage upset or frustrated patients or caregivers in the office setting. It covers tactics to prevent challenging situations, tips to stay calm and de-escalation strategies. This session is also available as an in-office lunch-and-learn meeting for practices. (1 hour)

For these and other on-demand resources, CME credits are available for physicians and CEUs are available for medical assistants and other health care professionals.

For more information, email PatientExperience@bcbsm.com or visit the Blue Cross Patient Experience site.

Requirements and codes changed for some medical benefit drugs

Blue Cross Blue Shield of Michigan and Blue Care Network encourage proper utilization of high-cost medications that are covered under the medical benefit. As part of this effort, we maintain comprehensive lists of requirements for our members.

In January, February and March 2024, we added requirements for some medical benefit drugs. These requirements went into effect on various dates. In addition, some drugs were assigned new HCPCS codes.

Changes in requirements

For Blue Cross commercial and BCN commercial members, we added prior authorization requirements, site-of-care requirements or both for the following drugs:

For Medicare Plus Blue℠ and BCN Advantage℠ members, we added prior authorization requirements for the following drugs:

Code changes

The table below shows HCPCS code changes that were effective January 2024 for the medical benefit drugs managed by Blue Cross and BCN.

Drug lists

For additional details, see the following drug lists:

• Commercial members: Blue Cross and BCN utilization management medical drug list
• Medicare Advantage members: Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members.

These lists are also available on the following pages of the ereferrals.bcbsm.com website:

• Blue Cross Medical Benefit Drugs
• BCN Medical Benefit Drugs

Additional information about these requirements

We communicated these changes previously through provider alerts, which contain additional details.

You can view the provider alerts on ereferrals.bcbsm.com and on our Provider Resources site, which is accessible through our provider portal, availity.com.***

Additional information for Blue Cross commercial groups

For Blue Cross commercial groups, authorization requirements apply only to groups that participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group List. A link to this list is also available on the Blue Cross Medical Benefit Drugs page of the ereferrals.bcbsm.com website.

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.

Reminder

An authorization approval isn’t a guarantee of payment. Health care providers need to verify eligibility and benefits for members.

**May be assigned a unique code in the future.

***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.

Prior authorization requirements changing for musculoskeletal pain management, spinal procedure codes

For dates of service on or after June 3, 2024, we’re adding prior authorization requirements for several pain management and spinal procedure codes that are managed through TurningPoint Healthcare Solutions LLC’s Musculoskeletal Surgical Quality and Safety Management program.

The tables below outline the changes. In the tables:

• Some of the procedure codes represent specific procedures that have been separated out from more general procedures already managed by TurningPoint.
• Other procedure codes replaced codes that were retired by the American Medical Association.

Note: This change doesn’t affect MESSA members. For additional information about which members are affected, see the Musculoskeletal Services and Pain Management Services pages on ereferrals.bcbsm.com.

Pain management procedure codes

Spinal procedure codes

Additional information

We updated the document titled Musculoskeletal procedure codes that require authorization by TurningPoint to reflect these changes.

For more information about TurningPoint’s Musculoskeletal Surgical Quality and Safety Management program, see the following pages on the ereferrals.bcbsm.com website:

• Blue Cross Musculoskeletal Services
• Blue Cross Pain Management Services
• BCN Musculoskeletal Services
• BCN Pain Management Services

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

Step therapy requirement to be added for VPRIV, Elelyso for Medicare Advantage members, starting June 1

For dates of service on or after June 1, 2024, health care providers must show that Medicare Plus Blue℠ and BCN Advantage℠ members tried and failed Cerezyme^® (imiglucerase) when requesting prior authorization for the following drugs:

• VPRIV^® (velaglucerase alfa), HCPCS code J3385
• Elelyso^® (taliglucerase alfa), HCPCS code J3060

Cerezyme is Blue Cross Blue Shield of Michigan and Blue Care Network’s preferred enzyme replacement therapy for Gaucher disease.

These drugs are covered under members’ medical benefits, not their pharmacy benefits.

Providers should submit prior authorization requests for VPRIV and Elelyso through the NovoLogix^® online tool.

As a reminder, Cerezyme doesn’t require prior authorization for dates of service on or after Jan. 1, 2024.

When prior authorization is required

VPRIV and Elelyso require prior authorization when they are administered by a provider in sites of care such as outpatient facilities or physician offices and are billed in one of the following ways:

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

Submit prior authorization requests through NovoLogix

To access NovoLogix, log in to our provider portal at availity.com,** click Payer Spaces in the menu bar and then click the BCBSM and BCN logo. You’ll find links to the NovoLogix tools on the Applications tab. 

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

List of requirements

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

We’ll update this list prior to the effective date.

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

NovoLogix is an independent company that provides an online prescription drug prior authorization tool for Blue Cross Blue Shield of Michigan and Blue Care Network.

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.

Michigan acute inpatient facilities should submit peer-to-peer review requests, appeals through the e-referral system

Acute inpatient facilities in Michigan should use the e-referral system to submit peer-to-peer review requests and appeals related to prior authorization requests for inpatient acute care medical and surgical (non-behavioral health) admissions. Submitting these requests through the e-referral system involves completing questionnaires and attaching clinical documentation when applicable.

Submitting through the e-referral system offers a streamlined process that:

• Can help you meet submission deadlines and get faster responses
• Allows you to see initial prior authorization requests, peer-to-peer review requests and appeals in the same location
• Prevents the need to search through emails, wonder if a fax went through or call to confirm that a request was received

Here are some resources you can use to learn more:

• The How to request a peer-to-peer review with a Blue Cross or BCN medical director document. We’ve updated it to include details you’ll need to know about using the e-referral system. In the table under Non-behavioral health services, look for the row labeled Inpatient non-behavioral health non‑elective admissions — in acute care hospitals for medical and surgical admissions.
• The Submitting requests for appeals and peer-to-peer reviews in e‑referral training course. For instructions on accessing this course, refer to this article in the March 2024 issue of The Record.
• The e-referral User Guide. Look in the section titled "Submit an inpatient authorization."

When the e-referral system is not available, you can:

• Submit peer-to-peer requests using the Physician peer-to-peer request form (for non-behavioral health cases). Follow the instructions on the form.
• Submit appeals through traditional methods (fax, email or U.S. mail) as instructed in the denial letter.

You can’t use the e-referral system to submit a peer-to-peer review request or appeal for prior authorization requests that:

• Were submitted prior to the member’s admission
• Were administratively denied
• Are for inpatient behavioral health admissions
• Are for outpatient medical, surgical or behavioral health services
• Are for inpatient hospital clinical edit denials, pre-service denials, post-service audit overturns, post-claim bundling and claim denials
• Are for professional service authorization denials
• Are for denials made by a vendor

Non-Michigan facilities can’t use the e-referral system to submit peer-to-peer review or appeal requests. They must continue to:

• Submit peer-to-peer requests using the Physician peer-to-peer request form (for non-behavioral health cases).
• Submit appeals through traditional methods (fax, email or U.S. mail) as instructed in the denial letter.

Emergency Department Facility Evaluation and Management Coding Policy takes effect June 1

Blue Cross Blue Shield of Michigan began using the Optum Emergency Department Claims Analyzer, or EDCA, Jan. 4, 2023, after adoption through the Participating Hospital Agreement contract administration process. Last fall, we paused the program to continue discussions with health care providers about coding variations and algorithms to see if there were alternative ways to reduce the trend of higher-level emergency department coding.  

Based on these discussions, we’ll begin using the EDCA again June 1, 2024, in conjunction with a new Emergency Department Facility Evaluation and Management Coding Policy. We developed this reimbursement policy to ensure that facilities are reimbursed based on the consistent coding that correctly describes a patient’s clinical condition and the health care services provided in accordance with industry standards and guidelines.

Why implement the Emergency Department Facility Evaluation and Management Coding Policy?

This policy will provide guidance for how Blue Cross will reimburse UB (facility) claims billed with evaluation and management, or E/M, codes at the appropriate level of service, based on the complexity of patient condition and diagnostic services provided in the outpatient emergency department. The policy is based on coding principles established by the Centers for Medicare & Medicaid Services and the CPT and HCPCS code descriptions.

What does this mean to facilities?

Blue Cross will initially review claims that are billed with a level 4 or 5 E/M code 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.

How will claims be reviewed?

An algorithm will be applied that takes three factors into account to determine a calculated visit level for the emergency department E/M services provided. The three factors are:

1. Presenting problems – as defined by the ICD-10 reason for visit, or RFV, diagnosis
2. Diagnostic services performed – based on intensity of the diagnostic workup as measured by the diagnostic CPT codes submitted on the claim (for example, lab tests; X-rays; EKG, RT or other diagnostic scans; CT, MRI or ultrasound)
3. Patient complexity and co-morbidity – based on complicating conditions or circumstances as defined by the ICD-10 principal, secondary and external cause of injury diagnosis codes

Applicable codes:

Facility claims may receive adjustments to the level 4 or 5 E/M codes submitted to reflect a lower E/M code calculated by the EDC analyzer or may receive a denial for the code level submitted. For those that are denied, facilities should review remittance information, as Blue Cross will indicate the appropriate E/M code for the claim to be accepted in accordance with the policy.

Facilities that are reimbursed for outpatient services on a percent of charge basis may rebill a denied level 4 or 5 E/M code with a correct E/M code and the corresponding corrected charge in accordance with their chargemaster.

Exclusions

Claims for the following may be excluded from an adjustment or denial:

1. Patients who were admitted from the emergency department or transferred to another health care setting (skilled nursing facility, long term care hospital, etc.)
2. Critical care patients (*99291, *99292)
3. Patients under 2 years of age
4. Certain diagnoses that when treated in the ED most often necessitate greater than average resource use, such as significant nursing time
5. Patients who have died in the ED
6. Facilities billing level 4 and 5 E/M codes that adhere to EDCA

The Emergency Department Facility Evaluation and Management Coding Policy can be found on the Provider Resources website:

1. Log in to our provider portal, availity.com.**
2. Click Payer Spaces on the menu bar, and then click the BCBSM and BCN logo.
3. Click the Resources tab.
4. Click Secure Provider Resources (Blue Cross and BCN).
5. Click Billing and Claims on the menu bar, and then click Codes and Criteria.
6. Scroll down to the Clinical Editing section and click on Emergency Department (ED) Facility Evaluation and Management (E&M) Coding Policy.

You can find additional information about the policy on the Provider Resources website.

**Blue Cross and BCN don’t own or control this website.

Clinical editing policies updated

To ensure correct coding and payment accuracy, we’re sharing the below information about forthcoming payment policy updates, new policies and coding reminders. 

Blue Cross Blue Shield of Michigan commercial

Modifier “AS” is required for assistant at surgery billing

The modifier “AS” is used to indicate that the assistant at the time of surgery was a physician's assistant, certified nurse practitioner, clinical nurse specialist or doctor of podiatric medicine.

Claims submitted without the modifier may be denied when major surgical procedures have also been billed by a physician. In August, we plan to add a new line appending modifier AS to ensure services are reimbursed at the correct rate.

Don’t bill multiple anesthesia codes

Only one anesthesia code should be reported per anesthesia administration encounter and when multiple surgical procedures are performed during a single anesthesia administration. Claims submitted for more than one anesthesia code may receive a denial.

Blue Care Network commercial

Preadmission testing

Testing that is related to an inpatient admission is considered inclusive to the inpatient stay. Claims submitted for preadmission testing when related to inpatient admission may receive a denial.

BCN Advantage℠

Frequency limit for subsequent visits
In alignment with the Centers for Medicare & Medicaid Services, BCN Advantage has removed frequency limits for subsequent inpatient visits, subsequent nursing facility visits and critical care consultation when reported with modifiers 93, 95, FQ, GT and GQ. This applies to telehealth place of service (02 and 10).

BCN commercial and BCN Advantage

Reporting multiple visits

Both BCN commercial and BCN Advantage don’t reimburse more than one emergency room visit on the same day. Multiple visits reported on the same day, with same revenue code, without condition code GO aren’t allowed.

Elrexfio, Talvey to require prior authorization for most members, starting June 20

For dates of service on or after June 20, 2024, the following drugs will require prior authorization through the Oncology Value Management program:

• Elrexfio™ (elranatamab-bcmm), HCPCS code J1323
• Talvey™ (talquetamab-tgvs), HCPCS code J3055

The Oncology Value Management program is administered by Carelon Medical Benefits Management. These drugs are part of members’ medical benefits, not their pharmacy benefits. 

Prior authorization requirements apply when these drugs are administered in outpatient settings for:

• Blue Cross Blue Shield of Michigan commercial:
• All fully insured members (group and individual)
• Members who have coverage through self-funded groups that have opted in to the Oncology Value Management program.
• Although UAW Retiree Medical Benefits Trust non-Medicare plans have opted into this program, these requirements may not apply. Refer to their medical oncology drug list, which is linked below.
• This requirement doesn’t apply to members who have coverage through the Blue Cross and Blue Shield Federal Employee Program^®.
• Medicare Plus Blue℠ members
• Blue Care Network commercial members
• BCN Advantage℠ members

How to submit prior authorization requests

Submit prior authorization requests to Carelon using one of the following methods:

• Go through the Carelon provider portal, which you can access by doing one of the following:
• Logging in to our provider portal (availity.com),** clicking Payer Spaces and then clicking the BCBSM and BCN logo. This takes you to the Blue Cross and BCN payer space, where you’ll click the Carelon ProviderPortal tile.

Note: If you need to request access to our provider portal, see the Register for web tools webpage on bcbsm.com.

• Logging in directly to the Carelon provider portal at providerportal.com.**
• Call the Carelon Contact Center at 1-844-377-1278.

Drug lists

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

• Blue Cross commercial and BCN commercial:
• Oncology Value Management program prior authorization list for Blue Cross and BCN commercial members
• Blue Cross and BCN utilization management medical drug list
• URMBT members with Blue Cross non-Medicare plans:
• Oncology Value Management program prior authorization list for UAW Retiree Medical Benefits Trust PPO non-Medicare members
• Medical Drug Management with Blue Cross for UAW Retiree Medical Benefits Trust PPO non-Medicare Members
• Medicare Plus Blue and BCN Advantage members:
• Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue and BCN Advantage members

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

Columvi, Daxxify, Qalsody to require prior authorization for URMBT members with Blue Cross non-Medicare plans

For dates of service on or after July 1, 2024, the drugs listed below will require prior authorization for UAW Retiree Medical Benefits Trust members with Blue Cross Blue Shield of Michigan non‑Medicare plans.

These drugs are part of members’ medical benefits, not their pharmacy benefits.

See the table below for:

• Drug names and HCPCS codes
• Where to submit prior authorization requests

The prior authorization requirement applies apply only when these drugs are administered in an outpatient setting.

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

How to submit prior authorization requests

To access the Carelon provider portal or the NovoLogix online tool, log in to our provider portal (availity.com),** click Payer Spaces in the menu bar and then click the BCBSM and BCN logo. On the Applications tab, click the tile for the Carelon provider portal or the appropriate NovoLogix tool.

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

You can also log in directly to the Carelon provider portal at providerportal.com.**

More about requirements for medical benefit drugs

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

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

We’ll update the drug lists to reflect the information in this message prior to 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 and Blue Care Network to offer provider portal and electronic data interchange services.

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

Cinryze, Elfabrio, Evkeeza to have site-of-care requirement for most commercial members, starting July 1

For dates of service on or after July 1, 2024, we’re adding a site-of-care requirement for Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members for the following drugs covered under the medical benefit:

• Cinryze^® (c-1 esterase), HCPCS code J0598
• Elfabrio^® (pegunigalsidase alfaiwxj), HCPCS code J2508
• Evkeeza^® (evinacumab-dgnb), HCPCS code J1305

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

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

Additional information or documentation may be required for requests to administer Cinryze, Elfabrio and Evkeeza in an outpatient hospital setting.

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

Members who start courses of treatment with Cinryze, Elfabrio or Evkeeza before July 1, 2024, will be able to continue receiving the drug in their current location until their existing authorization expires. If these members then continue treatment under a new prior authorization, the site-of-care requirement outlined above will apply.

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

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

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

List of requirements

For a full list of requirements related to drugs covered under the medical benefit, see the Blue Cross and BCN utilization management medical drug list for Blue Cross commercial and BCN commercial members.

We’ll update this list prior to the effective date.

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

• Blue Cross Medical Benefit Drugs page
• BCN Medical Benefit Drugs page

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

NovoLogix is an independent company that provides an online prescription drug prior authorization tool for Blue Cross Blue Shield of Michigan and Blue Care Network.

Udenyca Onbody to require prior authorization for most commercial members effective immediately

For dates of service on or after March 5, 2024, we’ve added a prior authorization requirement for most Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members for the following drug covered under the medical benefit:

• Udenyca^® Onbody (pegfilgrastim-cbqv), HCPCS code Q5111

Note: This change applies to UAW Retiree Medical Benefits Trust (non-Medicare) members.

How to submit prior authorization requests

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 at availity.com,** click Payer Spaces in the menu bar, and then click 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.

Some Blue Cross commercial groups aren’t subject to this requirement

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 don’t participate in the standard prior authorization program.

List of requirements

For a full list of requirements related to drugs covered under the medical benefit, see the Blue Cross and BCN utilization management medical drug list for Blue Cross commercial and BCN commercial members.
You can access this list and other information about requesting prior authorization on the following pages of the ereferrals.bcbsm.com website:

• 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.

** 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.

Questionnaire changes in e-referral system

On March 31, 2024, we added one questionnaire and updated other questionnaires in the e-referral system.

We’ve updated the Authorization criteria and preview questionnaires document on the ereferrals.bcbsm.com website to reflect these changes.

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

New questionnaire

We’ve added the following questionnaire to the e-referral system.

Updated questionnaires

We’ve 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.

Most commercial members must try preferred product for Zynteglo

For dates of service on or after April 19, 2024, we’ve added a step therapy requirement for Zynteglo™ (betibeglogene autotemcel), HCPCS code J3590.

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

We’ve updated the Blue Cross and BCN utilization management medical drug list to reflect the preferred drug.

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.

NovoLogix is an independent company that provides an online prescription drug prior authorization tool for Blue Cross Blue Shield of Michigan and Blue Care Network.