2024 CPT 3rd-quarter updates: New codes added, deleted

The American Medical Association has added several new codes as part of its quarterly Current Procedural Terminology update. The codes, effective dates and Blue Cross Blue Shield of Michigan’s coverage decisions are below.

Pathology and laboratory/proprietary laboratory analysis

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.

Carelon introduces provider portal feature to enhance prior authorization process

In early October, Carelon Medical Benefits Management is introducing a pilot program to allow health care providers to upload clinical documentation to their provider portal pages when submitting prior authorization requests.

This pilot feature applies to Medicare Plus Blue℠ members only and is part of our ongoing effort to enhance the health care provider experience.

Providers must still answer all clinical attestation questions pertaining to the case to ensure prompt medical criteria review. An “Attach File” feature will be available when the case requires additional documentation. Click on this button to upload documents to potentially avoid the need for a peer-to-peer review and an appeal.

Currently, providers can upload documentation after the prior authorization is submitted, until a decision is made and the case is closed. This feature stays unchanged. During the pilot program period, providers will also be able to upload the documents along with the prior authorization request, if necessary.

Carelon performs medical appropriateness reviews of the following services for Medicare Plus Blue members: high-tech radiology, cardiology, radiation oncology and medical oncology. Prior authorization programs vary based on the member’s group contract and benefits.

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.

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.

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.

To view the “October 2024 Billing chart,” click here.

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

Provider enrollment phone line closed Mondays, Fridays in September, October

During the months of September and October, the provider enrollment phone line (1‑800‑822‑2761) will be closed on Mondays and Fridays, but will remain open on Tuesdays, Wednesdays and Thursdays from 8 a.m. to 4 p.m., except for holiday closures.

Why we’re making this temporary change

We’re doing this so we can focus resources on processing provider enrollment and change requests. We’re behind in processing these requests, and the temporary phone line closures will allow us to dedicate more staff to complete this work.

What we recommend

Given the current backlog of requests, we recommend that you don’t call requesting a status on enrollment or change requests submitted less than 30 days ago.

If you call our provider enrollment phone line and the wait is expected to be 30 minutes or more, you’ll hear a message asking you to call back at another time. We’re doing this to help you avoid long wait times.

We apologize for any inconvenience and appreciate your patience until we’re back to our usual service levels.

Medicare Plus Blue expands membership migration from IkaSystems to NASCO in 2025

Blue Cross Blue Shield of Michigan will continue the transition of its Medicare Plus Blue℠ electronic membership files from ikaSystems to the NASCO operating system. This is an important step in enhancing our service delivery and ensuring a seamless claims handling process.

Members will receive new ID numbers that must be used in claims submission as part of this process.

Timeline and implementation

Last year, we began updating our internal processes in preparation for moving our Medicare Plus Blue membership to the NASCO operating system. We’ve already started processing groups new to Medicare Plus Blue in 2024 on the NASCO platform.

• In January 2025, we’ll move our Medicare Plus Blue individual and national Michigan group membership from ikaSystems to the NASCO system.
• In 2026, we plan to transition our key and large group membership to NASCO to ensure continuity and efficiency.

Changes to the provider vouchers

As outlined in the sample in the December 2023 issue of The Record, the Medicare Plus Blue voucher looks similar to the Blue Cross commercial voucher but has undergone the following changes to improve clarity and accuracy:

• A new field indicates the provider network.
• Additional columns identify the tax ID and electronic funds transfer dates.
• Adjustments such as sequestration and withhold amounts appear in the remittance advice section.
• Diagnosis-related group claims for acute inpatient or rehabilitation services are listed on a single line in the remittance.

Outpatient claims will continue to be listed on the claim line level.

See sample below.

Member ID cards update

The format of member ID cards will also be revised to include:

• An alphanumeric prefix
• A deidentified ID number
• A nine-digit group number for easier identification and processing

Individual Medicare Plus Blue PPO card with Medicare Rx

National Michigan Group Medicare Plus Blue PPO card with Medicare Rx

Beginning Jan. 1, 2025:

• If a migrated member doesn’t share their new ID card with their provider, the membership system at Blue Cross will cross-reference the old number to the new information.
• If the provider enters the old enrollee number in the membership system, the new number will replace the old number in the system response.
• If the provider submits a claim with the old number into the claims system, it will be rejected. The provider needs to resubmit the claim with the new enrollee number.

Further information

Please refer to the October 2023 issue of The Record for additional details on the changes to the check and EFT number series to prepare adequately for these updates.

We appreciate your cooperation and understanding as we enhance our systems to serve you better.

Webinars for physicians, coders focus on risk adjustment, coding

We’re offering webinars to explain 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 by clicking here.

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.

Clinical editing policy updated

To support correct coding and payment accuracy, we’re providing the information below to keep you informed about forthcoming payment policy updates, new policies and coding reminders. 

Blue Cross Blue Shield of Michigan commercial: Soft tissue tumor removal claims

When procedure codes that represent soft tissue tumor removal are submitted, the diagnosis codes should support that level of service. 

The appropriate procedure codes representing benign and malignant integumentary lesion excisions should be reported for excision of cutaneous lesions and superficial subcutaneous lesions, rather than the higher-level soft tissue tumor excision codes.

This editing will identify soft tissue tumor removal codes when diagnoses on the claim only describe a skin lesion, such as a sebaceous cyst or benign neoplasm.

Claims that contain a procedure code for soft tissue tumor removal with a diagnosis that doesn’t support that level of service may be denied.    

Follow these guidelines for billing split or shared visits

We have noticed that members who are involved in physical therapy, occupational therapy, speech therapy and applied behavior analysis are sometimes receiving two or more of these therapies in the same time interval.

As a result, we’re providing guidelines for how to bill when more than one therapy provider has provided services to the same Blue Cross Blue Shield of Michigan or Blue Care Network member during the same time interval — for example, from 1 to 2 p.m. on a specific day.

For our commercial members

For Blue Cross and BCN commercial members:

• The only time that two or more therapy providers can bill services for the same commercial member during the same time interval is when the procedure code definition allows for this.
• When the code definition doesn’t indicate that split or shared billing is appropriate, the provider who spent the most amount of time with the member is the only provider who is permitted to bill. In other words, when physical therapy, occupational therapy, speech therapy and applied behavior analysis are provided during the same interval, only the provider who spent the most amount of time with the member can bill for that interval.

This applies to but isn’t limited to procedure codes *97153, *97155, *0362T and *0373T.

For our Medicare Advantage members

For our Medicare Plus Blue℠ and BCN Advantage℠ members, follow the Centers for Medicare & Medicaid Services billing guidelines.

For all members

Providers are not prohibited from seeing a member at different times during the same day and billing for services. For example, if a patient receives an hour of physical therapy in the morning and an hour of occupational therapy in the afternoon, both providers can bill because the services occurred in different time intervals. This applies to all of our members.

Tips when billing E/M with preventive services

Blue Cross Blue Shield of Michigan and Blue Care Network commercial plans recently began reimbursing evaluation and management, or E/M, services at 50% of the allowed amount when billed on the same day as a preventive service. This was effective with dates of service beginning June 1, 2024, and was announced in the June 2024 issue of The Record and the July-August 2024 issue of BCN Provider News, Page 29.

Since June, some members have complained about being charged a copay, coinsurance or deductible following their preventive service when an E/M service was also billed. To maintain a positive member experience, Blue Cross and BCN recommend the following:

• Inform the patient when adding the E/M service — During a preventive service encounter, the practitioner should let the patient know when an additional service is going to be considered not preventive and potentially result in cost to the member. Then the patient can decide whether to proceed with that service.
• Explain that combining the service could possibly save them money — If the patient has coinsurance or a deductible, combining the service with the preventive service could save the patient money. Since the service is reimbursed at 50% of the allowed amount, out-of-pocket cost that’s based on the service cost will also be lower.
• Let the patient know that two services will be billed — If the patient goes forward with the additional service, you should explain that the patient will see two services billed — one for the preventive service with no out-of-pocket cost and one for the medical examination for the additional service, which may require a copay, coinsurance or a deductible, depending on the patient’s benefits.

Notes

• Members with fixed dollar copays will usually pay the same copay if the E/M service is provided on the same day as a preventive service. The only time the fixed dollar copay would be reduced is if 50% of the allowed amount for the E/M service is less than the member’s copay. In such a case, the member would pay the lower amount.
• Providers who are paid via capitation for BCN won’t receive additional reimbursement as these E/M codes and preventive services are included in capitation payments.
• Our Medicare Advantage plans, Medicare Plus Blue℠ and BCN Advantage℠, reimburse E/M on the same day as preventive services in alignment with Medicare rules.

Additional musculoskeletal spinal procedures may be covered, but will require prior authorization for Blue Cross commercial members

For dates of service on or after Nov. 27, 2024, spinal procedure codes *0164T, *0165T, *22857 and *22862 will no longer be considered experimental for Blue Cross Blue Shield of Michigan commercial members. These procedure codes will require prior authorization through TurningPoint Healthcare Solutions LLC.

What you need to know

• For dates of service before Nov. 27, the codes listed above are considered experimental for Blue Cross commercial members and don’t require prior authorization, as they are not covered.
• The codes listed above already require prior authorization for Medicare Plus Blue℠, Blue Care Network commercial and BCN Advantage℠ members.

For more information about TurningPoint’s musculoskeletal surgical quality and safety management program, see the following pages on ereferrals.bcbsm.com:

• 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.

Share information about childhood immunizations, prenatal care, where to go for care with FEP members

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

Disease prevention and management support a healthy life. But when urgent or emergent care is needed, knowing where to get treatment can help patients get back on track quickly.

Childhood immunizations

Routine immunizations can help prevent viral illnesses that may cause long-term health effects. Here is a vaccine schedule from healthychildren.org** listing vaccines needed by age 6** to share with patients.

Prenatal care

Reminders of the importance of prenatal care for patients in their childbearing years can help prevent pregnancy and delivery complications. The Blue Cross and Blue Shield Federal Employee Program^® offers benefits and incentives to encourage members to seek prenatal care:

• Prenatal care visits are a covered benefit for all FEP Service Benefit Plan members.
• The Pregnancy Care Incentive Program is available to Standard and Basic Option members and rewards a member with a Pregnancy Care Box after having a prenatal visit in the first trimester.

Follow-up care

When urgent or emergent care is needed, educating patients on where to go for care can help reduce their health care costs and possibly save a life. The Know Where to Go guide may help FEP members remember your recommendation in case of an emergency. If a patient is discharged from the emergency room or hospital, encouraging them to follow up seven and 30 days after discharge can help reduce their risk of readmission.

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

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

Webinar, on-demand opportunities available for training

Provider Experience continues to offer training resources for health care providers and staff. Live webinars and on-demand courses are designed to help you work more efficiently with Blue Cross Blue Shield of Michigan and Blue Care Network.

The following learning opportunities are available now.

“Prior Authorization Programs with Carelon” — Oct. 10, 10 to 11 a.m. Eastern time — This live session builds on the first webinar earlier this year to deep dive into some intermediate topics, such as denials and appeals. The presentation is followed by a question-and-answer period. Register for this webinar on the provider training website. To help prepare for the webinar, take one of the courses about working with Carelon:

• Carelon Medical Benefits Management overview e-learning — This 15-minute module reviews of the basics on working with Carelon Medical Benefits Management.
• Prior authorization program with Carelon Medical Benefits Management presentation — This webinar was recorded in June. It has an overview of the processes and a step-by-step demonstration of submitting a prior authorization request in the Carelon provider portal.

Medicare Advantage Post-Acute Care Prior Authorization Program — Learn about the changes related to post-acute care services for Medicare Advantage members. This recorded presentation discusses the process changes and what providers need to do starting Oct. 1, 2024.

How to access provider training

To access the training site, follow these steps:

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

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.

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.

Reminder: Home health care services won’t require prior authorization for Medicare Advantage members, starting Oct. 1

As we announced in a July 2, 2024, provider alert, home health care services for Medicare Advantage members will no longer require prior authorization, starting Oct. 1, 2024.

For claims that are submitted on or after Oct. 1, 2024, our systems won’t look for an approved prior authorization. In addition, we won’t accept retroactive authorization requests.

Our provider manuals and related documents have been updated to reflect these changes.

Reminders:

• 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.
• Be sure to check each member’s eligibility and benefits prior to performing services.

Oncology medical drug management moving to OncoHealth for most members Jan. 1

For dates of service on or after Jan. 1, 2025, OncoHealth^® will manage prior authorizations for medical benefit oncology drugs through the Oncology Value Management program. These drugs are managed by Carelon Medical Benefits Management for dates of service before Jan. 1, 2025.

Important: Blue Cross Blue Shield of Michigan and Blue Care Network will continue to manage prior authorization requests for cellular and gene therapies, such as CAR-T.

Pharmacy benefit oncology drugs will continue to be managed by Blue Cross and BCN for until March 31, 2025. OncoHealth will begin managing these drugs through the Oncology Value Management program for dates of service on or after April 1, 2025. Watch for provider alerts and articles in our provider newsletters about this upcoming change.  

OncoHealth will manage the following:

• Prior authorizations, including reviewing requests for medical necessity, preferred drugs, step therapy requirements and dose optimization
• Site of care transitions from higher- to lower-cost places of service, for Blue Cross and BCN commercial members only

This change will affect the following groups and members:

• Blue Cross commercial
• Fully insured groups and individual members
• Self-funded groups
• Note: The Oncology Value Management program changes won’t apply to Blue Cross commercial UAW Retiree Medical Benefits Trust non-Medicare members or to Blue Cross and Blue Shield Federal Employee Program^® members. Their medical benefit and pharmacy benefit oncology drugs will continue to be managed as they are today.
• Medicare Plus Blue℠ members
• BCN commercial members
• BCN Advantage℠ members

Watch for additional provider alerts and newsletter articles about this change, including how to register for webinars.

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.

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

Our program to help reduce avoidable inpatient readmissions for Medicare Advantage members is changing

We’re offering a new program through Blue Cross Coordinated Care℠ Core to reduce avoidable inpatient admissions for Medicare Plus Blue℠ and BCN Advantage℠ members.

On Sept. 30, 2024, the nonclinical, transitional care program through Home & Community Care (formerly known as naviHealth, Inc.) for members who are discharged from acute inpatient facilities to certain post-acute care facilities in Michigan will end. Home & Community Care navigation specialists provided support to all members who engaged with the program before the end date.

Starting Oct. 1, 2024, care managers from Blue Cross Coordinated Care will work with members who are eligible for the Blue Cross Coordinated Care program and are at risk for unsuccessful discharge to their homes from acute inpatient facilities or from post-acute care facilities.

For more information about Blue Cross Coordinated Care, see the document titled Blue Cross Coordinated Care Core: For members with complex, chronic and acute conditions.

Home & Community Care is an independent company that provides nonclinical, transitional care services for Blue Cross Blue Shield of Michigan and Blue Care Network members who have Medicare Advantage plans.

Learn more about changes related to post-acute care services for Medicare Advantage members, starting Oct. 1

In a May 15, 2024, provider alert, we announced that Home & Community Care (formerly known as naviHealth, Inc.) will no longer manage prior authorizations of post‑acute care services for Medicare Plus Blue℠ and BCN Advantage℠ members starting this fall. Instead, Blue Cross Blue Shield of Michigan and Blue Care Network will manage prior authorizations for these services.

Here’s the timeline for this change:

• For dates of service before Oct. 1, 2024, submit prior authorization requests to Home & Community Care.
• For dates of service on or after Oct. 1, 2024, submit prior authorization requests to Blue Cross or BCN through the e-referral system, which is accessible through our provider portal, Availity Essentials™. Patient-driven payment model, or PDPM, codes aren’t required for dates of service on or after Oct. 1. (If you’ve been submitting requests through CarePort Care Management, keep reading for more information.)

Note: For retroactive authorization requests with dates of service on or before Sept. 30, submit requests to Blue Cross or BCN through the e-referral system. Be sure to enter the Centers for Medicare & Medicaid Services-determined PDPM code in the Case Communication field. We’ll accept retroactive requests through Sept. 30, 2025. If you have questions, send them to UMMedicarePACCA@bcbsm.com.

Training resources

To access the recorded webinar or register for a live Q&A session about this change, log in to the Provider Training site and search on post-acute care. Look for the following training opportunities:

• Recorded webinar: Medicare Advantage Post-Acute Care Prior Authorization Program
• Live Q&A session: Medicare Advantage Post-Acute Care — Q&A. Tuesday, Oct. 15, 2024, from noon to 12:45 p.m.

To access the Provider Training site:

1. Log in to our provider portal (availity.com).**
2. Click on Payer Spaces in the menu bar and then click the BCBSM and BCN logo.
3. Click on the Provider Training Site tile in the Applications tab.
4. Select an organization and click Submit.

If you have issues regarding access to or navigating the site, email ProviderTraining@bcbsm.com.

If you’ve been submitting requests through CarePort Care Management

Starting Oct. 1, you’ll no longer be able to submit prior authorization requests for post-acute care services through CarePort Care Management. You’ll need to log in to our provider portal, Availity Essentials, and submit prior authorization requests through the e‑referral system, as you do for prior authorization requests for other services, such as inpatient admissions and post-acute care requests for commercial members.
For information about submitting prior authorization requests in the e-referral system, refer to the e-referral User Guide. See “Section IV: Referrals and Authorizations.” Look for the subsection titled “Submit an Outpatient Authorization.”

Additional information

We’re updating our provider manuals and related resources to reflect this change.

For information about post-acute care, see the post-acute care pages on our ereferrals.bcbsm.com website.

**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.

Home & Community Care is an independent company that manages prior authorizations for post-acute care services for Blue Cross Blue Shield of Michigan and Blue Care Network members who have Medicare Advantage plans.

Prior authorization changes for blepharoplasty, enteral nutrition, percutaneous left atrial appendage, varicose vein treatment

For dates of service on or after Sept. 8, 2024, Blue Cross Blue Shield of Michigan and Blue Care Network changed the prior authorization process for the following services for the lines of business listed in the second column of the table.

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

Training is available. To view the training:

1. Log in to our provider portal (availity.com).**
2. Click Payer Spaces in the menu bar, and then click the BCBSM and BCN logo.
3. Click the Provider Training Site tile in the Applications tab.
4. Select an organization and click Submit.
5. Enter InterQual in the search bar and press Enter.
6. Open the InterQual criteria in e-referral mini module.
7. Launch the course.

** 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.

Call Provider Inquiry to initiate Level 1 appeal according to the claim inquiry and appeal process in the provider manual for commercial PPO

Blue Cross Blue Shield of Michigan has updated the filing guidelines for submitting post service, commercial PPO claim appeals. We’ve updated the provider Level 1 appeal process in the Blue Cross Commercial Provider Manual with the new information. There is no change to how Level 1 appeals are handled and reviewed.

How to file an appeal

To submit a post service claim appeal, health care providers must first contact Provider Inquiry by phone. If you choose to request to an appeal during the phone call, and you have additional documentation to be reviewed, we’ll fax or mail you a Provider Level 1 Appeal Fax Cover Sheet, if you meet eligibility criteria. 

Post service claim appeals must be received with the Provider Level 1 Appeal Fax Cover Sheet from Provider Inquiry or on the provider’s office letterhead. If you submit an appeal on office letterhead, you must include the reference number, date and time of your call to Provider Inquiry and the representative’s name. The appeal will be considered ineligible if you use any other cover sheets or appeal forms. You won’t be eligible to make further attempts to appeal the claim.

The filing guidelines under the Appeals and Problem Resolution chapter of the provider manual has been updated with this information.

Blue Cross will directly handle network performance management duties, starting Nov. 1

Starting Nov. 1, 2024, Blue Cross Blue Shield of Michigan will monitor network performance, a service currently performed by SecureCare, an independent company. Blue Cross will directly conduct any future reviews.
 
This will apply to network performance management for the following outpatient services for Blue Cross commercial and Medicare Plus Blue℠ members:  

• Physical, occupational and speech therapy services provided by therapists
• Physical medicine services performed by chiropractors and athletic trainers
• Chiropractic services

There is no action required of health care providers at this time. If a provider is currently on a corrective action plan, the provider should continue working toward the goals put in place by SecureCare. Any follow-up communication about the corrective action plans will come directly from Blue Cross.

Please watch for more communications in our provider portal through Availity Essentials™ and The Record as we progress toward this change.

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.

Coding Advisor reviews now called Optum Coding Advisor

It can be challenging for health care providers and their office staff to select the Current Procedural Terminology, or CPT^®, codes that best reflect the complexity of a patient visit. That’s why Blue Cross Blue Shield of Michigan contracted with Optum to implement our Coding Advisor program in 2024.

Now called Optum Coding Advisor, the program reviews evaluation and management codes billed and other scenarios (such as modifier 25, observation care and nursing facility care) on claims submitted to Blue Cross. The program provides useful data insights to the provider community and works to maximize coding efficiency and accuracy through up-front education, rather than a traditional post-claim review process.

For your reference, we’ve included an example of a physician profile below.

Throughout the course of this program, Optum Coding Advisor will continue to monitor billing practices and send updated reports periodically. It may contact your practice to discuss coding variances and to offer one-on-one coding education. You’ll receive all correspondence from Optum.

If you have any questions, call the Optum Coding Advisor customer support line at
844-592-7009 or by fax at 612-454-2791, or by email at CodingAdvisorSupport@optum.com.

Example of a physician profile:

Do you have time for a Quality Minute about transitional, follow-up care?

This is another article in our 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.

Transitions of Care

• If a member is transferred from an inpatient stay to a skilled nursing facility, a follow-up should occur following the discharge from the SNF. Over half of the SNFs in Michigan are sending admissions, discharges and transfers through the Michigan Health Information Network. We expect this to increase as Blue Cross Blue Shield of Michigan and Blue Care Network continue outreach to SNFs to encourage sending admissions, discharges and transfers.
• Procedure code *1111F can be billed as soon as medication reconciliation is performed and documented in the patient’s outpatient medical record. Therefore, you don’t need to wait for an office visit or all components of a transitional care management visit to be complete to bill *1111F.
• Procedure code *1111F is reimbursable for Medicare Advantage patients, and there is no member out-of-pocket cost.
• Transitional care management codes will satisfy both the Patient Engagement and Medication Reconciliation Post-Discharge components of transitions of care.

Follow-Up After Emergency Department Visit for People with Multiple High-Risk Chronic Conditions

• Members will be in the denominator after each emergency department visit and could be in the denominator more than once.
• Blue Cross and BCN have worked with MiHIN to develop new ADT flags that identify high-risk member discharges for prompt post-discharge follow-up care.

For more information, see the Transitions of Care (TRC) or Follow-Up After Emergency Department Visit for People with Multiple High-Risk Chronic Conditions (FMC) tip sheets. Here’s how to find them.

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.

**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.

Blue Cross, BCN cover additional RSV vaccine

To increase access to vaccines and decrease the risk of vaccine-preventable disease outbreaks, Blue Cross Blue Shield of Michigan and Blue Care Network have added the following to our list of vaccines covered under pharmacy benefits.

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 member out-of-pocket cost.

 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.

Zynyz, Talvey will require prior authorization for URMBT members with Blue Cross non-Medicare plans

The following drugs will require prior authorization through Carelon Medical Benefits Management for UAW Retiree Medical Benefits Trust members with Blue Cross Blue Shield of Michigan non-Medicare plans. This change will be for dates of service on or after Nov. 21, 2024.

These drugs are covered under medical benefits.

This requirement applies only when these drugs are administered in an outpatient setting.

Note: This 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 authorization requests

To access the Carelon provider portal, log in to our provider portal at availity.com,** click on 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. 

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

You can also log in directly to the Carelon provider portal at providerportal.com** or call Carelon at 1-844-377-1278.

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:

• 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 providers 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. For more information, go to our ereferrals.bcbsm.com website.

Webinars for physicians, coders focus on risk adjustment, coding

We’re offering webinars to explain 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 by clicking here.

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.

Clinical editing policy updated

To support correct coding and payment accuracy, we’re providing the information below to keep you informed about forthcoming payment policy updates, new policies and coding reminders. 

Blue Cross Blue Shield of Michigan commercial: Soft tissue tumor removal claims

When procedure codes that represent soft tissue tumor removal are submitted, the diagnosis codes should support that level of service. 

The appropriate procedure codes representing benign and malignant integumentary lesion excisions should be reported for excision of cutaneous lesions and superficial subcutaneous lesions, rather than the higher-level soft tissue tumor excision codes.

This editing will identify soft tissue tumor removal codes when diagnoses on the claim only describe a skin lesion, such as a sebaceous cyst or benign neoplasm.

Claims that contain a procedure code for soft tissue tumor removal with a diagnosis that doesn’t support that level of service may be denied.    

Follow these guidelines for billing split or shared visits

We have noticed that members who are involved in physical therapy, occupational therapy, speech therapy and applied behavior analysis are sometimes receiving two or more of these therapies in the same time interval.

As a result, we’re providing guidelines for how to bill when more than one therapy provider has provided services to the same Blue Cross Blue Shield of Michigan or Blue Care Network member during the same time interval — for example, from 1 to 2 p.m. on a specific day.

For our commercial members

For Blue Cross and BCN commercial members:

• The only time that two or more therapy providers can bill services for the same commercial member during the same time interval is when the procedure code definition allows for this.
• When the code definition doesn’t indicate that split or shared billing is appropriate, the provider who spent the most amount of time with the member is the only provider who is permitted to bill. In other words, when physical therapy, occupational therapy, speech therapy and applied behavior analysis are provided during the same interval, only the provider who spent the most amount of time with the member can bill for that interval.

This applies to but isn’t limited to procedure codes *97153, *97155, *0362T and *0373T.

For our Medicare Advantage members

For our Medicare Plus Blue℠ and BCN Advantage℠ members, follow the Centers for Medicare & Medicaid Services billing guidelines.

For all members

Providers are not prohibited from seeing a member at different times during the same day and billing for services. For example, if a patient receives an hour of physical therapy in the morning and an hour of occupational therapy in the afternoon, both providers can bill because the services occurred in different time intervals. This applies to all of our members.

Additional musculoskeletal spinal procedures may be covered, but will require prior authorization for Blue Cross commercial members

For dates of service on or after Nov. 27, 2024, spinal procedure codes *0164T, *0165T, *22857 and *22862 will no longer be considered experimental for Blue Cross Blue Shield of Michigan commercial members. These procedure codes will require prior authorization through TurningPoint Healthcare Solutions LLC.

What you need to know

• For dates of service before Nov. 27, the codes listed above are considered experimental for Blue Cross commercial members and don’t require prior authorization, as they are not covered.
• The codes listed above already require prior authorization for Medicare Plus Blue℠, Blue Care Network commercial and BCN Advantage℠ members.

For more information about TurningPoint’s musculoskeletal surgical quality and safety management program, see the following pages on ereferrals.bcbsm.com:

• 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.

Reminder: Home health care services won’t require prior authorization for Medicare Advantage members, starting Oct. 1

As we announced in a July 2, 2024, provider alert, home health care services for Medicare Advantage members will no longer require prior authorization, starting Oct. 1, 2024.

For claims that are submitted on or after Oct. 1, 2024, our systems won’t look for an approved prior authorization. In addition, we won’t accept retroactive authorization requests.

Our provider manuals and related documents have been updated to reflect these changes.

Reminders:

• 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.
• Be sure to check each member’s eligibility and benefits prior to performing services.

Oncology medical drug management moving to OncoHealth for most members Jan. 1

For dates of service on or after Jan. 1, 2025, OncoHealth^® will manage prior authorizations for medical benefit oncology drugs through the Oncology Value Management program. These drugs are managed by Carelon Medical Benefits Management for dates of service before Jan. 1, 2025.

Important: Blue Cross Blue Shield of Michigan and Blue Care Network will continue to manage prior authorization requests for cellular and gene therapies, such as CAR-T.

Pharmacy benefit oncology drugs will continue to be managed by Blue Cross and BCN for until March 31, 2025. OncoHealth will begin managing these drugs through the Oncology Value Management program for dates of service on or after April 1, 2025. Watch for provider alerts and articles in our provider newsletters about this upcoming change.  

OncoHealth will manage the following:

• Prior authorizations, including reviewing requests for medical necessity, preferred drugs, step therapy requirements and dose optimization
• Site of care transitions from higher- to lower-cost places of service, for Blue Cross and BCN commercial members only

This change will affect the following groups and members:

• Blue Cross commercial
• Fully insured groups and individual members
• Self-funded groups
• Note: The Oncology Value Management program changes won’t apply to Blue Cross commercial UAW Retiree Medical Benefits Trust non-Medicare members or to Blue Cross and Blue Shield Federal Employee Program^® members. Their medical benefit and pharmacy benefit oncology drugs will continue to be managed as they are today.
• Medicare Plus Blue℠ members
• BCN commercial members
• BCN Advantage℠ members

Watch for additional provider alerts and newsletter articles about this change, including how to register for webinars.

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.

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

Our program to help reduce avoidable inpatient readmissions for Medicare Advantage members is changing

We’re offering a new program through Blue Cross Coordinated Care℠ Core to reduce avoidable inpatient admissions for Medicare Plus Blue℠ and BCN Advantage℠ members.

On Sept. 30, 2024, the nonclinical, transitional care program through Home & Community Care (formerly known as naviHealth, Inc.) for members who are discharged from acute inpatient facilities to certain post-acute care facilities in Michigan will end. Home & Community Care navigation specialists provided support to all members who engaged with the program before the end date.

Starting Oct. 1, 2024, care managers from Blue Cross Coordinated Care will work with members who are eligible for the Blue Cross Coordinated Care program and are at risk for unsuccessful discharge to their homes from acute inpatient facilities or from post-acute care facilities.

For more information about Blue Cross Coordinated Care, see the document titled Blue Cross Coordinated Care Core: For members with complex, chronic and acute conditions.

Home & Community Care is an independent company that provides nonclinical, transitional care services for Blue Cross Blue Shield of Michigan and Blue Care Network members who have Medicare Advantage plans.

Learn more about changes related to post-acute care services for Medicare Advantage members, starting Oct. 1

In a May 15, 2024, provider alert, we announced that Home & Community Care (formerly known as naviHealth, Inc.) will no longer manage prior authorizations of post‑acute care services for Medicare Plus Blue℠ and BCN Advantage℠ members starting this fall. Instead, Blue Cross Blue Shield of Michigan and Blue Care Network will manage prior authorizations for these services.

Here’s the timeline for this change:

• For dates of service before Oct. 1, 2024, submit prior authorization requests to Home & Community Care.
• For dates of service on or after Oct. 1, 2024, submit prior authorization requests to Blue Cross or BCN through the e-referral system, which is accessible through our provider portal, Availity Essentials™. Patient-driven payment model, or PDPM, codes aren’t required for dates of service on or after Oct. 1. (If you’ve been submitting requests through CarePort Care Management, keep reading for more information.)

Note: For retroactive authorization requests with dates of service on or before Sept. 30, submit requests to Blue Cross or BCN through the e-referral system. Be sure to enter the Centers for Medicare & Medicaid Services-determined PDPM code in the Case Communication field. We’ll accept retroactive requests through Sept. 30, 2025. If you have questions, send them to UMMedicarePACCA@bcbsm.com.

Training resources

To access the recorded webinar or register for a live Q&A session about this change, log in to the Provider Training site and search on post-acute care. Look for the following training opportunities:

• Recorded webinar: Medicare Advantage Post-Acute Care Prior Authorization Program
• Live Q&A session: Medicare Advantage Post-Acute Care — Q&A. Tuesday, Oct. 15, 2024, from noon to 12:45 p.m.

To access the Provider Training site:

1. Log in to our provider portal (availity.com).**
2. Click on Payer Spaces in the menu bar and then click the BCBSM and BCN logo.
3. Click on the Provider Training Site tile in the Applications tab.
4. Select an organization and click Submit.

If you have issues regarding access to or navigating the site, email ProviderTraining@bcbsm.com.

If you’ve been submitting requests through CarePort Care Management

Starting Oct. 1, you’ll no longer be able to submit prior authorization requests for post-acute care services through CarePort Care Management. You’ll need to log in to our provider portal, Availity Essentials, and submit prior authorization requests through the e‑referral system, as you do for prior authorization requests for other services, such as inpatient admissions and post-acute care requests for commercial members.
For information about submitting prior authorization requests in the e-referral system, refer to the e-referral User Guide. See “Section IV: Referrals and Authorizations.” Look for the subsection titled “Submit an Outpatient Authorization.”

Additional information

We’re updating our provider manuals and related resources to reflect this change.

For information about post-acute care, see the post-acute care pages on our ereferrals.bcbsm.com website.

**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.

Home & Community Care is an independent company that manages prior authorizations for post-acute care services for Blue Cross Blue Shield of Michigan and Blue Care Network members who have Medicare Advantage plans.

Call Provider Inquiry to initiate Level 1 appeal according to the claim inquiry and appeal process in the provider manual for commercial PPO

Blue Cross Blue Shield of Michigan has updated the filing guidelines for submitting post service, commercial PPO claim appeals. We’ve updated the provider Level 1 appeal process in the Blue Cross Commercial Provider Manual with the new information. There is no change to how Level 1 appeals are handled and reviewed.

How to file an appeal

To submit a post service claim appeal, health care providers must first contact Provider Inquiry by phone. If you choose to request to an appeal during the phone call, and you have additional documentation to be reviewed, we’ll fax or mail you a Provider Level 1 Appeal Fax Cover Sheet, if you meet eligibility criteria. 

Post service claim appeals must be received with the Provider Level 1 Appeal Fax Cover Sheet from Provider Inquiry or on the provider’s office letterhead. If you submit an appeal on office letterhead, you must include the reference number, date and time of your call to Provider Inquiry and the representative’s name. The appeal will be considered ineligible if you use any other cover sheets or appeal forms. You won’t be eligible to make further attempts to appeal the claim.

The filing guidelines under the Appeals and Problem Resolution chapter of the provider manual has been updated with this information.

Blue Cross plans to reimplement an existing policy for payment of external facility reviews

Blue Cross Blue Shield of Michigan plans to reimplement an existing policy that determines payment responsibility for external facility medical necessity reviews. We plan to do this for our commercial PPO (non-Medicare) business starting March 1, 2025, for inpatient medical necessity appeals. This is the same policy used when facilities appeal audits.

Second level external appeals in cases involving medical necessity, site of care or quality of care will be reviewed by a peer review organization composed of practicing physicians. If the peer review agency upholds Blue Cross’ decision, the facility will pay the cost of the appeal.

What this means to facilities

Facilities may incur attorney fees and other expenses in preparation for external reviews for upheld appeals (where the final decision is in Blue Cross' favor). These costs will be the facilities’ responsibility.

Independent external review process 

• The facility request must be received within 30 calendar days from the date on the reconsideration appeal reporting letter.
• An external peer review of records will take place within 45 calendar days.
• The facility will be notified of the peer review decision within 30 calendar days of the date that the peer review decision is received. The costs of peer review will be applied according to the chart below.
• The independent external review ends the appeal process for both Blue Cross and the facility.

Input requested

According to the Contract Administration Process — part of the Participating Hospital Agreement that went into effect July 1, 2021 — we allow non-binding input from participating facilities about such proposals.
Input from facilities is requested by Oct. 31, 2024. Send any input you may have to Liz Bowman at ebowman@bcbsm.com.

After input is received, Blue Cross has 30 calendar days to respond.          

Blue Cross proposes new policy for multiple therapy services

In 2022, Blue Cross Blue Shield of Michigan took the proposed payment reduction policy for physical, occupational and speech therapy through the Contract Administration Process. Based on the industry input that we received, the policy was put on hold.

Over the past couple of years, we’ve completed further analysis on the industry responses that lead to a policy modification. The proposed policy now excludes all therapy claims with a behavioral health diagnosis. With this change, Blue Cross is looking to implement this proposed policy in March 2025.

The proposed CMS multiple therapy policy will apply a reduction in reimbursement for the practice expense portions of therapy procedures when those services are the secondary or subsequent procedures provided on a single date of service by the same group physician and/or other qualified health care professional. This policy will not apply for therapy services rendered for behavioral health diagnoses.

• The rules align with CMS in determining which procedures are subject to the multiple therapy reduction and the primary or secondary ranking of these procedures based on practice expense relative value units, or RVU.
• The policy doesn’t interfere with benefit limits. Blue Cross allows 90 therapy visits per calendar year, and these rules won’t affect those limits.

What this means to facilities

When multiple therapy services are rendered on the same day, we’ll apply a “therapy pay percent edit.” The primary service will be reimbursed at 100% of the allowed amount, while secondary procedures performed on the same day will be reduced by 50% of the practice expense RVU.

The service with the highest RVU is considered the primary service. The practice expense RVU includes the nonphysician clinical and nonclinical labor of the practice, as well as expenses for building space, equipment and office supplies. Such expenses are considered duplicative for each subsequent therapy service and therefore will be reduced accordingly.

This practice expense reduction will result in an approximate average reimbursement of 83% of the allowed amount for all subsequent therapy services rendered on the same day.

The top five procedure codes that would receive the facility edit (reduced payment) include:

• *97140 – Manual therapy 1/> regions
• *97110 – Therapeutic exercises
• *97530 – Therapeutic activities
• *97112 – Neuromuscular reeducation
• *97116 – Gait training therapy

Input requested

According to the Contract Administration Process — part of the Participating Hospital Agreement that went into effect July 1, 2021 — we allow non-binding input from participating facilities about such proposals.

Input from facilities is requested by Oct. 31, 2024. Send any input you may have to Liz Bowman at ebowman@bcbsm.com.

After input is received, Blue Cross has 30 calendar days to respond.