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October 2020

Prior authorization requests for outpatient CAR-T therapy drugs for Medicare Advantage members

Update: Questionnaire updates in the e-referral system on Oct. 25

e-referral system out of service for maintenance overnight Oct. 17-18

Skyrizi® and Tegsedi® will be covered under the pharmacy benefit for Blue Cross' PPO and BCN HMOSM members, effective Oct. 8, 2020

Medicare Part B medical specialty drug prior authorization list is changing in January 2021

September 2020

Questionnaire updates in the e-referral system in September and October 2020

Medical specialty drug prior authorization lists will change in November for certain members

SNFs must register for and learn the e-referral system before submitting commercial SNF authorization requests through e-referral starting Dec. 1

e-referral system out of service for maintenance overnight September 19-20

Avoid SNF claim denials for Medicare Advantage by matching PDPM levels on claims to the PDPM levels naviHealth authorized

Cardiac implantable device services will require authorization by AIM Specialty Health® for many members

Update: Starting Sept. 1, BCN requires authorization for elective pediatric feeding programs (S0317)

Starting Dec. 1, some drugs covered under the medical benefit will require authorization for Blue Cross and Blue Shield Federal Employee Program® non-Medicare members

Professional providers and facilities can now register for training on TurningPoint's clinical model and more

Viltepso will require authorization for commercial members effective September and October 2020

August 2020

Sept. 7 holiday closure: How to submit inpatient authorization requests

IVIG dosing strategy is changing for the Medicare Part B medical specialty drug program, starting Dec. 7

New e-referral system upgrades

Tecartus will require authorization for commercial members effective August and September 2020

e-referral system out of service for maintenance overnight August 15-16

Effective Nov. 1, Blue Cross and BCN will have preferred hereditary angioedema medications for our commercial members

During the COVID-19 emergency, we're extending global referrals through at least Dec. 31 for BCN HMOSM members

July 2020

Clinical documentation requirements for authorization requests related to musculoskeletal procedures managed by TurningPoint

Medical specialty drug prior authorization lists are changing in September for BCN HMOSM, Medicare Plus BlueSM PPO and BCN AdvantageSM members

Uplizna will have authorization and site-of-care requirements for commercial members effective August and October 2020

e-referral system out of service for maintenance overnight July 18-19

Medicare Plus BlueSM PPO expands prior authorization program to genetic, molecular testing

Effective Oct. 1, Nivestym® and Zarxio® are the preferred filgrastim products for all Blue Cross and BCN commercial and Medicare Advantage members

June 2020

Medicare Part B medical specialty drug prior authorization list is changing Aug. 21 and Sept. 28

July 3 holiday closure: How to submit inpatient authorization requests

Avoid blocked inpatient authorization e-referral submissions by using the correct criteria

We're adding site-of-care requirements for Avsola, Reblozyl® and Tepezza for Blue Cross' PPO members, starting July 1

Updated e-referral questionnaire to open June 28 for BCN and Medicare Plus BlueSM PPO

Reminder: We're experiencing issues with processing some Supartz FX (sodium hyaluronate) claims for BCN AdvantageSM members

Medicare Part B medical specialty drug prior authorization list is changing in July and August

e-referral system out of service for maintenance overnight June 20-21

eviCore has updated corePath for physical and occupational therapy authorizations

eviCore simplifies authorization process for radiation oncology, starting July 1, 2020

New e-referral questionnaires to open June 14 for BCN HMOSM

Determinations on requests for inpatient acute care admissions are based on InterQual® criteria, not on the two-midnight rule

May 2020

Updated: More COVID-19-related utilization management changes

VyeptiTM will have authorization and site-of-care requirements for commercial members effective May and July 2020

Medical benefit specialty drug prior authorization lists are changing in July and August for Medicare Plus BlueSM PPO, BCN HMOSM and BCN AdvantageSM members

How to submit non-behavioral health inpatient authorization requests to Blue Cross and BCN during the May 25 holiday closure

Register for training on TurningPoint's clinical model and more

e-referral system out of service for maintenance overnight May 16-17

April 2020

Some Blue Care Network transitional care fax numbers discontinued starting June 1

Recommendations for submitting authorization requests for medical oncology drugs to AIM

Updated: Palforzia and Tepezza will have authorization and site-of-care requirements for commercial members effective March and May 2020

Updated: We're adding site-of-care requirements for Lemtrada and Tysabri for commercial members, starting May 1

Hospitals must notify naviHealth before transferring Medicare Advantage members to SNFs

We're experiencing issues with processing some Supartz FX (sodium hyaluronate) claims for BCN AdvantageSM members

Updated: Changes to authorization durations for elective and non-urgent procedures, including PT, OT and ST, during the COVID-19 pandemic

CHANGE: TurningPoint will manage musculoskeletal procedure authorizations with dates of service on or after July 1, 2020, for certain members

e-referral system out of service for maintenance overnight April 18-19

What to do about e-referral error message

Sarclisa® will require prior authorization starting May 15 for BCN HMOSM, Medicare Plus BlueSM PPO and BCN AdvantageSM members

How to submit inpatient authorization requests to Blue Cross and BCN during the April 10 holiday closure and the e referral weekend software upgrade

How to submit a plan notification for acute care hospital facility admissions and request for post-acute care admissions

Clinical review requirements suspended through May 31 for all admissions to acute care hospitals and for transfers to skilled nursing facilities

March 2020

We'll pay only inpatient facility claims for ZulressoTM starting July 1, for Blue Cross' PPO members

Use e-referral system while Blue Cross and BCN offices are closed on Tuesday, March 24

We’re adding site-of-care requirements for Adakveo® and Givlaari® for Blue Cross' PPO members starting April 1

e-referral system out of service for maintenance overnight March 21-22

Use e-referral system while Blue Cross and BCN offices are closed on March 20 and 23

Authorization requirements eased for COVID-19-related services

In April, we're making changes to coverage for infliximab biosimilar products for Medicare Advantage members

naviHealth is taking measures to keep Medicare Advantage members safe in response to COVID-19

Medicare Part B medical specialty drug prior authorization list is changing in June

No software upgrade on March 8-9 for e-referral system

February 2020

Professional providers and facilities can now register for training on TurningPoint's clinical model and more

Medicare Part B medical specialty drug prior authorization list is changing in April

e-referral system may be slow or problematic after data center move

Interventional pain management services for *64451 and *64625 require authorization starting May 1 for all Blue Cross and BCN members

e-referral system out of service for maintenance three times in February 2020

January 2020

Submit requests for swallow services to BCN, not to eviCore healthcare

Updated e-referral system questionnaires will be released for BCN and Medicare Plus BlueSM PPO on Feb. 2, 2020

Reblozyl® will have authorization and site-of-care requirements for commercial members effective February and April 2020

Authorization requirements are changing for home health, TPN and IDPN services for BCN members

We're removing zoledronic acid drugs from the Medicare Part B medical specialty drug prior authorization list in March

Attend a training session on changes to the Practitioner Performance Summary and utilization management categories for physical therapy providers

Musculoskeletal surgical procedures will require authorization by TurningPoint for Medicare Plus BlueSM PPO and BCN members

Radiation therapy services for A9590 require authorization starting April 1 for all Blue Cross and BCN members

Avsola and Givlaari will have authorization and site of care requirements for commercial members effective February and March 2020

How to submit inpatient authorization requests to Blue Cross during upcoming holiday closure

How to submit inpatient authorization requests to BCN during upcoming holiday closure

e-referral system out of service for maintenance Jan. 18-19

December 2019

We're adding two medical drugs to the site-of-care program for Blue Cross and Blue Care Network commercial members starting April 1, 2020

Updated — Medicare Part B medical specialty drug authorization: Clarification regarding Prolia and Xgeva

Additional medical benefit specialty drugs will have authorization and site of care requirements for Blue Cross’ PPO and BCN HMOSM members in January and February 2020

e-referral system out of service for maintenance Dec. 21-22

Medicare Part B medical specialty drug prior authorization list is changing in March

We've resolved issues with processing SNF claims for Medicare Advantage members

e-referral system unavailable from 8 to 10 a.m. Saturday, Dec. 7

How to submit inpatient authorization requests to BCN during upcoming holiday closures

How to submit inpatient authorization requests to Blue Cross during upcoming holiday closures

How to handle authorization requests for physical, occupational and speech therapy continuing into 2020

Reminder: Michigan board-certified behavior analysts must be licensed starting Jan. 7, 2020, to be reimbursed by BCN and Blue Cross

November 2019

We're adding two medical drugs to the PPO commercial site of care requirements starting in January

Provider appeal time frame extended for Blue Cross' PPO admissions

Additional medical benefit specialty drugs will require prior authorization for Blue Cross' PPO and BCN HMOSM members

How to submit inpatient authorization requests to Blue Cross during upcoming holiday closures

How to submit inpatient authorization requests to BCN during upcoming holiday closures

Register for a webinar about hyaluronic acid products for knee injections

e-referral system out of service for maintenance Nov. 16-17

We're aligning peer-to-peer review request processes for acute non-behavioral health non-elective inpatient admissions

Tell us what you think about our utilization management services

October 2019

Medicare Part B medical specialty drug prior authorization list is changing in February

For Blue Cross' PPO (commercial) and BCN HMOSM (commercial) members, ketoprofen 25 mg will require authorization and have new quantity limits

BCN to deny claims for unauthorized outpatient toxicology laboratory services by non-JVHL laboratories starting Jan. 1, 2020

Starting Nov. 1, changes in authorizing human organ transplants for BCN members

e-referral system out of service for maintenance Oct. 19-20

The oncology management program will include Medicare Advantage plans starting Jan. 1, 2020

September 2019

Starting Jan. 1, 2020, we'll cover select hyaluronic acid products

For Medicare Plus BlueSM PPO, the Specialty Medication Prior Authorization Program is expanding to include all sites of care except inpatient

Effective immediately, plan notification is no longer required for endometrial ablation and excisional breast biopsy procedures for BCN members

Effective Jan. 1, 2020, Eylea® and Lucentis® will require authorization for Blue Cross' PPO (commercial) members

Starting Jan. 1, 2020, Blue Cross' PPO and BCN HMOSM plans will cover hemophilia drugs under members' pharmacy benefits

Updated e-referral questionnaires to open Sept. 29 for BCN and Medicare Plus BlueSM PPO

Reminder: Starting Oct. 1, 2019, naviHealth will authorize PDPM levels for Medicare Advantage SNF admissions

e-referral system out of service for maintenance Sept. 21-22

How can we improve our online tools?

New webinars available in September and October for BCN

New webinars available in September and October for Blue Cross

August 2019

Providers invited to Medicare Stars events in Michigan

Endometrial ablation and excisional breast biopsy procedures for BCN members require plan notification, not authorization

Skilled nursing facilities must follow CMS guidelines for issuing NOMNC forms to Medicare Advantage members

naviHealth webinars about SNF PDPM payment methodology

Evenity® will be added to the Medicare Part B medical drug prior authorization list in November

Update: Board-certified behavior analysts must have current Michigan license by Jan. 7, 2020, to be reimbursed by Blue Cross and BCN

How to submit inpatient authorization requests to BCN during upcoming holiday closure

How to submit inpatient authorization requests to Blue Cross during upcoming holiday closure

New and updated e-referral questionnaires to open August 25 for BCN and Medicare Plus BlueSM PPO

How can we improve our online tools?

Medical record documentation requirements for ABA services are updated

Changes to BCN member transfer request form

Submit BCN enteral nutrition authorization requests using the e-referral system

Clarification: Preferred infliximab strategy for adult Blue Cross' PPO (commercial) members

TAVI/TAVR procedures for BCN members require plan notification, not authorization

Don’t add clinical documentation to denied requests in the e-referral system

Requirements for assessments of Medicare Advantage members in skilled nursing facilities

You may experience e-referral system performance issues August 3 and August 4

July 2019

Reminder: Effective August 1, authorizations must be obtained from AIM Specialty Health® for most medical oncology and supportive care medications for BCN HMOSM (commercial) members

We're making changes to the Medicare Advantage SNF post-payment audit and recovery process

Medicare Part B medical specialty drug prior authorization list is changing in October

Effective November 1, Inflectra® is the preferred infliximab product for adult Blue Cross' PPO (commercial) members

Correct fax number for submitting post-acute care discharge information to naviHealth

Reminder: Medicare Part B medical specialty drug prior authorization list changing July 22, 2019

Providers and office staff: register now for our upcoming training webinars

We're adding drugs to prior authorization, site of care programs for PPO members, effective October 2019

Comprehensive lists of requirements available for medical specialty drugs and pharmacy benefit drugs

Additional medical benefit specialty drugs have authorization and site of care requirements for BCN HMOSM members, effective Oct. 1, 2019

June 2019

We'll continue to update clinical edits to comply with current coding guidelines

NovoLogix® user interface enhancements coming soon

Enter BCN retrospective authorization requests for cardiology and radiology services in e-referral

How to submit inpatient authorization requests to Blue Cross during upcoming holiday closure

How to submit inpatient authorization requests to BCN during upcoming holiday closure

Important information about eviCore healthcare therapy authorization requests for BCN

Expanding BCN medical coverage for transgender employees of the University of Michigan

Register now for an AIM Specialty Health® oncology management program webinar

Contact eviCore healthcare's Client & Provider Services for help in using the new eviCore provider portal for BCN PT, OT and ST authorizations

More updated e-referral questionnaires open on June 23

Reminder: naviHealth manages authorization requests only for Medicare Advantage post-acute care

No authorization required for BCN initial PT, OT and ST evaluations

Additional medical benefit specialty drugs require prior authorization for Blue Cross' PPO and BCN HMOSM members

May 2019

Reminder: Medicare Advantage post-acute care authorization changes begin June 1

How to use Allscripts or CarePort Care Management for Medicare Advantage post-acute care requests

We're using updated utilization management criteria for behavioral health starting Aug. 1, 2019

Starting June 1, BCN and Blue Cross are accepting applied behavior analysis claims with 2019 procedure codes

Reminder: Submit BCN initial and follow-up authorization requests for PT, OT and ST to eviCore starting May 27, 2019

Updated authorization criteria and e-referral questionnaire for ethmoidectomy

How to submit inpatient authorization requests to Blue Cross during upcoming holiday closure

How to submit inpatient authorization requests to BCN during upcoming holiday closures

Medicare Part B medical specialty drug prior authorization list changing July 22, 2019

More BCN questionnaires to open on June 23 in e-referral

Learn about Medicare Advantage post-acute care authorization changes

Effective June 1, Spravato will be added the prior authorization program for Blue Cross and BCN commercial members.

April 2019

Effective July 1, transgender benefits expand for University of Michigan members

How to submit inpatient authorization requests to BCN during upcoming holiday closure

How to submit inpatient authorization requests to Blue Cross during upcoming holiday closure

Call BCN for cardiology and radiology authorization requests with dates of service prior to Oct. 1, 2018

BCN AdvantageSM to audit SNF claims for RUG codes starting June 1

March 2019

Effective July 1, KhapzoryTM and Fusilev® will be added the prior authorization program for PPO commercial members

Medicare Part B medical specialty drug prior authorization lists changing in June 2019

Submit BCN initial and follow-up authorization requests for PT, OT and ST to eviCore starting May 27, 2019

Behavioral health components of AAEC evaluation do not require authorization for BCN members

What to do when error messages display in e-referral

Use form to request criteria for BCN authorization decisions (non-behavioral health)

Additional changes to BCN process for requesting peer-to-peer review of non-behavioral health cases

February 2019

Home page change coming to e-referral, starting Feb. 25

Start transitioning adult BCN HMO members using infliximab products to Inflectra®

New vendor managing Medicare Advantage patient transfers to post-acute care facilities, starting June 1

Prior-authorization changes for Blue Cross URMBT non-Medicare members

Clarifying biofeedback and neurofeedback authorization requirements for BCN members

BCN otoplasty and rhinoplasty questionnaires to open on Feb. 10 in e-referral

Medicare Plus BlueSM facility claims for Prolastin® and AralastTM no longer deny for lack of documentation

January 2019

Sign up to receive Blues Brief electronically

Complete the new questionnaires in e-referral for BCN members

How to submit inpatient authorization requests to Blue Cross during upcoming holiday closure

How to submit inpatient authorization requests to BCN during upcoming holiday closure

December 2018

Effective April 1, FasenraTM and Radicava® are subject to a site-of-care requirement for BCN HMOSM members

BCN changes process for requesting a peer-to-peer review for non-behavioral health cases

Don't issue referrals for BCN AdvantageSM members staying in network

How to submit inpatient authorization requests to Blue Cross during upcoming holiday closures

How to submit inpatient authorization requests to BCN during upcoming holiday closures

Additional updated authorization criteria and e-referral questionnaires

e-referral User Guides, online eLearning updated

Xgeva® to require authorization for BCN AdvantageSM members

November 2018

eviCore to manage two radiopharmaceutical drugs, starting Feb. 1

Complete the provider specialty questionnaire in the e-referral system

Reminder: Submit BCN authorization requests to AIM for cardiology and high-tech radiology procedures

Updated authorization criteria and e-referral questionnaires

How to submit inpatient authorization requests to Blue Cross during upcoming holiday closures

How to submit inpatient authorization requests to BCN during upcoming holiday closures

Medicare Part B medical specialty drug prior authorization lists changing in 2019

October 2018

We're telling BCN AdvantageSM members they don't need referrals

Reminder: Submit BCN authorization requests to AIM for cardiology and high-tech radiology procedures

Additional updated authorization criteria and e-referral questionnaires

Register for Medicare Advantage webinar: Avastin® use for patients with retinal disorders

Onpattro, Poteligeo, Signifor LAR added to medical benefit specialty drug prior authorization program for commercial members

Tell us what you think about our utilization management services — you could win a prize!

Register now for an AIM Specialty Health® ProviderPortalSM webinar

Possible browser certificate error in e-referral for Windows 7 users starting Oct. 16, 2018

Treat Medicare Advantage members with Avastin® before other specialty drugs

Some medical benefit drugs for Medicare Advantage members need step therapy, starting Jan. 1

September 2018

Register today: NovoLogix® refresher course for medical specialty drug prior authorizations

Reminder: Starting Oct. 1, AIM Specialty Health® manages cardiology and high-tech radiology for Blue Care Network

BCN updates sleep study questionnaire in the e-referral system

Additional updated authorization criteria and e-referral questionnaires

Reminder: Effective Oct. 1, Prolia® and Xgeva® are subject to a site-of-care requirement for BCN HMOSM members

Reminder: Starting Oct. 1, additional specialty medications require authorization for BCN AdvantageSM members

August 2018

Fax authorization requests for BCN members moving to a SNF, rehabilitation facility or LTACH

Use in-network laboratories for toxicology, drug-of-abuse testing

Renflexis® requires authorization for BCN AdvantageSM starting Oct. 1

BCN to accept inpatient continued stay reviews and discharge notifications through the e-referral system starting Sept. 4

How to submit Blue Cross inpatient authorization requests during upcoming holiday closures

How to submit BCN inpatient authorization requests during upcoming holiday closures

FAQ available about LLPs and LMFTs

Additional updated authorization criteria and e-referral questionnaires in effect

Phone numbers change for BCN Case Management and Care Transition programs

Reminder: Starting Oct. 1, AIM Specialty Health® to manage cardiology and high-tech radiology services for Blue Care Network

Updated authorization criteria and e-referral questionnaires in effect

Error issue resolved in e-referral system

Reminder: Register for a medical specialty drug prior-authorization web tool refresher course

July 2018

2018 InterQual® criteria implementation delayed until Aug. 6

Starting Aug. 6, updated utilization management criteria used for behavioral health

2018 InterQual® criteria to be implemented starting Aug. 6

Last call for our provider training survey - Respond by July 31

Starting Oct. 1, AIM Specialty Health® to manage cardiology and high-tech radiology services for Blue Care Network

Starting Oct. 1, additional specialty medications require authorization for BCN AdvantageSM members

What to do when you get conflicting results in the e-referral system

Register for a medical specialty drug prior-authorization web tool refresher course

We're updating you on Blue Distinction® Specialty Care

Deleting your browsing history after an e-referral system outage

How to request peer-to-peer review of inpatient admissions

TrogarzoTM and Zilretta® require authorization for commercial members starting Oct. 1

Appealing Blue Cross Medicare Plus BlueSM PPO acute inpatient hospital authorization decisions

How to submit Blue Cross inpatient authorization requests during upcoming holiday closures

How to submit BCN inpatient authorization requests during upcoming holiday closures

June 2018

e-referral system is pending outpatient authorization requests for patients with the Blue Cross Blue Shield of Michigan plans

Updated authorization criteria and e-referral questionnaires are in effect

Effective Oct. 1, Prolia® and Xgeva® are subject to a site-of-care requirement for BCN HMOSM members

Where to get help in using the e-referral system

Effective June 22, submit appeals of eviCore decisions on BCN AdvantageSM requests to BCN, not to eviCore

Reminder: Effective July 1, Krystexxa® and Stelara® (SQ/IV) are subject to a site-of-care requirement for BCN HMOSM (commercial) members

May 2018

Sign up for a webinar on the Blue Cross Medicare Plus BlueSM PPO outpatient facility authorization requirements for specialty medical drugs

Complete the e-referral questionnaires for blepharoplasty and hyperbaric oxygen therapy for BCN members

How to submit Blue Cross inpatient authorization requests during upcoming holiday closures

How to submit BCN inpatient authorization requests during upcoming holiday closures

eviCore to handle BCN initial and follow-up authorization requests for PT, OT and ST starting later in 2018

Starting Aug. 7, FasenraTM and LuxturnaTM require authorization for Medicare Advantage members

No site-of-care requirement for BrineuraTM for BCN HMOSM (commercial) members

April 2018

e-referral not available 6 p.m. Friday, April 27, through 6 a.m. Monday, April 30

Starting June 1, no authorization is required for BCN routine outpatient behavioral health therapy

Medicare Outpatient Observation Notice requirements clarified

Starting June 1, Northwood will manage diabetic shoes and inserts for BCN and Blue Cross Medicare Plus BlueSM PPO members

Last call for our provider manual survey — Respond by April 30 for a chance to win a prize

Effective July 1, no authorization is required for multiple sclerosis medications for Blue Cross, BCN commercial members

BCN members can now get long-acting injectable medications at home

March 2018

Blue Cross, BCN will continue to cover hyaluronic acids until further notice

Effective April 2, use the flight information form for non-emergency air ambulance authorization requests

How to submit Blue Cross inpatient authorization requests during upcoming holiday closures

How to submit BCN inpatient authorization requests during upcoming holiday closures

Tell us what you think about our provider manuals – You could win a prize

Effective July 1, Krystexxa® and Stelara® (SQ/IV) are subject to a site-of-care requirement for BCN HMOSM (commercial) members

Provider forums are coming to a town near you

Effective immediately, two CAR T-cell therapies require authorization for Medicare Advantage members

Effective March 19, fax numbers are changing for BCN medical benefit drug authorization requests

MepseviiTM is subject to a site-of-care requirement for BCN HMOSM (commercial) members

February 2018

Proceed with outpatient authorization requests for knee arthroplasty in e-referral

Two additional medical benefit drugs require authorization for BCN effective April 1, 2018

January 2018

Non-emergency air ambulance services require authorization starting April 2, 2018, for commercial members

Response to Blue Cross PPO inpatient authorization requests submitted through e-referral for group 71575 now fixed

Blue Cross and Blue Care Network will no longer cover hyaluronic acids, starting April 1

How to submit Blue Cross inpatient authorization requests during upcoming holiday closures

How to submit BCN inpatient authorization requests during upcoming holiday closures

Use the e-referral system to submit BCN referrals and authorization requests

Submit functional limitation G codes for BCN AdvantageSM therapy services

December 2017

Blue Cross PPO inpatient authorization requests submitted through e-referral for group 71575 result in inaccurate instructions

Reminder: New BCN authorization requirements are effective Jan. 1, 2018

eviCore accepting Blue Cross PPO authorization requests starting Dec. 22

Authorization required for additional BCN cardiology procedures effective Jan. 1, 2018

November 2017

Behavioral health medical record documentation requirements apply to all lines of business

October 2017

New BCN authorization requirements are effective Jan. 1, 2018

Tell us what you think about BCN Care Management services – You could win a prize!

e-referral site wins communications awards

Do not refer new patients to MedEQUIP in Ann Arbor

Clarification on Blue Cross inpatient authorization requirements for newborns

We've heard your concerns: We're changing our Medicare Plus BlueSM PPO eviCore requirements for physical therapy

Changes in handling certain behavioral health requests for Medicare Plus Blue PPO members

September 2017

2017 InterQual criteria to be implemented starting October 2

New name for Blue Cross® Physician Choice PPO

Be aware of fall-winter holiday closures when faxing acute inpatient admission requests to BCN

REVISED: Use updated forms for BCN Advantage members being discharged from a hospital stay

ALERT: eviCore call centers may be affected by Hurricane Irma, use online portal

Blue Cross inpatient authorization requirements clarified

August 2017

FAQ on using e-referral system now available for Blue Cross authorization requests

BCN Behavioral Health Physician Review Line daytime number is changing effective August 21

Reminder: 2017 InterQual criteria delayed until October 2017

July 2017

Clarifying authorization requirements for Blue Cross members

Reminder: BCN uses InterQual criteria as guidelines in reviewing acute inpatient medical admissions

June 2017

For BCN and Blue Cross Medicare Plus Blue PPO, use 1-800-437-3803 to reach the Pharmacy Clinical Help Desk

Submit only the pertinent medical records for BCN initial inpatient admission requests

Register now for July e-referral training webinars for Blue Cross authorization requests

Reminder: Effective July 1, additional medical benefit drugs for BCN HMO members are subject to a site-of-care requirement

May 2017

2017 InterQual criteria delayed until October 2017

Blue Care Network changes authorization requirements for sleep management studies

Blue Care Network updates authorization guideline for external ECG monitoring

Effective July 1, additional medical benefit drugs for BCN HMO members are subject to a site-of-care requirement

April 2017

Providers can schedule phone appointments for eviCore clinical consultations on BCN radiology reviews

Be aware of holiday closures when faxing acute inpatient admission requests to BCN

Additional information on RC Claim Assist now available to Blue Cross and BCN providers

March 2017

BCN reviews inpatient readmissions within 14 days effective Jan. 19, 2017

RC Claim Assist tool is now available

January 2017

Use new PT, OT codes when billing BCN for physical and occupational therapy

Hospitals must give BCN Advantage members receiving outpatient observation services the Medicare Outpatient Observation Notice

Obstetrician-gynecologists can refer BCN and BCN Advantage members to specialists

December 2016

BCN will not require authorization for monitored anesthesia care during GI endoscopies starting Jan. 8, 2017

BCN revises codes managed by eviCore healthcare

Guidelines for submitting acute inpatient admission requests to BCN

November 2016

BCN requires authorization for additional drugs starting Jan. 1, 2017

BCN changing inpatient readmission review guidelines starting Jan. 17, 2017

REMINDER: eviCore healthcare to review additional outpatient pain management services for BCN effective Dec. 1

REMINDER: Beginning Dec. 5, 2016, BCN requires authorization for laparoscopic cholecystectomies

Dec. 1 changeover to Novologix web tool scheduled for drugs covered under the BCN medical benefit

Tell us what you think about BCN Care Management Services

October 2016

REMINDER AND CHANGE: Starting Nov. 1, submit authorization requests for outpatient ECT and TMS services via e-referral but no forms are required

ALERT: Phone issues on eviCore's BCN provider line

September 2016

Updated BCN authorization criteria and preview questionnaires now available

BCN's Behavioral Health e-referral User Guide updated

eviCore healthcare to review additional outpatient pain management services for BCN effective Dec. 1

REMINDER: BCN will review inpatient readmissions occurring within 30 days of discharge effective Oct. 1, 2016

Online self-paced training modules now available

Changeover to using Novologix web tool is delayed for BCN providers

ALERT: e-referral system is displaying updated BCN knee arthroscopy questionnaires earlier than expected

MSU Student and Graduate Assistant Health Plans information

Authorization requests for outpatient ECT and TMS services must be submitted via e-referral starting Nov. 1, 2016

eviCore to review additional radiation therapy codes for BCN effective Nov. 1, 2016

ALERT: e-referral system is displaying updated BCN sleep study questionnaire earlier than expected

August 2016

More Blue Cross® Personal Choice PPO information now available for providers

UPDATED: BCN will review inpatient readmissions occurring within 30 days of discharge effective October 1

BCN launches new Medical Benefit Drugs-Pharmacy web page

Sign up for online webinar on how to submit pain management authorization requests in eviCore's electronic system

UPDATED: Effective Aug. 18, in some instances, only eviCore's electronic system and letters will display the correct number of units authorized for cardiology, radiology and radiation therapy services for BCN members

Coming October 1 for BCN behavioral health higher levels of care: Changes in submitting initial authorization requests, concurrent reviews and discharge summaries

July 2016

e-referral User Guide updated and available

eviCore healthcare to review epidural and facet joint procedures for BCN effective September 1

Group practice staff should select correct provider ID in BCN and eviCore electronic systems

eviCore changes reconsideration process for PTs' utilization categories

June 2016

Radiology procedure code 75635 requires authorization in the e-referral system

UPDATED: Changes in BCN's sleep study requirements

Submit BCN obstetrical admissions one day after discharge – not sooner

May 2016

Some medical drugs no longer require authorization for BCN AdvantageSM members

InterQual® criteria used as guidelines in reviewing BCN acute inpatient medical admissions

2016 InterQual® criteria and BCN Local Rules take effect August 1

Welcome to the new referrals.bcbsm.com

We're updating our look

April 2016

Balloon ostial dilation for sinusitis requires referral but not clinical review, effective April 1, 2016

New Behavioral Health e-referral User Guide available

Additional information available about authorization requests for inpatient acute medical / surgical admissions

2016 InterQual® criteria to be used effective August 1, 2016

March 2016

0159T and 0190T codes require clinical review for BCN members even when used as add-on codes

What you need to know about the eviCore 2.0 provider portal

CLARIFIED: Effective May 1, BCN behavioral health providers must use e-referral to submit initial outpatient requests for authorization

Changes start May 1 for authorization requests submitted for inpatient acute medical / surgical admissions

Additional BCN Local Rules for acute care and skilled nursing facility services go into effect May 2

AMC Health to manage members with CHF and COPD effective April 1

We want your opinion

Updated nutrition assessment form now available for home infusion providers

February 2016

Updated preview questionnaire is available for excisional breast biopsy

Additional Local Rules for acute care and skilled nursing facility requests go into effect May 1

Care management requirements change for members with low back pain effective March 1

January 2016

Clarification of site of administration requirements for FCA and GM commercial members using select infusion drugs

eviCore authorization requirements change for pediatric members and for select procedure codes

December 2015

BCN Behavioral Health utilization management criteria is changing on January 1

Call Northwood at 1-800-393-6432 to identify a contracted supplier

What to do if you get an error message when submitting a case

Announcing e-referral enhancements beginning Dec. 7, 2015

Help us improve our services to you by taking our Care Management survey

November 2015

Global referral: What it allows a specialist to do

Changes in eviCore authorization requirements

Add correct servicing provider information when submitting requests to eviCore

Reminder: Prostatic urethral lift procedures require clinical review

October 2015

eviCore healthcare Web Portal webinars available

Updated Spine Care Referral Program questionnaire is now available

Some providers showing missing or incorrect address in e-referral

September 2015

Reminder: Effective Oct. 1, 2015, submit authorization requests to eviCore healthcare for select radiology, cardiology and radiation therapy services

Help us improve our services to you by taking our Care Management survey

Enter ICD-10 codes in e-referral for dates of service October 1 or later

Re-evaluation for ABA autism treatment services will not be required every three years, for all BCBSM and BCN members

Submit authorization requests to eviCore healthcare prior to October 1 for procedures with dates of service on or after October 1

August 2015

Select infusion drugs have new requirements for site of administration starting Oct. 1, 2015

Chiropractors may provide some physical therapy services for BCN commercial members

eviCore healthcare expanded procedure reviews coming — register now for September 2015 webinars

July 2015

Preventive lung cancer screening requires clinical review effective Oct. 1, 2015

New effective date for eviCore healthcare expanded reviews is Oct. 1, 2015

e-referral upgrade slated for Aug. 17

2015 InterQual® Home Care Criteria available only in Q&A format

June 2015

More procedures to be reviewed by eviCore healthcare effective September 1

eviCore healthcare Web address changes July 6

Upgrades coming to e-referral

2015 InterQual® criteria to be used effective August 3

May 2015

Additional medical drugs to require prior authorization/clinical review effective July 1, 2015

March 2015

Transplants undergo standard BCN clinical review process effective April 1, 2015

Finding home sleep study providers

Clinical review requirements for long-term continuous ECG rhythm recording and storage services

Register now for April 2015 behavioral health webinar

Training Tools

Blue Cross and Blue Care Network provide a variety of training opportunities to learn about e-referral. Your provider consultant is available by appointment to visit your office and assist with your e-referral training needs.

We offer the following training tools for the e-referral tool:

User guides and documentation

Online training

Note: Please see the Test your e-referral user ID and password flier (PDF) for instructions on how to log in, what to do if your account is not active and how to obtain a user ID and password.

Password information

  • To reset your password, contact the Web Support Help Desk at 1-877-258-3932, Monday through Friday, from 8 a.m. to 8 p.m.
  • To prevent your password from being deactivated, log in to e-referral and complete at least one transaction or activity each month.
News Archive

This archive contains messages that were previously posted in the e-referral News section. The content of these articles includes technical system issues that have been resolved or information that is now part of the regular Blue Care Network referral process.

BCN Care Management provider call volumes high

BCN Care Management is experiencing high call volumes. To avoid waiting on the phone line, providers should use BCN's e-referral system to submit or check the status of referrals or requests for clinical review. We encourage providers to call the Medical Information Specialist line at 1-800-392-2512 with urgent requests only.


How to access e-referral with Internet Explorer ® 11

Some provider offices have recently upgraded their computers to Internet Explorer version 11. If you are using Internet Explorer 11 and you receive a message that you cannot use e-referral when you try to access the system, please follow these steps (PDF).


Updated BCN provider affiliations codes on e-referral

When using the e-referral Provider Search feature, results will include a Provider Network column with a list of provider affiliation codes. Specific BCN networks are associated with these codes, for example U = University of Michigan/U-M Premier Care/GradCare. Find the latest codes and networks (PDF).

Blue Care Network announces date for program changes for breast biopsy (excisional)

BCN previously communicated in the Nov.-Dec BCN Provider News, clinical review will be required for breast biopsy (excisional) and CCTA for BCN commercial and BCN Advantage HMO-POSSM and BCN Advantage HMOSM members effective Jan. 1, 2014. The effective date of these changes will be Jan. 6, 2014.

Blue Care Network announces date for program changes for contrast-enhanced computed tomography angiography of the heart and/or coronary arteries (CTA, CCTA)

BCN previously communicated in the Nov.-Dec BCN Provider News, clinical review will be required for a CTA or CCTA for BCN commercial and HMO-POSSM and BCN Advantage HMOSM members effective Feb. 1, 2014. The effective date of these changes will be Feb. 3, 2014.

Blue Care Network offers Behavioral Health informational webinars

Blue Care Network invites you to attend a webinar for outpatient behavioral health clinics, individual behavioral health providers and provider groups.

The webinars are scheduled for the following dates, with two sessions available each day:

  • December 2
  • December 3
  • December 4
  • December 6

Each day, there will be a morning session from 9:30 to 11 a.m. and an afternoon session from 3 to 4:30 p.m. To RSVP, download the invitation (PDF) and follow the directions at the bottom of the form.

For more information, please contact Christina Caldwell at 734-332-2949.

Determining medical necessity for BCN Advantage members: inpatient vs. observation stays

When BCN AdvantageSM members are admitted for inpatient care, the process that is used to determine whether their stay is medically necessary is different than the process Original Medicare uses.

Here are some guidelines that clarify how BCN Advantage determines medical necessity:

  • BCN Advantage uses InterQual® criteria and BCN-developed Local Rules to make determinations of medical necessity for all BCN Advantage members.
  • BCN Advantage does not require physician certification of inpatient status to ensure that a member's inpatient admission is reasonable and necessary. For Original Medicare patients, however, this certification is mandated in the Original Medicare rule found in the Code of Federal Regulations, under 42 CFR Part 424 subpart B and 42 CFR 412.3.
  • When the application of InterQual criteria or BCN-developed Local Rules results in a BCN Advantage member's inpatient admission being changed to observation status, you should bill all services as observation (including all charges); you should not bill the services as ancillary only (TOB 0121).
  • The BCN Advantage clinical review process, as outlined in the Care Management and BCN Advantage chapters of the Blue Care Network Provider Manual, takes precedence over the Original Medicare coverage determination process. This applies to requests related to any inpatient vs. observation stay, including a denied inpatient stay billed as observation, inpatient-only procedures and the "two midnight" rule.

Additional information about InterQual criteria is available in the Care Management and BCN Advantage chapters of the Blue Care Network Provider Manual.

Enter to win a $250 gift certificate — Take the 2013 Care Management survey

Update: The survey period has now ended. Thank you to those who responded.

Blue Care Network Care Management Services wants to hear from you! How can we improve our services to better meet your needs and those of the BCN members you serve? Please take our online survey for a chance to win one of two $250 gift certificates. Survey responses must be submitted no later than December 31, 2013, to be eligible for the drawing. One entry per person. Winners will be chosen in January 2014. For more information, view the survey flier (PDF).

New questionnaires available for lumbar spine surgery

Effective Nov. 18, 2013, Blue Care Network updated the questionnaires for lumbar spine surgery that require clinical review.

The changes include but are not limited to:

  • Title changes for two of the lumbar spine surgery questionnaires.
  • Instructions for the question of whether the service is being performed for a pediatric patient less than 18 years of age to select "yes" and submit without completing the rest of the questionnaire for pediatric patients.
  • For the lumbar spine surgery questionnaire, trauma clarified as "acute" for questions seven through 10.
  • The CPT code of 22633 added to the lumbar fusion spine surgery questionnaire.
  • The CPT code of 22207 removed from requiring prior authorization.

The updated questionnaires are available on the e-referral Clinical Review & Criteria Charts page, under the Medical necessity criteria / benefit review section.

New questionnaires available for arthroscopy of the knee

Effective Nov. 18, 2013, Blue Care Network updated the questionnaires for arthroscopy of the knee that require clinical review.

The changes include but are not limited to:

  • Reference updates.
  • Instructions for the question of whether the service is being performed for a pediatric patient less than 18 years of age to select "yes" and submit without completing the rest of the questionnaire for pediatric patients.
  • For the questionnaire "Arthroscopy of the knee, (surgical), for chondroplasty," question six was updated to remove reference of the finding of crepitus.
  • For the questionnaire "Arthroscopy of the knee, (surgical), with meniscectomy or meniscus repair," the question related to the finding of a positive McMurray's test was removed.
  • For the questionnaire "Arthroscopy of the knee (diagnostic) and synovectomy (limited)," a question was added related to the finding of true knee locking.
  • For the questionnaire "Arthroscopy of the knee, (surgical), with lateral release," two questions were combined into one.

The updated questionnaires are available on the e-referral Clinical Review & Criteria Charts page, under the Medical necessity criteria / benefit review section.

2013 InterQual® acute care criteria take effect November 4

Blue Care Network's Care Management staff will begin using the 2013 McKesson Corporation Interim updates related to InterQual criteria for adult and pediatric care on Nov. 4, 2013, when making determinations on clinical review requests for members with coverage through BCN HMO products, BCN AdvantageSM HMO-POS and BCN Advantage HMO FocusSM. These criteria apply to inpatient admissions and continued stay discharge readiness.

Other 2013 InterQual criteria were implemented beginning July 1, 2013. Changes to BCN's Local Rules were also implemented July 1.

You can find additional information about these criteria updates in the July-August 2013 issue of the BCN Provider News, on page 27.

Reminder: Blue Cross Complete member authorizations must now go through NaviNet

Effective September 1, 2013, all Blue Cross Complete member authorization requests must go through NaviNet. If you try to submit a request for a Blue Cross Complete patient in e-referral, you will see an error message in red near the top of the screen and your request will not be saved or authorized. For more information, please review the Blue Cross Complete Provider News (PDF) found on MiBlueCrossComplete.com/providers.

Blue Cross Complete authorization requests must go through NaviNet beginning September 1

Blue Cross Complete (Medicaid) member authorization requests can be entered into e-referral until midnight on August 31, 2013. Effective September 1, Blue Cross Complete member authorization requests must go through NaviNet. Users entering information into e-referral for Blue Cross Complete patients after August 31 will see an error message redirecting them to NaviNet and their information will not be saved or authorized in e-referral. For more information, please review the Blue Cross Complete Provider News found on MiBlueCrossComplete.com/providers.

Blue Care Network announces date for sleep management program changes

Clinical review is required for BCN commercial, BCN Advantage HMO-POSSM and BCN Advantage HMOSM members for all home, outpatient facility and clinic-based sleep studies. BCN previously announced that a non-diagnostic home sleep study will be required to be considered for coverage of a sleep study in the outpatient facility or clinic for adult members with symptoms of obstructive sleep apnea without certain other comorbid conditions. The effective date of these changes will be August 5, 2013.

Blue Care Network announces questionnaire changes effective August 5

Blue Care Network is updating two questionnaires for procedures that require prior authorization. Updated questionnaires will be in effect August 5, 2013, for the following procedures:

  • Varicose Vein Treatment (Ligation, Stripping and Echosclerotherapy)
  • Endometrial Ablation

Updated sample questionnaires will be available by the effective date at ereferrals.bcbsm.com. Click on Clinical Review & Criteria Charts and look under Medical necessity criteria/benefit review requirements.

Lumbar spine surgery questionnaire updated effective July 29, 2013

Effective July 29, 2013, the procedure code *62287 will be removed from the lumbar spine questionnaire titled Lumbar Discectomy / Hemilaminectomy with or without Discectomy/Foraminotomy. However, prior authorization is still required for this procedure, which is considered experimental and investigational.

Blue Cross Complete announces changes effective August 1

Important changes are taking place August 1, 2013, that will affect how providers do business with Blue Cross Complete. These changes involve Blue Cross Complete claims, electronic payments, medical and pharmacy authorizations, some of the systems providers use and the phone numbers they call. We're making these changes because we want to make it easier for providers to do business with us as we prepare to grow as a Michigan Medicaid health plan and respond to changes that are coming with National Health Care Reform.

To announce these changes, we've created a special print publication called Blue Cross Complete Provider News. This publication was mailed June 25, 2013, to all contracted Blue Cross Complete providers.

Please contact your Blue Cross Complete provider representative for more information.

Blue Care Network announces delay in changes for sleep management

There has been a delay in changes announced previously for outpatient facility and clinic-based sleep studies. Changes were to be effective July 1, 2013. A nondiagnostic home sleep study will be required to be considered for coverage of a sleep study in the outpatient facility or clinic. This applies to adult members with symptoms of obstructive sleep apnea without certain other comorbid conditions.

We will communicate an updated effective date in the near future.

Blue Care Network requires clinical review for BCN commercial and BCN AdvantageSM members for all home, outpatient facility and clinic-based sleep studies.

Blue Care Network announces changes for frenulum surgery

Blue Care Network no longer requires clinical review for frenulum surgery, effective July 1, 2013. Please see the BCBSM/BCN medical policy for Frenulum Surgery (Frenumectomy, Frenulectomy, Frenectomy, Frenotomy) for inclusionary and exclusionary guidelines. The medical policy is available on web-DENIS in BCN Provider Publications and Resources on the Medical Policy Manual page.

2013 InterQual® criteria take effect July 1

Blue Care Network's care management staff uses McKesson Corporation's InterQual criteria when reviewing requests for Blue Care Network and BCN AdvantageSM members. InterQual criteria have been a nationally recognized industry standard for 20 years. Other criteria resources that may be used are BCN medical policies, the member's specific benefit certificate, and clinical review by the BCN medical directors for the most appropriate level of care.

McKesson Corporation's CareEnhanceTM solutions include InterQual clinical decision support tools. McKesson is a leading provider of supply, information and care management products and services designed to manage costs and improve health care quality.

BCN will begin using the following 2013 InterQual criteria on July 1, 2013:

Criteria/Version Application

InterQual Acute – Adult and Pediatrics
Exceptions-local rules

  • Inpatient admissions
  • Continued stay discharge readiness

InterQual Level of Care - Subacute and Skilled Nursing Facility
Exceptions-local rules

  • Subacute and skilled nursing facility admissions

InterQual Rehabilitation - Adult and Pediatrics
Exceptions-local rules

  • Inpatient admissions
  • Continued stay and discharge readiness

InterQual Level of Care – Long Term Acute Care
Exceptions-local rules

  • Long term acute care facility admissions

InterQual Level of Care – Home Care
Exceptions-local rules

  • Home care requests

InterQual Imaging

  • Imaging studies and X-rays

InterQual Procedures – Adult and Pediatrics

  • Surgery and invasive procedures

BCBSM/BCN medical policies

  • Services that require clinical review for medical necessity

Plan developed imaging criteria

  • Imaging studies and X-rays

Blue Care Network reimbursement for intra-articular hyaluronic acid injections

Intra-articular HA injections are approved by the U.S. Food and Drug Administration for relief of pain in patients 21 years and older with osteoarthritis of the knee who fail treatment with non-pharmacologic and conservative therapies (for example, acetaminophen or NSAIDs). There are currently six IA-HA products available for treatment. Based on current clinical evidence, differences in efficacy and safety between IA-HA preparations have not been demonstrated.

Blue Care Network's current reimbursement for each specific product is as follows:

HCPCS code for billing Drug Billing unit/qty Reimbursement
J7321 Supartz per dose $100
J7323 Euflexxa per dose $100
J7326 Gel-One 30 mg $300
J7324 Orthovisc per dose $87.5
J7325 Synvisc, One 1mg $6.25

BCN does not require prior authorization for these drugs. Clinical claims editing will apply to ensure appropriate use, including but not limited to diagnosis, dosing limits and frequency of administration. This does not apply to BCN AdvantageSM and Blue Cross Complete members. Actual payments will be according to contract terms with the provider.

Osteoporosis: Intravenous bisphosphonate therapy — Reclast infusion questionnaire

Bisphosphonates are currently the most predominately prescribed therapy for osteoporosis. Because there is no reliable evidence demonstrating one bisphosphonate is more effective or safe over another, the generic form of Fosamax brings the most value for prevention and treatment of osteoporosis.

For members who do not have the option of oral therapy, Reclast is available as an intravenous bisphosphonate indicated for treatment and prevention of osteoporosis. Blue Care Network requires clinical review for all Reclast requests for both BCN commercial and BCN AdvantageSM members to ensure safe and appropriate use of the medication.

Coverage for Reclast requires documentation that adequate trials of oral bisphosphonates (such as generic alendronate) have been ineffective based on objective documentation, not tolerated despite taking it as recommended, or contraindicated.

A new Reclast questionnaire (PDF) has been placed on the e-referral website to allow for efficient processing of requests. When requesting authorizations for Reclast on e-referral, the system will prompt the submitter to complete a questionnaire to determine the appropriateness of the request. If clinical criteria are met, approval will be granted for one visit for Reclast 5mg yearly.

Blue Care Network announces questionnaire update for sleep management

Clinical review is required for Blue Care Network commercial and BCN AdvantageSM members for all home, outpatient facility and clinic-based sleep studies.

Two new sleep study codes for attended sleep studies in children younger than 6 years of age have been added to the Outpatient Treatment Setting Sleep Study Questionnaire. These codes — *95782 and *95783 — will also be reflected in the near future in the updated medical policy for Sleep Disorders, Diagnosis and Medical Management.

Detailed information about BCN's Sleep Management Program is available on the e-referral home page at ereferrals.bcbsm.com. Click on Sleep Management.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2012 American Medical Association. All rights reserved.

Global referrals automatically entered with new BCN minimum requirements effective May 3, 2013

Last fall, we announced changes to the global referral process for Blue Care Network and Blue Cross Complete, effective January 1, 2013.

  • Global referrals should be written for a minimum of 90 days.
  • For three chronic conditions — oncology, rheumatology and renal management — global referrals should be written for one year.

We have been manually correcting the end dates of referrals written for less than the required minimum days until system changes were in place.

Effective May 3, 2013, our system automatically corrects referrals that are not written for the 90- and 365-day requirements. If you attempt to enter a referral for less than the minimum requirement, you will receive a warning message and the system will automatically enter the correct minimum.

Radiology management program changes effective May 1, 2013

Updated appropriateness questionnaires for eight high-tech radiology procedures are now available. Click on Radiology Management for information about the Radiology Management program and a list of the updated questionnaires. Scroll down to the Resources section for a link to sample questionnaires for high-tech radiology procedures.

How to access e-referral with Internet Explorer ® 10 or 11

If you're having issues accessing the new e-referral system, it may be your Internet browser. If you are using Internet Explorer 10 or 11, please follow these steps (PDF).

Quick Guides
Blue Distinction Centers®

Our centers of excellence program is called Blue Distinction Centers for Specialty Care®.

The Blue Distinction Specialty Care designation recognizes health care facilities and other providers that demonstrate proven expertise in delivering safe, effective and cost-efficient care for select specialty areas. This program assists consumers in finding quality specialty care nationwide while encouraging health care providers to improve the overall quality and delivery of specialty care.

Blue Distinction Center programs include:

  • Bariatric surgery
  • Cardiac care
  • Cancer care
  • Knee and hip replacements
  • Maternity care
  • Spine surgery
  • Transplants

For more information, go to the Blue Distinction Center page on bcbsm.com.

More information on bariatric surgery for BCN members is available on the Bariatric Surgery page on this website.



Prior authorization requests for outpatient CAR-T therapy drugs for Medicare Advantage members

For dates of service on or after Jan. 1, 2021, outpatient CAR-T therapy drugs such as Yescarta®, Kymriah® and Tecartus will be managed by Blue Cross or BCN under the medical benefit for Medicare Plus BlueSM PPO and BCN AdvantageSM members. For dates of service prior to Jan. 1, 2021, CAR-T cell therapy is covered under Original Medicare.

You must submit prior authorization requests for outpatient CAR-T therapy drugs before providing the service.

Submit prior authorization requests, including all relevant clinical documentation, using one of these methods:

  • Enter the request in the NovoLogix® online tool. For more information about entering requesting in NovoLogix, see the “NovoLogix” section below.
  • Fax the request to the Pharmacy Part B help desk at 1-866-392-6465.

Note: Prior authorization for CAR-T drugs is NOT managed by AIM Specialty Health®.

If you have questions about this, please message us at MASRX@bcbsm.com.

How to bill

For Medicare Plus Blue and BCN Advantage, we require authorization for all outpatient places of service when you bill these medications as a professional service or as an outpatient facility service:

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

NovoLogix

For these types of drugs, submit authorization requests through NovoLogix. It offers real-time status checks and immediate approvals for certain medications. If you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

If you need to request access to Provider Secured Services, complete the Provider Secured Access Application (PDF) form and fax it to the number on the form.

List of requirements

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

Posted: October 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



e-referral system out of service for maintenance overnight Oct. 17-18

Here's the next planned downtime for the e-referral system:

From 10 p.m. on Saturday, Oct. 17 to 10 a.m. on Sunday, Oct. 18

Note: All times are Eastern time.

The e-referral system will not be available at all during these times. Here's additional information:

  • On Sunday, the system will be available by 10 a.m. It may be available earlier if maintenance tasks are completed.
  • We expect the system to be available during the remaining time over the weekend, although you may experience minor performance issues.

To see more planned downtimes and to learn how to handle requests while the system is down, review the list of e-referral system planned downtimes and what to do (PDF).

You can get to this list anytime from any page of this website. Scroll down the left navigation pane and look for the blue tile at the bottom.

We're providing this information so you can plan ahead. We apologize for any inconvenience you may experience while the e-referral system is down.

Posted: October 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Skyrizi® and Tegsedi® will be covered under the pharmacy benefit for Blue Cross' PPO and BCN HMOSM members, effective Oct. 8, 2020

We're changing how we cover Skyrizi and Tegsedi for our Blue Cross' PPO (commercial) and BCN HMO (commercial) members.

Beginning Oct. 8, 2020, Blue Cross' PPO and BCN HMO plans will no longer cover the following medications under the medical benefit. Instead, they'll be covered under the pharmacy benefit.

  • Skyrizi (risankizumab-rzaa), HCPCS codes C9399, J3590
  • Tegsedi (inotersen), HCPCS codes C9399, J3490

Coverage for these drugs is moving to the pharmacy benefit because the drugs can be safely and conveniently self-administered in the member's home.

These drugs will continue to require prior authorization and are available through pharmacies that dispense specialty drugs, including AllianceRx Walgreens Prime Specialty Pharmacy.

We'll contact any member who is affected by this change and advise them to talk to their doctor about prescribing these medications for purchase from a pharmacy.

Providers who administer these medications to their patients on or after Oct. 8, 2020, will be responsible for the cost.

Are there any changes to the management for these therapies?

There are no changes to the management of these therapies.

  • Both Skyrizi and Tegsedi will continue to require prior authorization. For information about submitting prior authorization requests, see "Submitting prior authorization requests" below.
  • For Skyrizi, quantity limits continue to apply.
  • For Tegsedi, documentation requirements continue to apply.

Submitting prior authorization requests

Providers can submit prior authorization requests for these drugs as follows:

  • Electronically: Through CoverMyMeds® or another free ePA tool, such as Surescripts® or ExpressPAth®. See Save time and submit your prior authorization requests electronically for pharmacy benefit drugs (PDF) for more information.
  • By phone: Call 1-800-437-3803.
  • By fax: Call the Pharmacy Clinical Help Desk at 1-800-437-3803 to obtain the pertinent medication request form, which you can then submit by fax.
    • For Blue Cross’ PPO members: Fax the medication request form to 1-866-601-4425.
    • For BCN HMO members: Fax the medication request form to 1-877-442-3778.
  • By written request: Mail a written request to:

    Blue Cross Blue Shield of Michigan
    Attention: Pharmacy Services
    Mail Code 512
    Detroit, MI 48226-2998

List of requirements

To view requirements for Skyrizi, Tegsedi and other drugs covered under the pharmacy benefit, see the Blue Cross and BCN Prior authorization and step therapy coverage criteria (PDF) document. This document is available from the following pages on the this website.

For a 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 PPO (commercial) and BCN HMO (commercial) members (PDF) document.

Posted: October 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Medicare Part B medical specialty drug prior authorization list is changing in January 2021

We're adding medications to the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM PPO and BCN AdvantageSM members. The specialty medications on this list are administered by a healthcare professional in a provider office, at the member's home, in an off-campus outpatient hospital or in an ambulatory surgical center (place of service 11, 12, 19, 22 and 24).

For dates of service on or after Jan. 1, 2021, the following CAR-T medications will require prior authorization through the NovoLogix® online tool:

  • Yescarta® (axicabtagene ciloleucel), HCPCS code Q2041
  • Kymriah® (tisagenlecleucel), HCPCS code Q2042
  • Tecartus (brexucabtagene autoleucel), HCPCS code J9999

The following medication will also require prior authorization through NovoLogix for dates of service on or after Jan. 1, 2021:

  • Viltepso (viltolarsen), HCPCS codes J3490, J3590

How to bill

For Medicare Plus Blue and BCN Advantage, we require authorization for all outpatient places of service when you bill these medications as a professional service or as an outpatient facility service:

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

Important reminder

For these drugs, submit authorization requests through NovoLogix. It offers real-time status checks and immediate approvals for certain medications. If you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

If you need to request access to Provider Secured Services, complete the Provider Secured Access Application (PDF) form and fax it to the number on the form.

List of requirements

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

Posted: October 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Questionnaire updates in the e-referral system in September and October 2020

We use our authorization criteria and medical policies and your answers to the questionnaires in the e-referral system when making utilization management determinations on your authorization requests.

In September and October:

  • We're updating two questionnaires in the e-referral system.
  • We're removing one questionnaire from the e-referral system.

As questionnaires are updated or removed, we'll update or remove the corresponding preview questionnaires on this website.

Updated questionnaires

  • Endoscopy, upper gastrointestinal, for gastroesophageal reflux disease: On Sept. 27, 2020, we’ll update the list of procedure codes for which providers must complete this questionnaire for BCN HMOSM and BCN AdvantageSM members.

    Starting Sept. 27, providers must complete this questionnaire for these procedure codes: *43191, *43192, *43193, *43195, *43196, *43197, *43198, *43200, *43201, *43202, *43214, *43231, *43233, *43235, *43237, *43238, *43239, *43241, *43242, *43248, *43249, *43250, *43253, and *43259

    Providers will no longer need to complete the questionnaire for these procedure codes: *43180 and *43254.

  • Sacral nerve neuromodulation/stimulation: On Oct. 11, we'll update this questionnaire for Medicare Plus BlueSM PPO, BCN HMO and BCN Advantage members.

Removed questionnaire

On Sept. 27, we'll remove the Lumbar spine surgery, minimally invasive questionnaire for BCN Advantage members. The e-referral system will automatically approve requests for code G0276.

Preview questionnaires

You can access preview questionnaires on this website. The preview questionnaires show the questions you'll need to answer in the actual questionnaires that open in the e-referral system. This can help you prepare your answers ahead of time.

To find the preview questionnaires:

  • For BCN: Click BCN and then click Authorization Requirements & Criteria. Scroll down and look under the “Authorization criteria and preview questionnaires” heading.
  • For Medicare Plus Blue: Click Blue Cross and then click Authorization Requirements & Criteria. In the "Medicare Plus Blue PPO members" section, look under the “Authorization criteria and preview questionnaires - Medicare Plus Blue PPO” heading.

Authorization criteria and medical policies

The pertinent authorization criteria and medical policies are also available on the Authorization Requirements & Criteria pages.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2019 American Medical Association. All rights reserved.

Posted: September 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Medical specialty drug prior authorization lists will change in November for certain members

For dates of service on or after Nov. 20, 2020, we're removing prior authorization requirements for one drug and adding prior authorization requirements for several drugs.

This affects BCN HMOSM, Medicare Plus BlueSM PPO, BCN AdvantageSM and UAW Retiree Medical Benefits Trust PPO non-Medicare members.

Drug that will no longer require prior authorization

For dates of service on or after Nov. 20, we'll no longer require prior authorization for the following drug for Medicare Plus Blue, BCN Advantage and UAW Retiree Medical Benefits Trust PPO non-Medicare members:

  • Lartruvo® (olaratumab), HCPCS code J9285

Drugs that will require prior authorization

For dates of service on or after Nov. 20, we're adding prior authorization requirements for specialty drugs covered under the medical benefit as follows.

  • For BCN HMO, Medicare Plus Blue and BCN Advantage members: Providers will have to request prior authorization through AIM Specialty Health® for the following drugs:
    • Blenrep (belantamab mafodotin-blmf), HCPCS codes J3490, J3590, J9999, C9399
    • Monjuvi (tafasitamab-cxix), HCPCS codes J3490, J3590, J9999, C9399
  • For UAW Retiree Medical Benefits Trust PPO non-Medicare members: Providers will have to request prior authorization through AIM for the following drugs:
    • Belrapzo (bendamustine hcl), HCPCS code J9036
    • Doxil® (doxorubicin liposomal), HCPCS code Q2050
    • Lipodox® (doxorubicin liposomal), HCPCS code Q2049
    • Herceptin® (trastuzumab), HCPCS code J9355
    • Imfinzi® (durvalumab), HCPCS code J9173
    • Imlygic® (talimogene laherparepvec), HCPCS code J9325
    • Mvasi (bevacizumab-awwb), HCPCS code Q5107

How to submit authorization requests

Submit authorization requests to AIM using one of the following methods:

For information about registering for and accessing the AIM ProviderPortal, see the Frequently asked questions page* on the AIM website.

More about the authorization requirements

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

For additional information on requirements related to drugs covered under the medical benefit, see the following documents:

We'll update these lists with the new information about these drugs prior to the effective dates.

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're required to let you know we're not responsible for its content.

Posted: September 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



SNFs must register for and learn the e-referral system before submitting commercial SNF authorization requests through e-referral starting Dec. 1

Starting Dec. 1, 2020, skilled nursing facilities must submit authorization requests for Blue Cross' PPO and BCN HMOSM members through the e-referral system and not by fax.

Currently, SNFs are completing a form and submitting it by fax. Starting Dec. 1, you'll still need to complete the form, but you'll attach it to the request in the e-referral system instead of faxing it.

This requirement will apply to requests for admissions and requests for additional SNF days.

We've communicated about this before and now we’re sharing these new details:

  • This change starts Dec. 1, 2020.
  • It's important for SNFs to use the online training tools to familiarize themselves with the e referral system.
  • We're offering supplemental webinar overviews of the e-referral system.

To prepare for this change, there are three important things you need to do right away.

  1. Register now for access to the e-referral system
    We encourage you to register now for access to the e-referral system. It takes some time to process registration requests and we want to make sure everyone has access before Dec. 1.

    To register, follow the instructions on the Sign Up or Change a User webpage on this website.
  2. Use the online tools to learn the e-referral system — before attending a webinar

    Visit the Training Tools page of this website for:

    It's important that you use the online tools to learn how to use the e-referral system before attending a webinar — especially:

    • Checking member eligibility and benefits
    • Submitting an inpatient authorization request
    • Attaching a document to the authorization request
  3. Sign up for a webinar overview of the e-referral system
    To supplement what you learned through the online tools, we're offering webinars that are tailored to SNFs. Each webinar is 1 hour and 30 minutes and includes time for questions and answers.

    Click on one of the links below to sign up for a webinar:
Date and time WebEx link
Tuesday, November 10
10 to 11:30 a.m.
Click here to register
Wednesday, November 11
2 to 3:30 p.m.
Click here to register
Thursday, November 12
10 to 11:30 a.m.
Click here to register
Tuesday, November 17
2 to 3:30 p.m.
Click here to register
Wednesday, November 18
10 to 11:30 a.m.
Click here to register
Thursday, November 19
2 to 3:30 p.m.
Click here to register
Tuesday, December 1
10 to 11:30 a.m.
Click here to register
Wednesday, December 2
2 to 3:30 p.m.
Click here to register

Posted: September 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



e-referral system out of service for maintenance overnight September 19-20

Here's the next planned downtime for the e-referral system:

From 10 p.m. on Saturday, September 19 to 10 a.m. on Sunday, September 20

Note: All times are Eastern time.

The e-referral system will not be available at all during these times. Here's additional information:

  • On Sunday, the system will be available by 10 a.m. It may be available earlier if maintenance tasks are completed.
  • We expect the system to be available during the remaining time over the weekend, although you may experience minor performance issues.

To see more planned downtimes and to learn how to handle requests while the system is down, review the list of e-referral system planned downtimes and what to do.(PDF)

You can get to this list anytime from any page of this website. Scroll down the left navigation pane and look for the blue tile at the bottom.

We're providing this information so you can plan ahead. We apologize for any inconvenience you may experience while the e-referral system is down.

Posted: September 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Avoid SNF claim denials for Medicare Advantage by matching PDPM levels on claims to the PDPM levels naviHealth authorized

In the fourth quarter of 2020, Blue Cross Blue Shield of Michigan and Blue Care Network will begin denying skilled nursing facility claims when patient-driven payment model levels don't match the levels naviHealth authorized. Facilities can resubmit denied claims with the approved PDPM levels.

This applies to SNF claims for Medicare Plus BlueSM PPO and BCN AdvantageSM members.

In a future web-DENIS message, we’ll let you know the exact date on which we'll begin denying claims.

As a reminder, naviHealth:

  • Authorizes PDPM levels during the patient's skilled nursing facility stay (from preservice through discharge) for dates of service on or after Oct. 1, 2019
  • Works with skilled nursing facilities to ensure billers submit proper PDPM levels for reimbursement

For more information, see Post-acute care services: Frequently asked questions by providers (PDF).

Posted: September 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Cardiac implantable device services will require authorization by AIM Specialty Health® for many members

Starting Jan. 1, 2021, we're expanding the AIM Specialty Health cardiology program to include services that involve cardiac implantable devices.

What this means

For dates of service on or after Jan. 1, 2021, the following services will require authorization by AIM Specialty Health for these members:

  • For Medicare Plus BlueSM PPO, BCN HMOSM and BCN AdvantageSM members:
    • Cardiac resynchronization therapy
    • Implantable cardioverter-defibrillator
  • For Medicare Plus Blue members only:
    • Arterial ultrasound

You'll be able to submit authorization requests to AIM starting Dec. 14, 2020.

Authorization requests must be submitted prior to the service being performed.

Watch for more details

Watch for articles in upcoming issues of The Record and BCN Provider News, where we'll publish the procedure codes and other information.

Additional information

The webpages below have information about requesting authorization from AIM, including how to register for and use the AIM provider portal*:

We'll update these webpages along with pertinent documents prior to Jan. 1, to reflect this change.

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're required to let you know we're not responsible for its content.

Posted: September 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Professional providers and facilities can now register for training on TurningPoint's clinical model and more

TurningPoint Healthcare Solutions LLC is expanding its surgical quality and safety management program for dates of service on or after Jan. 1, 2021.

Professional providers and facilities can now register for training for the expanded program. Training will cover the TurningPoint clinical model and using the TurningPoint Provider Portal.

Training sessions are scheduled for various dates in November, December and January. To register for a training session and to learn more about the program expansion, see the following articles:

Additional information

You can find information about TurningPoint on the Musculoskeletal Services pages on this website. Soon, we'll update these pages and the documents to which they link to reflect the changes that are coming on Jan. 1.

Posted: September 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Viltepso will require authorization for commercial members effective September and October 2020

We're adding authorization requirements for Viltepso (viltolarsen), HCPCS code J3490, a medical benefit specialty drug, for the following members:

  • For BCN HMOSM members: Viltepso will require authorization for members who begin therapy on or after Sept. 1, 2020.
  • For Blue Cross' PPO members: Viltepso will require authorization for members who begin therapy on or after Oct. 1, 2020.

Blue Cross Blue Shield of Michigan and Blue Care Network consider Viltepso to be investigational/experimental due to insufficient evidence of clinical benefit. We'll continue to consider this drug to be investigational/experimental until the results of clinical trials provide evidence of clinical benefit.

How to submit authorization requests

Submit authorization requests through NovoLogix. It offers real-time status checks and immediate approvals for certain medications.

To learn how to submit requests through NovoLogix, do the following from within this website:

  • For BCN HMO members: Click BCN and then click Medical Benefit Drugs. In the BCN HMO (commercial) column, see the "How to submit authorization requests electronically using NovoLogix" section.
  • For Blue Cross' PPO members: Click Blue Cross and then click Medical Benefit Drugs. In the Blue Cross PPO (commercial) column, see the "How to submit authorization requests electronically using NovoLogix" section.

More about the authorization requirements

These authorization requirements apply only to groups that currently participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. These changes don't apply to members covered by the Federal Employee Program® Service Benefit Plan.

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

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Blue Cross and BCN utilization management medical drug list for Blue Cross PPO (commercial) and BCN HMO (commercial) members (PDF) document, which is available from these pages of this website:

We'll update the requirements list with this information prior to each effective date.

Posted: September 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Sept. 7 holiday closure: How to submit inpatient authorization requests

On Monday, Sept. 7, 2020, Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will be closed for the Labor Day holiday.

Refer to the document Holiday closures: How to submit authorization requests for instructions on how to submit authorization requests for inpatient admissions during the closure.

You can access this document on these webpages:

Here are the additional upcoming closures that will occur during 2020, so you can plan ahead:

  • Election Day: Tuesday, November 3
  • Thanksgiving Day: Thursday, November 26
  • Day after Thanksgiving: Friday, November 27
  • Christmas Eve: Thursday, December 24
  • Christmas Day: Friday, December 25
  • New Year's Eve: Thursday, December 31

Posted: August 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



IVIG dosing strategy is changing for the Medicare Part B medical specialty drug program, starting Dec. 7

Blue Cross Blue Shield of Michigan and Blue Care Network require authorization for immune globulin products covered under the medical benefit for Medicare Plus BlueSM PPO and BCN AdvantageSM members.

As part of the authorization process, we're updating our dosing strategy for intravenous and subcutaneous immune globulin therapy to minimize drug waste, reduce unnecessary drug exposure and decrease the risk of adverse events.

Effective Dec. 7, 2020, we'll calculate doses using adjusted body weight for members when:

  • The member's body mass index is 30 kg/m2 or greater
  • The member's actual body weight is 20% higher than their ideal body weight

This applies to all Medicare Plus Blue and BCN Advantage members who start therapy on or after Dec. 7, 2020, when the therapy is administered by a health care professional in a provider office, at the member's home, in an off-campus outpatient hospital or in an ambulatory surgical center (sites of care 11, 12, 19, 22 and 24).

Members who currently receive immune globulin will continue to receive their current dose until their authorizations expire.

Important reminder

For these drugs, submit authorization requests through the NovoLogix® online tool. It offers real-time status checks and immediate approvals for certain medications.

For Medicare Plus Blue and BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

If you need to request access to Provider Secured Services, complete the Provider Secured Access Application (PDF) form and fax it to the number on the form.

List of requirements

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

Posted: August 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Tecartus will require authorization for commercial members effective August and September 2020

We're adding authorization requirements for Tecartus (brexucabtagene autoleucel), HCPCS code J9999, a specialty drug covered under the medical benefit, for the following members:

  • For BCN HMOSM members: Tecartus will require authorization for members who begin therapy on or after Aug. 10, 2020.
  • For Blue Cross' PPO members: Tecartus will require authorization for members who begin therapy on or after Sept. 1, 2020.

How to submit authorization requests

Submit authorization requests through NovoLogix. It offers real-time status checks and immediate approvals for certain medications.

To learn how to submit requests through NovoLogix, do the following from within this website:

  • For BCN HMO members: Click BCN and then click Medical Benefit Drugs – Pharmacy. In the BCN HMO (commercial) column, see the "How to submit authorization requests electronically using NovoLogix" section.
  • For Blue Cross' PPO members: Click Blue Cross and then click Medical Benefit Drugs - Pharmacy. In the Blue Cross PPO (commercial) column, see the "How to submit authorization requests electronically using NovoLogix" section.

More about the authorization requirements

These authorization requirements apply only to groups that currently participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. These changes don't apply to members covered by the Federal Employee Program® Service Benefit Plan.

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

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Blue Cross and BCN utilization management medical drug list for Blue Cross PPO (commercial) and BCN HMO (commercial) members (PDF) document, which is available from these pages of this website:

We'll update the requirements list with this information prior to each effective date.

Posted: August 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



e-referral system out of service for maintenance overnight August 15-16

Here's the next planned downtime for the e-referral system:

From 10 p.m. on Saturday, August 15 to 10 a.m. on Sunday, August 16

Note: All times are Eastern time.

The e-referral system will not be available at all during these times. Here’s additional information:

  • On Sunday, the system will be available by 10 a.m. It may be available earlier if maintenance tasks are completed.
  • We expect the system to be available during the remaining time over the weekend, although you may experience minor performance issues.

To see more planned downtimes and to learn how to handle requests while the system is down, review the list of e-referral system planned downtimes and what to do.

You can get to this list anytime from any page of our this website. Scroll down the left navigation pane and look for the blue tile at the bottom.

We're providing this information so you can plan ahead. We apologize for any inconvenience you may experience while the e-referral system is down.

Posted: August 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Effective Nov. 1, Blue Cross and BCN will have preferred hereditary angioedema medications for our commercial members

Currently, all hereditary angioedema, or HAE, medications require prior authorization for Blue Cross and Blue Care Network commercial members. Effective Nov. 1, 2020, Blue Cross and BCN will have preferred medications for HAE therapy for those members.

This means that:

  • We'll require our commercial members to use preferred HAE drugs for acute treatment and for preventive therapy that begins on or after Nov. 1, 2020.
  • For commercial members currently receiving a nonpreferred HAE drug:
    • These members are authorized to continue their current therapy until through Oct. 31, 2020.
    • We've proactively authorized therapy with the preferred medications from Nov. 1, 2020, through Oct. 31, 2021, to avoid any interruptions in care.
    • We encourage you to discuss any concerns members may have as they transition to the preferred medications.

We'll be mailing letters to impacted members to notify them of these changes.

These changes apply to all Blue Cross' PPO and BCN HMOSM members.

Note: For HAE therapy covered under the medical benefit, the requirements outlined in this message apply only to groups that are currently participating in the standard commercial Medical Drug Prior Authorization Program. Proactive authorizations for preferred therapy on the pharmacy benefit apply to members who have their pharmacy benefit with Blue Cross Blue Shield of Michigan or Blue Care Network.

Which medications are preferred?

Here's what you need to know about the medications:

For acute HAE treatment

  • Preferred medication: Icatibant (HCPCS code J1744)
  • Nonpreferred medications:
    • Firazyr® (brand icatibant, HCPCS code J1744)
    • Berinert® (c1 esterase inhibitor, human, HCPCS code J0597)
    • Kalbitor® (ecallantide, HCPCS code J1290)
    • Ruconest® (c1 esterase inhibitor, recombinant, HCPCS code J0596)

For HAE prevention

  • Preferred medications:
    • Haegarda® (c1 esterase inhibitor, human)
    • Takhzyro® (lanadelumab-flyo)
  • Nonpreferred medication: Cinryze® (c1 esterase inhibitor, human, HCPCS code J0598)

Additional information

For additional information on requirements related to drugs for our commercial members, see:

Posted: August 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Clinical documentation requirements for authorization requests related to musculoskeletal procedures managed by TurningPoint

A new Documentation requirements for musculoskeletal procedures (PDF) document is now available on the ereferrals.bcbsm.com website.

This document lists the clinical documentation that you must include when submitting authorization requests to TurningPoint Healthcare Solutions, LLC, for musculoskeletal procedures.

You can find this document and related documents on the following pages of this website:

As a reminder, TurningPoint currently manages inpatient and outpatient authorization requests for dates of service on or after July 1, 2020, as follows:

  • Joint procedures for Medicare Plus BlueSM PPO, BCN HMOSM and BCN AdvantageSM members
  • Spine procedures for BCN HMO and BCN Advantage members.

Posted: July 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Medical specialty drug prior authorization lists are changing in September for BCN HMOSM, Medicare Plus BlueSM PPO and BCN AdvantageSM members

We're adding authorization requirements for three specialty drugs covered under the medical benefit for BCN HMO, Medicare Plus Blue and BCN Advantage members.

For dates of service on or after Sept. 25, 2020, the following drugs will require authorization through AIM Specialty Health®:

  • Zepzelca (lurbinectedin), HCPCS codes J3490, J3590, J9999
  • Phesgo (pertuzumab/trastuzumab/hyaluronidase-zzxf), HCPCS codes J3490, J3590, J9999
  • Nyvepria (pegfilgrastim-apgf), HCPCS codes J3490, J3590, J9999

How to submit authorization requests

Submit authorization requests to AIM using one of the following methods:

For information about registering for and accessing the AIM ProviderPortal, see the Frequently asked questions page* on the AIM website.

More about the authorization requirements

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

For additional information on requirements related to drugs covered under the medical benefit, see:

We'll update these lists with the new information about these drugs prior to the effective dates.

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're required to let you know we're not responsible for its content.

Posted: July 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Uplizna will have authorization and site-of-care requirements for commercial members effective August and October 2020

We're adding authorization and site-of-care requirements for Uplizna (inebilizumab-cdon, HCPCS code J3590), a specialty drug covered under the medical benefit, for BCN HMOSM (commercial) and Blue Cross' PPO (commercial) members:

  • For BCN HMO members: Uplizna will require authorization and have site-of-care requirements for members who begin therapy on or after Aug. 1, 2020.
  • For Blue Cross' PPO members: Uplizna will require authorization for members who begin therapy on or after Oct. 1, 2020.

More about the authorization requirements

The authorization requirements apply only to groups that currently participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. These changes don't apply to members covered by the Federal Employee Program® Service Benefit Plan.

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

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Blue Cross and BCN utilization management medical drug list for Blue Cross PPO (commercial) and BCN HMO (commercial) members (PDF) document, which is available from these pages this website:

We'll update the requirements list with this information prior to each effective date.

Posted: July 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



e-referral system out of service for maintenance overnight July 18-19

Here's the next planned downtime for the e-referral system:

From 10 p.m. on Saturday, July 18 to 10 a.m. on Sunday, July 19

Note: All times are Eastern time.

The e-referral system will not be available at all during these times. Here’s additional information:

  • On Sunday, the system will be available by 10 a.m. It may be available earlier if maintenance tasks are completed.
  • We expect the system to be available during the remaining time over the weekend, although you may experience minor performance issues.

To see more planned downtimes and to learn how to handle requests while the system is down, review the list of e-referral system planned downtimes and what to do (PDF).

You can get to this list anytime from any page of our ereferrals.bcbsm.com website. Scroll down the left navigation pane and look for the blue tile at the bottom.

We're providing this information so you can plan ahead. We apologize for any inconvenience you may experience while the e-referral system is down.

Posted: July 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Effective Oct. 1, Nivestym® and Zarxio® are the preferred filgrastim products for all Blue Cross and BCN commercial and Medicare Advantage members

For dates of service on or after Oct. 1, 2020, the preferred filgrastim products for all Blue Cross and Blue Care Network commercial and Medicare Advantage members will be:

  • Nivestym (filgrastim-aafi; HCPCS code Q5110)
  • Zarxio (filgrastim-sndz; HCPCS code Q5101)

Note: For commercial members, the requirements outlined in this message apply only to groups that are currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. They don't apply to non-Medicare members covered through the UAW Retiree Medical Benefits Trust. They also don't apply to members covered by the Federal Employee Program® Service Benefit Plan.

Patients should take the preferred drugs when possible

Here's what to keep in mind about the members who are prescribed these drugs:

  • Members starting treatment on or after Oct. 1 should use a preferred filgrastim product.
  • Members currently receiving a filgrastim product other than Nivestym or Zarxio should transition to Nivestym or Zarxio.

    The filgrastim products other than Nivestym and Zarxio are:

    • Neupogen® (filgrastim; HCPCS code J1442)
    • Granix® (tbo-filgrastim; HCPCS code J1447)

      For commercial members, we'll notify those currently taking the nonpreferred drugs and encourage them to discuss treatment options with you.

Here are the authorization requirements for members starting or transitioning to the preferred drugs:

  • For Blue Cross' PPO members, the preferred drugs don't require authorization.
  • For BCN HMOSM, Medicare Plus BlueSM PPO and BCN AdvantageSM members, the preferred drugs require authorization through AIM Specialty Health®.

Request authorization for patients who must take the nonpreferred drugs

For members you feel need to take Neupogen or Granix rather than Nivestym and Zarxio, here are the requirements:

  • For Blue Cross’ PPO members, authorization is required. Submit the authorization request through the NovoLogix® online tool.
  • For BCN HMO, Medicare Plus Blue and BCN Advantage members, both step therapy and authorization are required. Submit the authorization request through AIM Specialty Health®.

More about the authorization requirements

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

For additional information on requirements related to drugs covered under the medical benefit, see:

We'll update the requirements lists with the new information prior to Oct. 1, 2020.

Posted: July 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Medicare Part B medical specialty drug prior authorization list is changing Aug. 21 and Sept. 28

We're adding medications to the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM PPO and BCN AdvantageSM members. The specialty medications on this list are administered by a healthcare professional in a provider office, at the member's home, in an off-campus outpatient hospital or in an ambulatory surgical center (sites of care 11, 12, 19, 22 and 24).

For dates of service on or after Aug. 21, 2020, the following medications will require authorization through the NovoLogix® online tool:

  • A gene therapy for hemophilia A
    • Roctavian (valoctocogene roxaparvovec, HCPCS code J3590)
  • Other medications
    • Uplizna (inebilizumab-cdon, HCPCS code J3590)
    • Avsola (infliximab-axxq, HCPCS code Q5121)*

For dates of service on or after Sept. 28, 2020, the following medications will require prior authorization through NovoLogix:

  • Ilaris® (canakinumab, HCPCS code J0638)
  • Cutaquig® (immune globulin subcutaneous (human) - hipp, HCPCS code J1599)
  • Xembify® (immune globulin subcutaneous (human) - klhw, HCPCS code J1558)

How to bill

For Medicare Plus Blue and BCN Advantage, we require authorization for the sites of care referenced above when you bill these medications as follows:

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

Important reminder

For these drugs, submit authorization requests through NovoLogix. It offers real-time status checks and immediate approvals for certain medications.

For Medicare Plus Blue and BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

If you need to request access to Provider Secured Services, complete the Provider Secured Access Application (PDF) form and fax it to the number on the form.  

List of requirements

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

*Note: On March 16, 2020, we published a web-DENIS message and a news items on the ereferrals.bcbsm.com website stating that Avsola doesn't require authorization. However, for dates of service on or after Aug. 21, 2020, Avsola will require authorization.

Posted: June 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



July 3 holiday closure: How to submit inpatient authorization requests

On Friday, July 3, 2020, Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will be closed for the Independence Day holiday.

Refer to the document Holiday closures: How to submit authorization requests (PDF) for instructions on how to submit authorization requests for inpatient admissions during the closure.

You can access this document from this website, on these webpages:

Here are the additional upcoming closures that will occur during 2020, so you can plan ahead:

  • Labor Day, Monday, September 7
  • Election Day, Tuesday, November 3
  • Thanksgiving Day, Thursday, November 26
  • Day after Thanksgiving, Friday, November 27
  • Christmas Eve, Thursday, December 24
  • Christmas Day, Friday, December 25
  • New Year's Eve, Thursday, December 31

Posted: June 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Avoid blocked inpatient authorization e-referral submissions by using the correct criteria

For a successful inpatient authorization submission in e-referral, please note the following

  • When submitting a non-elective medical admission in e-referral, providers should enter the following in the Inpatient Authorization drop-down menus:
    • Type of Care: Direct, Elective, Emergency, Transfer or Urgent
    • Place of Service: Inpatient Hospital
    • Primary Procedure Code: *99221-99239
  • If a lumbar spinal fusion surgery has already been authorized by eviCore healthcare® for Blue Cross' PPO and Medicare Plus BlueSM PPO members, and the provider believes the member should be admitted as inpatient, the facility should request an Inpatient Authorization in e-referral using the following drop-down menus:
    • Type of Care: Direct
    • Place of Service: Inpatient Hospital
    • Primary Procedure Code: *99222

Submitting incorrect information for these lumbar spinal fusion procedures will result in an error message indicating that you are unable to submit the request and ask you to modify the Type of Care or CPT code.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2019 American Medical Association. All rights reserved.

Posted: June 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Updated e-referral questionnaire to open June 28 for BCN and Medicare Plus BlueSM PPO

Starting June 28, 2020, an updated Vascular embolization or occlusion (TACE/RFA) questionnaire will open in the e-referral system. We'll also update the related preview questionnaire on this website.

The preview questionnaire shows the questions you'll need to answer in the actual questionnaire that opens in the e-referral system. This will help you prepare your answers ahead of time.

We use our authorization criteria and medical policies and your answers to the questionnaires when making utilization management determinations on your authorization requests.

To find the preview questionnaire on this website:

  • For BCN: Click BCN and then click Authorization Requirements & Criteria. Scroll down and look under the "Authorization criteria and preview questionnaires" heading.
  • For Medicare Plus Blue: Click Blue Cross and then click Authorization Requirements & Criteria. In the "Medicare Plus Blue PPO members" section, look under the "Authorization criteria and preview questionnaires - Medicare Plus Blue PPO" heading.

Posted: June 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Reminder: We're experiencing issues with processing some Supartz FX (sodium hyaluronate) claims for BCN AdvantageSM members

We continue to experience issues with processing some Supartz FX (sodium hyaluronate) claims for BCN AdvantageSM members.

We're still working to resolve the issues.

In the meantime, here's what you need to do:

  • For Supartz FX claims that were denied with a message of "NLX Authorization Not Found" (QH9), you don't need to do anything. We'll reprocess your claims for payment within 30 days.
  • For future Supartz FX claims, submit them as usual with the appropriate HCPCS code and the correct National Drug Code, or NDC, for BCN Advantage members. If the claims are denied, we’ll reprocess them within 30 days.

We apologize for any inconvenience. When this issue has been resolved, we'll post a web-DENIS message and a news item on the ereferrals.bcbsm.com website to let you know.

Note: We first communicated about this issue on April 21, 2020, through a web-DENIS message and a news item on this website.

Posted: June 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Medicare Part B medical specialty drug prior authorization list is changing in July and August

We're making changes to the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM PPO and BCN AdvantageSM members. The specialty medications on this list are administered by a healthcare professional in a provider office, at the member's home, in an off-campus outpatient hospital or in an ambulatory surgical center (sites of care 11, 12, 19, 22 and 24).

New authorization requirement

For dates of service on or after July 9, 2020, the following medication for wet age-related macular degeneration will require authorization through the NovoLogix® online tool:

  • J3590, abicipar pegol

Authorization requirement removed

For dates of service on or after Aug. 1, 2020, the following medications for osteoporosis and other diagnoses involving bone health will no longer require authorization:

  • Boniva® (J1740, ibandronate)
  • Aredia® (J2430, pamidronate)

How to bill

For Medicare Plus Blue and BCN Advantage, we require authorization for all outpatient sites of care when you bill these medications as a professional service or as an outpatient facility service:

  • Electronically through an 837P transaction or on a professional CMS-1500 claim form
  • Electronically through an 837I transaction or by using the UB-04 claim form for a hospital outpatient type of bill 013x

Important reminder

Submit authorization requests through NovoLogix. It offers real-time status checks and immediate approvals for certain medications. For Medicare Plus Blue and BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

If you need to request access to Provider Secured Services, complete the Provider Secured Access Application form and fax it to the number on the form.

List of requirements

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

Posted: June 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



e-referral system out of service for maintenance overnight June 20-21

Here's the next planned downtime for the e-referral system:

From 10 p.m. on Saturday, June 20 to 10 a.m. on Sunday, June 21

Note: All times are Eastern time.

The e-referral system will not be available at all during these times. Here's additional information:

  • On Sunday, the system will be available by 10 a.m. It may be available earlier if maintenance tasks are completed.
  • We expect the system to be available during the remaining time over the weekend, although you may experience minor performance issues.

To see more planned downtimes and to learn how to handle requests while the system is down, review the list of e-referral system planned downtimes and what to do.

You can get to this list anytime from any page of this website. Scroll down the left navigation pane and look for the blue tile at the bottom.

We're providing this information so you can plan ahead. We apologize for any inconvenience you may experience while the e-referral system is down.

Posted: June 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



eviCore has updated corePath for physical and occupational therapy authorizations

Effective immediately, eviCore healthcare® has made changes to the corePathSM therapy authorization model for first authorization requests for new episodes of treatment. This change applies to:

  • Physical therapy providers in categories B and C
  • Occupational therapists in category B

Here's what changed

For providers in categories B and C: When initial authorization requests meet certain conditions, eviCore is approving a greater number of visits over a longer authorization duration period. The logic in eviCore's corePath model determines the number of visits and authorization duration based on the patient's condition and complexity.

For more information about how this affects occupational therapy providers, see eviCore's Physical Therapy Practitioner Performance Summary and Provider Category FAQs (PDF) document.* See the question titled "How does my category impact my authorization requirements for occupational therapy?"

Note: There haven't been any changes to the number of visits granted or the authorization duration period for providers in category A.

Additional information

You can find information about this change in the June 2020 issue of eviCore's provider newsletter.

To learn more about category assignments, see eviCore's Physical Therapy Practitioner Performance Summary and Provider Category FAQs (PDF) document.*

You can find additional information on this website:

As a reminder, eviCore manages physical therapy and occupational therapy services for non-autism diagnoses for Medicare Plus BlueSM PPO, BCN HMOSM (commercial) and BCN AdvantageSM members. eviCore also manages physical therapy and occupational therapy services for adult BCN HMO members ages 19 and older with autism diagnoses.

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're required to let you know we're not responsible for its content.

Posted: June 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



eviCore simplifies authorization process for radiation oncology, starting July 1, 2020

On July 1, 2020, eviCore healthcare® will simplify the authorization process for radiation oncology by asking Clinical Decision Support questions, rather than their traditional clinical questions. This applies to authorizations for breast, prostate and non-small-cell lung cancer.

As a result, you'll need to answer far fewer clinical questions when submitting these authorization requests.

What you need to do

The steps to submit authorization requests to eviCore won't change. You'll follow the typical process of logging in to the eviCore portal at www.evicore.com*, initiating a request for Clinical Certification for Radiation Therapy and entering information about the member.

For breast, prostate and non-small-cell lung cancer, the system will prompt you to answer the CDS clinical questions. After answering the questions, you'll be presented with a list of treatment regimens that you can select from. There's also an option to enter a custom treatment regimen.

Additional information

eviCore manages authorizations for radiation oncology for most Blue Cross' PPO fully insured groups and for Medicare Plus BlueSM PPO, BCN HMOSM and BCN AdvantageSM members.

For more information, see the Blue Cross eviCore-Managed Procedures or the BCN eviCore-Managed Procedures pages of this website.

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're required to let you know we're not responsible for its content.

Posted: June 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Determinations on requests for inpatient acute care admissions are based on InterQual® criteria, not on the two-midnight rule

The Blue Cross / Blue Care Network Utilization Management department makes determinations on authorization requests for inpatient acute care admissions based on InterQual criteria, not on the two-midnight rule.

This applies to admissions of members covered by all our lines of business.

We're clarifying this because we recently received some questions from providers about the two-midnight rule.

Providers should do the following:

We're updating the pertinent provider manuals to include a statement clarifying that we do not use the two-midnight rule in making determinations on authorization requests for inpatient acute care admissions.

Posted: June 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Updated: More COVID-19-related utilization management changes

We've updated this news item, which was first published on May 26, 2020. The new date on which clinical review is again required for acute care admissions with non-COVID-19-related diagnoses is June 13, 2020. (We had previously announced the date was June 1, 2020.) Please use this news item as the most current source of information on these changes.

Over the past few weeks, Blue Cross Blue Shield of Michigan and Blue Care Network implemented utilization management changes aimed at supporting our providers during the COVID-19 emergency.

We're making additional utilization management changes at this time.

Here are the important things you need to know.

Temporary change ending: Waiving of clinical review requirements for acute care admissions with non-COVID-19 diagnoses

Starting June 13, 2020, clinical review is again required by Blue Cross / BCN Utilization Management for acute care admissions with non-COVID-19-related diagnoses. This means you'll need to submit clinical documentation along with your authorization requests.

Note: For admissions with COVID-19-related diagnoses, see the section titled "Changes extended temporarily," below.

Changes extended temporarily, through June 30, 2020:

  • For acute care admissions with COVID-19-related diagnoses, no clinical review is required. However, you must still continue to notify the plan (that is, you must submit an authorization request without clinical documentation).
  • For CT scans of the chest to rule out pneumonia diagnosis associated with COVID-19, AIM Specialty Health does not require clinical review for procedure codes *71250, *71260 and *71270. You only need to notify AIM Specialty Health®.
  • For the first three days of admission to a skilled nursing facility for members transferred from acute care, Blue Cross / BCN Utilization Management and naviHealth do not require clinical review. However, you must notify Blue Cross / BCN (by submitting the authorization request with no clinical documentation) or naviHealth (by contacting navIHealth prior to transferring the member).

Starting July 1, 2020, you must submit clinical documentation along with your authorization requests for the acute care admissions, CT scans and SNF admissions described in this section.

Change in the duration of authorization approvals for elective and non-urgent services

For elective and non-urgent services:

  • All authorizations approved on or before May 25, 2020, will be valid through Dec. 31, 2020.
  • All authorizations approved on or after May 26, 2020, will also be valid through Dec. 31, 2020. Exception: For authorizations approved with an end date that goes beyond Dec. 31, the end date identified in the authorization approval will be honored.

This applies to authorizations approved for in-state and out-of-state providers on or after the following dates:

  • Blue Cross / BCN Utilization Management: March 13, 2020
  • AIM Specialty Health: April 6, 2020
  • eviCore healthcare: March 26, 2020

This doesn't apply to Flexlink® groups for which a third-party administrator makes authorization determinations. Contact the third-party administrator on the back of the member's ID card for instructions.

Additional change: Turnaround time on post-acute care determinations

naviHealth will make a same-day determination on all Medicare Advantage post-acute care requests and, for certain admissions to SNFs, will implement an expedited review process. Due to increased workloads, naviHealth is no longer able to make a determination on these requests within two hours.

Both Blue Cross / BCN Utilization Management (for commercial members) and naviHealth (for Medicare Advantage members) will continue to assist providers in locating post-acute care providers, especially for difficult transitions.

More information

The information in this message has been added to the COVID-19 utilization management changes (PDF) document, which you can access on this website, on the Blue Cross Authorization Requirements & Criteria page and the BCN Authorization Requirements & Criteria page.

This information applies to the following members, unless otherwise noted:

  • Blue Cross' PPO (commercial)
  • BCN HMOSM (commercial)
  • Medicare Plus BlueSM PPO (Medicare Advantage)
  • BCN AdvantageSM (Medicare Advantage)

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2019 American Medical Association. All rights reserved.

Posted: May 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



VyeptiTM will have authorization and site-of-care requirements for commercial members effective May and July 2020

We're adding authorization and site-of-care requirements for Vyepti (eptinezumab-jjmr), a specialty drug covered under the medical benefit, for BCN HMOSM (commercial) and Blue Cross' PPO (commercial) members.

Vyepti will require authorization and will have site-of-care requirements for members who begin therapy on or after the following dates:

  • BCN HMO members: May 28, 2020
  • Blue Cross' PPO members: July 1, 2020

Currently the HCPCS code for this drug is J3590. However, as of July 1, 2020, the HCPCS code will be C9063.

More about the authorization requirements

These requirements apply only to groups that are currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. These changes don't apply to members covered by the Federal Employee Program® Service Benefit Plan.

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

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Blue Cross and BCN utilization management medical drug list for Blue Cross PPO (commercial) and BCN HMO (commercial) members (PDF) document on this website:

We'll add the Vyepti information to the requirements list prior to the dates on which authorization is required.

Posted: May 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Medical benefit specialty drug prior authorization lists are changing in July and August for Medicare Plus BlueSM PPO, BCN HMOSM and BCN AdvantageSM members

We're adding authorization requirements for four specialty drugs covered under the medical benefit for Medicare Plus Blue PPO, BCN HMO and BCN Advantage members.

For dates of service on or after July 24, 2020, the following drugs will require authorization through AIM Specialty Health®:

  • Trodelvy (sacituzumab govitecan-hziy, J3490, J3590, J9999)
  • Jelmyto (mitomycin, J3490, J3590, J9999)
  • Darzalex Faspro (daratumumab and hyaluronidase-fihj, J3490, J3590, J9999)

For dates of service on or after Aug. 24, 2020, the following drug will require authorization through AIM:

  • Imlygic® (talimogene laherparepvec, J9325)

How to submit authorization requests

Submit authorization requests to AIM using one of the following methods:

For information about registering for and accessing the AIM ProviderPortal, see the Frequently asked questions page* on the AIM website.

More about the authorization requirements

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

For additional information on requirements related to drugs covered under the medical benefit, see:

We'll update these lists with the new information about these drugs prior to the effective dates.

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're required to let you know we're not responsible for its content.

Posted: May 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



How to submit non-behavioral health inpatient authorization requests to Blue Cross and BCN during the May 25 holiday closure

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will be closed on Monday, May 25, for Memorial Day.

See below for instructions on submitting non-behavioral health inpatient authorization requests during this closure. Note that all times are Eastern time.

IMPORTANT! For urgent requests, always call the after-hours number 1-800-851-3904 when other options are not available.

Type of request What to do
Acute inpatient admissions and continued stays Submit requests 24/7 through the e-referral system. If the e-referral system is not available:
  • Blue Cross' PPO: Fax to 1-800-482-1713
  • Medicare Plus BlueSM PPO: Fax to 1-866-464-8223
  • BCN HMOSM: Fax to 1-866-313-8433
  • BCN AdvantageSM: Fax to 1-866-526-1326

Note: You can also submit requests through the X12N 278 Health Care Services Review - Request for Review and Response electronic standard transaction.
Sick and ill newborns
  • Blue Cross' PPO: Fax to 1-800-482-1713
  • BCN HMO: Fax to 1-866-313-8433
Post-acute care admissions
Other requests Blue Cross' PPO: Fax the following requests to 1-800-482-1713:
  • Federal Employee Program® members with contract eligibility issues
  • Ineligible members or members with no contract

Reminder: We've suspended clinical review requirements through May 31, 2020, for acute care medical admissions and for transfers to skilled nursing facilities, due to the COVID-19 crisis. This means that all authorization requests for acute inpatient medical admissions and for the first three days of skilled nursing care following transfer from acute care will be approved without clinical review. However:

  • For all members being admitted to an acute care hospital, you still need to submit an authorization request, which will serve as plan notification.
  • For members being transferred from an acute care hospital to a SNF:
    • For Blue Cross' PPO and BCN HMO members, you still need to submit an authorization request to the plan, which will serve as plan notification.
    • For Medicare Plus Blue and BCN Advantage members, you still need to notify naviHealth prior to transferring the member.

Requests submitted to the plan that are received via phone or fax on the May 25 holiday will be entered into the e-referral system by our Utilization Management staff on Tuesday, May 26. Your approval will be available in the system by Tuesday night.

For more information refer to the COVID-19 utilization management changes document.

Posted: May 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Register for training on TurningPoint's clinical model and more

As we communicated previously, TurningPoint Healthcare Solutions, LLC will manage authorizations for surgical procedures related to musculoskeletal conditions for Medicare Plus BlueSM PPO, BCN HMOSM and BCN AdvantageSM members for dates of service on or after July 1, 2020.

TurningPoint is offering webinar training sessions for professional providers and facilities. Here are some details about what the training sessions will cover:

  • The professional provider sessions will cover TurningPoint's clinical model and operational changes and a demonstration of using the TurningPoint Provider Portal to submit authorization requests. In addition, a portal-only training session is available for professional providers.
  • The facility provider sessions will cover TurningPoint's clinical model and operational changes.

Professional providers can start submitting authorization requests to TurningPoint on June 1, 2020, for dates of service on or after July 1, 2020. We're offering webinar training sessions before June 1 so you can be prepared for this change. We're also offering webinar training sessions after June 1.

Register for the webinars

Use the following links to register for webinars that will take place before June 1, 2020:

  • Professional providers can register for training here.
  • Facility providers can register for training here.

Use the following links to register for webinars that will take place after June 1:

  • Professional provider webinars can register for training here.
  • Professional providers can register for portal-only training here.
  • Facility providers can register for training here.

Additional information

To learn more, see the following articles:

As a reminder, only professional providers can register for and access the TurningPoint Provider Portal at this time. Professional providers can request an authorization through the portal and then provide the appropriate facility with the authorization number. Facilities can view the status of an authorization request through the e-referral system 24 hours after TurningPoint makes a determination.

You can also find information about TurningPoint on the Musculoskeletal Services pages on this website:

Posted: May 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



e-referral system out of service for maintenance overnight May 16-17

Here's the next planned downtime for the e-referral system:

From 10 p.m. on Saturday, May 16 to 10 a.m. on Sunday, May 17

Note: All times are Eastern time.

The e-referral system will not be available at all during these times. Here's additional information:

  • On Sunday, the system will be available by 10 a.m. It may be available earlier if maintenance tasks are completed.
  • We expect the system to be available during the remaining time over the weekend, although you may experience minor performance issues.

To see more planned downtimes and to learn how to handle requests while the system is down, review the list of e-referral system planned downtimes and what to do (PDF).

You can get to this list anytime from any page of our ereferrals.bcbsm.com website. Scroll down the left navigation pane and look for the blue tile at the bottom.

We're providing this information so you can plan ahead. We apologize for any inconvenience you may experience while the e-referral system is down.

Posted: May 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Recommendations for submitting authorization requests for medical oncology drugs to AIM

Here are some recommendations to follow when submitting authorization requests for medical oncology drugs to AIM Specialty Health®:

  • Wait to submit the request until you have all the pertinent information, including but not limited to tumor testing results and information on tumor staging and prior therapy regimens.
  • Provide all the clinical information needed for clinical review, including the rationale for the requested regimen.
  • Ensure that the phone number you provide is an accurate one, so AIM can contact you to schedule a peer-to-peer consultation if they need more information to establish medical necessity.

When you follow these guidelines, the process of reviewing authorization requests goes more smoothly and takes less time.

The information in this message applies to all members whose plans require authorization of medical oncology drugs by AIM:

  • Medicare Advantage plans: Medicare Plus BlueSM PPO and BCN AdvantageSM
  • Commercial plans: BCN HMOSM and select Blue Cross' PPO groups

How to submit authorization requests

For medical oncology drugs, submit authorization requests to AIM using one of the following methods:

For information about registering for and accessing the AIM ProviderPortal, see the Frequently asked questions page on the AIM Specialty Health website.*

Lists of requirements

To see the requirements related to drugs covered under the medical benefit, including medical oncology drugs, refer to:

The specialty medications on these lists are administered in outpatient sites of care, including a physician's office, an outpatient facility or a member's home.

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're required to let you know we're not responsible for its content.

Posted: April 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Updated: We're adding site-of-care requirements for Lemtrada and Tysabri for commercial members, starting May 1

We've updated this message, which was first published on Jan. 31, 2020. We added a link to the document Lemtrada and Tysabri site-of-care program: Frequently asked questions by providers, which contains additional program information and details on authorized administration sites in Michigan and elsewhere in the U.S..

Starting May 1, 2020, the medical drug site-of-care program is expanding for Blue Cross' PPO (commercial) and BCN HMOSM (commercial) members to include:

  • Lemtrada® (alemtuzumab, HCPCS code J0202)
  • Tysabri® (natalizumab, HCPCS code J2323)

Through April 30, 2020, members who receive these drugs in one of the following locations are authorized to continue treatment:

  • Doctor's office or other health care provider's office
  • Ambulatory infusion center
  • Hospital outpatient facility

Starting May 1, 2020, infusions of Tysabri and Lemtrada may not be covered at hospital outpatient facilities.* Before May 1, members should talk to their doctors to make arrangements to receive infusion services at one of the following locations:

  • Doctor's office or other health care provider's office
  • Ambulatory infusion center

*Based on Risk Evaluation and Mitigation Strategies, or REMS, program restrictions, administration of Lemtrada and Tysabri is limited to authorized locations. For Lemtrada, we'll restrict transitions to select locations that have safety protocols in place for adverse reactions. To aid in member transition, please refer to the document Lemtrada and Tysabri site-of-care program: Frequently asked questions by providers, which contains additional program information and details on authorized administration sites in Michigan and elsewhere in the U.S..

More about the authorization requirements

The authorization requirements apply only to groups that are currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. These changes don't apply to the Federal Employee Program® Service Benefit Plan members.

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

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Requirements for drugs covered under the medical benefit - BCN HMO and Blue Cross PPO document located on our ereferrals.bcbsm.com website:

We've updated the requirements list with the new information about Lemtrada and Tysabri.

Posted: April 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Hospitals must notify naviHealth before transferring Medicare Advantage members to SNFs

As communicated previously, we waived the requirement to obtain clinical review for the first three days of skilled nursing facility stays for Medicare Plus BlueSM PPO and BCN AdvantageSM members transferred from acute care hospitals. This is in effect for transfers that take place from April 3 through May 31, 2020.

Hospitals are still obligated to notify naviHealth about transfers.

However, we're finding that some hospitals are transferring our Medicare Advantage members to SNFs without notifying naviHealth.

To avoid problems, we're clarifying what you need to do:

  • Notify naviHealth by submitting an authorization request but not attaching clinical documentation. You can do this through:
    • CarePort Care Management (formerly known as Allscripts®)
    • nH Access, the naviHealth provider portal
    • Calling 1-855-851-0843
    • Faxing to 1-844-899-3730
  • Submit the following information to naviHealth with your notification:
    • Name and contact information for person notifying the plan
    • Patient demographics (name, date of birth, enrollee ID, etc.)
    • Name of ordering physician
    • Patient diagnosis
    • Name of accepting SNF
    • Note: If you need assistance locating a SNF, include a request for assistance when you submit notification to naviHealth. They'll have their clinicians reach out to local facilities.

We're asking SNFs to confirm that naviHealth has received the required notification for each member before they accept the transfer. Once naviHealth receives the notification, they'll provide a three-day authorization to transfer the patient to the SNF.

Failure to notify naviHealth means there's no authorization in our system when we receive the claim from the SNF.

We'll update the COVID-19 utilization management changes document with the details about the information you must send when notifying naviHealth.

Posted: April 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



CHANGE: TurningPoint will manage musculoskeletal procedure authorizations with dates of service on or after July 1, 2020, for certain members

Due to the COVID-19 pandemic, we're delaying the date on which TurningPoint Healthcare Solutions, LLC will begin managing authorizations for spine and joint replacement surgeries and other related procedures. This applies to Medicare Plus BlueSM PPO, BCN HMOSM (commercial) and BCN AdvantageSM members.

TurningPoint will manage musculoskeletal procedure authorizations for dates of service on or after July 1, 2020. You'll be able to begin submitting authorization requests to TurningPoint on June 1.

You don't need to do anything different until June 1. For dates of service prior to July 1, 2020, Medicare Plus Blue Utilization Management and BCN Utilization Management will continue to manage these authorizations, as they do today.

We're also delaying webinars for professional providers and facilities about TurningPoint's clinical model. For professional providers, these webinars will include a demonstration of their Provider Portal. Watch for web-DENIS messages about new webinar dates.

We apologize for any inconvenience, and we'll update our communications to reflect this change.

Posted: April 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



e-referral system out of service for maintenance overnight April 18-19

Here's the next planned downtime for the e-referral system:

From 10 p.m. on Saturday, April 19 to 10 a.m. on Sunday, April 20

Note: All times are Eastern time.

The e-referral system will not be available at all during these times. Here's additional information:

  • On Sunday, the system will be available by 10 a.m. It may be available earlier if maintenance tasks are completed.
  • We expect the system to be available during the remaining time over the weekend, although you may experience minor performance issues.

To see more planned downtimes and to learn how to handle requests while the system is down, review the list of e-referral system planned downtimes and what to do.

You can get to this list anytime from any page of our ereferrals.bcbsm.com website. Scroll down the left navigation pane and look for the blue tile at the bottom.

We're providing this information so you can plan ahead. We apologize for any inconvenience you may experience while the e-referral system is down.

Posted: April 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



What to do about e-referral error message

Providers are sometimes getting an "Unknown Error" message in the e-referral system. This error message is connected to the e-referral system software upgrade that occurred over this last weekend.

When you get this error message, you're unable to search or submit or otherwise move forward with the referral or the authorization request.

What to do

Refresh your browser window, re-enter the information and continue working. Most of the time, this will resolve the issue.

Working to resolve the issue

We are working to resolve this issue as soon as possible. We apologize for any inconvenience this may cause.

Posted: April 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Sarclisa® will require prior authorization starting May 15 for BCN HMOSM, Medicare Plus BlueSM PPO and BCN AdvantageSM members

We're expanding the prior authorization program for specialty drugs covered under the medical benefit for BCN HMO, Medicare Plus Blue and BCN Advantage members.

For dates of service on or after May 15, 2020, Sarclisa (isatuximab-irfc, HCPCS code J3490, J3590, J9999) will require authorization through AIM Specialty Health®.

How to submit authorization requests

For this drug, submit authorization requests to AIM using one of the following methods:

For information about registering for and accessing the AIM ProviderPortal, see the Frequently asked questions page* on the AIM website.

More about the authorization requirements

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

For additional information on requirements related to drugs covered under the medical benefit, see:

We'll update the requirements lists with the new information about Sarclisa prior to May 15.

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're required to let you know we're not responsible for its content.

Posted: April 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



UPDATE: Changes to authorization durations for elective and non-urgent procedures, including PT, OT and ST, during the COVID-19 pandemic

Due to the COVID-19 pandemic, we're delaying the date on which TurningPoint Healthcare Solutions, LLC will begin managing authorizations for musculoskeletal surgical and other related procedures. Providers won't be able to begin submitting requests to TurningPoint until June 1, 2020, so we removed information about TurningPoint from this message.

Due to the COVID-19 pandemic, the federal government has mandated that providers postpone all elective and non-urgent procedures.

As a result and to reduce your administrative burden, we're making the following changes to authorization requests for elective procedures, including physical, occupational and speech therapy.

  • For requests that have already been approved: The approvals will be valid for 180 days from the date on which the authorization was approved.

This change applies to authorization requests that were approved on or after the following dates:

  • Blue Cross or BCN utilization management: March 13, 2020
  • AIM Specialty Health®: April 6, 2020
  • eviCore healthcare®: March 26, 2020
  • For requests that are received between now and May 31, 2020: If approved, authorizations will be valid for 180 days.

These changes are in effect through May 31, 2020, and apply to in-state and out-of-state providers, for all lines of business, including Blue Cross' PPO, BCN HMOSM, Medicare Plus BlueSM PPO and BCN AdvantageSM.

Exception: These changes don't apply to Flexlink® groups for which a third-party administrator makes authorization determinations. Contact the third-party administrator on the back of the member's ID card for instructions.

Posted: April 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



How to submit inpatient authorization requests to Blue Cross and BCN during the April 10 holiday closure and the e-referral weekend software upgrade

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will be closed on Friday, April 10, for Good Friday. In addition, the e-referral system will be unavailable this weekend for a software upgrade.

See below for what to do during these occurrences. Note that all times are Eastern time.

IMPORTANT! For urgent requests, always call the after-hours number 1-800-851-3904 when the phone lines are not available.

Date What's happening What to do (options in order of preference)
Friday, April 10 - Good Friday holiday closure and e-referral software upgrade begins The e-referral system will be available but only until 6 p.m.
  • Before 6 p.m., submit requests using e-referral.
  • After 6 p.m.:
    • Wait until Monday at 6 a.m. to use e-referral.
    • Fax requests using the information shown below.
Saturday, April 11 - e-referral software upgrade continues The e-referral system will not be available at all.
  • Wait until Monday at 6 a.m. to use e-referral.
  • Fax requests using the information shown below.
  • Between 8 a.m. and 4 p.m.:
    • Call inpatient Medicare Plus BlueSM PPO and BCN AdvantageSM requests in to 1-866-807-4811.
    • Call inpatient Blue Cross’ PPO and BCN HMOSM requests in to 1-877-399-1673.
Sunday, April 12 - e-referral software upgrade continues The e-referral system will not be available at all.
  • Wait until Monday at 6 a.m. to use e-referral.
  • Fax requests using the information shown below.
Monday, April 13 - e-referral software upgrade ends The e-referral system will be available starting at 6 a.m.
  • Submit requests using e-referral starting at 6 a.m.

Reminder: We've suspended clinical review requirements for acute care medical admissions and transfers to skilled nursing facilities through May 31, 2020, due to the COVID-19 crisis.

This means that all authorization requests for acute inpatient medical admissions and transfers to skilled nursing facilities will be approved without clinical review. However, you'll still need to submit an authorization request, which will serve as plan notification. Requests received via phone or fax on the April 10 holiday or over the weekend will be entered into the e-referral system by our Utilization Management staff on Monday. Your approval will be available in the system by Monday night.

For more information refer to the COVID-19 utilization management changes (PDF) document.

Fax numbers

Type of request Line of business / fax number / other information
Acute inpatient admissions and continued stays
  • Blue Cross' PPO: Fax to 1-800-482-1713
  • BCN HMO: Fax to 1-866-313-8433
  • Medicare Plus Blue: Fax to 1-866-464-8223
  • BCN Advantage: Fax to 1 866 526 1326
  • Note: You can also submit requests through the X12N 278 Health Care Services Review - Request for Review and Response electronic standard transaction.

Sick and ill newborns
  • Blue Cross’ PPO: Fax to 1-800-482-1713
  • BCN HMO: Fax to 1 866 313 8433
Post-acute care admissions
Other requests
  • Blue Cross' PPO: Fax the following requests to 1-800-482-1713:
    • Federal Employee Program® members with contract eligibility issues
    • Ineligible members or members with no contract

Posted: April 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



How to submit a plan notification for acute care hospital facility admissions and request for post-acute care admissions

On Thursday, April 2, we announced that clinical review requirements have been suspended through May 31 for all admissions to acute care hospitals and for transfers to skilled nursing facilities. For acute care hospital facility and transfers to post-acute care admissions, there is one step required - submitting a plan notification for each admission. Here's what you need to know about these plan notifications:

  • A plan notification is a request for authorization submitted through e-referral.
  • No clinical documentation is required with this submission. This includes any request that pends for review.
    • For inpatient hospital admissions for all lines of business: submit via e-referral.
    • For Blue Cross' PPO and BCN HMOSM post-acute requests: submit via e-referral or by fax.
    • For Medicare Plus BlueSM PPO and BCN AdvantageSM requests: submit to naviHealth.
  • Some of these submissions will receive real-time approval. Blue Cross Blue Shield of Michigan and Blue Care Network will respond to requests that pend within two hours during normal business hours.
  • Some submissions sent after business hours or on weekends will receive real-time approval. Blue Cross and BCN will respond to requests that pend with approval the next business day.

Posted: April 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Clinical review requirements suspended through May 31 for all admissions to acute care hospitals and for transfers to skilled nursing facilities

To enable inpatient medical facilities to prioritize patient care during this challenging time, we've already suspended the requirement for clinical review of acute care admissions of Blue Cross Blue Shield of Michigan and Blue Care Network members with COVID-19-related diagnoses.

Based on the evolving nature of this crisis, we have approved several other actions, effective immediately:

  • Acute care hospitals: Clinical review requirements at all acute care hospitals for all diagnoses are suspended. This applies to all medical admissions.
  • Post-acute care facilities: Clinical review requirements for the first three days of all skilled nursing facility admissions are suspended for members who are transferring from an acute care hospital.

How to submit these requests

  • For acute care admissions, no clinical review is required.
    • There is an important notification step to take. Eligible facilities must submit a plan notification for each admission so that an authorization is in our system when we receive the claim. We strongly encourage facilities to submit plan notifications through our e referral system. When facilities use e referral, they won't wait on hold on the phone. We're updating the e-referral system to automatically approve these requests without clinical review. While we're updating the system, some requests may pend, in error. In those cases, our staff will provide approval to the facility within two hours of submission during normal business hours.

    Note: We reserve the right to audit these admissions at a later date.

  • For post-acute care admissions:
    • There is an important notification step to take. For SNF admissions, we're suspending clinical review requirements for the first three days when patients are transferred from an acute care hospital. However, facilities must submit a plan notification for each admission so that an authorization is in our system when we receive the claim. Facilities are not required to submit clinical documentation until the continued stay review, starting on the fourth day of stay.
    • Inpatient rehabilitation and long-term acute care admissions still require clinical review. Blue Cross has adjusted our clinical review process to expedite these requests. A determination will be made within two hours, during normal business hours.
    • Continue to submit Blue Cross' PPO and BCN HMOSM post-acute requests through the e referral system or by fax. A decision will be provided within 2 hours during normal business hours.
    • Continue to submit Medicare Plus BlueSM PPO and BCN AdvantageSM SNF post-acute admission requests to naviHealth. A decision will be provided within 2 hours during normal business hours.

    Important!

    These changes are in effect through May 31, 2020, and apply to Michigan facilities, for all lines of business, including Blue Cross' PPO, BCN HMO, Medicare Plus Blue and BCN Advantage.

    Exception: These changes do not apply to Flexlink® groups for which a third-party administrator makes authorization determinations. Facilities should check the back of the member's ID card to determine whether a third-party administrator needs to be contacted prior to an admission.

Posted: April 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Use e-referral system while Blue Cross and BCN offices are closed on Tuesday, March 24

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices have extended the closure of their buildings for an additional day, through Tuesday, March 24, 2020.

How to handle requests related to medical services

During this office closure, use the e-referral system to:

  • Submit all referrals and authorization requests for medical services that are managed by Blue Cross or BCN Utilization Management
  • Attach clinical information to the case as needed
  • Check the status of these authorization requests

This applies to requests for all medical services, for all Blue Cross and BCN members.

While our offices are closed, our Utilization Management staff are not available to answer calls related to medical requests.

However, if a case pends and you need a decision in an emergency or an urgent situation, call the Utilization Management after-hours phone at 1-800-851-3904.

Our Utilization Management offices will reopen on at 8:30 am Eastern time on Wednesday, March 25.

For instructions on how to submit requests through the e-referral system and attach clinical information to the case, refer to the e-referral User Guide (PDF). You'll find additional information about the e-referral system and about referral and authorization requirements on this website.

Peer-to-peer reviews on medical cases to be completed but no new ones scheduled during closure

Peer-to-peer reviews on medical cases scheduled for March 24 will be completed. However, no new medical peer-to-peer reviews will be scheduled until we reopen on March 25.

How to handle requests related to behavioral health services

During this office closure, use the e-referral system to submit authorization requests for behavioral health services as well.

Behavioral Health department staff members are available to discuss a case, if needed. To reach a staff member:

  • Medicare Plus BlueSM PPO: Call 1-888-803-4960.
  • BCN HMOSM (commercial): Call 1-800-482-5982.
  • BCN AdvantageSM: Call 1-800-431-1059.

Posted: March 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



e-referral system out of service for maintenance overnight March 21-22

Here's the next planned downtime for the e-referral system:

From 10 p.m. on Saturday, March 21 to 10 a.m. on Sunday, March 22

Note: All times are Eastern time.

The e-referral system will not be available at all during these times. Here's additional information:

  • On Sunday, the system will be available by 10 a.m. It may be available earlier if maintenance tasks are completed.
  • We expect the system to be available during the remaining time over the weekend, although you may experience minor performance issues.

To see more planned downtimes and to learn how to handle requests while the system is down, review the list of e-referral system planned downtimes and what to do (PDF).

You can get to this list anytime from any page of this website. Scroll down the left navigation pane and look for the blue tile at the bottom.

We're providing this information so you can plan ahead. We apologize for any inconvenience you may experience while the e-referral system is down.

Posted: March 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Use e-referral system while Blue Cross and BCN offices are closed on March 20 and 23

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices are closed on the following days:

  • Friday, March 20, 2020
  • Monday, March 23, 2020

How to handle requests related to medical services

During this office closure, use the e-referral system to:

  • Submit all referrals and authorization requests for medical services that are managed by Blue Cross or BCN Utilization Management
  • Attach clinical information to the case as needed
  • Check the status of these authorization requests

This applies to requests for all medical services, for all Blue Cross and BCN members.

While our offices are closed, our Utilization Management staff are not available to answer calls related to medical requests.

However, if a case pends and you need a decision in an emergency or an urgent situation, call the Utilization Management after-hours phone at 1-800-851-3904.

Our Utilization Management offices will reopen on at 8:30 am Eastern time on Tuesday, March 24.

For instructions on how to submit requests through the e-referral system and attach clinical information to the case, refer to the e-referral User Guide (PDF). You'll find additional information about the e-referral system and about referral and authorization requirements on this website.

Peer-to-peer reviews on medical cases to be completed but no new ones scheduled during closure

Peer-to-peer reviews on medical cases scheduled for March 20 and 23 will be completed. However, no new medical peer-to-peer reviews will be scheduled until we reopen on March 24.

How to handle requests related to behavioral health services

During this office closure, use the e-referral system to submit authorization requests for behavioral health services as well.

Behavioral Health department staff members are available to discuss a case, if needed. To reach a staff member:

  • Medicare Plus BlueSM PPO: Call 1-888-803-4960.
  • BCN HMOSM (commercial): Call 1-800-482-5982.
  • BCN AdvantageSM: Call 1-800-431-1059.

Posted: March 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Authorization requirements eased for COVID-19-related services

Blue Cross Blue Shield of Michigan and Blue Care Network are temporarily reducing some authorization requirements to make it easier for providers - both contracted and noncontracted - to deliver COVID-19-related testing and treatment services to our members.

Some of our contracted vendors are also easing authorization requirements.

See a description of these changes in the document COVID-19 utilization management changes (PDF), which you can access on this website. Do one of the following:

Look for the document on those pages.

The changes described in this document apply to the plans listed below, for any members who are subject to authorization requirements:

  • Blue Cross' PPO (commercial)
  • BCN HMOSM (commercial)
  • Medicare Plus BlueSM PPO
  • BCN AdvantageSM

We encourage you to check the COVID-19 utilization management changes document from time to time; we'll update it as new information becomes available.

Additional information about the COVID-19 coronavirus is available on our "Coronavirus information updates for providers" page, which you can access by logging in to Provider Secured Services and then doing one of the following:

  • Clicking BCN Provider Publications and Resources
  • Clicking BCBSM Provider Publications and Resources and then clicking Newsletters and Resources

Finally, click the blue Coronavirus information updates for providers box.

Posted: March 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



In April, we're making changes to coverage for infliximab biosimilar products for Medicare Advantage members

In April, we're removing authorization requirements for certain infliximab biosimilar drugs and designating preferred infliximab biosimilar drugs for Medicare Plus BlueSM PPO and BCN AdvantageSM members.

Removing authorization requirements

For dates of service on or after April 3, 2020, we'll no longer require authorization for the following infliximab biosimilars for Remicade® for Medicare Plus Blue and BCN Advantage members:

  • Q5103 Inflectra®
  • Q5104 Renflexis®

Designating preferred biosimilar drugs

Starting April 20, 2020, we'll designate the following drugs as preferred infliximab biosimilar products for Medicare Plus Blue and BCN Advantage members:

  • J3590 Avsola
  • Q5103 Inflectra
  • Q5104 Renflexis

As part of our shared commitment to keeping health care affordable for all, we encourage you to switch members to one of the preferred infliximab biosimilar products before April 20.

Important! Remicade won't be considered a preferred biosimilar and will continue to require authorization for Medicare Plus Blue and BCN Advantage members.

List of requirements

We'll update the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members with these changes prior to the effective dates.

The specialty medications on this list are administered in outpatient sites of care, a physician's office, an outpatient facility or a member's home.

Posted: March 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



naviHealth is taking measures to keep Medicare Advantage members safe in response to COVID-19

naviHealth is taking measures to keep Medicare Plus BlueSM PPO and BCN AdvantageSM members safe in post-acute care settings in response to coronavirus disease, or COVID-19.

In an effort to contain the spread of COVID-19, naviHealth will conduct all care coordination activities remotely, effective immediately. Care coordinators will use telepresence and other remote capabilities to attend meetings and communicate with patients, families of patients and post-acute care personnel.

Care coordinators will continue to perform all typical care coordination activities, including discharge planning.

In post-acute care settings where care coordinators have been working remotely, you won't notice any changes. In settings where care coordinators have been working onsite, they'll return when it's deemed safe to do so.

For more information, see the email message with the subject "COVID 19 - Keeping Patients Safe" that naviHealth sent to post-acute care providers on March 12. naviHealth sent this message to the leaders within interdisciplinary teams at skilled nursing facilities, inpatient rehabilitation facilities and long-term acute hospitals.

Please direct any questions to your naviHealth Provider Relations Manager.

Posted: March 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Medicare Part B medical specialty drug prior authorization list is changing in June

We updated this message on March 16, 2020, to remove J3590 Avsola from the list of drugs that will require authorization starting June 15. Avsola won't require prior authorization.

We're adding medications to the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM PPO and BCN AdvantageSM members. The specialty medications on this list are administered by a healthcare professional in a provider office, at the member's home, in an off-campus outpatient hospital or in an ambulatory surgical center (sites of care 11, 12, 19, 22 and 24).

For dates of service on or after June 15, 2020, the following medications will require prior authorization through NovoLogix®:

  • J1428 Exondys 51®
  • J3490 Vyondys 53
  • J3490 Givlaari®
  • J3590 Tepezza
  • J3590 Vyepti

How to bill

For Medicare Plus Blue and BCN Advantage, we require authorization for all outpatient sites of care when you bill these medications as a professional service or as an outpatient facility service:

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

Important reminder

For these drugs, submit authorization requests through the NovoLogix online tool. It offers real-time status checks and immediate approvals for certain medications. Also note:

  • For Medicare Plus Blue, if you have a Type 1 (individual) NPI and you checked the "Medical Drug PA" box when you completed the Provider Secured Access Application form, you already have access to NovoLogix. If you didn't check that box, you can complete an Addendum P form to request access to NovoLogix and fax it to the number on the form.
  • For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

If you need to request access to Provider Secured Services, complete the Provider Secured Access Application form and fax it to the number on the form.

List of requirements

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

Posted: March 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



No software upgrade on March 8-9 for e-referral system

The e-referral system software upgrade most recently planned for March 8-9, 2020, will not occur on those dates after all. This means the e-referral system will be available for your use on those dates.

We don't yet know the dates on which the software upgrade will occur, but we'll announce the new dates as soon as we know them.

The only e-referral system downtime currently planned for March 2020 is this one:

  • Routine monthly maintenance: The system will be unavailable from 10 p.m. Saturday, March 21 to 10 a.m. Sunday, March 22.

    Note: The e-referral system will not be available at all during these routine maintenance times. On Sunday, the system will be available by 10 a.m. and may be available earlier if maintenance tasks are completed. During the remaining time over the weekend, we expect the system to be available, although you may experience minor performance issues.

To see more planned downtimes and to learn how to handle requests while the system is down, review the list of e-referral system planned downtimes and what to do.

You can get to this list anytime from any page of this website. Scroll down the left navigation pane and look for the blue tile at the bottom.

We're providing this information so you can plan ahead. We apologize for any inconvenience you may experience while the e-referral system is down.

Posted: March 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Professional providers and facilities can now register for training on TurningPoint's clinical model and more

Professional providers and facilities can now register for training. For professional providers, the training will cover TurningPoint Healthcare Solution's clinical model and working in the TurningPoint Provider Portal. For facilities, the training will cover TurningPoint's clinical model and facility-specific information.

Webinar training sessions are available on various dates in April.

  • Professional providers can register for training here.
  • Facility providers can register for training here.

Note: Only professional providers can register for and access the TurningPoint Provider Portal at this time. Professional providers can request an authorization through the portal and then provide the appropriate facility with the authorization number. Facilities can view the status of an authorization request through the e-referral system 24 hours after TurningPoint makes a determination.

To learn more, see the following articles:

As we communicated previously, TurningPoint will manage authorizations for surgical procedures related to musculoskeletal conditions for Medicare Plus BlueSM PPO, BCN HMOSM and BCN AdvantageSM members for dates of service on or after June 1, 2020.

You can also find information about TurningPoint on the Musculoskeletal Services pages on this website:

Posted: February 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Updated: Palforzia and Tepezza will have authorization and site-of-care requirements for commercial members effective March and May 2020

We updated this message to correct the HCPCS code for Palforzia.

We're adding authorization and site-of-care requirements for specialty drugs covered under the medical benefit for Blue Cross' PPO (commercial) and BCN HMOSM (commercial) members for the following drugs:

  • Palforzia (peanut [Arachis hypogaea] allergen powder-dnfp, HCPCS code J3590)
  • Tepezza (teprotumumab-trbw, HCPCS code J3590)

For BCN HMO members

  • We'll require authorization for Palforzia and Tepezza for members who begin therapy on or after March 1, 2020.
  • We'll add Tepezza to the site-of-care program for BCN HMO members effective March 1, 2020.

For Blue Cross' PPO members

We'll require authorization for Palforzia and Tepezza for members who begin therapy on or after May 1, 2020.

More about the authorization requirements

These requirements apply only to groups that are currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. These changes don't apply to members covered by the Federal Employee Program® Service Benefit Plan.

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

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Blue Cross and BCN utilization management medical drug list for Blue Cross PPO (commercial) and BCN HMO (commercial) members (PDF) document on this website:

We'll update the requirements list for the drugs listed above prior to the effective dates for the changes.

Posted: April 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Medicare Part B medical specialty drug prior authorization list is changing in April

We're adding medications to the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM PPO and BCN AdvantageSM members. The specialty medications on this list are administered by a healthcare professional in a provider office, at the member's home, in an off-campus outpatient hospital or in an ambulatory surgical center (sites of care 11, 12, 19, 22 and 24).

For dates of service on or after April 1, 2020, the following medications will require authorization through AIM Specialty Health®.

  • J3490, J3590, J9999 Padcev
  • J3490, J3590, J9999 Enhertu®
  • J3490, J3590, J9999 Ziextenzo®

How to bill

For Medicare Plus Blue and BCN Advantage, we require authorization for all outpatient sites of care when you bill these medications as a professional service or as an outpatient facility service:

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

How to submit authorization requests

For these drugs, submit authorization requests to AIM using one of the following methods:

For information about registering for and accessing the AIM ProviderPortal, see the Frequently asked questions page on the AIM Specialty Health website*.

List of requirements

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

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're required to let you know we're not responsible for its content.

Posted: February 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



e-referral system may be slow or problematic after data center move

Here's what to do to resolve problems if you can't log in to the e-referral system over the next few days:

  • Contact the Web Support Help Desk at 1 877 258 3932.
  • Clear your browser history and cookies and restart your browser.
  • Submit your authorization requests by phone or fax. Refer to the document e-referral system planned downtimes and what to do (PDF) for the phone and fax numbers to use for various types of requests.

Here's some additional information you may find useful:

  • Feb. 8 through 10, we moved the data center out of which the e-referral system is operated. The move went well, but the e-referral system is still stabilizing.
  • You can get to the document e-referral system planned downtimes and what to do (PDF) from any page of this website. Scroll down the left navigation pane and look for the blue tile at the bottom.

We apologize for any inconvenience you may experience with the e-referral system. We are working hard to resolve the problems and we expect the system to be working smoothly soon.

Posted: February 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Interventional pain management services for *64451 and *64625 require authorization starting May 1 for all Blue Cross and BCN members

For dates of service on or after May 1, 2020, interventional pain management services associated with procedure codes *64451 and *64625 require authorization by eviCore healthcare.

This applies to all Blue Cross and Blue Care Network members with plans subject to eviCore healthcare authorization requirements:

  • Blue Cross' PPO
  • Medicare Plus BlueSM PPO
  • BCN HMOSM
  • BCN AdvantageSM

We've updated the document titled Procedures that require clinical review by eviCore healthcare (PDF) to reflect this new requirement.

How to submit authorization requests

Submit authorization requests to eviCore in one of these ways:

  • Preferred: Use evicore's provider portal at www.evicore.com.**
  • Alternative: Call eviCore at 1-855-774-1317.
  • Alternative: Fax to eviCore at 1-800-540-2406.

Additional information

For more information, refer to the document titled eviCore Management Program: Frequently Asked Questions (PDF).

You can find this document and other resources on this website:

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2019 American Medical Association. All rights reserved.

**Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're required to let you know we're not responsible for its content.

Posted: February 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



e-referral system out of service for maintenance three times in February 2020

The e-referral system will be unavailable for use during three planned downtimes in February. Typically, the system is unavailable during its routine monthly maintenance but in February, we're also moving the data center and upgrading the system's software.

Here are the three planned downtimes for the e-referral system in February 2020:

  • Data center move: The system will be unavailable from 3 a.m. Saturday, Feb. 8, to 7 a.m. Monday, Feb. 10.
  • Routine monthly maintenance: The system will be unavailable from 10 p.m. Saturday, Feb. 15, to 9 a.m. Sunday, Feb. 16.*

    *The e-referral system will not be available at all during these times. On Sunday, the system will be available by 9 a.m. and may be available earlier if maintenance tasks are completed. During the remaining time over the weekend, we expect the system to be available, although you may experience minor performance issues.

  • Software upgrade: The system will be unavailable from 2 a.m. Sunday, Feb. 23, to 6 a.m. Monday, Feb. 24.

To see more planned downtimes and to learn how to handle requests while the system is down, review the list of e-referral system planned downtimes and what to do (PDF).

You can get to this list anytime from any page of this website. Scroll down the left navigation pane and look for the blue tile at the bottom.

We're providing this information so you can plan ahead. We apologize for any inconvenience you may experience while the e-referral system is down.

Posted: February 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



We're adding site-of-care requirements for Lemtrada and Tysabri for commercial members, starting May 1

Starting May 1, 2020, the medical drug site-of-care program is expanding for Blue Cross' PPO (commercial) and BCN HMOSM (commercial) members to include:

  • Lemtrada® (alemtuzumab, HCPCS code J0202)
  • Tysabri® (natalizumab, HCPCS code J2323)

Through April 30th, 2020, members who receive these drugs in one of the following locations are authorized to continue treatment:

  • Doctor's office or other health care provider's office
  • Ambulatory infusion center
  • Hospital outpatient facility

Starting May 1, 2020, infusions of Tysabri and Lemtrada won't be covered at hospital outpatient facilities.* Before May 1, members should talk to their doctors to make arrangements to receive infusion services at one of the following locations:

  • Doctor's office or other health care provider's office
  • Ambulatory infusion center

*Based on Risk Evaluation and Mitigation Strategies, or REMS, program restrictions, administration of Lemtrada and Tysabri are limited to authorized locations. We'll post information about in-state and nationally authorized administration sites to this website soon to aid in member transition; we'll provide an update when this information is available.

More about the authorization requirements

The authorization requirements apply only to groups that are currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. These changes don't apply to the Federal Employee Program® Service Benefit Plan members.

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

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Requirements for drugs covered under the medical benefit - BCN HMO and Blue Cross PPO (PDF) document located on this website:

We'll update the requirements list for the drugs listed above prior to May 1, 2020.

Posted: January 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Updated e-referral system questionnaires will be released for BCN and Medicare Plus BlueSM PPO on Feb. 2, 2020

In the January-February issue of BCN Provider News (page 41) and in the January issue of The Record, we listed the questionnaires that we expected to release in the e-referral system by Jan. 26, 2020.

Most of the questionnaires listed in the articles were updated on Dec. 8, 2019. However, we had to postpone the release of the following questionnaires to Feb. 2:

  • Breast reduction - We'll combine the Breast reduction, adult and the Breast reduction, adolescent questionnaires for BCN HMOSM and BCN AdvantageSM members into a single questionnaire for both adult and adolescent BCN HMO and BCN Advantage members.
  • Spinal cord stimulator or epidural or intrathecal catheter (trial or permanent placement) — We'll replace this questionnaire with the following three questionnaires:
    • Spinal cord stimulator - For BCN HMO members
    • Spinal cord stimulator - For Medicare Plus Blue and BCN Advantage members
    • Intrathecal catheter — For Medicare Plus Blue, BCN HMO and BCN Advantage members

We'll also update the following questionnaire on Feb. 2:

  • Sleep studies - Opens only for BCN HMO and BCN Advantage members

Here's some additional information you need to know:

  • We'll update the preview questionnaires, authorization criteria and medical policies on this website for the questionnaire updates soon.
  • We use our authorization criteria and medical policies and your answers to the questionnaires when making utilization management determinations on your authorization requests.
  • For all of these services, you'll soon be able to access preview questionnaires on this website. The preview questionnaires show the questions you'll need to answer in the actual questionnaires that open in the e-referral system. This can help you prepare your answers ahead of time. To find the preview questionnaires:
    • For BCN: Click BCN and then click Authorization Requirements & Criteria. Scroll down and look under the "Authorization criteria and preview questionnaires" heading.
    • For Medicare Plus Blue: Click Blue Cross and then click Authorization Requirements & Criteria. In the "Medicare Plus Blue PPO members" section, look under the "Authorization criteria and preview questionnaires - Medicare Plus Blue PPO" heading.

Posted: January 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Reblozyl® will have authorization and site-of-care requirements for commercial members effective February and April 2020

We're adding authorization and site-of-care requirements for specialty drugs covered under the medical benefit to include Reblozyl (luspatercept-aamt, HCPCS code J3590) for commercial members:

  • For BCN HMOSM (commercial) members: Reblozyl will require authorization and have site-of-care requirements for members who begin therapy on or after Feb. 1, 2020.

  • For Blue Cross' PPO (commercial) members: Reblozyl will require authorization for members who begin therapy on or after April 2, 2020.

More about the authorization requirements

The authorization requirements apply only to groups that are currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. These changes don't apply to members covered by the Federal Employee Program® Service Benefit Plan.

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

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Requirements for drugs covered under the medical benefit - BCN HMO and Blue Cross PPO document located on the following pages of this website:

We'll update the requirements list for the drug listed above prior to the effective dates for the changes.

Posted: January 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



We're removing zoledronic acid drugs from the Medicare Part B medical specialty drug prior authorization list in March

We're removing medications from the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus BlueSM PPO and BCN AdvantageSM members. These specialty medications are administered in outpatient sites of care, a physician's office, an outpatient facility or a member's home.

For dates of service on or after March 2, 2020, the following medications for osteoporosis, bone metastases due to solid tumors and other diagnoses involving bone health will no longer require authorization:

  • J3489 zoledronic acid (Reclast®, Zometa®)

Important reminder

NovoLogix allows you to quickly submit authorization requests. It offers real-time status checks and immediate approvals for certain medications. Also note:

  • For Medicare Plus Blue, if you have a Type 1 (individual) NPI and you checked the "Medical Drug PA" box when you completed the Provider Secured Services Application form, you already have access to NovoLogix. If you didn't check that box, you can complete an Addendum P form to request access to NovoLogix and fax it to the number on the form.
  • For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

If you need to request access to Provider Secured Services, complete the Provider Secured Access Application form and fax it to the number on the form.

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Medical Drug and Step Therapy Prior Authorization List.

Posted: January 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Attend a training session on changes to the Practitioner Performance Summary and utilization management categories for physical therapy providers.

Orientation sessions will be led by eviCore healthcare to help providers understand the changes to the Practitioner Performance Summary and utilization management categories that will be effective on April 1 for physical therapy providers. This is effective for Medicare Plus BlueSM PPO, BCN HMOSM and BCN AdvantageSM providers.

We'll cover:

  • The new model for provider tiering
  • Updated training material related to the PPS scores and reconsideration process

Dates (all Eastern Standard Time)

Online sessions require advance registration

  • Feb. 3, 1 p.m.
  • Feb. 4, 1 p.m.
  • Feb. 5, Noon

How to register

Please read the following instructions to register for and participate in a session:

  1. Once you have selected a provider specific session, please go to http://eviCore.webex.com/*
  2. Click on the menu bar on the far left hand side, then choose "Webex Training"
  3. Under Live Sessions, click the "Upcoming" tab, then enter the desired topic name exactly as below and search: PPS and Utilization Management Categories for BCBSM/BCN
  4. Click "Register" next to the sessions with the date and time you wish to attend
  5. Complete the registration information

Keep the registration email you receive so you'll have the link to the Web conference and call-in number for your session.


Questions?

Contact the Web Support team by email at portal.support@evicore.com or call 1-800-646-0418.

(Option 2)

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're required to let you know we're not responsible for its content.

Posted: January 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Musculoskeletal surgical procedures will require authorization by TurningPoint for Medicare Plus BlueSM PPO and BCN members

TurningPoint Healthcare Solutions will manage authorizations for surgical procedures related to musculoskeletal conditions for Medicare Plus Blue, BCN HMOSM and BCN AdvantageSM members. These are the dates you need to know:

  • June 1, 2020: Services performed on or after this date will require authorization by TurningPoint.
  • May 1, 2020: You'll be able to submit authorization requests to TurningPoint.

TurningPoint specializes in utilization management of musculoskeletal surgeries and related procedures. They focus on improving patient outcomes for patients undergoing procedures such as joint replacements.

To learn more, see the following articles:

We'll provide additional details in future newsletters and other communications.

Posted: January 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Radiation therapy services for A9590 require authorization starting April 1 for all Blue Cross and BCN members

For dates of service on or after April 1, 2020, services associated with HCPCS code A9590 (iodine i-131, iobenguane, 1 millicurie) require authorization by eviCore healthcare.

This applies to all Blue Cross and Blue Care Network members with plans subject to eviCore healthcare authorization requirements:

  • Blue Cross' PPO
  • Medicare Plus BlueSM PPO
  • BCN HMOSM
  • BCN AdvantageSM

We've updated the document titled Procedures that require clinical review by eviCore healthcare to reflect this new requirement.

How to submit authorization requests

Submit authorization requests to eviCore in one of these ways:

  • Preferred: Use evicore's provider portal at www.evicore.com.*
  • Alternative: Call eviCore at 1-855-774-1317.
  • Alternative: Fax to eviCore at 1-800-540-2406.

Additional information

For more information, refer to the document titled eviCore Management Program: Frequently Asked Questions.

You can find this document and other resources on this website:

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

Posted: January 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Avsola and Givlaari will have authorization and site of care requirements for commercial members effective February and March 2020

We're adding authorization and site of care requirements for specialty drugs covered under the medical benefit for the following drugs for Blue Cross' PPO (commercial) and BCN HMOSM (commercial) members:

  • Avsola (infliximab-axxq, HCPCS code J3590)
  • Givlaari (givosiran, HCPCS code J3490)

For BCN HMO members

  • We'll require authorization for Avsola and Givlaari for members who begin therapy on or after Feb. 6, 2020.
  • Avsola and Givlaari will be added to the site of care program for BCN HMO members, effective Feb. 6, 2020.

For Blue Cross' PPO members

We'll require authorization for Avsola and Givlaari for members who begin therapy on or after March 1, 2020.

More about these requirements

These requirements apply only to groups that are currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. These changes don't apply to members covered by the Federal Employee Program® Service Benefit Plan.

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

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Requirements for drugs covered under the medical benefit - BCN HMO and Blue Cross PPO document located on this website:

We'll update the requirements list for these drugs prior to the effective dates for the changes.

Posted: January 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



e-referral system out of service for maintenance Jan. 18-19

Here's the next planned downtime for the e-referral system:

From 10 p.m. on Saturday, January 18 to 10 a.m. on Sunday, January 19

The e-referral system will not be available at all during these times. On Sunday, the system will be available by 10 a.m. and may be available earlier if maintenance tasks are completed. During the remaining time over the weekend, we expect the system to be available, although you may experience minor performance issues.

To see more planned downtimes and to learn how to handle requests while the system is down, review the list of e-referral system planned downtimes and what to do.

You can get to this list anytime from any page of this website. Scroll down the left navigation pane and look for the blue tile at the bottom.

We're providing this information so you can plan ahead. We apologize for any inconvenience you may experience while the e-referral system is down.

Posted: January 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

We're adding two medical drugs to the site-of-care program for Blue Cross and Blue Care Network commercial members starting April 1, 2020

The site of care program for specialty drugs covered under the medical benefit is expanding starting April 1, 2020. This applies to Blue Cross' PPO (commercial) and BCN HMOSM (commercial) members for the following drugs:

  • Hemlibra® (emicizumab-kxwh, HCPCS code J7170)
  • Onpattro® (patisiran, HCPCS code J0222)

What to do by April 1

Before April 1, 2020, providers should encourage commercial members to select one of the following infusion locations instead of an outpatient hospital facility:

  • A doctor's or other health care provider's office
  • An ambulatory infusion center
  • The member's home, from a home infusion therapy provider

If members currently receive infusions for these drugs at a hospital outpatient facility, providers must:

  • Obtain prior authorization for that location
  • Check the directory of participating home infusion therapy providers and infusion centers to see where the member may be able to continue infusion therapy

If the infusion therapy provider can accommodate the member, they'll work with the member and the member's practitioner to make this change easy. The member may also contact the ordering practitioner directly for help with the change.

More about the authorization requirements

The authorization requirements apply only to groups that are currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. These changes don't apply to members covered by the Federal Employee Program® Service Benefit Plan.

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

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Requirements for drugs covered under the medical benefit – BCN HMO and Blue Cross PPO document located on this website:

We'll update the requirements list for these drugs prior to April 1.

Posted: December 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Updated — Medicare Part B medical specialty drug authorization: Clarification regarding Prolia and Xgeva

This message was updated to show that authorization requests for Xgeva should be submitted using the brand name and not the generic name of the drug.

Part B specialty drugs Prolia® and Xgeva® have the same generic name, denosumab, and HCPCS code, J0897. Both drugs require authorization for Medicare Plus BlueSM PPO and BCN AdvantageSM members.

However, the system through which you request authorization varies as follows:

  • If you're administering Prolia, which is used to treat osteoporosis, request authorization through the NovoLogix® online tool.
  • If you're administering Xgeva, which is primarily used to treat bone metastases due to solid tumors, request authorization through the AIM ProviderPortalSM.
  • Note: Be sure to use the brand name when requesting Xgeva through the AIM ProviderPortal so AIM will know you are ordering the correct medication. Using the generic name, denosumab, can cause delays in the prior authorization process.

How to bill

Be sure to enter the following National Drug Code numbers on the claim, along with the HCPCS code J0897, to ensure appropriate and timely reimbursement.

  • Prolia - Enter NDC 55513071001
  • Xgeva - Enter NDC 55513073001

For Medicare Plus Blue and BCN Advantage, we require authorization for these medications for all outpatient sites of care when you bill the medications as a professional service or as an outpatient facility service and you bill as follows:

  • Electronically through an 837P transaction or on a professional CMS-1500 claim form
  • or

  • Electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x

Important reminder

You can quickly submit authorization requests through the NovoLogix online tool and through AIM Specialty Health.

  • NovoLogix: You can access NovoLogix through Provider Secured Services. It offers real-time status checks and immediate approvals for certain medications. Also note:
    • For Medicare Plus Blue, if you have a Type 1 (individual) NPI and you checked the "Medical Drug PA" box when you completed the Provider Secured Services Application form, you already have access to NovoLogix. If you didn't check that box, you can complete an Addendum P form to request access to NovoLogix and fax it to the number on the form.
    • For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.
  • If you need to request access to Provider Secured Services, complete the Provider Secured Services Application form and fax it to the number on the form.

  • AIM Specialty Health: You can submit authorizations through the AIM ProviderPortal or by calling AIM at 1-844-377-1278.

For information about registering for and accessing the AIM ProviderPortal, see the Frequently asked questions page on the AIM Specialty Health website*.

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're required to let you know we're not responsible for its content.

Posted: December 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Additional medical benefit specialty drugs will have authorization and site of care requirements for Blue Cross' PPO and BCN HMOSM members in January and February 2020

The prior authorization and site of care program for specialty drugs covered under the medical benefit is expanding to include the following drugs for Blue Cross' PPO (commercial) and BCN HMO (commercial) members:

  • Adakveo® (crizanlizumab-tmca, HCPCS code J3590)
  • Vyondys 53 (golodirsen, HCPCS code J3490)

For Blue Cross' PPO members:
  • We'll require authorization for Adakveo and Vyondys 53 for members who begin therapy on or after Feb. 1, 2020.

For BCN HMO members:

  • We'll require authorization for Adakveo and Vyondys 53 for members who begin therapy on or after Jan. 2, 2020.
  • Adakveo and Vyondys 53 will be added to the site of care program for BCN HMO members effective Jan. 2, 2020.

More about the authorization requirements

The authorization requirements apply only to groups that are currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit.

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

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Requirements for drugs covered under the medical benefit – BCN HMO and Blue Cross PPO document located on this website:

We'll update the requirements list for each drug shown above prior to the date of the change for that drug.

Posted: December 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

e-referral system out of service for maintenance Dec. 21-22

Here's the next planned downtime for the e-referral system:

From 10 p.m. on Saturday, December 21 to 10 a.m. on Sunday, December 22

The e-referral system will not be available at all during these times. On Sunday, the system will be available by 10 a.m. and may be available earlier if maintenance tasks are completed. During the remaining time over the weekend, we expect the system to be available, although you may experience minor performance issues.

To see more planned downtimes and to learn how to handle requests while the system is down, review the list of e-referral system planned downtimes and what to do.

You can get to this list anytime from any page of this website. Scroll down the left navigation pane and look for the blue tile at the bottom.

We're providing this information so you can plan ahead. We apologize for any inconvenience you may experience while the e-referral system is down.

Posted: December 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Medicare Part B medical specialty drug prior authorization list is changing in March

We're adding medications to the Medicare Plus BlueSM PPO and BCN AdvantageSM Part B medical specialty prior authorization drug list. These specialty medications are administered in outpatient sites of care, such as a physician's office, an outpatient facility or a member's home.

For dates of service on or after March 16, 2020, you'll need to request authorization for the following medications through the system specified below.

Through the NovoLogix® online tool

  • J3590 Adakveo®
  • J3490 Scenesse®
  • J3490 Reblozyl®

Through the AIM Specialty Health® ProviderPortalSM

  • J9309 Polivy
  • J9036 Belrapzo
  • J9118 Asparlas
  • J9313 Lumoxiti
  • J9356 Herceptin Hylecta
  • Q5116 Trazimera
  • Q5117 Kanjiti
  • Q5118 Zirabev

How to bill

For Medicare Plus Blue and BCN Advantage, we require authorization for these medications for all outpatient sites of care when you bill the medications as a professional service or as an outpatient facility service and you bill as follows:

  • Electronically through an 837P transaction or on a professional CMS-1500 claim form
  • or

  • Electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x

Important reminder

Depending on the medication, you can quickly submit authorization requests through NovoLogix or through AIM.

  • NovoLogix: You can access NovoLogix through Provider Secured Services. It offers real-time status checks and immediate approvals for certain medications. Also note:
    • For Medicare Plus Blue, if you have a Type 1 (individual) NPI and you checked the "Medical Drug PA" box when you completed the Provider Secured Services Application form, you already have access to NovoLogix. If you didn't check that box, you can complete an Addendum P form to request access to NovoLogix and fax it to the number on the form.
    • For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.
  • If you need to request access to Provider Secured Services, complete the Provider Secured Services Application form and fax it to the number on the form.

  • AIM: You can submit authorizations through the AIM ProviderPortal or by calling AIM at 1-844-377-1278.

For information about registering for and accessing the AIM ProviderPortal, see the Frequently asked questions page on the AIM Specialty Health website*.

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Medical Drug and Step Therapy Prior Authorization List.

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're required to let you know we're not responsible for its content.

Posted: December 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

We've resolved issues with processing SNF claims for Medicare Advantage members

This is an update to a message originally posted on Nov. 25, 2019.

We updated our systems to resolve the issues we were experiencing with processing some skilled nursing facility claims for Medicare Plus BlueSM PPO and BCN AdvantageSM members.

On Dec. 8, 2019, we resumed regular processing of these SNF claims, and we began processing any SNF claims we'd been holding.

We previously notified you of the following:

  • For Medicare Plus Blue member claims denied with a message stating that you needed to resubmit with a HIPAA valid CPT code, we told you that you didn't need to do anything and that we would reprocess these claims when the issue was fixed.
  • For BCN Advantage member claims denied with a message stating that you need to resubmit with valid codes, we told you to resubmit these claims with the same PDPM levels. We noted that you would have received a letter stating that these claims were denied and would need to be resubmitted with valid codes.

We apologize for any inconvenience.

As a reminder, naviHealth authorizes PDPM levels during the patient's stay (from preservice through discharge) for dates of service on or after Oct. 1, 2019, to align with CMS payment methodology. naviHealth works with SNFs to ensure the biller submits the appropriate PDPM level for reimbursement.

For more information, see the Post-acute care services: Frequently asked questions by providers document.

Posted: December 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

e-referral system unavailable from 8 to 10 a.m. Saturday, Dec. 7

The e-referral system will be unavailable from 8 to 10 a.m. (Eastern time) on Saturday, Dec. 7, 2019, while we do software upgrades.

During the rest of the weekend, we expect the system to be available, although you may experience minor performance issues.

Other planned downtimes and what to do

To see more planned downtimes and to learn how to handle requests while the system is down, review the list of e-referral system planned downtimes and what to do.

You can get to this list anytime from any page of our ereferrals.bcbsm.com website. Scroll down the left navigation pane and look for the blue tile at the bottom.

We apologize for any inconvenience you may experience while the e-referral system is down.

Posted: December 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

How to handle authorization requests for physical, occupational and speech therapy continuing into 2020

For members receiving physical, occupational or speech therapy in 2019 that needs to continue into 2020, here's some information on how to submit these authorization requests to eviCore healthcare®:

  • You may submit an authorization request for additional visits as early as 14 days prior to or as late as seven days after the requested start date.
  • Waiver visits previously granted through Landmark Healthcare (six visits for Category B providers and three for Category C providers) no longer apply.
  • Category B and C providers must submit clinical information with their requests; the requests will be subject to a medical necessity review.

As a reminder, eviCore manages the following therapy services for non-autism diagnoses:

  • Physical and occupational therapy for Medicare Plus BlueSM PPO, BCN HMOSM (commercial) and BCN AdvantageSM members
  • Speech therapy for BCN HMO (commercial) and BCN Advantage members

Additional information is available on the ereferrals.bcbsm.com website:

Posted: December 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Reminder: Michigan board-certified behavior analysts must be licensed starting Jan. 7, 2020, to be reimbursed by BCN and Blue Cross

Starting Jan. 7, 2020, board-certified behavior analysts practicing in Michigan must be licensed by the state of Michigan to be eligible for reimbursement from Blue Cross Blue Shield of Michigan and Blue Care Network. BCBAs who aren't licensed aren't eligible for reimbursement for services provided on or after Jan. 7, 2020.

For information on the licensing process, refer to the Behavior Analysts webpage of the Michigan Department of Licensing and Regulatory Affairs website.

Note that we've introduced a Behavioral Health edition of Blues Brief. To add Blues Brief to your subscriptions, click the Manage Subscriptions link at the bottom of your BCN Provider News or The Record newsletter emails. If you haven't subscribed to our publications, go to bcbsm.com/providers, click Our Provider Newsletters, and then click Subscribe to choose your preferred publications.

Posted: December 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Additional medical benefit specialty drugs will require prior authorization for Blue Cross' PPO and BCN HMOSM members

We're expanding the prior authorization program for specialty drugs covered under the medical benefit to include the following drugs for Blue Cross' PPO (commercial) and BCN HMO (commercial) members:

  • Beovu® (brolucizumab, HCPCS code J3490/J3590)
  • Macugen® (pegaptanib, HCPCS code J2503)
  • Scenesse® (afamelanotide, HCPCS code J3490)

For BCN HMO members:

  • We'll require authorization for Beovu and Scenesse for members who begin therapy on or after Nov. 15, 2019.
  • We'll require authorization for Macugen for members who begin therapy on or after Jan. 1, 2020.

For Blue Cross' PPO members:

  • We'll require authorization for Beovu, Macugen and Scenesse for members who begin therapy on or after Jan. 1, 2020.

More about the authorization requirements

The authorization requirements apply only to groups that are currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. These changes don't apply to members covered by Medicare Plus BlueSM PPO, BCN AdvantageSM or the Federal Employee Program® Service Benefit Plan; however, Medicare Plus Blue and BCN AdvantageSM have required authorization for Macugen since 2017 and will require authorization for Beovu starting on Feb. 3, 2020.

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

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Requirements for drugs covered under the medical benefit - BCN HMO and Blue Cross PPO document located on this website:

We'll update the requirements list for the drugs listed above prior to the date on which each drug will require authorization.

Posted: November 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Register for a webinar about hyaluronic acid products for knee injections

As we communicated previously, starting Jan. 1, 2020, Blue Cross Blue Shield of Michigan and Blue Care Network will consider some hyaluronic acid drugs to be preferred or covered and others to be nonpreferred or noncovered. You can find the full details in the article titled Blue Cross and BCN to cover select hyaluronic acid products, starting Jan. 1 in the November 2019 issue of The Record.

We're holding webinars to provide information about hyaluronic acid products for knee injections for Blue Cross' PPO, Medicare Plus BlueSM PPO, BCN HMOSM and BCN AdvantageSM members.

Click one of the following links to register for the webinar. All times are Eastern time.

Once the host approves your registration, you'll receive a confirmation email with instructions for joining the session.

Note: We first communicated this change on Sept. 30, 2019, via a web-DENIS message and a news item on the ereferrals.bcbsm.com website.

Posted: November 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

e-referral system out of service for maintenance Nov. 16-17

Here's the next planned downtime for the e-referral system:

From 10 p.m. on Saturday, November 16 to 10 a.m. on Sunday, November 17

The e-referral system will not be available at all during these times. On Sunday, the system will be available by 10 a.m. and may be available earlier if maintenance tasks are completed. During the remaining time over the weekend, we expect the system to be available, although you may experience minor performance issues.

To see more planned downtimes and to learn how to handle requests while the system is down, review the list of e-referral system planned downtimes and what to do.

You can get to this list anytime from any page of this website. Scroll down the left navigation pane and look for the blue tile at the bottom.

We're providing this information so you can plan ahead. We apologize for any inconvenience you may experience while the e-referral system is down

Posted: November 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

We're aligning peer-to-peer review request processes for acute non-behavioral health non-elective inpatient admissions

For acute non-behavioral health non-elective inpatient admissions, the process for requesting a peer-to-peer review with a Blue Cross Blue Shield of Michigan or Blue Care Network medical director is now the same for all lines of business. This applies to inpatient admission authorization requests denied for Blue Cross' PPO, Medicare Plus BlueSM PPO, BCN HMOSM and BCN AdvantageSM members.

Here's what you need to know about peer-to-peer review requests for acute non-behavioral health non-elective inpatient admissions:

  • Submit all requests using the Physician peer-to-peer request form (for non-behavioral health cases). Complete the form and fax it to 1-866-373-9468 during normal business hours of 8 a.m. to 5 p.m. Eastern time (except weekends and holidays).
  • Note: We'll outreach to you the next business day. The peer-to-peer review will be scheduled on business days, Monday through Friday between 9 a.m. and 4 p.m. Eastern time (except holidays).

  • Using the form is optional for now but will be mandatory starting Jan. 1, 2020.
  • Note: Currently, for Blue Cross' PPO and Medicare Plus Blue requests, you call 1-866-346-7299 to request a peer-to-peer review. However, on Jan. 1, 2020, that number will be taken out of service.

  • The request process is not changing for BCN HMO and BCN Advantage. Currently, you submit BCN requests using the form. It's the process for Blue Cross' PPO and Medicare Plus Blue requests that's changing.
  • The form is available on this website, on the Blue Cross Authorization & Requirements & Criteria page and the BCN Authorization & Requirements & Criteria page. The form has been updated for use with all lines of business.

Additional information

For information about requesting peer-to-peer reviews on denied authorization requests for various types of services, refer to the description of the process in the document How to request a peer-to-peer review with a Blue Cross or BCN medical director. This document is also available on the Blue Cross and BCN Authorization Requirements & Criteria pages on this website.

The only process that's changing is the one for requesting acute non-behavioral health non-elective inpatient admissions. The processes for requesting peer-to-peer reviews for other types of services are staying the same.

Posted: November 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Tell us what you think about our utilization management services

Your feedback is important to us. Please complete the 2019 Blue Cross Blue Shield of Michigan and Blue Care Network Utilization Management Survey and encourage your office colleagues to do so as well, including physicians, nurses and referral coordinators. Your input will help us evaluate our efforts and determine other improvements we can make to enhance our utilization management processes.

The survey will be available online through Dec. 31, 2019.

Posted: November 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Medicare Part B medical specialty drug prior authorization list is changing in February

We're adding the following medications to the Medicare Plus BlueSM PPO and BCN AdvantageSM Part B specialty prior authorization drug list. These specialty medications are administered in outpatient sites of care, such as a physician's office, an outpatient facility or a member's home.

For dates of service on or after Feb. 3, 2020, the following medications will require authorization:

  • J3490/C9399 Beovu®
  • J3590 Zolgensma®
  • J3590 Skyrizi
  • J3490 Spravato
  • J7170 Hemlibra®
  • J1555 Cuvitru
  • J1599 Panzyga®
  • Q4074 Ventavis®

How to bill

For Medicare Plus Blue and BCN Advantage, we require authorization for these medications for the following sites of care when you bill the medications as a professional service or as an outpatient facility service and you bill electronically through an 837P transaction or on a professional CMS 1500 claim form:

  • Physician office (place of service code 11)
  • Outpatient facility (place of service code 19, 22 or 24)
  • Home (place of service code 12)

We also require authorization when you bill electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x.

Important reminder

You must obtain authorization prior to administering these medications. Use the NovoLogix® online tool to quickly submit your authorization requests. It offers real-time status checks and immediate approvals for certain medications. Also note:

  • For Medicare Plus Blue, if you have a Type 1 (individual) NPI and you checked the "Medical Drug PA" box when you completed the Provider Secured Services Application form, you already have access to NovoLogix. If you didn't check that box, you can complete an Addendum P form to request access to NovoLogix and fax it to the number on the form.
  • For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

If you need to request access to Provider Secured Services, complete the Provider Secured Services Application form and fax it to the number on the form.

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Medical Drug and Step Therapy Prior Authorization List.

The authorization requirements for these drugs will be reflected on the drug list on Jan. 1, 2020.

Posted: October 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

For Blue Cross' PPO (commercial) and BCN HMOSM (commercial) members, ketoprofen 25 mg will require authorization and have new quantity limits

The following changes are coming for Blue Cross' PPO (commercial) and BCN HMO (commercial) members:

  • For new courses of treatment involving ketoprofen 25 mg that begin on or after Dec. 1, 2019, you'll have to obtain authorization. If you don't obtain authorization, the member may be responsible for the full cost of the drug.
  • Effective March 1, 2020, ketoprofen 25 mg will be limited to four capsules per day or 120 capsules per 30 days. Requests for Blue Cross Blue Shield of Michigan and Blue Care Network to cover greater quantities will need to include documentation showing that the greater quantity is medically necessary.

Members who start taking ketoprofen prior to Dec. 1, 2019, can continue their treatment courses. However, as of March 1, 2020, you'll need to obtain authorization for these members to continue therapy.

For treatment courses starting on or after Dec. 1, 2019, you'll need to obtain authorization before members begin taking ketoprofen.

We'll notify affected members of these changes, and we'll encourage them to talk to you if they have concerns.

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

Note: These requirements don't apply to Medicare Plus BlueSM PPO or BCN AdvantageSM members.

Posted: October 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

e-referral system out of service for maintenance Oct. 19-20

Here's the next planned downtime for the e-referral system:

From 10 p.m. on Saturday, October 19 to 10 a.m. on Sunday, October 20

The e-referral system will not be available at all during these times. On Sunday, the system will be available by 10 a.m. and may be available earlier if maintenance tasks are completed. During the remaining time over the weekend, we expect the system to be available, although you may experience minor performance issues.

To see more planned downtimes and to learn how to handle requests while the system is down, review the list of e-referral system planned downtimes and what to do.

You can get to this list anytime from any page of this website. Scroll down the left navigation pane and look for the blue tile at the bottom.

We're providing this information so you can plan ahead. We apologize for any inconvenience you may experience while the e-referral system is down.

Posted: October 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

The oncology management program will include Medicare Advantage plans starting Jan. 1, 2020

On Jan. 1, 2020, a utilization management program for medical oncology drugs will begin for Medicare Plus BlueSM PPO and BCN AdvantageSM members. Providers will need to obtain authorizations from AIM Specialty Health® for some medical oncology and supportive care medications.

This program became effective for BCN HMOSM (commercial) members in August 2019.

For details about the program, see page 10 of the September-October 2019 issue of BCN Provider News.

Frequently asked questions

We've updated the Oncology management program: Frequently asked questions for providers document for the addition of Medicare Plus Blue and BCN Advantage members.

Oct. 24 webinar

Learn about the new medical oncology program and how to use the AIM ProviderPortalSM by attending a webinar on Oct. 24 (intended for non-clinical provider staff).

Make sure to view the article in the November-December issue of BCN Provider News (posting on Oct. 23) for more information and additional webinars.

Posted: October 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Starting Jan. 1, 2020, we'll cover select hyaluronic acid products

Effective Jan. 1, 2020, Blue Cross Blue Shield of Michigan and Blue Care Network will consider the following hyaluronic acid products to be either covered or preferred under the medical benefit:

  • Durolane®
  • Euflexxa®
  • Gelsyn-3
  • Supartz FX

Starting Jan. 1, we'll consider the following to be either noncovered or nonpreferred hyaluronic acid products: Gel-one®, GenVisc 850®, Hyalgan®, Hymovis®, Monovisc®, Orthovisc®, Synvisc®, Synvisc-One®, TriVisc®, Visco-3, Synojoynt and Triluron.

This change will apply to Blue Cross' PPO (commercial), Medicare Plus BlueSM PPO, BCN HMOSM (commercial) and BCN AdvantageSM members. This change won't apply to self-funded General Motors, Fiat Chrysler Automobiles, Ford Motor Company, and UAW Retiree Medical Benefit Trust commercial groups.

Blue Cross' PPO and BCN HMO commercial members

  • Members who began receiving noncovered hyaluronic acid products prior to Jan. 1, 2020, can continue their treatment courses to completion. For future treatment courses that begin on or after Jan. 1, 2020, we encourage providers to talk to their patients about using a covered hyaluronic acid product.
  • For treatment courses that begin on or after Jan. 1, 2020, we'll require members to use a covered hyaluronic acid product; these products don't require authorization.
  • We'll deny claims for noncovered hyaluronic acid drugs.
  • We'll notify affected members of these changes and encourage them to discuss treatment options with you.

Medicare Plus Blue and BCN Advantage members

  • Members who began receiving nonpreferred hyaluronic acid products prior to Jan. 1, 2020, can continue their treatment courses to completion. For future treatment courses that begin on or after Jan. 1, 2020, we encourage providers to talk to their patients about using a preferred hyaluronic acid product.
  • For treatments on or after Jan. 1, 2020, we'll require members to use preferred hyaluronic acid products; these products won't require authorization. If you select a nonpreferred hyaluronic acid product for a member, you will have to obtain authorization.

Additional information

The U.S. Food and Drug Administration has approved 16 hyaluronic acid products. To date, no study has shown that one hyaluronic acid product is superior to others.

Posted: September 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Starting Jan. 1, 2020, Blue Cross' PPO and BCN HMOSM plans will cover hemophilia drugs under members' pharmacy benefits

Starting Jan. 1, 2020, Blue Cross Blue Shield of Michigan and Blue Care Network will change how we cover hemophilia drugs for commercial (PPO and HMO) members. If a member has Blue Cross' PPO or BCN HMO pharmacy coverage, all hemophilia drugs should be billed under his or her pharmacy benefits.

This change doesn't affect all commercial members. For example, if a member has pharmacy coverage through a company other than Blue Cross or BCN, hemophilia drugs will continue to be covered under the medical benefit.

To determine whether this change applies to a specific member:

  • For Blue Cross' PPO members, review the member's benefits in Benefit Explainer.
  • For BCN HMOSM members, review the member's benefits in web-DENIS.

We'll notify affected members of these changes. Members don't have to do anything. Their medication and treatment won't change.

For complete details, see the We'll cover hemophilia drugs under the pharmacy benefit for most commercial members, starting Jan. 1 article in the October 2019 issue of The Record. A similar article will appear in the November-December 2019 issue of BCN Provider News.

Posted: September 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Updated e-referral questionnaires to open Sept. 29 for BCN and Medicare Plus BlueSM PPO

Starting Sept. 29, 2019, updated questionnaires will open in the e-referral system for certain procedures. In addition, updated preview questionnaires and authorization criteria will be available on this website.

We use our authorization criteria and medical policies and your answers to the questionnaires when making utilization management determinations on your authorization requests.

Updates to existing questionnaires

Updated questionnaires will open in the e-referral system starting on Sept. 29 for the following services:

  • Cervical spine fusion with artificial disc replacement - opens for BCN HMOSM and BCN AdvantageSM
  • Dental anesthesia or repair of trauma to natural teeth - opens for BCN HMO and BCN Advantage
  • Noncoronary vascular stents - opens for BCN HMO, BCN Advantage and Medicare Plus Blue

Preview questionnaires

For all of these services, you'll soon be able to access preview questionnaires on this website. The preview questionnaires show the questions you'll need to answer in the actual questionnaires that open in the e-referral system. This can help you prepare your answers ahead of time.

To find the preview questionnaires:

  • For BCN: Click BCN and then click Authorization Requirements & Criteria. Scroll down and look under the "Authorization criteria and preview questionnaires" heading.
  • For Medicare Plus Blue: Click Blue Cross and then click Authorization Requirements & Criteria. In the "Medicare Plus Blue PPO members" section, look under the "Authorization criteria and preview questionnaires - Medicare Plus Blue PPO" heading.

Authorization criteria

We'll also update the pertinent authorization criteria on the Authorization Requirements & Criteria pages.

Posted: September 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Reminder: Starting Oct. 1, 2019, naviHealth will authorize PDPM levels for Medicare Advantage SNF admissions

For Medicare Plus BlueSM PPO and BCN AdvantageSM skilled nursing facility admissions with dates of service on or after Oct. 1, 2019, naviHealth will authorize patient-driven payment model levels during the patient's stay (from preservice through discharge) to align with the Centers for Medicare & Medicaid Services payment methodology. We first communicated this change in late July.

When submitting claims for stays with dates of service starting on or before Sept. 30, 2019, and extending through or beyond Oct. 1, you'll need to include both the resource utilization group levels and the PDPM levels that naviHealth authorized.

Medicare Plus Blue PPO and BCN Advantage follow CMS payment methodology for skilled nursing facilities. As a result, the payment methodology will change from RUG levels to PDPM levels on Oct. 1, 2019.

You can view additional information on The Patient Driven Payment Model (PDPM) - Information and Resources for Provider Partners page of the naviHealth website.*

As a reminder, naviHealth manages authorization requests for Medicare Plus Blue PPO and BCN Advantage members admitted to post-acute care on or after June 1, 2019. For details, see the Post-acute care services: Frequently asked questions by providers document.

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

Posted: September 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

e-referral system out of service for maintenance Sept. 21-22

Here's the next planned downtime for the e-referral system:

From 7 a.m. on Saturday, Sept. 21 to 10 p.m. on Sunday, Sept. 22 (Eastern time)

To see more planned downtimes and to learn how to handle requests while the system is down, review the list of e-referral system planned downtimes and what to do.

You can get to this list anytime from any page of our ereferrals.bcbsm.com website. Scroll down the left navigation pane and look for the blue tile at the bottom.

We're providing this information so you can plan ahead. We apologize for any inconvenience you may experience while the e-referral system is down.

Posted: September 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

How can we improve our online tools?

Blue Cross Blue Shield of Michigan and Blue Care Network want to know how we can make our online tools easier to use and more useful for you, our partner providers. We specifically want to know about your experience using online provider tools and services, including the tools available when you log in to our secure provider website at bcbsm.com.

Can you spare eight minutes to share your thoughts? Your input will help us focus future improvements that are most helpful to you.

Take survey now.

This survey will be available through the end of September. Thank you for sharing your opinions. Your responses will be confidential.

Posted: September 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Providers invited to Medicare Stars events in Michigan

Providers are invited to attend the Stars Premiere event held in movie theatres across the state in September. The event will include information about the Medicare Star Rating System, HEDIS measures, the Health Outcomes Survey and much more.

See the article in the September Record or the September-October BCN Provider News, Page 15 for dates, times and registration information.

Posted: August 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Skilled nursing facilities must follow CMS guidelines for issuing NOMNC forms to Medicare Advantage members

BCN AdvantageSM and Medicare Plus BlueSM PPO members sometimes remain in skilled nursing facilities for days beyond the service end date on the Notice of Medicare Non-Coverage form. Sometimes the extended stay is due to a provider's failure either to deliver a completed NOMNC form in a timely manner or to comply with guidelines from Livanta, LLC, the quality improvement organization. This results in days added to the member's stay that may not be medically necessary.

On behalf of Blue Cross Blue Shield of Michigan, naviHealth will issue an administrative denial for these days if they occur because the SNF provider didn't handle the NOMNC in accordance with the Centers for Medicare and Medicaid Services guidelines. In an administrative denial, the authorization is approved but the reimbursement for the extra days is denied.

Examples of improper handling and delivery of the NOMNC include:

  • Late delivery of the NOMNC. Members must receive the NOMNC 48 hours prior to the planned discharge date.

    Note: naviHealth completes as much of the NOMNC as possible and tells the provider when to issue the NOMNC.
  • Failure to fill out the NOMNC in its entirety. All fields in the NOMNC must be completed, including all date and signature fields. For more information, see the Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123*.
  • Not submitting the requested medical information to the QIO in a timely manner, when the member appealed the service end date with the QIO

Note: To view CMS instructions about appropriate delivery of the NOMNC, see sections 260.2 to 260.4.5 of the CMS Manual System: Pub 100-04 Medicare Claims Processing, Transmittal 2711.*

When SNF providers have repeated difficulties handling the NOMNC according to CMS guidelines, their naviHealth care coordinators will reach out to provide education about CMS guidelines and health plan requirements. If, after receiving education, a SNF provider continues to have difficulties, naviHealth will deliver an administrative denial letter to the provider when members stay beyond the end date stated on the NOMNC.

The administrative denial letter will include details on the specific CMS guideline violations. Blue Cross and Blue Care Network will hold the provider responsible for the additional days the member stayed in the SNF. Per CMS guidelines, providers can't bill members for the additional days.

You can find information about CMS guidelines and Medicare Plus Blue and BCN Advantage requirements in the following locations.

As a reminder, naviHealth manages authorization requests for Medicare Plus Blue and BCN Advantage members admitted to post-acute care on or after June 1, 2019. For details, see the Post-acute care services: Frequently asked questions by providers document.

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

Posted: August 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

naviHealth webinars about SNF PDPM payment methodology

For Medicare Advantage skilled nursing facility admissions with service dates on or after Oct. 1, 2019, naviHealth will authorize Patient-Driven Payment Model levels during the patient's stay (from preservice through discharge) to align with the Centers for Medicare & Medicaid payment methodology. We first communicated this change in late July.

To learn how naviHealth has been preparing for the changes to payment methodology with PDPM, register for and attend one of their live webinars, which are scheduled for September 3, 4 and 5.

During the webinars, naviHealth will cover the following:

  • The naviHealth clinical model under PDPM
  • The enhancements that are planned for the nH Predict|Outcome reports and nH Predict|Pulse
  • The process for PDPM level assignment including:
    • The additional clinical information necessary to process a request
    • How to request a level reconsideration
    • A review of claims processing

You can view additional information on The Patient Driven Payment Model (PDPM) - Information and Resources for Provider Partners page of the naviHealth website.*

As a reminder, naviHealth manages authorization requests for Medicare Plus BlueSM PPO and BCN AdvantageSM members admitted to post-acute care on or after June 1, 2019. For details, see the Post-acute care services: Frequently asked questions by providers document.

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

Posted: August 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Evenity® will be added to the Medicare Part B medical drug prior authorization list in November

We're adding Evenity® (J3111) to the Medicare Plus BlueSM PPO and BCN AdvantageSM Part B medical drug prior authorization list.

For dates of service on or after Nov. 1, 2019, Evenity will require prior authorization.

Medicare Plus Blue PPO

For Medicare Plus Blue, we require authorization for this medication for the following sites of care when you bill the medication electronically through an 837P transaction or on a professional CMS-1500 claim form:

  • Physician office (place of service code 11)
  • Outpatient facility (place of service code 19, 22 or 24)

BCN Advantage

For BCN Advantage, we require authorization for this medication for the following sites of care when you bill the medication as a professional service or as an outpatient facility service, and when you bill electronically through an 837P transaction or on a professional CMS-1500 claim form:

  • Physician office (place of service code 11)
  • Outpatient facility (place of service code 19, 22 or 24)
  • Home (place of service code 12)

We also require authorization when you bill electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x.

Important reminder

You must obtain an authorization before administering this medication. Use the NovoLogix® online tool to quickly submit your authorization requests. It offers real-time status checks and immediate approvals for certain medications.

If you have access to Provider Secured Services but you need access to NovoLogix, do one of the following:

If you need to request access to Provider Secured Services, complete the Provider Secured Services Application form and fax it to the number on the form.

Posted: August 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Update: Board-certified behavior analysts must have current Michigan license by Jan. 7, 2020, to be reimbursed by Blue Cross and BCN

Starting Jan. 7, 2020, board-certified behavior analysts practicing in Michigan must have a current license from the State of Michigan to be eligible for reimbursement from Blue Cross and Blue Care Network. BCBAs who are not licensed are not eligible to be reimbursed for services provided on or after Jan. 7, 2020.

For information on the licensing process, refer to the Behavior Analysts webpage of the Michigan Department of Licensing and Regulatory Affairs website.

Note: An earlier version of this message indicated that a license is required by Jan. 1, 2020. The actual date on which a license is required is Jan. 7, 2020.

Posted: August 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

New and updated e-referral questionnaires to open August 25 for BCN and Medicare Plus BlueSM PPO

Starting Aug. 25, 2019, new and updated questionnaires will open in the e-referral system for certain procedures. In addition, new and updated preview questionnaires, authorization criteria and medical policies will be available on this website.

New questionnaires

Starting August 25, questionnaires will open in the e-referral system for BCN HMOSM and BCN AdvantageSM authorization requests for the procedures listed below, which already require authorization.

Service Age Procedure codes
Bariatric surgery - BCN HMO Adult and adolescents *43644, *43645, *43770, *43771, *43772, *43773, *43774, *43775, *43842, *43843, *43845, *43846, *43847, *43848, *43886, *43887, *43888 and *44130
Bone-anchored hearing aid Adult and pediatric (5 years old and older) *69714, *69715, *69717 and *69718
Cardiac rehabilitation - BCN HMO Adult and pediatric *93797 and *93798 (for select diagnoses)
Cardiac rehabilitation - BCN Advantage
Pregnancy termination - BCN HMO Adult *01966, *59100, *59840, *59841, *59850, *59851, *59852, *59855, *59856, *59857, *59866, *88304, *88305, S0190, S0191, S0199, S2260, S2265, S2266 and S2267
Pregnancy termination - BCN Advantage
Pulmonary rehabilitation Adult and pediatric G0237, G0238, G0239, G0302, G0303, G0304, G0424 and S9473
Radiofrequency ablation, peripheral nerves Adult *64640
Visual training, orthotic and pleoptic Adult and pediatric *92065

Updates to existing questionnaires

In addition, updated questionnaires will open in the e-referral system on August 25 for BCN HMO, BCN Advantage and Medicare Plus Blue authorization requests (unless otherwise noted), for the following services:

  • Cervical spine surgery - opens only for BCN HMO and BCN Advantage
  • Cholecystectomy (laparoscopic) - opens only for BCN HMO and BCN Advantage
  • Endovascular intervention, peripheral artery - The updated questionnaire for this service was originally scheduled to open starting on July 28 for Medicare Plus Blue requests but will actually open starting August 25.
  • Ethmoidectomy
  • Hammertoe correction surgery
  • Hip arthroplasty, total, revision
  • Knee arthroplasty, total, revision
  • Sacral nerve neuromodulation/stimulation
  • Sinusotomy, frontal, endoscopic
  • Sleep studies, outpatient facility or clinic-based setting - opens only for BCN HMO and BCN Advantage
  • Vascular embolization or occlusion of hepatic tumors (TACE/RFA)

Preview questionnaires

We'll make preview questionnaires available on this website soon. To find them:

  • For BCN: Click BCN and then click Authorization Requirements & Criteria. Scroll down and look under the "Authorization criteria and preview questionnaires" heading.
  • For Medicare Plus Blue: Click Blue Cross and then click Authorization Requirements & Criteria. In the "Medicare Plus Blue PPO members" section, look under the "Authorization criteria and preview questionnaires - Medicare Plus Blue PPO" heading.

The preview questionnaires show the questions you'll need to answer in the actual questionnaires that open in the e-referral system. This will help you prepare your answers ahead of time.

Authorization criteria and medical policies

We'll also post links to the pertinent authorization criteria and medical policies on the Authorization Requirements & Criteria pages.

We use our authorization criteria and medical policies and your answers to the questionnaires when making utilization management determinations on your authorization requests.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.

Posted: August 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

How can we improve our online tools?

Blue Cross Blue Shield of Michigan and Blue Care Network want to know how we can make our online tools easier to use and more useful for you, our partner providers. We specifically want to know about your experience using online provider tools and services, including the tools available when you log in to our secure provider website at bcbsm.com.

Can you spare eight minutes to share your thoughts? Your input will help us focus future improvements that are most helpful to you.

Take survey now.

This survey will be available through the end of September. Thank you for sharing your opinions. Your responses will be confidential.

Posted: August 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Medical record documentation requirements for ABA services are updated

We updated the medical record documentation requirements for applied behavior analysis services to clarify documentation requirements for services involving tutors and technicians.

These guidelines apply to services for Blue Cross' PPO (commercial) and BCN HMOSM (commercial) members.

You can view the guidelines on this website by clicking BCN or Blue Cross and then clicking Behavioral Health. Finally, click the Documentation requirements for applied behavior analysis services link.

You can also view the guidelines within Provider Secured Services. Here's how:

  1. Visit bcbsm.com/providers.
  2. Click Login and log in to Provider Secured Services.
  3. Click web-DENIS.

To access the guidelines through BCBSM Provider Publications and Resources:

  1. Click BCBSM Provider Publications and Resources.
  2. Click Newsletters & Resources.
  3. Click Clinical Criteria & Resources.
  4. Click Autism under the Resources heading.
  5. Click Documentation requirements for applied behavior analysis services.

To access the guidelines through BCN Provider Publications and Resources:

  1. Click BCN Provider Publications and Resources.
  2. Click Autism.
  3. Click Documentation requirements for applied behavior analysis services.

Posted: August 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Don't add clinical documentation to denied requests in the e-referral system

When we deny an authorization request in the e-referral system, we contact your office to inform you of that determination and then we close the case, which means that the case no longer appears in our queues.

We don't receive notification of changes to authorization requests that have been closed.

For this reason, we ask that you don't submit additional clinical documentation or make any other changes on denied requests. Instead, submit the clinical documentation during the appeals process. This will help to ensure that we see and review the additional documentation.

The denial letter includes instructions for submitting an appeal.

Posted: August 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Requirements for assessments of Medicare Advantage members in skilled nursing facilities

Here's some important information about the assessments required for Blue Cross and Blue Care Network Medicare Advantage members admitted to skilled nursing facilities:

  • You must complete an Omnibus Reconciliation Act, or OBRA, assessment for each member.
  • You may opt to complete an additional Prospective Payment System assessment, but you are not required to complete one.

If you complete a PPS assessment:

  • No Resource Utilization Group level is required, because naviHealth will determine the RUG level.
  • A RUG level included in a PPS assessment may not match the level naviHealth assigns. If the levels don't match and you enter the RUG level from a PPS assessment rather than the naviHealth-assigned RUG level, this may cause a claim payment error.
  • You must bill using the RUG level naviHealth assigns, which you'll find in the authorization on nH Access at access.navihealth.com.

If you choose not to complete a PPS assessment, there will be no penalties, even if you're following CMS protocols.

This applies to BCN AdvantageSM and Medicare Plus BlueSM PPO members admitted for skilled nursing care on or after June 1, 2019.

For more information, see the following documents on the Blue Cross Blue Shield of Michigan and Blue Care Network resources page of the naviHealth website*:

If you have questions, contact your naviHealth network manager.

We'll incorporate this information into the Post-acute care services: Frequently asked questions by providers document.

Additional information:

  • Starting Oct. 1, 2019, naviHealth will authorize Patient-Driven Payment Model levels during the patient's stay, which aligns with CMS payment methodology. Before this change takes place, we'll let you know how it will affect the assessments you must complete.
  • As a reminder, naviHealth manages authorization requests for Medicare Plus Blue and BCN Advantage members admitted to post-acute care on or after June 1, 2019.
  • As part of their partnership with Blue Cross Blue Shield of Michigan, naviHealth assigns and authorizes RUG levels for Medicare Advantage members' stays in skilled nursing facilities.

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

Posted: August 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

You may experience e-referral system performance issues August 3 and August 4

You may experience performance issues with the e-referral system from midnight to 6 a.m. on these dates:

  • Saturday, August 3
  • Sunday, August 4

This is because we'll be loading a large membership file into the system during these times.

Any problems you experience using the e-referral system during these times should be resolved by the start of business on Monday, August 5.

We're placing a notice about this on the Provider Secured Services landing page, near the e-referral system link.

Posted: August 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

We're making changes to the Medicare Advantage SNF post-payment audit and recovery process

Blue Cross Blue Shield of Michigan and Blue Care Network are making changes to the post-payment audit and recovery process for skilled nursing facilities. The changes apply to Medicare Plus BlueSM PPO and BCN AdvantageSM members.

Here's what you need to know:

  • HMS® no longer performs post-payment SNF audits. Instead, Blue Cross and BCN review paid SNF claims on a quarterly basis. We'll ensure that Resource Utilization Group or Patient-Driven Payment Model levels in the claims match the RUG or PDPM levels on the authorizations.
  • You won't need to submit medical records during the quarterly post-payment review process.
  • Prior to discharge, a naviHealth care coordinator will work with your biller to verify that the authorized RUG or PDPM levels are submitted for reimbursement. When you submit SNF Medicare Advantage claims, make sure the RUG or PDPM levels on each claim match the levels on the authorization connected to the stay.

For complete details, see the We're making changes to the Medicare Advantage SNF post-payment audit, recovery process article in the August 2019 issue of The Record. A similar article will appear in the September-October 2019 issue of BCN Provider News.

Posted: July 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Medicare Part B medical specialty drug prior authorization list is changing in October

We're adding the following medications to the Medicare Plus BlueSM PPO and BCN AdvantageSM Part B specialty prior authorization drug list.

For dates of service on or after Oct. 1, 2019, the following medications will require prior authorization:

  • J1599 Asceniv
  • J1301 Radicava®
  • J0584 Crysvita®
  • J0565 Zinplava

Medicare Plus Blue PPO

For Medicare Plus Blue, we require prior authorization for these medications for the following sites of care when you bill the medications electronically through an 837P transaction or on a professional CMS-1500 claim form:

  • Physician office (place of service code 11)
  • Outpatient facility (place of service code 19, 22 or 24)

BCN Advantage

For BCN Advantage, we require prior authorization for these medications for the following sites of care when you bill the medications as a professional service or as an outpatient-facility service and you bill electronically through an 837P transaction or on a professional CMS-1500 claim form:

  • Physician office (place of service code 11)
  • Outpatient facility (place of service code 19, 22 or 24)
  • Home (place of service code 12)

We also require prior authorization when you bill electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x.

Important reminder

You must obtain authorization prior to administering these medications. Use the NovoLogix® online tool to quickly submit your authorization requests. It offers real-time status checks and immediate approvals for certain medications. Also note:

  • For Medicare Plus Blue, you can fax an Addendum P form to gain access to the NovoLogix online tool.
  • For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

Posted: July 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Correct fax number for submitting post-acute care discharge information to naviHealth

It recently came to our attention that some of our documents contained an incorrect fax number for sending post-acute care discharge information to naviHealth. We've updated the documents to include the correct fax number, which is 1-844-729-2951. The incorrect fax number contained the last four digits: 2591.

Providers who sent discharge information to the incorrect fax number before July 13, 2019, should be aware that naviHealth didn't receive it. The fax attempt failed and no one received the information.

If you faxed discharge information and you didn't receive a fax confirmation, or you aren't sure that naviHealth received the fax, resend the information. If naviHealth doesn't receive discharge information within the expected time frame, a naviHealth care coordinator will follow up with the facility.

We apologize for any confusion.

As a reminder, naviHealth manages authorization requests for Medicare Plus BlueSM PPO and BCN AdvantageSM members admitted to post-acute care on or after June 1, 2019.

Posted: July 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Reminder: Medicare Part B medical specialty drug prior authorization list changing July 22, 2019

As a reminder, we're making changes to the Medicare Plus BlueSM PPO and BCN AdvantageSM Part B specialty prior authorization drug list, as follows:

  • For dates of service on or after July 22, 2019, Darzalex® (J9145) will require prior authorization.

Here's some additional information you need to know about the change for Darzalex.

Medicare Plus Blue PPO

For Medicare Plus Blue, we require prior authorization for Darzalex when you bill electronically through an 837P transaction or on a professional CMS-1500 claim form, for the following sites of care:

  • Physician office (place of service code 11)
  • Outpatient facility (place of service code 19, 22 or 24)

BCN Advantage

For BCN Advantage, we require prior authorization for Darzalex when you bill it as a professional service or an outpatient facility service electronically through an 837P transaction or on a professional CMS-1500 claim form for:

  • Physician office (place of service code 11)
  • Outpatient facility (place of service code 19, 22 or 24)
  • Home (place of service code 12)

We also require prior authorization when you bill electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x.

Important reminder

You must get authorization prior to administering these medications. Use the Novologix® online web tool to quickly submit your requests. It offers real-time status checks and immediate approvals for certain medications. Also note:

  • For Medicare Plus Blue, you can fax an Addendum P form to gain access to the Novologix online web tool.
  • For BCN Advantage, if you have access to Provider Secured Services, you already have access to submit authorization requests through Novologix.

Posted: July 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Providers and office staff: register now for our upcoming training webinars

We're offering several upcoming training opportunities for providers and staff with the following webinars:

Blues 101 – Understanding the Basics

  • Tuesday, July 16, 1 to 2 p.m. Register

Blues 201 – Enrollment

  • Tuesday, July 23, 2 to 4 p.m. Register
  • Thursday, July 25, 10 a.m. to noon Register

Pharmacy Site of Care

  • Wednesday, July 17, 10 to 11 a.m. Register
  • Thursday, July 25, 1:30 to 2:30 p.m. Register

These events can be also be found on Page 2 of the July-August 2019 BCN Provider News.

We're also offering a webinar on Thursday, Aug. 22, noon to 1 p.m., to learn more about the new medical oncology program managed by AIM Specialty Health®. Register here and read more about it on Page 26 of the May-June 2019 BCN Provider News.

Posted: July 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Comprehensive lists of requirements available for medical specialty drugs and pharmacy benefit drugs

We've developed comprehensive lists of requirements for medical specialty drugs and pharmacy benefit drugs for Blue Cross Blue Shield of Michigan PPO and Blue Care Network HMO commercial members. These lists, which are typically updated monthly, include the most current information on utilization management requirements.

  • Medical benefit drugs: The medical specialty drug list identifies medical drugs targeted in the prior authorization and site-of-care programs, and includes the following information about them:
    • Medical necessity criteria
    • Quantity limits
    • Step therapy requirements
  • Pharmacy benefit drugs: The pharmacy benefit drug list identifies pharmacy drugs targeted in the prior authorization program and includes step therapy requirements.

For more information, see the following articles:

Posted: July 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



NovoLogix® user interface enhancements coming soon

If you use NovoLogix® to submit electronic prior authorizations for certain Part B medical specialty drugs, you'll soon see an enhanced user interface when you log in to the online web tool. The enhancements will streamline the process of creating authorization requests.

The interface changes are minimal and easy to navigate, and you'll be able to switch between the current and enhanced interfaces while you adjust to the changes. We'll provide more information, such as user guides and training videos, as we get closer to the release date.

As a reminder, you can always find information about authorization requirements for these drugs on this website:

Posted: June 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



More updated e-referral questionnaires open on June 23

Starting June 23, 2019, updated questionnaires will open in the e-referral system for authorization requests for the procedures listed below, which already require authorization.

Procedure New codes Line of business
Breast biopsy, excisional No new codes; existing codes are in preview questionnaire
  • BCN HMOSM
  • BCN AdvantageSM
Endovascular intervention, peripheral artery New codes: *34101, *34111, *34151, *34201, *34203, *37184 and *37222
Existing codes are in preview questionnaire
  • BCN HMO
  • BCN Advantage
  • Medicare Plus BlueSM PPO
Otoplasty No new codes; existing codes are in preview questionnaire
  • BCN HMO
  • BCN Advantage
Rhinoplasty No new codes; existing codes are in preview questionnaire
  • BCN HMO
  • BCN Advantage

For some of these procedures, we are also updating the authorization criteria.

We use the criteria and questionnaires when making utilization management determinations on authorization requests submitted for the affected members.

The updated authorization criteria and preview questionnaires are available at ereferrals.bcbsm.com. Here's where to find them:

You can look over the preview questionnaires to see what questions you'll need to answer in the actual questionnaires that open in the e-referral system for these services. Once you know what questions you'll need to answer, you can prepare your answers in advance to cut down on the time it takes to submit the authorization request.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.

Posted: June 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Reminder: naviHealth manages authorization requests only for Medicare Advantage post-acute care

As a reminder, naviHealth manages initial, continued stay and retrospective authorization requests only for Medicare Advantage post-acute care for Medicare Plus BlueSM PPO and BCN AdvantageSM members admitted on or after June 1, 2019. Post-acute care includes skilled nursing facility, inpatient rehabilitation facility and long-term acute hospital care.

To facilitate the timely review of your authorization requests, please do not submit the following requests to naviHealth:

  • Non-post-acute care authorization requests for any member
  • Post-acute care authorization requests for commercial members

Requesting authorization for non-post-acute care services

If you need to request authorization for services unrelated to post-acute care, refer to the Summary of utilization management programs for Michigan providers to determine where to submit the request. Do not submit these requests to naviHealth.

Requesting authorization for Medicare Advantage post-acute care

To submit Medicare Advantage post-acute care authorization requests to naviHealth, refer to the Post-acute care services: Frequently asked questions for providers for information.

Posted: June 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Additional medical benefit specialty drugs require prior authorization for Blue Cross' PPO and BCN HMOSM members

This message, originally published on May 31, 2019, is republished on June 3, 2019, to include information about Zolgensma®.

The prior authorization program for specialty drugs covered under the medical benefit is expanding for BCN and Blue Cross commercial members:

  • Asceniv (immune globulin, HCPCS code J1599)
  • Evenity (rosmosozumab-aqqb, HCPCS code J3590)
  • Zolgensma (onasemnogene abeparvovec-xioi, HCPCS codes J3490/J3590)

For BCN HMO members:

  • Authorization for Asceniv, Evenity and Zolgensma is required for dates of service on or after June 1, 2019.
  • Asceniv and Evenity will be added to the Site of Care Program for BCN HMO members effective June 1, 2019.

For Blue Cross' PPO members:

  • Authorization for Asceniv is required for dates of service on or after June 1, 2019. Asceniv will also be added to the Site of Care Program for Blue Cross' PPO members, effective June 1, 2019.
  • Authorization for Evenity and Zolgensma is required for dates of service on or after Aug. 1, 2019.

More about the authorization requirements

The authorization requirements apply only to groups that are currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. These changes don't apply to BCN AdvantageSM, Medicare Plus BlueSM PPO or Federal Employee Program® members.

A prior authorization approval isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Requirements for drugs covered under the medical benefit - BCN HMO and Blue Cross PPO document located on this website:

The new prior authorization requirements that took effect on June 1 are included in the requirements list. The requirements that take effect on Aug. 1 will be reflected in the requirements list before that date. Blue Cross Blue Shield of Michigan and Blue Care Network reserve the right to review for medical necessity prior to the effective dates listed in this message.

Posted: June 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Reminder: Medicare Advantage post-acute care authorization changes begin June 1

Starting June 1, 2019, naviHealth will manage authorizations for admissions for Medicare Plus BlueSM PPO and BCN AdvantageSM members who need skilled nursing, inpatient rehabilitation or long-term acute care. The last webinars for skilled nursing facilities, acute care facilities, inpatient rehabilitation and long-term acute care facilities are on June 5 and 6. For more information, see the June issue of The Record and the May-June issue of BCN Provider News on page 6. You can also review our frequently asked questions document.

Posted: May 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



How to use Allscripts or CarePort Care Management for Medicare Advantage post-acute care requests

Skilled nursing facilities, inpatient acute rehabilitation centers and long-term acute care hospitals can continue to submit authorization requests for post-acute care services using Allscripts®, now known as CarePort Care Management. Instructions are available in naviHealth's document, Submitting Pre-service Authorization Requests using CarePort Care Management (PDF)*.

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

Posted: May 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



We're using updated utilization management criteria for behavioral health starting Aug. 1, 2019

On Aug. 1, 2019, Medicare Plus BlueSM PPO, Blue Cross Blue Shield of Michigan's Medicare Advantage plan, and Blue Care Network's commercial and Medicare Advantage plans (BCN HMOSM and BCN AdvantageSM) will begin using the 2019 InterQual® criteria for behavioral health utilization management determinations.

In addition, certain types of determinations will be based on modifications to InterQual criteria or on local rules or medical policies, as shown in the table below:

Line of business Modified 2019 InterQual criteria for: Local rules or medical policies for:
BCN HMO (commercial) and BCN Advantage
  • Substance use disorders: partial hospital program and intensive outpatient program
  • Residential mental health treatment (adult, geriatric, child and adolescent members)
  • Applied behavior analysis for autism spectrum disorder: (for BCN HMO only)
  • Neurofeedback for attention deficit disorder and attention deficit hyperactivity disorder
  • Transcranial magnetic stimulation
  • Telemedicine (telepsychiatry and teletherapy)
Medicare Plus Blue PPO
  • Substance use disorders: partial hospital program and intensive outpatient program
None

Note: Determinations on Blue Cross PPO (commercial) behavioral health authorization requests are handled by New Directions, a Blue Cross vendor.

Links to the updated versions of the modified criteria, local rules and medical policies are available on the Blue Cross Behavioral Health page and the BCN Behavioral Health page on this website.

Posted: May 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Starting June 1, BCN and Blue Cross are accepting applied behavior analysis claims with 2019 procedure codes

For dates of service on or after June 1, 2019, BCN and Blue Cross are accepting claims for behavior analysis services billed with the following codes:

  • *97151
  • *97152
  • *97153
  • *97154
  • *97155
  • *97156
  • *97157
  • *97158
  • *0362T
  • *0373T

Claims billed with the following codes will still be honored:

  • H0031
  • H0032
  • H2019
  • H2014
  • S5108
  • S5111

This applies to BCN HMOSM and Blue Cross’ PPO members. All services continue to require authorization.

Billing guidelines

We're updating the ABA billing guidelines to reflect the 2019 codes. Look for the updated guidelines sometime in June on the Autism pages within Provider

Secured Services, which you can access by visiting bcbsm.com/providers and logging into Provider Secured Services. Then:

  • To access the BCN Autism page:
    1. Click BCN Provider Publications and Resources (on the right).
    2. Click Autism(in the left navigation).
    3. Click Applied Behavior Analysis Billing Guidelines and Procedure Codes under the "Autism provider resource materials" heading.
  • To access the Blue Cross Autism page:
    1. Click BCBSM Provider Publications and Resources (on the right).
    2. Click Clinical Criteria & Resources(in the left navigation).
    3. Scroll down and click Autism (in the Resources section).
    4. Click Applied Behavior Analysis Billing Guidelines and Procedure Codes under the "Autism provider resource materials" heading.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.

Posted: May 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Updated authorization criteria and e-referral questionnaire for ethmoidectomy

We're making updates to the ethmoidectomy authorization criteria and questionnaire in the e-referral system.

You'll see the updated questionnaire in the e-referral system starting May 26, 2019.

We use the criteria and questionnaire when making utilization management determinations for the following members:

  • BCN HMOSM
  • BCN AdvantageSM
  • Medicare Plus BlueSM PPO

The updated authorization criteria and preview questionnaire are available on this website. Here's where to find them:

You can look over the preview questionnaire to see what questions you'll need to answer in the actual questionnaire that opens in the e-referral system for this service. Once you know what questions you'll need to answer, you can prepare your answers ahead of time. This can cut down on the time it takes to submit the authorization request.

Posted: May 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Medicare Part B medical specialty drug prior authorization list changing July 22, 2019

We're making changes to the Medicare Plus BlueSM PPO and BCN AdvantageSM Part B specialty prior authorization drug list, as follows:

  • For dates of service on or after July 22, 2019, Darzalex® (J9145) will require prior authorization.
  • Effective immediately, Myozyme® (J0220) is removed from the prior authorization list because it is no longer available in the U.S. market.

Here's some additional information you need to know about the change for Darzalex.

Medicare Plus Blue PPO

For Medicare Plus Blue, we require prior authorization for Darzalex when you bill electronically through an 837P transaction or on a professional CMS-1500 claim form, for the following sites of care:

  • Physician office (place of service code 11)
  • Outpatient facility (place of service code 19, 22 or 24)

BCN Advantage

For BCN Advantage, we require prior authorization for Darzalex when you bill it as a professional service or an outpatient facility service electronically through an 837P transaction or on a professional CMS-1500 claim form for:

  • Physician office (place of service code 11)
  • Outpatient facility (place of service code 19, 22 or 24)
  • Home (place of service code 12)

We also require prior authorization when you bill electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x.

Important reminder

You must get authorization prior to administering these medications. Use the Novologix® online web tool to quickly submit your requests. It offers real-time status checks and immediate approvals for certain medications. Also note:

  • For Medicare Plus Blue, you can fax an Addendum P form to gain access to the Novologix online web tool.
  • For BCN Advantage, if you have access to Provider Secured Services, you already have access to submit authorization requests through Novologix.

Posted: May 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Learn about Medicare Advantage post-acute care authorization changes

Starting June 1, 2019, naviHealth will manage authorizations for admissions for Medicare Plus BlueSM PPO and BCN AdvantageSM members who need skilled nursing, inpatient rehabilitation or long-term acute care. Learn more by attending a training session.

More information is available in the May issue of The Record and in the May-June issue of BCN Provider News on page 6.

Posted: May 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Effective June 1, Spravato will be added the prior authorization program for Blue Cross and BCN commercial members.

Effective June 1, 2019, Spravato (esketamine, HCPCS code J3490) will be added to the Medical Drug Prior Authorization Program for Blue Cross Blue Shield of Michigan PPO and BCN HMOSM (commercial) members. This applies to any members covered by commercial plans who are starting therapy on or after June 1.

The authorization requirement only applies to groups that are currently participating in the commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. These changes don't apply to BCN AdvantageSM, Medicare Plus BlueSM PPO or Federal Employee Program® members.

As a reminder, approval of an authorization request isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members. Members are responsible for the full cost of medications not covered under their medical benefit coverage.

The new requirements for Spravato will appear in the list of requirements for drugs covered under the medical benefit - BCN HMO and Blue Cross PPO before the June 1 start date.

For additional information about drugs covered under the medical benefit, visit the ereferrals.bcbsm.com website:

Posted: May 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Effective July 1, transgender benefits expand for University of Michigan members

Starting July 1, 2019, Blue Cross Blue Shield of Michigan and Blue Care Network will begin covering additional transgender services for University of Michigan employees with Blue Cross PPO (commercial) or BCN HMOSM (commercial) coverage through U-M Premier Care. The additional services, known as facial feminization procedures, include:

  • Facial hair removal
  • Facial feminization surgery
  • Chondrolaryngoplasty (Adam's apple reduction)

An expanded list of included/excluded procedures can be found here. Currently, Michigan Medicine is the only provider in our network that performs most of these services. Prior authorization is required, and members must meet specific criteria to establish medical necessity for services to be covered. These services must be performed by in-network providers.

Posted: April 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Medicare Part B medical specialty drug prior authorization lists changing in June 2019

We're making changes to the Medicare Plus BlueSM PPO and BCN AdvantageSM Part B specialty prior authorization drug list. The following medications are being added to the list.

Medicare Plus Blue PPO

For dates of service on or after June 3, 2019, the following medications will require prior authorization:

  • J3590 Ultomiris
  • J9999 (C9044) Libtayo®
  • J3245 Ilumya
  • Q510X Ixifi
  • J3590/J9999 Elzonris
  • J3397 Mepsevii
  • J3490 Tegsedi
  • J9173 Imfinzi®
  • J3304 Zilretta®

For Medicare Plus Blue, we require prior authorization for these medications when you bill them electronically through an 837P transaction or on a professional CMS-1500 claim form, for the following sites of care:

  • Physician office (place of service code 11)
  • Outpatient facility (place of service code 19, 22 or 24)

BCN Advantage

For dates of service on or after June 3, 2019, the following medications will require prior authorization:

  • J3590 Ultomiris
  • J9999 (C9044) Libtayo®
  • J3245 Ilumya
  • Q510X Ixifi
  • J3590/J9999 Elzonris
  • J3397 Mepsevii
  • J3490 Tegsedi
  • J9173 Imfinzi®
  • J3304 Zilretta®

For BCN Advantage, we require prior authorization for these medications when you bill them as a professional service or an outpatient facility service electronically through an 837P transaction or on a professional CMS-1500 claim form for:

  • Physician office (place of service code 11)
  • Outpatient facility (place of service code 19, 22 or 24)
  • Home (place of service code 12)

We also require prior authorization when you bill electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x.

Important reminder

You must get authorization prior to administering these medications. Use the Novologix® online web tool to quickly submit your requests. It offers real-time status checks and immediate approvals for certain medications. Also note:

  • For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through Novologix.
  • For Medicare Plus Blue, you can fax an Addendum P form to gain access to the Novologix online web tool.

Posted: March 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

What to do when error messages display in e-referral

If you're a provider trying to edit one of your cases in the e-referral system, you may see an error message that says:

"The case is unavailable because it's being reviewed. Please try again later."

Recently, e-referral began displaying these messages when a provider tries to edit a case that's locked because our Utilization Management team is working on it.

This error message can appear for any Blue Cross Blue Shield of Michigan or Blue Care Network case in the e-referral system, including commercial and Medicare Advantage cases. If you encounter one of these messages, we ask that you edit the case later to give our team time to review and exit the case.

If you encounter another type of other error message, contact the Web Support Help Desk at 1-877-258-3932.

Posted: March 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Home page change coming to e-referral, starting Feb. 25

Starting Feb. 25, 2019, e-referral's home-page dashboard will only display new or updated cases from the previous 60 days. This change applies to all Blue Cross Blue Shield of Michigan and Blue Care Network cases in the e-referral system, including commercial and Medicare Advantage.

Important to know:

  • Your cases will display faster on the home page. This will be especially helpful if you typically have a lot of cases.
  • We don't delete cases that are past the 60-day-display time frame. You can access all of your cases by searching for them with the reference number or the member's contract number.

Blue Cross and BCN will continue to make enhancements to the e-referral system to make it easier to use. Watch for future web-DENIS messages and news items on the ereferrals.bcbsm.com website announcing upcoming updates.

Posted: February 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

New vendor managing Medicare Advantage patient transfers to post-acute care facilities, starting June 1

Starting June 1, 2019, our new vendor, naviHealth, will manage authorizations for Medicare Plus BlueSM PPO and BCN AdvantageSM members who require a transfer from an acute inpatient facility to a skilled nursing, long-term acute care or inpatient rehabilitation facility. naviHealth will be reviewing both in- and out-of-state post-acute care cases.

Look for upcoming articles in The Record and BCN Provider News on training opportunities and how to submit naviHealth requests.

Posted: February 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Sign up to receive Blues Brief electronically

Blues Brief has a new look and is now available via email subscription. Blues Brief is a quick summary of headlines that reference more in-depth articles found in the BCN Provider News or The Record.

To sign up and avoid possible subscription errors, add Blues Brief to your subscriptions by clicking the Manage Subscriptions link at the bottom of your BCN Provider News or The Record newsletter emails. Once you make your changes to your subscription, simply click Update and we'll process your changes. Our system doesn't automatically acknowledge your changes, but we'll be sure to add you to the distribution list. You can also visit the subscription page to choose your preferred Blues Brief versions. These include the:

Keep in mind that Blues Brief is not intended to be a replacement for BCN Provider News or The Record.

Posted: January 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

e-referral User Guides, online eLearning updated

The e-referral User Guides and Submitting an Outpatient Authorization online eLearning module have been updated on the Training Tools page of ereferrals.bcbsm.com. They are dated November 2018.

These User Guides and eLearning module have been updated to include:

  • The new Place of Service drop-down menu items. The Outpatient Hospital option has now been split into On Campus Outpatient Hospital and Off Campus Outpatient Hospital. Other Unlisted Facility and Telehealth have also been added as choices but providers should not use these.

The updated User Guides also include:

  • A page has been added with instruction on completing a new questionnaire when submitting to a multispecialty group in the Submitting a Global Referral chapter. An e-referral news message has also been posted regarding the questionnaire.

Posted: December 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

eviCore to manage two radiopharmaceutical drugs, starting Feb. 1

For dates of services on or after Feb. 1, 2019, the following radiopharmaceutical drugs require authorization through eviCore healthcare:

  • Lutathera® (lutetium Lu 177 dotatate, HCPCS code C9513)
  • Xofigo® (radium Ra 223 dichloride, HCPCS code A9606)

This applies to members covered by:

  • Blue Cross PPO (commercial) and Blue Cross Medicare Plus BlueSM PPO

    Note: eviCore already manages procedures associated with code A9606 for Blue Cross PPO and Medicare Plus Blue members. eviCore will begin managing procedures associated with code C9513 on Feb. 1.

  • BCN HMOSM (commercial) and BCN AdvantageSM

    Note: Lutathera was previously managed for BCN HMO members under the prior authorization program for drugs covered under the medical benefit. eviCore already manages procedures associated with code C9513 for BCN Advantage members. For BCN HMO members, C codes aren't payable. However, services associated with the administration of an approved treatment plan with Lutathera are payable for BCN HMO members. eviCore will begin managing procedures associated with code A9606 for both BCN HMO and BCN Advantage on Feb. 1.

Submit authorization requests to eviCore online at evicore.com or by telephone at 1-855-774-1317.

We'll update the Procedures that require authorization by eviCore healthcare document prior to the effective date of the change.

Note: These changes do not apply to MESSA members.

Posted: November 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Updated authorization criteria and e-referral questionnaires

We're making updates to the authorization criteria and to the questionnaires in the e-referral system for the following services:

  • Cervical spine surgery with artificial disc replacement
  • Deep brain stimulation
  • Endometrial ablation
  • Shoulder replacement surgery

For most of these services, you'll see the updated questionnaires in the e-referral system starting Nov. 25, 2018. You'll see the questionnaire for shoulder replacement surgery starting Nov. 11.

We use these criteria and questionnaires when making utilization management determinations for the following members:

  • BCN HMOSM (commercial)
  • BCN AdvantageSM
  • Blue Cross Medicare Plus BlueSM PPO

Note: The criteria and questionnaires for endometrial ablation and cervical spine surgery apply to BCN HMO and BCN Advantage members only.

The updated authorization criteria and preview questionnaires will be available on this website shortly before the revised questionnaires are set to open in the e-referral system. Here's where to find them:

You can look over the preview questionnaires to see what questions you'll need to answer in the actual questionnaire that opens in the e-referral system for each service. Once you know what questions you'll need to answer, you can prepare your answers ahead of time. This can cut down on the time it takes to submit the authorization request.

Posted: November 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Medicare Part B medical specialty drug prior authorization lists changing in 2019

Some updates are coming for the Part B medical specialty medical prior authorization drug list for Blue Cross Medicare Plus BlueSM PPO and BCN AdvantageSM members. These changes include additions and removals from the prior authorization program as follows.

Medicare Plus Blue PPO

    Removals — for dates of service starting Jan. 1, 2019:

    • J0202 Lemtrada®
    • J2323 Tysabri®
    • J2350 Ocrevus®

    Additions — for dates of service starting Feb. 1, 2019:

    • J2840 Kanuma®
    • J2860 Sylvant®
    • J3357 Stelara® SQ
    • J3358 Stelara® IV
    • J3490/C9036 OnpattroTM
    • J1746 TrogarzoTM
    • J9022 Tecentriq®
    • J9023 Bavencio®
    • J9042 Adcetris®
    • J9176 Empliciti®
    • J9308 Cyramza®
    • J9352 Yondelis®

For Medicare Plus Blue, we require prior authorization for these medications when you bill them on a professional CMS-1500 claim form or by electronic submission via an 837P transaction, for the following sites of care:

  • Physician office (Place of Service Code 11)
  • Outpatient facility (Place of Service Code 19, 22 or 24)

We do not require authorization for these medications when you bill them on a facility claim form (such as a UB04) or electronically via an 837I transaction.

BCN Advantage

    Removals — for dates of service starting Jan. 1, 2019:

    • J9032 Beleodaq®
    • J9310 Rituxan®

    Additions — for dates of service starting Feb. 1, 2019:

    • J2860 Sylvant®
    • J3357 Stelara® SQ
    • J3358 Stelara® IV
    • J3490/C9036 OnpattroTM
    • J1746 TrogarzoTM
    • J9022 Tecentriq®
    • J9023 Bavencio®
    • J9042 Adcetris®
    • J9176 Empliciti®
    • J9352 Yondelis®

For BCN Advantage, we require prior authorization for these medications when you bill them on a professional CMS-1500 claim form (or submit them electronically via an 837P transaction) or on a facility claim form such as a UB04 (or submit them electronically via an 837I transaction), for the following sites of care:

  • Physician office (Place of Service Code 11)
  • Outpatient facility (Place of Service Code 19, 22 or 24)
  • Home (Place of Service Code 12)

Important reminder

You must get authorization prior to administering these medications. Use the Novologix® online web tool to quickly submit your requests.

Posted: November 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Additional updated authorization criteria and e-referral questionnaires

We made updates to the authorization criteria and to the questionnaires in the e-referral system for the following services:

  • Hip replacement surgery procedure, initial
  • Hyperbaric oxygen therapy, outpatient
  • Knee replacement surgery, nonunicondylar, initial
  • Knee replacement surgery, unicondylar, initial
  • Lumbar spine surgery for adults
  • Transcatheter arterial chemoembolization of hepatic tumors (TACE)

You'll see the updated questionnaires in the e-referral system starting Oct. 28, 2018.

We use these criteria and questionnaires when making utilization management determinations for the following members:

  • BCN HMOSM (commercial)
  • BCN AdvantageSM
  • Blue Cross Medicare Plus BlueSM PPO

Note: The criteria and questionnaires for hyperbaric oxygen therapy and lumbar spine surgery apply to BCN HMO and BCN Advantage members only.

The updated authorization criteria and preview questionnaires are available on this website. Here's where to find them:

You can look over the preview questionnaires to see what questions you'll need to answer in the actual questionnaire that opens in the e-referral system for each service. Once you know what questions you'll need to answer, you can prepare your answers ahead of time. This can cut down on the time it takes to submit the authorization request.

Posted: October 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Register for Medicare Advantage webinar: Avastin® use for patients with retinal disorders

Learn about the safe and effective use of Avastin for retinal disorders and how to correctly bill Medicare Plus BlueSM PPO and BCN AdvantageSM for maximum reimbursement.

Register for one of the following webinars now:

Once the host approves your registration, you'll receive a confirmation email with instructions for joining the session.

Posted: October 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Onpattro, Poteligeo, Signifor LAR added to medical benefit specialty drug prior authorization program for commercial members

The prior authorization program for specialty drugs covered under the medical benefit is expanding for BCN HMOSM and Blue Cross PPO commercial members as follows:

Brand name / HCPCS code Prior authorization requirements for all dates of service on or after:
OnpattroTM / J3490 HMO – Nov. 1, 2018
PPO – Dec. 1, 2018
Poteligeo® / J9999 HMO – Nov. 1, 2018 (only for members starting treatment on or after that date)
PPO – None required
Signifor LAR® / J2502 HMO – Feb. 1, 2019
PPO – Already required

These changes don't apply to BCN AdvantageSM, Blue Cross Medicare Plus BlueSM PPO or Federal Employee Program® members.

How to submit authorization requests

Submit authorization requests prior to the start of services for medical benefit drugs that require authorization using the NovoLogix® web tool within Provider Secured Services.

Always verify benefits

Approval of a prior authorization request isn't a guarantee of payment. You need to verify each member's eligibility and benefits. Members are responsible for the full cost of medications not covered under their medical benefit coverage.

Posted: October 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Tell us what you think about our utilization management services — you could win a prize!

Your feedback is important to us. Please complete the 2018 Blue Cross Blue Shield of Michigan and Blue Care Network Utilization Management Survey and encourage your office colleagues to do so as well, including physicians, nurses and referral coordinators. Your input will help us evaluate our efforts and determine other improvements we can make to enhance our utilization management processes.

The survey will be available online through Dec. 31, 2018.

Information about a drawing for two $250 gift certificates is available on page 18 of the September-October 2018 issue of BCN Provider News.

Posted: October 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Possible browser certificate error in e-referral for Windows 7 users starting Oct. 16, 2018

Internet Explorer, Google Chrome and Mozilla Firefox have announced that new versions of their Internet browsers, being introduced on Oct. 16, 2018, will not trust Symantec certificates. The browsers will display a block page explaining that the site is categorized as "untrusted." If you are a Windows 7 user, you may see a certificate error message starting Oct. 16 when you try to access e-referral.

If you do see a certificate error message, please complete the following steps (PDF), reopen your browser and access e-referral.

If you are still experiencing issues after following the steps, please contact your web support team.

Posted: October 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Treat Medicare Advantage members with Avastin® before other specialty drugs

Starting Jan. 1, 2019, when requesting authorization for Eylea®, Lucentis® or Macugen® for Medicare Advantage members, you'll need to show you've already tried eye injections with compounded Avastin (bevacizumab).

If you're currently treating members with wet, neovascular, age-related macular edema, we:

  • Encourage you to start Avastin therapy now
  • Don't require authorization for Avastin injections
  • Reimburse $173 per eye for medical drug claims with compounded Avastin eye injections

Look for more information, including billing instructions, in upcoming issues of The Record and BCN Provider News.

This change follows Centers for Medicare & Medicaid Services guidance for allowing Part B specialty drug step therapy. And, it applies to Blue Cross Medicare Plus BlueSM PPO and BCN AdvantageSM members for dates of service on or after Jan. 1, 2019.

Posted: October 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Some medical benefit drugs for Medicare Advantage members need step therapy, starting Jan. 1

In the new year, according to Centers for Medicare & Medicaid Services guidance, certain Medicare Part B specialty drugs will have additional step therapy authorization requirements. This will apply to Medicare Plus BlueSM PPO and BCN AdvantageSM members for dates of service on or after Jan. 1, 2019.

Step therapy is treatment for a medical condition that starts with the most preferred drug therapy and progresses to other drug therapies only if necessary. The goal of step therapy is to encourage better clinical decision-making.

What's changing?

For drugs requiring step therapy, authorization request questions will be different from the ones you currently answer. Some examples of drugs that require step therapy are:

  • Botox® for migraines and overactive bladder
  • Eylea®, Lucentis® and Macugen® for neovascular age-related macular edema
  • Prolia® for osteoporosis

Use NovoLogix® to submit authorization requests

We encourage you to send prior authorization requests for Medicare Part B specialty drugs through the NovoLogix web tool via Provider Secured Services. It's the most efficient way to get a determination.

Look for more information on step therapy requirements in upcoming issues of The Record and BCN Provider News.

Posted: October 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Register today: NovoLogix® refresher course for medical specialty drug prior authorizations

Refresh your skills with the NovoLogix web tool, and learn how to create provider administered specialty medical drug prior-authorization requests for members with:

  • Blue Cross Medicare Plus BlueSM PPO
  • BCN AdvantageSM
  • Blue Cross PPO
  • BCN HMOSM

Register for a webinar now:

Once the host approves your registration, you'll receive a confirmation email with instructions for joining the session.

Posted: September 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Additional updated authorization criteria and e-referral questionnaires

We made updates to the authorization criteria and questionnaires in the e-referral system, for the following services:

  • Cervical spine surgery
  • Hammertoe correction surgery
  • Sinusotomy, frontal endoscopic

The updated questionnaires will begin opening in the e-referral system starting Sept. 23, 2018.

We use these criteria and questionnaires when making utilization management determinations for the following members:

  • BCN HMOSM (commercial)
  • BCN AdvantageSM
  • Blue Cross Medicare Plus BlueSM PPO

Note: The criteria and questionnaire for cervical spine surgery apply to BCN HMO and BCN Advantage members only.

The updated authorization criteria and preview questionnaires are available on this website. Here's where to find them:

You can look over the preview questionnaires to see what questions you'll need to answer in the actual questionnaire that opens in the e-referral system for each service. Once you know what questions you'll need to answer, you can prepare your answers ahead of time. This can cut down on the time it takes to submit the authorization request.

Posted: September 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Use in-network laboratories for toxicology, drug-of-abuse testing

Providers affiliated with Blue Cross Blue Shield of Michigan and Blue Care Network have a contractual obligation to use in-network providers when referring our members for services. This includes referring members for toxicology and drug-of-abuse testing services. And, this applies for members covered by all Blue Cross and BCN products:

  • Blue Cross PPO
  • Blue Cross Medicare Plus BlueSM PPO
  • BCN HMOSM
  • BCN AdvantageSM

A significant number of contracted providers refer members to out-of-network laboratories. This puts members at risk of having to pay higher costs. Since the tests are available at in-network labs, these costs are unnecessary. Please follow the conditions of your provider agreement and the directions in our provider manuals, which require you to refer these members to in-network labs.

Our goal is to:

  • Give your patients convenient access to high-quality, cost-efficient toxicology testing services that properly meet their clinical needs.
  • Help our members avoid higher copayments and other out-of-pocket costs that may result from using out-of-network labs.

Confirm which labs are in-network or out-of-network with these resources

    Blue Cross PPO

    For salaried employees covered through Ford, General Motors and the Michigan Public School Employees' Retirement System, call: Quest DiagnosticsTM – 1-866-697-8378.

    For all other Blue Cross PPO members, use the Blue Cross online provider directory.

    Blue Cross Medicare Plus Blue PPO

    Call either of the following resources:

    • Joint Venture Hospital Laboratories – 1-800-445-4979
    • Quest Diagnostics – 1-866-697-8378

    BCN HMO and BCN Advantage

    Call Joint Venture Hospital Laboratories at 1-800-445-4979.

Need more help?

If you need more help locating an in-network lab or want to discuss specific lab testing needs you may have, please call one of the following Provider Automated Response System numbers during normal business hours:

    Blue Cross PPO, BCN HMO or BCN Advantage

    • Professional providers in Michigan, call 1-800-344-8525.
    • Facility providers in Michigan, call 1-800-249-5103.

    Blue Cross Medicare Plus Blue PPO

    Call 1-866-309-1719.

After confirming member benefits using the automated system, you can speak to someone in Provider Inquiry to get help finding an in-network lab.

Posted: September 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

FAQ available about LLPs and LMFTs

The answers to questions providers have asked about limited licensed psychologists and licensed marriage and family therapists is now available in the document LLPs and LMFTs – Frequently asked questions. You'll find the FAQ document on this website at these locations:

The FAQ document is intended to clarify questions about LLP and LMFT requirements related to providing services to Blue Cross PPO (commercial), BCN HMOSM (commercial) and BCN AdvantageSM members. We announced this change in The Record (March 2018 article) and BCN Provider News (January-February 2018 issue, article on page 1).

A link to the FAQ document is also located on Blue Cross Clinical Criteria & Resources page within Provider Secured Services. To access that page, visit bcbsm.com/providers, log in to Provider Secured Services and click BCBSM Provider Publications and Resources at the lower right. Then click Clinical Criteria & Resources. Finally, scroll down and look in the "Behavioral Health Information" section of the page, under "General Resources."

Posted: August 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Additional updated authorization criteria and e-referral questionnaires in effect

We made updates to the authorization criteria and questionnaires in the e-referral system, for the following services:

  • Endovascular intervention, peripheral artery
  • Ethmoidectomy, endoscopic
  • Sacral nerve stimulation

The updated questionnaires began opening in the e-referral system starting Aug. 26, 2018.

We use these criteria and questionnaires when making utilization management determinations for the following members:

  • BCN HMOSM (commercial)
  • BCN AdvantageSM
  • Blue Cross Medicare Plus BlueSM PPO

The updated authorization criteria and preview questionnaires are available on this website. Here's where to find them:

You can look over the preview questionnaires to see what questions you'll need to answer in the actual questionnaire that opens in the e-referral system for each service. Once you know what questions you'll need to answer, you can prepare your answers ahead of time. This can cut down on the time it takes to submit the authorization request.

Posted: August 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Updated authorization criteria and e-referral questionnaires in effect

We made updates to the authorization criteria and questionnaires in the e-referral system, for the following services:

  • Knee arthroplasty for adults, total revision
  • Noncoronary vascular stents
  • Spinal cord stimulator or epidural or intrathecal catheter (trial or permanent placement)

The updated questionnaires began opening in the e-referral system starting Aug. 12, 2018.

We use these criteria and questionnaires when making utilization management determinations for the following members:

  • BCN HMOSM (commercial)
  • BCN AdvantageSM
  • Blue Cross Medicare Plus BlueSM PPO

The updated authorization criteria and preview questionnaires are available on this website. Here's where to find them:

You can look over the preview questionnaires to see what questions you'll need to answer in the actual questionnaire that opens in the e-referral system for each service. Once you know what questions you'll need to answer, you can prepare your answers ahead of time. This can cut down on the time it takes to submit the authorization request.

Posted: August 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Error issue resolved in e-referral system

Between Aug. 6 and Aug. 10, 2018, we received reports of an issue in the e-referral system that was preventing providers from viewing certain cases. Some providers told us they had received a message that said "Unknown Error. Please contact health plan administrator."

The issue, which occurred when the e-referral system was recently updated to the 2018 InterQual® criteria, has been resolved.

We apologize for any confusion you may have experienced when you got the error message.

Posted: August 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

2018 InterQual® criteria implementation delayed until Aug. 6

We communicated in June that Blue Cross Blue Shield of Michigan and Blue Care Network would implement the 2018 InterQual criteria and local rules starting Aug. 1, 2018, for all levels of care.

However, the implementation of the 2018 criteria was delayed. The new implementation date is Aug. 6.

Until that date, the 2017 InterQual criteria and local rules will continue to be used in making utilization management and care management determinations for the services subject to review.

This affects both behavioral health and non-behavioral health services for the following lines of business, unless otherwise noted:

  • Blue Cross PPO (commercial)
  • Note: Determinations on Blue Cross PPO (commercial) behavioral health services are handled by New Directions, a Blue Cross vendor, and are not affected by these criteria changes.

  • Blue Cross Medicare Plus BlueSM PPO
  • BCN HMOSM (commercial)
  • BCN AdvantageSM

In addition, the e-referral system won't be available from 6 p.m. on Friday, Aug. 3 through 6 a.m. on Monday, Aug. 6, while it's being updated with the new criteria. Here's some information on how to process certain requests while the e-referral system is down:

  • For urgent acute inpatient requests that need to be processed within 24 hours, call the appropriate number below:
    • For Blue Cross requests, call the critical phone line at (313) 448-3619.
    • For BCN requests, call 1-800-392-2512.

  • For BCN post-acute and concurrent admission reviews, follow the current process you use to submit these requests by fax at 1-866-534-9994.

  • For behavioral health requests, call the appropriate number below:
    • For BCN behavioral health requests, call 1-800-482-5982.
    • For Blue Cross Medicare Plus Blue PPO behavioral health requests, call 1-888-803-4960.

  • For non-urgent authorization requests: Please wait to submit those until the e-referral system is available again.

Posted: July 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Starting Aug. 6, updated utilization management criteria used for behavioral health

Starting Aug. 6, 2018, Blue Care Network and Blue Cross Medicare Plus BlueSM PPO will use the 2018 InterQual® criteria for behavioral health utilization management determinations. The 2017 InterQual criteria will be used until that date.

Note: In earlier messages, we communicated that the 2018 InterQual criteria would be implemented starting Aug. 1, 2018, but that date has been changed to Aug. 6.

For certain services, we will base utilization management decisions on modified 2018 InterQual criteria, local rules or medical policies, instead. These changes will also begin Aug. 6. The services affected by these changes are outlined in this table.

Line of business Modified 2018 InterQual criteria for: Local rules or medical policy for:
BCN HMOSM (commercial) and BCN AdvantageSM
  • Substance use disorders: partial hospital program and intensive outpatient program
  • Residential mental health treatment (adult/geriatric and child/adolescent)
  • Autism spectrum disorder / applied behavior analysis (local rules)
  • Neurofeedback for attention deficit disorder / attention deficit hyperactivity disorder (medical policy)
  • Transcranial magnetic stimulation (medical policy)
Medicare Plus Blue PPO
  • Substance use disorders: partial hospital program and intensive outpatient program
None

Note: Determinations on Blue Cross PPO (commercial) behavioral health services are handled by New Directions, a Blue Cross vendor.

Links to the updated versions of the modified criteria, local rules and medical policies will be available by Aug. 3 on the Blue Cross Behavioral Health page and the BCN Behavioral Health page on this website. Links to the current criteria are available on those pages until then.

Posted: July 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

2018 InterQual® criteria to be implemented starting Aug. 6

Blue Cross Blue Shield of Michigan and Blue Care Network will implement the 2018 InterQual criteria starting Aug. 6, 2018, for all levels of care. Until that date, the 2017 InterQual criteria will be used.

Note: In earlier messages, we communicated that the 2018 InterQual criteria would be implemented starting Aug. 1, 2018, but that date has been changed to Aug. 6.

The InterQual criteria are used to make utilization management and care management determinations for the services subject to review, for the follow members:

  • Blue Cross PPO (commercial)
  • Blue Cross Medicare Plus BlueSM PPO
  • BCN HMOSM (commercial)
  • BCN AdvantageSM

Blue Cross and BCN also use local rules – modifications of InterQual criteria – in making utilization management and care management determinations. The 2018 local rules will be implemented as follows:

  • For behavioral health determinations, the 2018 local rules will be used starting Aug. 6. The updated rules will be available by Aug. 3 on the Blue Cross Behavioral Health page and the BCN Behavioral Health page on this website. This applies to BCN HMO (commercial), BCN Advantage and Medicare Plus Blue PPO requests.

    Note: Determinations on Blue Cross PPO (commercial) behavioral health services are handled by New Directions, a Blue Cross vendor.

  • For non-behavioral health determinations, the 2018 local rules will be implemented starting Oct. 1. We'll let you know through our standard communication channels how to access those rules, once they're available.

Until the 2018 local rules are implemented, the 2017 local rules will be used.

Posted: July 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Last call for our provider training survey - Respond by July 31

Time is running out to give us your opinion on provider training. You have until July 31 to complete our online survey. Your response will help us improve the way we distribute information to you. Thank you for your time and your input.

Posted: July 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

What to do when you get conflicting results in the e-referral system

When you submit an authorization request in the e-referral system, it may take up to a minute to show the authorization results, especially if the system is handling many requests at one time.

While you're waiting to get the decision on an authorization request, the e-referral system may display messages that conflict with each other. For example, the Authorization Details screen may show a status of "pending decision" along with a note in the Actions field that shows the request was approved.

If you encounter conflicting messages such as these, we suggest you make a note of the Reference ID number and use it to check back in a few minutes. This should give the system the time it needs to finish processing the authorization and display the decision without the conflicting messages.

Posted: July 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

We're updating you on Blue Distinction Specialty Care

In an article in the July-August 2018 Hospital and Physician Update, we provided an update on Blue Distinction Specialty Care. This program recognizes health care facilities and providers nationwide that demonstrate proven expertise in delivering high-quality, effective and cost-efficient care for select specialty areas. The article outlines selection criteria and recent program changes, along with information on what's coming next and program results. For complete details, click here.

This information applies to both Blue Cross PPO (commercial) and Blue Care Network HMOSM (commercial) members. The article that was published in Hospital and Physician Update will also be included in the September-October 2018 issue of BCN Provider News, which will be available online in late August.

Posted: July 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Deleting your browsing history after an e-referral system outage

The e-referral system is available again.

After an outage of the e-referral system, you may experience difficulties logging in to the system. Deleting your browsing history may make the login process easier.

Click here for instructions on how to delete your browsing history if you use Internet Explorer 11 as your browser.

If you use a browser other than Internet Explorer 11, contact your IT support staff for instructions or look up how to clear your browsing history on the Internet.

Posted: July 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

How to request peer-to-peer review of inpatient admissions

Blue Cross Blue Shield of Michigan and Blue Care Network allow onsite physician advisors at contracted facilities to discuss reviews of inpatient admissions with a Blue Cross or BCN medical director. According to our policy, facilities should start peer-to-peer conversations only through their employed physician advisors, and not through third-party advisors or organizations.

This applies to members with coverage with Blue Cross PPO (commercial), BCN HMOSM (commercial), Blue Cross Medicare Plus BlueSM PPO and BCN AdvantageSM products.

The purpose of the peer-to-peer discussion is to exchange information about the clinical nuances of the member's medical condition and the medical necessity of the inpatient admission, not to discuss InterQual® criteria or Blue Cross and BCN local rules.

The peer-to-peer phone lines are open Monday through Friday, 8 a.m. to 5 p.m. Eastern time, except for holidays. We'll return your call within 48 business hours.

Use the following guidelines to request a peer-to-peer review with a Blue Cross or BCN medical director.

Non-behavioral health inpatient admissions

For BCN HMO (commercial) and BCN Advantage members:

  1. Call 248-799-6312.
  2. Select prompt 3 for a peer-to-peer discussion.
  3. Leave a message that includes the:
    • Reason for requesting a peer-to-peer review
    • Member's name, date of birth and contract number
    • Physician advisor's or physician's name and phone number
    • Best date and time to reach the physician advisor or physician

For Blue Cross PPO (commercial) and Medicare Plus Blue members:

  1. Call 1-866-346-7299.
  2. Select prompt 2 for the Facility Precertification department
  3. Select prompt 1 to request a provider peer-to-peer review.
  4. Wait for the prompt to leave a message, then provide the:
    • Reason for requesting a peer-to-peer review
    • Member's name, date of birth and contract number
    • Physician advisor's or physician's name and phone number
    • Best date and time to reach the physician advisor or physician

Behavioral health inpatient admissions

For BCN HMO (commercial), BCN Advantage and Medicare Plus Blue members:

  1. Call 1-877-293-2788.
  2. If a live operator doesn't answer the call, leave a message that includes the:
    • Name of the person calling and a call-back number
    • Member's name, date of birth and contract or case number
    • Specific times the provider is available to discuss the case
    • Physician advisor's or physician's name and phone number

For Blue Cross PPO (commercial) members: Call the behavioral health number on the back of the member's ID card.

Posted: July 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

TrogarzoTM and Zilretta® require authorization for commercial members starting Oct. 1

For dates of service on or after Oct. 1, 2018, Trogarzo and Zilretta will be added to the medical drug prior authorization program for Blue Cross PPO (commercial) and BCN HMOSM (commercial) members.

Trogarzo will also be subject to a site-of-care requirement for BCN HMO (commercial) members only, effective Oct. 1, 2018. The site-of-care program redirects members receiving select drugs in an outpatient hospital setting to a lower-cost, alternate site of care, such as the physician's office or the member's home.

See the table below for a summary of the requirements.

Drug name HCPCS code Prior authorization requirement Site-of-care requirement
Trogarzo (ibalizumab-uiyk) J3590 Blue Cross PPO (commercial) and BCN HMO (commercial) BCN HMO (commercial) only
Zilretta (triamcinolone acetonide extended release) Q9993 Blue Cross PPO (commercial) and BCN HMO (commercial) No

Note:

  • For members currently on Trogarzo, no action is required.

  • For members currently on Zilretta, authorization will be required for dates of service on or after Oct. 1, 2018.

You can refer to the opt-out list to see which groups don't require members to participate in these programs. This applies to Blue Cross PPO (commercial) groups only. To access the list, complete these steps:

  1. Visit bcbsm.com/providers.
  2. Log in to Provider Secured Services.
  3. Click BCBSM Provider Publications and Resources.
  4. Click Newsletters & Resources.
  5. Click Forms.
  6. Click Physician administered medications.
  7. Click BCBSM Medical Drug Prior Authorization Program list of groups that have opted out.

And remember: approval of an authorization request isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members. Members are responsible for the full cost of medications not covered under their medical benefits.

Additional information on medical benefit drugs is available at ereferrals.bcbsm.com, on the Blue Cross Medical Benefit Drugs — Pharmacy page and the BCN Medical Benefit Drugs — Pharmacy page.

Posted: July 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Starting Aug. 1, updated utilization management criteria used for behavioral health

Starting Aug. 1, 2018, Blue Care Network and Blue Cross Medicare Plus BlueSM PPO will use the 2018 InterQual® criteria for behavioral health utilization management determinations. The 2017 InterQual criteria will be used through the end of July.

For certain services, we will base utilization management decisions on modified 2018 InterQual criteria, local rules or medical policies, instead. These changes will also begin Aug. 1. The services affected by these changes are outlined in this table.

Line of business Modified 2018 InterQual criteria for: Local rules or medical policy for:
BCN HMOSM (commercial) and BCN AdvantageSM
  • Substance use disorders: partial hospital program and intensive outpatient program
  • Residential mental health treatment (adult/geriatric and child/adolescent)
  • Autism spectrum disorder / applied behavior analysis (local rules)
  • Neurofeedback for attention deficit disorder / attention deficit hyperactivity disorder (medical policy)
  • Transcranial magnetic stimulation (medical policy)
Medicare Plus Blue PPO
  • Substance use disorders: partial hospital program and intensive outpatient program
None

Note: Determinations on Blue Cross PPO (commercial) behavioral health services are handled by New Directions, a Blue Cross vendor.

Links to the updated versions of the modified criteria, local rules and medical policies will be available at the end of July on the Blue Cross Behavioral Health page and the BCN Behavioral Health page on this website. Links to the current criteria are available on those pages until then.

Posted: June 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Updated authorization criteria and e-referral questionnaires are in effect

For certain services, the authorization criteria and the questionnaires in the e-referral system have been updated. These are used in making utilization management determinations for the following members:

  • BCN HMOSM (commercial)
  • BCN AdvantageSM
  • Blue Cross Medicare Plus BlueSMPPO

Click here for a list of the authorization criteria and questionnaires that were updated in May and June 2018.

The updated authorization criteria and preview questionnaires are available on this website, on these pages:

You can look over the preview questionnaires to see what questions you'll need to answer in the actual questionnaire that opens in the e-referral system for each service. Once you know what questions you'll need to answer, you can prepare your answers ahead of time. This can cut down on the time it takes to submit the authorization request.

As a reminder, new questionnaires will open in the e-referral system for blepharoplasty and repair of brow ptosis (starting June 25, for any date of service) and hyperbaric oxygen therapy (for dates of service on or after July 1). We first communicated about this in May, in a web-DENIS message and a news item on this website. You'll see these questionnaires included in the list of updated authorization criteria and questionnaires.

Posted: June 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

2018 InterQual® criteria to be implemented starting Aug. 1

Blue Cross Blue Shield of Michigan and Blue Care Network will implement the 2018 InterQual criteria starting Aug. 1, 2018, for all levels of care. Until that date, the 2017 InterQual criteria will be used.

The InterQual criteria are used to make utilization management and care management determinations for the services subject to review, for the follow members:

  • Blue Cross PPO (commercial)
  • Blue Cross Medicare Plus BlueSM PPO
  • BCN HMOSM (commercial)
  • BCN AdvantageSM

Blue Cross and BCN also use local rules – modifications of InterQual criteria – in making utilization management and care management determinations. The 2018 local rules will be implemented as follows:

  • For behavioral health determinations, the 2018 local rules will be used starting Aug. 1. The updated rules will be available at the end of July on the Blue Cross Behavioral Health page and the BCN Behavioral Health page on this website. This applies to BCN HMO (commercial), BCN Advantage and Medicare Plus Blue PPO requests.

    Note: Determinations on Blue Cross PPO (commercial) behavioral health services are handled by New Directions, a Blue Cross vendor.

  • For non-behavioral health determinations, the 2018 local rules will be implemented starting Oct. 1. We'll let you know through our standard communication channels how to access those rules, once they're available.

Until the 2018 local rules are implemented, the 2017 local rules will be used.

Posted: June 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Where to get help in using the e-referral system

Recently, the Web Support Help Desk has been experiencing an increase in calls for e-referral assistance. As a reminder, the Web Support Help Desk is only available to assist with password reset, navigation and technical help.

Please follow these guidelines for other e-referral issues:

  • For Blue Cross PPO (commercial) members, you can find the appropriate Provider Inquiry phone number in the Blue Cross provider resource guide at a glance document, on the Quick Guides page of this website.

  • For Blue Cross Medicare Plus BlueSM PPO members, you can find the appropriate Provider Inquiry phone number in the Services That Require Authorization – Medicare Plus Blue PPO document, on the Authorization Requirements & Criteria page in the Blue Cross section of this website.

  • For BCN HMOSM (commercial) or BCN AdvantageSM members, please call 1-800-392-2512.

For additional help using e-referral, contact your provider consultant or consult the user guides and online training available on the Training Tools page on this website.

Posted: June 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Starting Aug. 7, FasenraTM and LuxturnaTM require authorization for Medicare Advantage members

For dates of service on or after Aug. 7, 2018, authorization is required for the following Part B specialty drugs covered under the medical benefit:

  • Fasenra (benralizumab)
  • Luxturna (voretigene neparvovec-rzyl)

This authorization requirement applies to Blue Cross Medicare Plus BlueSM PPO and BCN AdvantageSM members.

Note: Authorization is already required for Blue Cross PPO and BCN HMOSM (commercial) members.

For Medicare Plus Blue and BCN Advantage members, authorization is required for these medications when they are billed on a professional HCFA 1500 claim form or by electronic submission via ANSI 837P, for the following sites of care:

  • Physician office (Place of Service 11)
  • Outpatient facility (Place of Service 19, 22 or 24)

Authorization is not required for these medications when they are billed on a facility claim form (such as the UB-92, UB-04 or UCB).

Both medications are billed with HCPCS procedure code J3590.

You must submit authorization requests for these medications through the NovoLogix online tool. Authorization must be obtained prior to the medications being administered.

Posted: May 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

e-referral not available 6 p.m. Friday, April 27, through 6 a.m. Monday, April 30

Several new upgrades and changes are coming to the e-referral system. The biggest change is the combining of BCN and BCBSM e-referral systems into one portal.

In order to upgrade the system, e-referral will not be available starting 6 p.m. on Friday, April 27, 2018. At 6 a.m. on Monday, April 30, 2018, users will see only one e-referral link to be used for both Blue Cross and BCN submissions. Please see the article on page 42 of the May-June 2018 BCN Provider News for full details.

Here's some information on how to process certain requests while the e-referral system is down.

For urgent acute inpatient requests that need to be processed within 24 hours, call the appropriate number below:

  • For Blue Cross requests, call the critical phone line at (313) 448-3619.
  • For BCN requests, call the BCN After-Hours Care Manager Hotline at 1-800-851-3904.

For BCN post-acute and concurrent admission reviews, follow the current process you use to submit these requests by fax at 1-866-534-9994.

To reach BCN Behavioral Health, call 1-800-482-5982.

Posted: April 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Medicare Outpatient Observation Notice requirements clarified

We're clarifying the requirements for notifying Medicare Advantage members using the Medicare Outpatient Observation Notice form.

Here's when hospitals need to notify members

Hospitals must use the Medicare Outpatient Observation Notice form, available on the CMS website* under Downloads, to notify Blue Cross Medicare Plus BlueSM PPO and BCN AdvantageSM members that they're receiving outpatient, rather than inpatient, services when a member is:

  • In the emergency department and is being considered for inpatient admission but has not yet been approved for admission by Blue Cross or BCN
  • Being moved to observation status within the hospital from any other status or source
  • In observation status for 24 hours or more, if the member has not already received the form before being admitted for observation

For Medicare Advantage members in these circumstances, hospitals must present the member with a completed Medicare Outpatient Observation Notice. This is a Centers for Medicare & Medicaid Services requirement.

Hospitals should also review the instructions for notifying members using the Medicare Outpatient Observation Notice.

Here's when hospitals do not need to notify members

When Blue Cross or BCN has approved an inpatient admission, there's no need to notify the member using the form. When the member is not being considered for inpatient care, there's no need to notify either the member or the plan.

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

Posted: April 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Starting June 1, Northwood will manage diabetic shoes and inserts for BCN and Blue Cross Medicare Plus BlueSM PPO members

For dates of service on or after June 1, 2018, diabetic shoes and inserts will be managed by Northwood, Inc., for Blue Care Network HMOSM (commercial), BCN AdvantageSM and Blue Cross Medicare Plus Blue PPO members. This applies to HCPCS codes A5500 through A5513 and code K0903.

J&B Medical Supply currently manages these items and will manage them for dates of service on or before May 31, 2018.

Here's how to contact these vendors:

  • Northwood: Call Northwood at 1-800-393-6432 to identify a contracted supplier near you. The supplier submits the request to Northwood for review. Northwood representatives are available weekdays from 8:30 a.m. to 5 p.m. Northwood on-call associates are available after normal business hours at the same number.

  • J&B Medical Supply: Call J&B at 1-888-896-6233. J&B representatives are available weekdays from 8 a.m. to 5 p.m. J&B on-call associates are available after normal business hours at the same number.

We'll be updating the BCN and Blue Cross Medicare Plus Blue PPO provider manuals to reflect the changes related to diabetic shoes and inserts.

Posted: April 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Last call for our provider manual survey — Respond by April 30 for a chance to win a prize

Time is running out to give us your opinion on our provider manuals. Please complete our online survey by April 30. You could win a $25 gift certificate. For more information see recent articles in The Record and page 13 of BCN Provider News.

Posted: April 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Blue Cross, BCN will continue to cover hyaluronic acids until further notice

Earlier this year, we notified you and members that Blue Cross and Blue Care Network will no longer cover hyaluronic acids beginning April 1.

After further review, we've decided to continue covering hyaluronic acids while we conduct additional research. We hope to have a final decision in the next few months and will continue to update you on this critical initiative.

Members will receive a letter soon with the updated information.

Posted: March 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Effective April 2, use the flight information form for non-emergency air ambulance authorization requests

As a reminder, effective for dates of service on or after April 2, 2018, all non-emergency air ambulance transports for Blue Cross Blue Shield of Michigan PPO (commercial) and Blue Care Network HMOSM (commercial) members require authorization.

Requests to authorize non-emergency flights must be submitted to and approved by Alacura Medical Transportation Management, LLC, prior to the flight. This requirement applies to both in-state and out-of-state air ambulance transports.

Emergency flights – when the patient cannot safely wait six hours to take off – do not require authorization. This includes situations that involve delays due to weather or stabilizing the patient. When it's an emergency, just transport the patient.

How to request an authorization for non-emergency flights

To contact Alacura about authorizing a non-emergency flight request, do the following:

  1. Complete the Air ambulance flight information (non-emergency) form and fax it, along with clinical documentation in support of the request, to Alacura at 1-844-608-3572.
  2. Call Alacura at 1-844-608-3676 to obtain an authorization number.

Additional information

You'll find additional information about air ambulance requirements on page 2 of the Air ambulance flight information (non-emergency) form and in upcoming issues of The Record and BCN Provider News. The Blue Cross and BCN provider manuals are also being updated.

The following articles were published in past newsletter issues:

Posted: March 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Tell us what you think about our provider manuals – You could win a prize

We're working to improve our service to you and would like your opinion on our provider manuals. Please complete our online survey by April 30. You could win a $25 gift certificate. For more information, see recent articles in The Record and BCN Provider News.

Posted: March 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Provider forums are coming to a town near you

Blue Cross Blue Shield of Michigan and Blue Care Network's 2018 provider forums begin in May. You can register for the full day or choose to attend just the morning or afternoon session. Dates, times, locations and registration information can be found on our provider forum flyer (PDF).

The morning sessions will have content specifically geared to physician office staff who are responsible for closing gaps related to quality measures and coding and will include:

  • The patient experience - why it's important to your practice and how you can improve it
  • 2018 CPT updates and coding scenarios for primary care physicians and specialists
  • HEDIS® measures

The afternoon sessions will be geared toward all office personnel and will include:

  • New provider service model
  • eviCore and prior authorizations
  • e-referral
  • The opioid epidemic
  • Behavioral health
  • Provider enrollment and provider inquiry updates

We hope you can join us.

HEDIS® is a registered trademark of the National Committee for Quality Assurance, or NCQA.

Posted: March 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Effective immediately, two CAR T-cell therapies require authorization for Medicare Advantage members

Effective immediately, the following CAR (chimeric antigen receptor) T-cell therapies require authorization for Blue Cross Medicare Plus BlueSM PPO and BCN AdvantageSM members:

HCPCS code Brand name Generic name
Q2041 YescartaTM axicabtagene ciloleucel
Q2040 KymriahTM tisagenlecleucel

To request authorization for these therapies:

  1. Complete the Medication Authorization Request Form on this page for the medication you're requesting.
  2. Gather the following supporting clinical documentation:
    • The member's eligibility for autologous hematopoietic stem cell transplant
    • Testing for CD19 tumor expression
    • Previous gene therapy
    • Detailed information about the therapies the member has already received
  3. Fax the completed form and the clinical documentation to 1-866-392-6465.

Since these requests require thorough review, we ask that you request an expedited review only if the standard review time frame could place the member's health in serious jeopardy.

Posted: March 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Proceed with outpatient authorization requests for knee arthroplasty in e-referral

When submitting authorization requests for knee arthroplasty procedures in an outpatient setting, you may see a message in the e-referral system indicating "Procedure is not appropriate for treatment setting."

Here's what to do: Please ignore the message and proceed with the outpatient authorization request.

This applies to procedure codes *27446 and *27447, for BCN HMOSM (commercial), BCN AdvantageSM and Blue Cross Medicare Plus BlueSM members.

This year, the Centers for Medicare & Medicaid Services began allowing knee arthroplasty procedures to be done in an outpatient setting. The e-referral system will accept those authorization requests but it's displaying the message that makes it seem like it won't. We're getting many calls from providers asking what they should do.

The e-referral system is being adjusted to stop displaying the message, but the update won't be completed until sometime in April. At that time, you'll no longer see the "Procedure is not appropriate for treatment setting" message when submitting outpatient knee arthroplasty authorization requests.

Meanwhile, ignore the message and proceed with the outpatient request.

We appreciate your patience as we update the e-referral system.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2017 American Medical Association. All rights reserved.

Posted: February 2018
Line of business: Blue Cross and Blue Care Network

Non-emergency air ambulance services require authorization starting April 2, 2018, for commercial members

Effective for dates of service on or after April 2, 2018, all non-emergency air ambulance transports for Blue Cross PPO (commercial) and Blue Care Network HMOSM (commercial) members require authorization. Requests for authorization must be submitted to Alacura Medical Transportation Management, LLC, prior to the flight. Information about the process to use in submitting these requests will be made available closer to the April effective date.

This requirement applies to both in-state and out-of-state air ambulance transports.

Blue Cross and BCN are partnering with Alacura to provide review of non-emergency air ambulance flights. Alacura will use the Blue Cross and BCN medical policy titled Air Ambulance Services to determine the appropriateness of non-emergency flights.

There are no changes to member benefits related to air ambulance services. Non-emergency air ambulance services are eligible for reimbursement if the member has the benefit and if Alacura authorizes the flight.

Reason for this change: Air ambulance transports that are not medically necessary or that are flown by noncontracted providers expose Blue Cross and BCN members to significantly greater out-of-pocket costs and are much costlier for the plan. The requirement for authorization prior to non-emergency flights is expected to lower costs for Blue Cross and BCN members and customers.

Billing air ambulance claims: As a reminder, instructions for billing emergency and non-emergency air ambulance services for dates of service on or after Jan. 1, 2017, are now available. For the details, see the web-DENIS message posted Jan. 12, 2018, titled "Air ambulance billing instructions are now available."

Posted: January 2018
Line of business: Blue Cross and Blue Care Network

Blue Cross and Blue Care Network will no longer cover hyaluronic acids, starting April 1

Blue Cross Blue Shield of Michigan PPO (commercial) and Blue Care Network HMOSM (commercial) plans won't cover hyaluronic acids, beginning April 1, 2018.

Hyaluronic acids, also known as viscosupplements, are used to treat osteoarthritis of the knee.

Randomized controlled trials and national guidelines have examined the effect of hyaluronic acids on pain and function. The combined data show:

  • A lack of defined meaningful clinical improvements over placebo
  • Well-characterized biases among trials
  • Publication bias
  • Missing study results

Effective April 1, 2018, the following hyaluronic acids will be considered investigational and won't be covered for Blue Cross and BCN commercial (non-Medicare) members.

J code Drug description
J7320 Hyaluronan or derivative, GenVisc® 850 for intra-articular injection, 1 mg
J7321 Hyaluronan or derivative, Hyalgan® for SupartzTM for intra-articular injection, per dose
J7322 Hyaluronan or derivative, Hymovis® for intra-articular injection, 1 mg
J7323 Hyaluronan or derivative, Euflexxa® for intra-articular injection, per dose
J7324 Hyaluronan or derivative, Orthovisc® for intra-articular injection, per dose
J7325 Hyaluronan or derivative, Synvisc® or Synvisc-One® for intra-articular injection, 1 mg
J7326 Hyaluronan or derivative, Gel-One® for intra-articular injection, per dose
J7327 Hyaluronan or derivative, Monovisc® for intra-articular Injection, per dose
J7328 Hyaluronan or derivative, Gel-SynTM for intra-articular injection, 0.1 mg
Future J codes Future hyaluronan or derivative products, not yet approved by the FDA

Posted: January 2018
Line of business: Blue Cross and Blue Care Network

Behavioral health medical record documentation requirements apply to all lines of business

Behavioral health medical record documentation requirements are now available online. These requirements apply across all lines of business (Blue Cross PPO, Blue Cross Medicare Plus BlueSM PPO, BCN HMOSM and BCN AdvantageSM).

The requirements are available on this website, on both the Blue Cross Behavioral Health page and the BCN Behavioral Health page.

Professional, hospital and facility behavioral health providers contracted with Blue Cross or BCN must follow these requirements when documenting behavioral health services provided to our members.

One set of guidelines is for applied behavior analysis services. The other set applies to non-ABA services.

For additional information on these requirements, including why they were put in place, please review the following news articles:

Posted: November 2017
Line of business: Blue Cross and Blue Care Network

e-referral site wins communications awards

The e-referral site was honored recently with two awards from the International Association of Business Communicators.

Locally, the site received a Detroit Renaissance Award of Merit in Digital Communications. The Detroit chapter includes professional communicators from southeast Michigan.

At a regional level, the site received a Silver Quill Award of Merit from the IABC Heritage Region, which includes 17 states and the District of Columbia. The e-referral redesign was the only project from Michigan to receive this prestigious award.

Congratulations to the team behind the award-winning e-referral site.

Posted: October 2017
Line of business: Blue Cross and Blue Care Network

Do not refer new patients to MedEQUIP in Ann Arbor

Michigan Medicine's MedEQUIP provider of durable medical equipment is not accepting new patients as of Oct. 20, 2017. This is a temporary situation. Please see the MedEQUIP website for any exceptions and the latest information.

Posted: October 2017
Line of business: Blue Cross and Blue Care Network

2017 InterQual criteria to be implemented starting October 2

Blue Cross Blue Shield of Michigan and Blue Care Network will implement the 2017 InterQual® criteria starting Oct. 2, 2017, for all levels of care. These criteria are used to make utilization management and care management determinations for the services subject to review.

Until that date, the 2016 InterQual criteria will be used.

In addition, starting October 2, Blue Cross and BCN will implement their local rules. Until that date, the 2016 local rules will be used.

To access the 2017 Blue Cross Local Rules, do the following:

  1. Log in to Provider Secured Services.
  2. Click BCBSM Provider Publications and Resources.
  3. Click Newsletters & Resources.
  4. Click Clinical Criteria & Resources.
  5. Scroll down to the heading "BCBSM modifications to InterQual criteria."
  6. Click 2017 BCBSM modifications to InterQual criteria.

To access the 2017 BCN Local Rules, visit BCN's Clinical Review & Criteria Charts page on this website and click BCN's current Local Rules.

As a reminder, implementation of the 2017 criteria and local rules was delayed due to upgrades being made to the e-referral system.

Posted: September 2017
Line of business: Blue Cross and Blue Care Network

ALERT: eviCore call centers may be affected by Hurricane Irma, use online portal

While the eviCore call centers, located in Florida and South Carolina, may be affected by Hurricane Irma, the online portal will remain fully operational.

You are encouraged to use the online portal at evicore.com to initiate authorization requests and check case status until the area has recovered. Calls will continue to be answered, but you may experience longer phone hold times or other issues.

Thank you for your patience.

Posted: September 2017
Line of business: Blue Cross and Blue Care Network

Reminder: 2017 InterQual criteria delayed until October 2017

As a reminder, Blue Cross Blue Shield of Michigan and Blue Care Network will delay implementing the 2017 InterQual® criteria until October 2017. This delay is due to upgrades being made to the e-referral system.

Until these upgrades are complete, we will continue to follow the 2016 InterQual criteria for all levels of care.

When we have a new date for implementing the 2017 criteria, we'll let you know through our standard channels of communication.

Posted: August 2017
Line of business: Blue Cross and Blue Care Network

For BCN and Blue Cross Medicare Plus Blue PPO, use 1-800-437-3803 to reach the Pharmacy Clinical Help Desk

Providers who need to contact the Pharmacy Clinical Help Desk about drugs covered under the medical benefit should call 1-800-437-3803, effective July 5, 2017. This applies to members covered through BCN HMOSM (commercial), BCN AdvantageSM and Blue Cross Medicare Plus BlueSM PPO products.

Providers who have been using other numbers to contact the Pharmacy Clinical Help Desk for drugs covered under the medical benefit should begin using the 1-800-437-3803 number effective July 5, 2017. All other numbers to the Pharmacy Clinical Help Desk will be discontinued as of July 5, 2017.

Posted: June 2017
Line of business: Blue Cross and Blue Care Network

2017 InterQual criteria delayed until October 2017

Blue Cross Blue Shield of Michigan and Blue Care Network will delay implementing the 2017 InterQual® criteria until October 2017. This delay is due to upgrades being made to the e-referral system.

Until these upgrades are complete, we will continue to follow the 2016 InterQual criteria for all levels of care.

When we have a new date for implementing the 2017 criteria, we'll let you know through our standard channels of communication.

Posted: May 2017
Line of business: Blue Cross and Blue Care Network

Additional information on RC Claim Assist now available to Blue Cross and BCN providers

Providers who bill for drugs covered under the medical benefit for their Blue Cross and Blue Care Network commercial members are encouraged to review the additional information now available on the RC Claim Assist tool.

On this website, select BCN or Blue Cross and click to open:

The resources available include:

About RC Claim Assist

RC Claim Assist, created by RJ Health Systems, is a free resource now available to Blue Cross Blue Shield of Michigan and Blue Care Network contracted providers who bill for drugs covered under the medical benefit. The tool can help ensure that you are billing:

  • The correct National Drug Code with the billable HCPCS/CPT code
  • The correct NDC quantity
  • The correct unit of measure

Additional webinars to be scheduled later in the year

Additional provider webinars on the RC Claim Assist tool will be scheduled later in 2017. In the meantime, you should review the information currently available, register for the tool and begin using it. Click here to register for RC Claim Assist or to log in, if you are already registered.

Posted: April 2017
Line of business: Blue Cross and Blue Care Network

RC Claim Assist tool is now available

RC Claim Assist, created by RJ Health Systems, is a free resource now available to Blue Cross Blue Shield and Blue Care Network contracted providers who bill for drugs covered under the medical benefit. The tool can help ensure that you are billing:

  • The correct National Drug Code with the billable HCPCS/CPT®* code
  • The correct NDC quantity
  • The correct unit of measure

Training webinar

Click to open our webinar invitation and sign up to attend one of the RC Claim Assist training webinars we're hosting on March 14, 2017.

How do I access RC Claim Assist?

Visit the RC Claim Assist log-in page. Register to use RC Claim Assist by completing the following steps:

  1. Enter your NPI. (Very important!)
  2. Enter your first name and last name.
  3. Create your unique password when you are prompted to do so.

RC Claim Assist should be used only for claims submitted for Blue Cross Blue Shield of Michigan and Blue Care Network commercial members.

Questions?

Here's how to get your questions answered:

  • For questions concerning the data you see on RC Claim Assist, please email info@rjhealthsystems.com
  • For questions about billing or claims, contact Provider Inquiry.
  • For questions about a claim that are contractual or complex in nature, contact your provider consultant.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2016 American Medical Association. All rights reserved.

Posted: March 2017
Line of business: Blue Cross and Blue Care Network

Online self-paced training modules now available

You can now train on e-referral at your own speed. Go to the Training Tools page and look for Online self-paced learning modules in the Online training section. While you're there, check out the other training tools available to you.

Posted: September 2016
Line of business: Blue Cross and Blue Care Network



Welcome to the new referrals.bcbsm.com

You've probably already noticed things have changed. On our new site, to find the BCN information you've used in the past, just click "BCN" along the top or at the left of any page. You'll find all of the BCN-related referral and authorization information in the section that opens.

As time goes on, more information will be added to the Blue Cross section of the website.

When you first enter ereferrals.bcbsm.com, you're in the Home area where you’ll find pages like Provider Search and Quick Guides. This is information that may apply to both BCN and Blue Cross. When a page first displays in the Home section, all BCN and Blue Cross information is visible. To see information specific to a certain line of business, click either the Blue Cross or the BCN filter button at the top of the content section. To see all of the information again, click "Show All."

When you access one of these pages from within the BCN or Blue Cross section, though, only the information relevant to that line of business will be displayed and no filter buttons will appear.

The new ereferrals.bcbsm.com site also includes a Search feature. Look in the upper right part of the page. You can choose to search the Full Site or just the BCN or Blue Cross sections of the site. Enter your search term, select where you want to search from the drop-down, and click "Go."

Thank you to those who participated in the survey held earlier this year. Your input was used to determine some of the enhancements made to the site. If you have comments, please send us feedback.

Posted: May 2016
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

We're updating our look

In mid-May, ereferrals.bcbsm.com is launching a makeover. All the news, forms and information you've come to expect from the site will still be available, but we hope you'll find the new colors and photos more appealing. A new search feature will make the site easier to use. We're also adding a new section for Blue Cross content. Here's a sample of what's coming:

Posted: May 2016
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Update: Questionnaire updates in the e-referral system on Oct. 25

This message was originally posted on Oct. 12, 2020. On Oct. 20, we updated this message to reflect that we’ll be updating two additional questionnaires on Oct. 25.

We use our authorization criteria and medical policies and your answers to the questionnaires in the e-referral system when making utilization management determinations on your authorization requests.

On Oct. 25, 2020, we'll update the following questionnaires in the e-referral system for BCN HMOSM and BCN AdvantageSM members:

  • Breast implant management
  • Breast reconstruction
  • Breast reduction
  • Orthognathic surgery

Preview questionnaires

You'll be able to access updated preview questionnaires within this website. The preview questionnaires show the questions you'll need to answer in the actual questionnaires that open in the e-referral system. This can help you prepare your answers ahead of time.

To find the preview questionnaires, click BCN and then click Authorization Requirements & Criteria. Scroll down and look under the "Authorization criteria and preview questionnaires" heading.

Authorization criteria and medical policies

The pertinent authorization criteria and medical policies are also available on the Authorization Requirements & Criteria page.

Posted: October 2020
Line of business: Blue Care Network



Update: Starting Sept. 1, BCN requires authorization for elective pediatric feeding programs (S0317)

We're updating an earlier message to clarify that providers should use S0317 with elective inpatient and outpatient pediatric feeding programs. Please use this message as your source of information about BCN's pediatric feeding program authorization requirements.

For dates of service on or after Sept. 1, 2020, services provided through pediatric feeding programs (S0317) require authorization.

This applies to:

  • BCN HMOSM (commercial) members
  • Elective inpatient and elective outpatient programs

Submitting authorization requests

Providers should submit authorization requests through the e-referral system. Here's what to do:

  • Use S0317 when submitting requests for both inpatient and outpatient programs.
  • For elective inpatient requests, do not add the length-of-stay procedure code. Use only the S0317 code when submitting authorization requests.

Claim submission for elective inpatient programs

For inpatient authorization requests that BCN approves, the length-of-stay procedure code will be added to the case so that you'll be able to bill a regular inpatient admission for reimbursement purposes. Bill the inpatient admission as you normally would. Do not bill elective inpatient pediatric feeding programs with the S0317 code.

Criteria

The criteria used to make determinations on these authorization requests are included in the Pediatric Feeding Programs medical policy (PDF), which was effective May 1, 2020.

We referred to this medical policy in the May-June 2020 (PDF) issue of BCN Provider News, in an article titled "Medical Policy Updates" (page 12).

Additional information

We're updating the following documents to reflect this new authorization requirement:

These documents are available on the Authorization Requirements & Criteria page in the BCN section of this website. Look under the "Referral and authorization information" heading.

Posted: September 2020
Line of business: Blue Care Network



New e-referral system upgrades

Blue Care Network made improvements to the e-referral system making it easier for you to submit authorization requests. These changes went into effect on July 27, 2020.

Here's what changed:

  • We're blocking duplicate referrals to prevent unnecessary pends in the system.
  • We're allowing only the member's assigned primary care physician to submit certain requests.
  • Specialists can submit authorization requests for services only if there's a global referral on file for the member. Please see Page 19 of the e-referral User Guide for rules when a global referral is required.

These changes were announced in an article on Page 35 of the July-August 2020 BCN Provider News. (PDF)

You can access our e-referral changes webinar recording previously held in July to learn more. To find the on-demand training:

  • Log in to Provider Secured Services
  • Go to BCN Provider Publications and Resources
  • Click on Learning opportunities under Other Resources

The e-referral User Guide (PDF) and eLearning modules have also been updated on the Training Tools page to reflect these changes.

Posted: August 2020
Line of business: Blue Care Network



During the COVID-19 emergency, we're extending global referrals through at least Dec. 31 for BCN HMOSM members

Blue Care Network is implementing another utilization management change aimed at supporting our providers during the COVID-19 emergency.

Change in the duration of global referrals for elective and non-urgent services

Here's what's changing for global referrals submitted for BCN HMO (commercial) members on or after March 13, 2020:

  • For referrals with end dates in 2020, the end date will automatically be extended to Dec. 31, 2020.
  • For referrals with end dates after Dec. 31, 2020, the end date specified in the e-referral system will apply.

This applies to global referrals submitted by both in-state and out-of-state providers.

This doesn't apply to BCN AdvantageSM, Medicare Plus BlueSM PPO or Blue Cross' PPO members, because global referrals are not required for those members.

More information

We'll add this information to the COVID-19 utilization management changes document, which you can access on this website, on the Blue Cross Authorization Requirements & Criteria page and the BCN Authorization Requirements & Criteria page.

You can also find this document on our public website at bcbsm.com/coronavirus and through Provider Secured Services.

Posted: August 2020
Line of business: Blue Care Network



New e-referral questionnaires to open June 14 for BCN HMOSM

Starting June 14, 2020, new questionnaires will open in the e-referral system for certain procedures. In addition, new preview questionnaires will be available on this website.

We're replacing the Pregnancy termination 1 - Medically necessary or elective questionnaire with the following two questionnaires for adult BCN HMO members:

  • Pregnancy termination 1 - Medically necessary. Applicable procedure codes are: *01966, *59100, *59840, *59841, *59850, *59851, *59852, *59855, *59856, *59857, *59866, S0190, S0191, S0199, S2260, S2265, S2266, S2267.
  • Pregnancy termination 3 - Elective. Applicable procedure codes are: *01966, *59100, *59840, *59841, *59850, *59851, *59852, *59855, *59856, *59857, *59866, S0190, S0191, S0199, S2260, S2265, S2266, S2267.

We'll make preview questionnaires available for the new questionnaires soon. To find the preview questionnaires, click BCN and then click Authorization Requirements & Criteria. Scroll down and look under the "Authorization criteria and preview questionnaires" heading.

The preview questionnaires show the questions you'll need to answer in the actual questionnaires that open in the e-referral system. This will help you prepare your answers ahead of time.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2019 American Medical Association. All rights reserved.

Posted: June 2020
Line of business: Blue Care Network



Some Blue Care Network transitional care fax numbers discontinued starting June 1

Starting June 1, 2020, the following BCN transitional care fax numbers will be discontinued:

  • 1-866-652-8985
  • 1-866-578-5482

If you're currently faxing transitional care authorization requests or clinical documentation - or any other documentation - to those numbers, you must submit those materials using a different method starting June 1.

Here's what you need to know.

Home health care services

For home health care services such as nursing visits and physical, occupational and speech therapy provided by a home health care facility in a members' home:

  • For BCN HMOSM and BCN AdvantageSM members covered through the UAW Retiree Medical Benefits Trust (group number 00278806), don't submit anything to us. Neither referral nor authorization is required for traditional home health care services. This applies to both contracted and noncontracted providers.
  • For BCN HMO and BCN Advantage members not covered through the UAW Retiree Medical Benefits Trust, submit home health authorization requests only for these providers:
    • Noncontracted providers: Call these requests in to BCN Utilization Management at 1-800-392-2512.
    • Contracted providers who don't belong to the provider network associated with the member's plan: Submit these authorization requests through the e referral system.

Note: For other contracted providers, don't submit referrals or authorization requests. Neither is required.

Home enteral feedings

For all BCN members, authorization is required for enteral feeding services. Submit authorization requests through the e-referral system and complete the questionnaire that opens.

Note: Authorization is not required for either total parenteral nutrition or intradialytic parenteral nutrition services. This applies to both contracted and noncontracted providers and to all BCN HMO and BCN Advantage members.

Fax number for transitional care services

Once the two fax numbers mentioned above are discontinued, the only fax number for BCN transitional care services will be 1-866-526-1326. Providers should use that fax number to submit authorization requests for home health care and home enteral feedings only when the e-referral system is unavailable.

Posted: April 2020
Line of business: Blue Care Network



We're experiencing issues with processing some Supartz FX (sodium hyaluronate) claims for BCN AdvantageSM members

We're currently experiencing issues with processing some Supartz FX (sodium hyaluronate) claims for BCN Advantage members.

We're working to resolve the issues as quickly as possible.

In the meantime, here's what you need to do:

  • For Supartz FX claims that were denied with a message of "NLX Authorization Not Found" (QH9), you don't need to do anything. We'll reprocess your claims for payment within 30 days.
  • For future Supartz FX claims, submit them as usual with the appropriate HCPCS code and the correct National Drug Code, or NDC, for BCN Advantage members. If the claims are denied, we'll reprocess them within 30 days.

We apologize for any inconvenience. When this issue has been resolved, we'll post a web-DENIS message and a news item on the ereferrals.bcbsm.com website to let you know.

Posted: April 2020
Line of business: Blue Care Network



Submit requests for swallow services to BCN, not to eviCore healthcare

In this message, we're clarifying:

  • That BCN Utilization Management manages authorizations for outpatient swallow services for BCN HMOSM (commercial) and BCN AdvantageSM members
  • That swallow services are handled separately from speech therapy, which is managed by eviCore healthcare
  • How to request approval for these services

Here's what you need to know.

Submit requests for swallow services to BCN

Requests for outpatient swallow services must be submitted to BCN Utilization Management through the e-referral system or by calling 1-800-392-2912.

Here are the requirements for these services:

  • Swallow evaluations (procedure code *92610) and swallow studies (procedure codes *92611 through *92617) require plan notification.
  • Swallow therapy (procedure code *92526) requires authorization. Determinations are made based on medical necessity review. You must submit clinical information along with the authorization request.

Refer to the e-referral User Guide for instructions on how to submit plan notifications and authorization requests using the e-referral system.

Submit requests for speech therapy to eviCore

Swallow evaluations, studies and therapy are handled separately from speech therapy, which is managed by eviCore healthcare.

Submit authorization requests for outpatient speech therapy to eviCore in one of the following ways:

  • Recommended: Use the eviCore healthcare provider portal at www.evicore.com.**
  • Alternatives: Call eviCore at 1-855-774-1317 or fax to eviCore at 1-800-540-2406.

We'll update our documents

We'll update the following documents to clarify the requirements for swallow services:

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2019 American Medical Association. All rights reserved.

**Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're required to let you know we're not responsible for its content.

Posted: January 2020
Line of business: Blue Care Network



Authorization requirements are changing for home health, TPN and IDPN services for BCN members

Authorization requirements are changing for home health, total parenteral nutrition and intradialytic parenteral nutrition services for Blue Care Network members.

Here's what's changing.

Home health services

For traditional home health care, including services such as nursing visits and physical, occupational and speech therapy, the following changes are occurring:

  • For BCN HMOSM (commercial) and BCN AdvantageSM members covered through the UAW Retiree Medical Benefits Trust, home health no longer requires authorization. This was effective in December 2019 and applies to both contracted and noncontracted providers.
  • For BCN HMO and BCN Advantage members not covered through the UAW Retiree Medical Benefits Trust, home health requires authorization for these providers:
    • Noncontracted providers. Call these authorization requests in to BCN Utilization Management at 1-800-392-2512.
    • Providers who are contracted with BCN but who do not belong to the provider network associated with the member's plan. Submit these authorization requests through the e-referral system.

TPN and IDPN services

TPN and IDPN services won't require authorization for BCN members starting Feb. 3, 2020. This applies to both contracted and noncontracted home infusion providers and to all BCN HMO and BCN Advantage members.

Additional information

In February 2020, we'll update the Care Management chapter of the BCN Provider Manual to reflect the changes related to home health, TPN and IDPN. Look in the section titled "Guidelines for transitional care."

We'll also remove the Home care form and the TPN Nutrition Assessment / Follow-up Form from our ereferrals.bcbsm.com website.

These changes don't affect enteral nutrition services, which continue to require authorization. Submit authorization requests for enteral nutrition through the e-referral system and complete the questionnaire that opens.

Posted: January 2020
Line of business: Blue Care Network



How to submit inpatient authorization requests to BCN during upcoming holiday closure

On Monday, Jan. 20, 2020, Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will be closed for the Martin Luther King, Jr., holiday.

During this office closure, follow the guidelines outlined below when submitting inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

Acute initial inpatient admissions. Submit these authorization requests as well as concurrent reviews through the e-referral system, which is available 24 hours a day, seven days a week. If the e-referral system is not available, you can fax requests for inpatient admissions and continued stays to BCN HMO (commercial) at 1 866 313 8433 and to BCN Advantage at 1 866 526 1326.

Note: These requests may also be submitted through the X12N 278 Health Care Services Review - Request for Review and Response electronic standard transaction.

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

Post-acute initial and concurrent admission reviews.

Other authorization requests. The types of requests listed below must be submitted by fax. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

  • Authorization requests for sick or ill newborns
  • Requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN after-hours utilization management hotline at 1-800-851-3904 and listen to the prompts for help with the following:

  • Determining alternatives to inpatient admissions and triage to alternative care settings
  • Handling expedited appeals of utilization management decisions

Note: Do not use the after-hours utilization management phone number to request authorization for routine inpatient admissions.

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member’s medical condition and coordinate care prior to admitting the member.

Posted: January 2020
Line of business: Blue Care Network



How to submit inpatient authorization requests to BCN during upcoming holiday closures

As a reminder, Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will be closed on these days:

  • Tuesday, Dec. 24 and Wednesday, Dec. 25, for the Christmas holidays
  • Tuesday, Dec. 31 and Wednesday, Jan. 1, for the New Year’s holidays

During these office closures, follow the guidelines outlined below when submitting inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

Acute initial inpatient admissions. Submit these authorization requests as well as concurrent reviews and discharge dates through the e-referral system, which is available 24 hours a day, seven days a week. If the e-referral system is not available, you can fax requests for inpatient admissions and continued stays to BCN HMO (commercial) at 1 866 313 8433 and to BCN Advantage at 1 866 526 1326.

Note: These requests may also be submitted through the X12N 278 Health Care Services Review - Request for Review and Response electronic standard transaction.

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

Post-acute initial and concurrent admission reviews.

Other authorization requests. The types of requests listed below must be submitted by fax. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

  • Authorization requests for sick or ill newborns
  • Requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN After-Hours Care Manager hotline at 1-800-851-3904 and listen to the prompts for help with the following:

  • Determining alternatives to inpatient admissions and triage to alternative care settings
  • Arranging for emergency home health care, home infusion services and in-home pain control
  • Arranging for durable medical equipment
  • Handling emergency discharge planning coordination and authorization
  • Handing expedited appeals of utilization management decisions

Note: Do not use the after-hours care manager phone number to request authorization for routine inpatient admissions.

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member's medical condition and coordinate care prior to admitting the member.

Posted: December 2019
Line of business: Blue Care Network



How to submit inpatient authorization requests to BCN during upcoming holiday closures

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will be closed on these days:

  • Thursday, Nov. 28 and Friday, Nov. 29, for the Thanksgiving holidays
  • Tuesday, Dec. 24 and Wednesday, Dec. 25, for the Christmas holidays
  • Tuesday, Dec. 31 and Wednesday, Jan. 1, for the New Year’s holidays

During these office closures, follow the guidelines outlined below when submitting inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

Acute initial inpatient admissions. Submit these authorization requests as well as concurrent reviews and discharge dates through the e-referral system, which is available 24 hours a day, seven days a week. If the e-referral system is not available, you can fax requests for inpatient admissions and continued stays to BCN HMO (commercial) at 1 866 313 8433 and to BCN Advantage at 1 866 526 1326.

Note: These requests may also be submitted through the X12N 278 Health Care Services Review - Request for Review and Response electronic standard transaction.

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

Post-acute initial and concurrent admission reviews.

Other authorization requests. The types of requests listed below must be submitted by fax. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

  • Authorization requests for sick or ill newborns
  • Requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN After-Hours Care Manager hotline at 1-800-851-3904 and listen to the prompts for help with the following:

  • Determining alternatives to inpatient admissions and triage to alternative care settings
  • Arranging for emergency home health care, home infusion services and in-home pain control
  • Arranging for durable medical equipment
  • Handling emergency discharge planning coordination and authorization
  • Handing expedited appeals of utilization management decisions

Note: Do not use the after-hours care manager phone number to request authorization for routine inpatient admissions.

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member's medical condition and coordinate care prior to admitting the member.

Posted: November 2019
Line of business: Blue Care Network



BCN to deny claims for unauthorized outpatient toxicology laboratory services by non-JVHL laboratories starting Jan. 1, 2020

Effective Jan. 1, 2020, BCN will deny claims for outpatient toxicology laboratory services provided by an out-of-network laboratory without authorization from Joint Venture Hospital Laboratories. This applies to BCN HMOSM (commercial) claims.

BCN contracts with JVHL to provide the statewide provider network for all outpatient laboratory services. This means:

  • Claims for outpatient toxicology laboratory services are eligible for payment only if the service provider is affiliated with JVHL or proper authorization is obtained from JVHL for out-of-network services.
  • Claims for outpatient laboratory services must be submitted to JVHL
  • Referring providers should use JVHL network laboratories.
  • To obtain a service that is not provided by a JVHL laboratory, you must first submit a request for clinical review to JVHL.

Here's additional information you need to know regarding toxicology laboratory testing:

  • It is the responsibility of the physician who orders the toxicology laboratory services to know whether the laboratory is in network and whether the procedure is covered by BCN. This information can be verified by JVHL.
  • The procedure must be properly authorized before the service is provided and before the specimen is directed to an out-of-network laboratory.
  • A BCN member whose toxicology laboratory services are denied as out of network may not be balance-billed.

For assistance in identifying a JVHL network laboratory, call the JVHL administrative offices at 1-800-445-4979. JHVL business hours are 8 a.m. to 4:30 p.m. Monday through Friday; they are closed during the lunch hour, from noon to 1 p.m. (All times are Eastern time.) Messages can be left 24/7 and a return call will be placed during business hours.

Posted: October 2019
Line of business: Blue Care Network



Starting Nov. 1, changes in authorizing human organ transplants for BCN members

Starting Nov. 1, 2019, some changes will occur in the process of authorizing human organ transplants for BCN HMOSM and BCN AdvantageSM members.

Here's what's staying the same:

  • You'll continue to submit these authorization requests either through the e-referral system or by calling BCN Utilization Management at 1-800-392-2512, as you do now.
  • You'll continue to fax your initial clinical information to BCN Utilization Management at 1-800-675-7278, as you do now.

Here's what’s changing:

  • Checklist for additional clinical information, if required. If additional clinical information is needed before a determination can be made on your request, you'll receive a checklist from the corporate Human Organ Transplant Program unit. In that checklist:
    • You'll see the fax number to use when submitting the additional clinical information; the number is 1-866-752-5769.
    • You'll get the phone number for the corporate Human Organ Transplant Program unit; the number is 1-800-242-3504. You'll call that number with questions or for follow up.
  • Two authorization numbers. You'll receive two authorization numbers for approved requests - one for the transplant procedure and one for the inpatient stay. (Currently, you receive only one authorization number that covers both the procedure and the stay.)
  • Where to find the authorization numbers. Once the determination is made, you'll see both authorization numbers in the e-referral system and you'll receive a letter that will show both numbers. We will fax the letter to the person who requested the authorization. (Currently, you see one number in the e-referral system and don't receive any letters.)
  • Attachment A included. For approved authorizations, the letter you receive will include the Human Organ Transplant Program Attachment A: Authorization Form. This will indicate that your claim will be reimbursed with a global rate, which includes payment for both the procedure and the inpatient stay. (Currently, you don't receive this form for BCN authorizations.)
  • Call 1-800-242-3504. You'll call the corporate Human Organ Transplant Program unit at 1-800-242-3504 with any questions or for any follow up needed after you submit the initial authorization request. This number will be included in any faxes and letters you receive. (As noted earlier, you currently call 1-800-392-2512.)
  • You must initiate reauthorization after one year. If the patient does not receive the transplant within one year of the date of the initial authorization, you must request a new authorization either through the e-referral system or by calling BCN Utilization Management at 1-800-392-2512. (Currently, the reauthorization request is handled internally by BCN.)

We're working to minimize any inconvenience to you as we make changes in how we handle the human organ transplant authorization process. If you have any questions or need after-hours assistance, contact the corporate Human Organ Transplant Program unit at 1-800-242-3504.

Posted: October 2019
Line of business: Blue Care Network



Effective immediately, plan notification is no longer required for endometrial ablation and excisional breast biopsy procedures for BCN members

Effective immediately, plan notification is no longer required for endometrial ablation and excisional breast biopsy procedures for BCN HMOSM (commercial) and BCN AdvantageSM members. However, standard regional referral requirements still apply; for example, a global referral is still required where applicable.

This change applies to the following procedure codes:

  • Endometrial ablation: *58353, *58356 and *58563
  • Excisional breast biopsy: *19101, *19120, *19125 and *19126

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.

Posted: September 2019
Line of business: Blue Care Network



New webinars available in September and October for BCN

Provider Experience is continuing its series of training webinars for health care providers and staff.

September sessions focus on AIM Specialty Health.

October sessions focus on the claims and appeals process for Blue Cross Blue Shield of Michigan, Blue Care Network, Medicare Plus BlueSM and BCN AdvantageSM facility and professional claims.

See the Sept.-Oct. issue of BCN Provider News, Page 4 for dates and registration information.

Posted: September 2019
Line of business: Blue Care Network



Endometrial ablation and excisional breast biopsy procedures for BCN members require plan notification, not authorization

Effective immediately, authorization and clinical review are not required for endometrial ablation and excisional breast biopsy procedures for BCN HMOSM (commercial) and BCN AdvantageSM members.

As a result, you no longer need to submit clinical documentation for these requests.

However, these procedures require plan notification to facilitate claims payment. Refer to the e-referral User Guide for instructions on how to submit a plan notification.

This applies to the following procedure codes:

  • Endometrial ablation: *58353, *58356 and *58563
  • Excisional breast biopsy: *19101, *19120, *19125 and *19126

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.

Posted: August 2019
Line of business: Blue Care Network



How to submit inpatient authorization requests to BCN during upcoming holiday closure

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will be closed on Monday, September 2 for the Labor Day holiday.

During this office closure, follow these guidelines when submitting inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

Acute initial inpatient admissions. Submit these authorization requests as well as concurrent reviews and discharge dates through the e-referral system, which is available 24 hours a day, seven days a week. If the e-referral system is not available, you can fax requests for inpatient admissions and continued stays to BCN HMO (commercial) at 1 866 313 8433 and to BCN Advantage at 1 866 526 1326.

Note: These requests may also be submitted through the X12N 278 Health Care Services Review - Request for Review and Response electronic standard transaction.

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

Post-acute initial and concurrent admission reviews.

Other authorization requests. The types of requests listed below must be submitted by fax. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

  • Authorization requests for sick or ill newborns
  • Requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN After-Hours Care Manager hotline at 1-800-851-3904 and listen to the prompts for help with the following:

  • Determining alternatives to inpatient admissions and triage to alternative care settings
  • Arranging for emergency home health care, home infusion services and in-home pain control
  • Arranging for durable medical equipment
  • Handling emergency discharge planning coordination and authorization
  • Handing expedited appeals of utilization management decisions

Note: Do not use the after-hours care manager phone number to request authorization for routine inpatient admissions.

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member's medical condition and coordinate care prior to admitting the member.

Posted: August 2019
Line of business: Blue Care Network



Changes to BCN member transfer request form

We've made the following changes to the form you use to ask us to transfer a member to another BCN primary care physician:

  • You no longer have to enter the medical care group's name, number or region.
  • You must enter the NPI for the current primary care physician assigned to the member.
  • We added a statement that you can check the web-DENIS Member Eligibility/Coverage screen to verify that the member has an active BCN contract, to confirm that you're the primary care physician assigned to this member and to see the date you were assigned to the member.

We've also updated the description of the member transfer request process to reflect these changes.

As a reminder, you can access the process description and the form in a single document posted on BCN's Forms page within Provider Secured Services. Here's how to get to it:

  1. Visit bcbsm.com/providers.
  2. Click Login.
  3. Log in to Provider Secured Services using your user ID and password.
  4. Click BCN Provider Publications and Resources, on the right.
  5. Click Forms.
  6. Click Member Transfer FAQ and Request Form, under the "Member transfer" heading.

We recommend that when you open the form, you download it and save it to your hard drive before entering information into the fields.

Posted: August 2019
Line of business: Blue Care Network



Submit BCN enteral nutrition authorization requests using the e-referral system

You must submit authorization requests for enteral nutrition for BCN members using the e-referral system. We no longer accept these requests when you submit them by fax.

This applies to BCN HMOSM (commercial) and BCN AdvantageSM members, for procedure codes B4034, B4035, B4036, B4081, B4082, B4083, B4087, B4088, B4102, B4103, B4104, B4105, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B9002, B9998, S9341, S9342 and S9343.

Note: You must still submit authorization requests for total parenteral nutrition by fax.

Here's some additional information you need to know:

  • Enteral nutrition requests are approved for a maximum of 90 calendar days. For additional services after 90 days, you must submit a new authorization request through the e-referral system.
  • You'll need to complete the questionnaire that opens in the e-referral system. Refer to the enteral nutrition preview questionnaire, so you can prepare your answers ahead of time.
  • Refer to the e-referral User Guide for instructions on how to submit an outpatient authorization request.
  • You'll find additional resources on how to use the e-referral system on this website, on the Training Tools page.
  • You'll find a link to the enteral nutrition medical policy on BCN's Authorization Requirements & Criteria page on this website.
  • We use our medical policy and your answers to the questionnaire when making utilization management determinations for the authorization requests you submit.
  • We've revised the form you previously used to submit these requests by fax. You should now use that form only for total parenteral nutrition requests.
  • We'll update the Care Management chapter of the BCN Provider Manual in the near future to reflect these changes.

Posted: August 2019
Line of business: Blue Care Network



TAVI/TAVR procedures for BCN members require plan notification, not authorization

Effective immediately, authorization and clinical review are not required for transcatheter aortic valve implantation and transcatheter aortic valve replacement for BCN HMOSM (commercial) and BCN AdvantageSM members. As a result, you no longer need to submit clinical documentation for these requests.

However, TAVI/TAVR procedures require plan notification to facilitate claims payment. When you submit the plan notification, the request will pend. If the request is for the member to see a contracted provider, we will update the pended request to approved. We are in the process of updating the e-referral system so that these requests will automatically approve in the future.

Refer to the e-referral User Guide for instructions on how to submit a plan notification.

This applies to the following procedures codes, which are for TAVI/TAVR: *33361, *33362, *33363, *33364, *33365, *33366, *33367, *33368 and *33369.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.

Posted: August 2019
Line of business: Blue Care Network



Reminder: Effective August 1, authorizations must be obtained from AIM Specialty Health® for most medical oncology and supportive care medications for BCN HMOSM (commercial) members

Effective for dates of service on or after Aug. 1, 2019, Blue Care Network will implement a new utilization management program for medical oncology drugs for BCN HMO (commercial) members. Authorizations must be obtained from AIM Specialty Health for most medical oncology and supportive care medications.

Learn about the new oncology management program and how to use the AIM ProviderPortalSM by attending a webinar (intended for nonclinical provider staff). Webinar dates and registration links are available on page 26 of the July-August 2019 BCN Provider News.

For more information, see the Oncology Management Program: Frequently asked questions for providers document, which is available on this website.

Posted: July 2019
Line of business: Blue Care Network



Additional medical benefit specialty drugs have authorization and site of care requirements for BCN HMOSM members, effective Oct. 1, 2019

Effective Oct. 1, 2019, additional medical benefit specialty drugs have authorization and site of care requirements for BCN HMOSM (commercial) members. These changes don't apply to BCN AdvantageSM members.

Prior authorization requirements

For members initiating ther