Additional medical benefit specialty drugs will have authorization and site of care requirements for Blue Cross' PPO and BCN HMO^SM 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)

• 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:

• The Blue Cross Medical Benefit Drugs - Pharmacy webpage
• The BCN Medical Benefit Drugs - Pharmacy webpage

We'll update the requirements list for each drug shown above prior to the date of the change for that drug.

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.

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

We're adding medications to the Medicare Plus Blue^SM PPO and BCN Advantage^SM 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^® ProviderPortal^SM

• 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.

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 Blue^SM PPO and BCN Advantage^SM 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.

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.

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 Blue^SM PPO, BCN HMO^SM (commercial) and BCN Advantage^SM members
• Speech therapy for BCN HMO (commercial) and BCN Advantage members

Additional information is available on the ereferrals.bcbsm.com website:

• On BCN's Outpatient PT, OT, ST page
• On the Blue Cross eviCore-Managed Procedures page. Look in the "For Medicare Care Plus Blue PPO members" section.

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.

Additional medical benefit specialty drugs will require prior authorization for Blue Cross' PPO and BCN HMO^SM 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 Blue^SM PPO, BCN Advantage^SM or the Federal Employee Program^® Service Benefit Plan; however, Medicare Plus Blue and BCN Advantage^SM 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:

• The Blue Cross Medical Benefit Drugs - Pharmacy webpage
• The BCN Medical Benefit Drugs - Pharmacy webpage

We'll update the requirements list for the drugs listed above prior to the date on which each drug will require authorization.

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 Blue^SM PPO, BCN HMO^SM and BCN Advantage^SM members.

Click one of the following links to register for the webinar. All times are Eastern time.

• Thursday, Jan. 30, 1 to 1:30 p.m.
• Tuesday, Feb. 11, 1 to 1:30 p.m.
• Tuesday, Feb. 18, 10 to 10:30 a.m.

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.

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

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 HMO^SM and BCN Advantage^SM 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.

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.

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

We're adding the following medications to the Medicare Plus Blue^SM PPO and BCN Advantage^SM 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.

For Blue Cross' PPO (commercial) and BCN HMO^SM (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 Blue^SM PPO or BCN Advantage^SM members.

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.

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 Blue^SM PPO and BCN Advantage^SM 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 HMO^SM (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 ProviderPortal^SM 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.

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 Blue^SM PPO, BCN HMO^SM (commercial) and BCN Advantage^SM 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.

Starting Jan. 1, 2020, Blue Cross' PPO and BCN HMO^SM 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 HMO^SM 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.

Updated e-referral questionnaires to open Sept. 29 for BCN and Medicare Plus Blue^SM 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 HMO^SM and BCN Advantage^SM
• 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.

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

For Medicare Plus Blue^SM PPO and BCN Advantage^SM 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.

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.

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.

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.

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

BCN Advantage^SM and Medicare Plus Blue^SM 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.

• Medicare Claims Processing Manual, Chapter 30*: See section "260.3.6 - Financial Liability for Failure to Deliver a Valid NOMNC."
• Medicare Plus Blue PPO Manual: See the Utilization Management section. Look under the "Post-acute care skilled nursing, inpatient rehabilitation and long-term acute care facilities" heading.
• BCN Provider Manual: See the BCN Advantage chapter. Look in the "BCN Advantage provider appeals" section.

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.

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 Blue^SM PPO and BCN Advantage^SM 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.

• For BCN Advantage, access to Provider Secured Services gives you automatic access to NovoLogix. There's nothing more you need to do.
• 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.

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.

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.

New and updated e-referral questionnaires to open August 25 for BCN and Medicare Plus Blue^SM 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 HMO^SM and BCN Advantage^SM authorization requests for the procedures listed below, which already require authorization.

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.

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.

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 HMO^SM (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:

4. Click BCBSM Provider Publications and Resources.
5. Click Newsletters & Resources.
6. Click Clinical Criteria & Resources.
7. Click Autism under the Resources heading.
8. Click Documentation requirements for applied behavior analysis services.

To access the guidelines through BCN Provider Publications and Resources:

4. Click BCN Provider Publications and Resources.
5. Click Autism.
6. Click Documentation requirements for applied behavior analysis services.

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.

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 Advantage^SM and Medicare Plus Blue^SM 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*:

• naviHealth-assigned RUG level for Medicare Advantage Members
• Frequently Asked Questions: Claims Processing

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.

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.

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 Blue^SM PPO and BCN Advantage^SM 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.

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

We're adding the following medications to the Medicare Plus Blue^SM PPO and BCN Advantage^SM 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.

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 Blue^SM PPO and BCN Advantage^SM members admitted to post-acute care on or after June 1, 2019.

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 Blue^SM PPO and BCN Advantage^SM 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.

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.

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:

• Comprehensive lists of requirements for medical specialty drugs and pharmacy benefit drugs available in the July 2019 issue of The Record
• Enhanced documents now available for Blue Cross and BCN commercial utilization management requirements for medical and pharmacy benefit drugs on page 27 of the July-August 2019 issue of BCN Provider News

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:

• Blue Cross page: Medical Benefit Drugs - Pharmacy
• Blue Care Network page: Medical Benefit Drugs - Pharmacy

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.

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:

• For BCN documents - Click BCN, then click Authorization Requirements & Criteria. Next, look in the "Authorization criteria and preview questionnaires" section.
• For Medicare Plus Blue documents - Click Blue Cross, then click Authorization Requirements & Criteria. Next, look in the "For Medicare Plus Blue PPO members" section.

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.

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 Blue^SM PPO and BCN Advantage^SM 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.

Additional medical benefit specialty drugs require prior authorization for Blue Cross' PPO and BCN HMO^SM 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 Advantage^SM, Medicare Plus Blue^SM 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 Blue Cross Medical Benefit Drugs - Pharmacy webpage
• The BCN Medical Benefit Drugs - Pharmacy webpage

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.

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

Starting June 1, 2019, naviHealth will manage authorizations for admissions for Medicare Plus Blue^SM PPO and BCN Advantage^SM 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.

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.

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

On Aug. 1, 2019, Medicare Plus Blue^SM PPO, Blue Cross Blue Shield of Michigan's Medicare Advantage plan, and Blue Care Network's commercial and Medicare Advantage plans (BCN HMO^SM and BCN Advantage^SM) 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:

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.

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 HMO^SM 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.

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 HMO^SM
• BCN Advantage^SM
• Medicare Plus Blue^SM PPO

The updated authorization criteria and preview questionnaire are available on this website. Here's where to find them:

• For BCN documents - Click BCN, then click Authorization Requirements & Criteria. Next, look in the "Authorization criteria and preview questionnaires" section.
• For Medicare Plus Blue documents - Click Blue Cross, then click Authorization Requirements & Criteria. Next, look in the "For Medicare Plus Blue PPO members" section.

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.

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

We're making changes to the Medicare Plus Blue^SM PPO and BCN Advantage^SM 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.

Learn about Medicare Advantage post-acute care authorization changes

Starting June 1, 2019, naviHealth will manage authorizations for admissions for Medicare Plus Blue^SM PPO and BCN Advantage^SM members who need skilled nursing, inpatient rehabilitation or long-term acute care. Learn more by attending a training session.

• Skilled nursing facility in-person forums or webinars
• Acute care facility webinars
• Inpatient rehabilitation and long-term acute care webinars

More information is available in the May issue of The Record and in the May-June issue of BCN Provider News on page 6.

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 HMO^SM (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 Advantage^SM, Medicare Plus Blue^SM 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:

• The Medical Benefit Drugs - Pharmacy page in the BCN section
• The Medical Benefit Drugs - Pharmacy page in the Blue Cross section. Look under the "For Blue Cross commercial members" heading.

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 HMO^SM (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.

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

We're making changes to the Medicare Plus Blue^SM PPO and BCN Advantage^SM 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.

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.

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.

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 Blue^SM PPO and BCN Advantage^SM 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.

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:

• Monthly physician office version
• Quarterly hospitals and facilities version
• Or specialty-specific versions coming this year for chiropractic, behavioral health, physical, occupational and speech therapy offices or oncology providers

Keep in mind that Blues Brief is not intended to be a replacement for BCN Provider News or The Record.

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 Blue^SM 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 HMO^SM (commercial) and BCN Advantage^SM

  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 HMO^SM (commercial)
• BCN Advantage^SM
• Blue Cross Medicare Plus Blue^SM 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:

• For BCN documents — Click BCN, then click Authorization Requirements & Criteria. Next, look in the "Authorization criteria and preview questionnaires" section.
• For Medicare Plus Blue documents — Click Blue Cross, then click Authorization Requirements & Criteria. Next, look in the "For Blue Cross Medicare Plus Blue PPO members" section.

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 Blue^SM PPO and BCN Advantage^SM 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 Onpattro^TM
• J1746 Trogarzo^TM
• 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 Onpattro^TM
• J1746 Trogarzo^TM
• 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 HMO^SM (commercial)
• BCN Advantage^SM
• Blue Cross Medicare Plus Blue^SM 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:

• For BCN documents — Click BCN, then click Authorization Requirements & Criteria. Next, look in the "Authorization criteria and preview questionnaires" section.
• For Medicare Plus Blue documents — Click Blue Cross, then click Authorization Requirements & Criteria. Next, look in the "For Blue Cross Medicare Plus Blue PPO members" section.

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 Blue^SM PPO and BCN Advantage^SM for maximum reimbursement.

Register for one of the following webinars now:

• Thursday, Dec. 6, 2018, 1 to 1:30 p.m.
• Friday, Dec. 7, 2018, 10 to 10:30 a.m

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 HMO^SM and Blue Cross PPO commercial members as follows:

These changes don't apply to BCN Advantage^SM, Blue Cross Medicare Plus Blue^SM 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 Blue^SM PPO and BCN Advantage^SM 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 Blue^SM PPO and BCN Advantage^SM 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 Blue^SM PPO
• BCN Advantage^SM
• Blue Cross PPO
• BCN HMO^SM

Register for a webinar now:

• Wednesday, Oct. 3, 2018, 1 to 2 p.m.
• Friday, Oct. 5, 2018, 10 to 11 a.m.

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 HMO^SM (commercial)
• BCN Advantage^SM
• Blue Cross Medicare Plus Blue^SM 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:

• For BCN documents — Click BCN, then click Authorization Requirements & Criteria. Next, look in the "Authorization criteria and preview questionnaires" section.
• For Medicare Plus Blue documents — Click Blue Cross, then click Authorization Requirements & Criteria. Next, look in the "For Blue Cross Medicare Plus Blue PPO members" section.

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 Blue^SM PPO
• BCN HMO^SM
• BCN Advantage^SM

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 Diagnostics^TM – 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:

• Blue Cross Behavioral Health page
• BCN Behavioral Health page

The FAQ document is intended to clarify questions about LLP and LMFT requirements related to providing services to Blue Cross PPO (commercial), BCN HMO^SM (commercial) and BCN Advantage^SM 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 HMO^SM (commercial)
• BCN Advantage^SM
• Blue Cross Medicare Plus Blue^SM PPO

The updated authorization criteria and preview questionnaires are available on this website. Here's where to find them:

• For BCN documents — Click BCN, then click Authorization Requirements & Criteria. Next, look in the "Authorization criteria and preview questionnaires" section.
• For Medicare Plus Blue documents — Click Blue Cross, then click Authorization Requirements & Criteria. Next, look in the "For Blue Cross Medicare Plus Blue PPO members" section.

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 HMO^SM (commercial)
• BCN Advantage^SM
• Blue Cross Medicare Plus Blue^SM PPO

The updated authorization criteria and preview questionnaires are available on this website. Here's where to find them:

• For BCN documents — Click BCN, then click Authorization Requirements & Criteria. Next, look in the "Authorization criteria and preview questionnaires" section.
• For Medicare Plus Blue documents — Click Blue Cross, then click Authorization Requirements & Criteria. Next, look in the "For Blue Cross Medicare Plus Blue PPO members" section.

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 Blue^SM PPO
• BCN HMO^SM (commercial)
• BCN Advantage^SM

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 Blue^SM 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.

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 Blue^SM PPO
• BCN HMO^SM (commercial)
• BCN Advantage^SM

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 HMO^SM (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 HMO^SM (commercial), Blue Cross Medicare Plus Blue^SM PPO and BCN Advantage^SM 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

Trogarzo^TM 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 HMO^SM (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.

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 Blue^SM 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.

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 HMO^SM (commercial)
• BCN Advantage^SM
• Blue Cross Medicare Plus Blue^SMPPO

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:

• Links to the BCN documents are on the BCN Authorization Requirements & Criteria page. Look in the section titled "Authorization criteria and preview questionnaires."
• Links to the Medicare Plus Blue documents are on the Blue Cross Authorization Requirements & Criteria page. Look in the section titled "For Blue Cross Medicare Plus Blue PPO members."

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 Blue^SM PPO
• BCN HMO^SM (commercial)
• BCN Advantage^SM

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 Blue^SM 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 HMO^SM (commercial) or BCN Advantage^SM 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, Fasenra^TM and Luxturna^TM 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 Blue^SM PPO and BCN Advantage^SM members.

Note: Authorization is already required for Blue Cross PPO and BCN HMO^SM (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 Blue^SM PPO and BCN Advantage^SM 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 Blue^SM 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 HMO^SM (commercial), BCN Advantage^SM 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 HMO^SM (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:

• The article titled Starting April 2, 2018, non-emergency air ambulance services require authorization for commercial members in the March 2018 issue of The Record
• The article titled Non-emergency air ambulance services require authorization starting April 2, 2018, for commercial members on page 41 of the March-April 2018 issue of BCN Provider News

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 Blue^SM PPO and BCN Advantage^SM members:

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 HMO^SM (commercial), BCN Advantage^SM and Blue Cross Medicare Plus Blue^SM 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 HMO^SM (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 HMO^SM (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.

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 Blue^SM PPO, BCN HMO^SM and BCN Advantage^SM).

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:

• In the November 2017 issue of The Record, see the article Behavioral health documentation guidelines now available.
• In the November-December 2017 issue of BCN Provider News, see the article Behavioral health documentation guidelines now available.

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.