Additional updated authorization criteria and e-referral questionnaires

We're making updates to the authorization criteria and questionnaires in the e-referral system, for the following services:

• Cholecystectomy (laparoscopic) for adults
• Endoscopy, upper gastrointestinal, for gastroesophageal reflux disease
• Hyperbaric oxygen therapy
• Varicose vein treatment

For these services, you'll see the updated questionnaires in the e-referral system starting Dec. 16, 2018.

We use these criteria and questionnaires when making utilization management determinations for the following members:

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

The updated authorization criteria and preview questionnaires are available at ereferrals.bcbsm.com. To find them, click BCN, then click Authorization Requirements & Criteria. Next, look in the "Authorization criteria and preview questionnaires" 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: December 2018
Line of business: Blue Care Network

Xgeva^® to require authorization for BCN Advantage^SM members

Xgeva (J0897) will continue to require authorization for BCN Advantage members in 2019.

On Nov. 1, 2018, a web-DENIS message and a news item at ereferrals.bcbsm.com were posted indicating that Xgeva would not require authorization starting Jan. 1, 2019, for BCN Advantage members.

However, you'll need to continue to submit authorization requests for this drug. We apologize for any inconvenience this may cause.

We've updated the earlier communications, titled "Medicare Part B medical specialty drug prior authorization lists changing in 2019," to reflect the change. You may want to review the earlier communications to refresh your memory on the other changes that will take place.

Additional information

For BCN Advantage, we require prior authorization for Xgeva when you bill it as a professional service or an outpatient facility service based on the following:

Professional CMS-1500 claim form (or electronically via an 837P transaction) for the following sites of care:

• Physician office (Place of Service Code 11)
• Home (Place of Service Code 12)

Facility UB04 claim form (or electronically via an 837I transaction):

• Outpatient facility (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.

Posted: December 2018
Line of business: Blue Care Network

Complete the provider specialty questionnaire in the e-referral system

We'e added a questionnaire to the e-referral system that asks you to select the specialty of the provider you're referring a member to. That's the only question you'll need to answer.

You'll see this provider specialty questionnaire only when you're submitting a global referral to a multispecialty group. As a reminder, only BCN HMO^SM (commercial) members require a global referral.

If you're making a global referral to a multispecialty group, you'll see a prompt asking you to complete the provider specialty questionnaire. Here's what to do:

1. Click the link to open the questionnaire.
2. Select the specialty of the provider you're referring to from the drop-down menu.
3. Click Next to continue submitting your global referral.

Completing the questionnaire will help your referral get to the right provider in the multispecialty group.

The provider specialty questionnaire began opening in the e-referral system on Oct. 28, 2018.

We're updating the e-referral User Guide with information on the provider specialty questionnaire.

Posted: November 2018
Line of business: Blue Care Network

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

A new provider training tool is available to give providers a summary of our authorization programs through AIM Specialty Health^®. The presentation also explains when a new AIM authorization is required.

The AIM presentation is posted in three areas:

• On this website, on BCN's AIM-Managed Procedures page
• On the BCN Provider Publications and Resources website, on the Learning Opportunities page
• On the BCBSM Provider Publications and Resources website, on the Provider Training page

As a reminder, for dates of service on or after Oct. 1, 2018, you must submit authorization requests for cardiology and high-tech radiology procedures for BCN members to AIM Specialty Health.

Some providers are still submitting these requests to eviCore in error.

Here are some important things to know:

• AIM started accepting authorization requests on Sept. 17, 2018, for dates of service on or after Oct. 1. You can submit these requests either through the AIM provider portal or by calling AIM at 1-844-377-1278.


• For dates of service prior to Oct. 1, continue to submit your authorization requests to eviCore healthcare. eviCore will handle all requests for dates of service prior to Oct. 1, including postservice requests.

This applies to BCN HMO^SM (commercial) and BCN Advantage^SM members.

Information about what AIM manages for BCN

Look on the new AIM-Managed Procedures page in the BCN section of this website to find:

• Link to the AIM provider portal


• Procedures that require authorization by AIM Specialty Health – A list of codes representing the procedures AIM manages for BCN for dates of service on or after Oct. 1, 2018


• Cardiology and radiology procedures managed by AIM and eviCore – A list comparing the cardiology and radiology procedure codes AIM manages for BCN for dates of service on or after Oct. 1, 2018, and those managed by eviCore healthcare for dates of service prior to Oct. 1


• Frequently asked questions about AIM – Answers to some questions about working with AIM


• More frequently asked questions about AIM – Additional questions and answers about working with AIM

Posted: November 2018
Line of business: Blue Care Network

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

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will close on the following holidays:

• Tuesday, Nov. 6, 2018 (Election Day)
• Thursday, Nov. 22, 2018 (Thanksgiving)
• Friday, Nov. 23, 2018 (day after Thanksgiving)

During these office closures, BCN's inpatient utilization management area will still accept inpatient authorization requests for BCN HMO^SM (commercial) and BCN Advantage^SM members.

Here's what you need to know about submitting inpatient authorization requests to BCN when our corporate offices are closed.

Acute initial inpatient admissions. Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week.

Note: These requests may also be submitted through the X12N 278 Health Care Services Review – Request for Review and Response electronic standard transaction.

Post-acute initial and concurrent admission reviews. Follow the current process you use to submit these requests by fax at 1-866-534-9994. Refer to the document Post-acute care admissions: Submitting authorization requests to BCN for additional information.

Other authorization requests. The types of requests listed below must be submitted by fax. For these requests, faxes are processed only Monday through Friday. They are not processed on weekends or on the holidays on which BCN is closed. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

• Authorization requests for sick or ill newborns
• Authorization requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN after-hours care manager hotline at 1-800-851-3904 and listen to the prompts for help with the following:

• Determining alternatives to inpatient admissions and triage to alternative care settings
• Arranging for emergency home health care, home infusion services and in-home pain control
• Arranging for durable medical equipment
• Handling emergency discharge planning coordination and authorization
• Handing expedited appeals of utilization management decisions

Note: Do not use the after-hours care manager phone number to request authorization for routine inpatient admissions.

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member's medical condition and coordinate care prior to admitting the member.

Posted: November 2018
Line of business: Blue Care Network

We're telling BCN Advantage^SM members they don't need referrals

We're letting BCN Advantage members know they don't need a referral from their primary care physician for covered services with a specialist who's in the provider network for the member's health plan. Authorizations are still required for certain services.

For details, see the article in the November-December 2018 BCN Provider News, on page 10.

Posted: October 2018
Line of business: Blue Care Network

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

As a reminder, for dates of service on or after Oct. 1, 2018, you must submit authorization requests for cardiology and high-tech radiology procedures for BCN members to AIM Specialty Health^®.

Some providers are still submitting these requests to eviCore in error.

Here are some important things to know:

• AIM started accepting authorization requests on Sept. 17, 2018, for dates of service on or after Oct. 1. You can submit these requests either through the AIM provider portal or by calling AIM at 1-844-377-1278.


• For dates of service prior to Oct. 1, continue to submit your authorization requests to eviCore healthcare. eviCore will handle all requests for dates of service prior to Oct. 1, including postservice requests.

This applies to BCN HMO^SM (commercial) and BCN Advantage^SM members.

Information about what AIM manages for BCN

Look on the new AIM-Managed Procedures page in the BCN section of this website to find:

• Link to the AIM provider portal


• Procedures that require authorization by AIM Specialty Health – A list of codes representing the procedures AIM manages for BCN for dates of service on or after Oct. 1, 2018


• Cardiology and radiology procedures managed by AIM and eviCore – A list comparing the cardiology and radiology procedure codes AIM manages for BCN for dates of service on or after Oct. 1, 2018, and those managed by eviCore healthcare for dates of service prior to Oct. 1


• Frequently asked questions about AIM – Answers to some questions about working with AIM


• More frequently asked questions about AIM – Additional questions and answers about working with AIM

Posted: October 2018
Line of business: Blue Care Network

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

As a reminder, for dates of service on or after Oct. 1, 2018, AIM Specialty Health manages the authorization process for cardiology and high-tech radiology procedures for BCN HMO^SM (commercial) and BCN Advantage^SM members. We first communicated about this in the article AIM Specialty Health to manage cardiology and high-tech radiology procedures for BCN starting October 1 in the July-August 2018 issue of BCN Provider News, on page 33.

Here are some important things to know:

• AIM started accepting authorization requests on Sept. 17, 2018, for dates of service on or after Oct. 1. You can submit these requests either through the AIM provider portal or by calling AIM at 1-844-377-1278.
• For dates of service prior to Oct. 1, continue to submit your authorization requests to eviCore healthcare. eviCore will handle all requests for dates of service prior to Oct. 1, including postservice requests.

Information about what AIM manages for BCN

Look on the new AIM-Managed Procedures page in the BCN section of this website to find:

• Link to the AIM provider portal
• Procedures that require authorization by AIM Specialty Health – A list of codes representing the procedures AIM manages for BCN for dates of service on or after Oct. 1, 2018
• Cardiology and radiology procedures managed by AIM and eviCore – A list comparing the cardiology and radiology procedure codes AIM manages for BCN for dates of service on or after Oct. 1, 2018, and those managed by eviCore healthcare for dates of service prior to Oct. 1
• Frequently asked questions about AIM – Answers to some questions about working with AIM
• More frequently asked questions about AIM – Additional questions and answers about working with AIM

Webinars offered in October

There's still time to sign up for training webinars to learn how to register for and use the AIM ProviderPortal^SM, an online tool used to request authorization from AIM. Here are the days and times for the remaining webinars:

• Wednesday, Oct. 3, 10-11 a.m.
• Thursday, Oct. 4, 2-3 p.m.

For the instructions on how to register, see the webinar invitation.

Posted: September 2018
Line of business: Blue Care Network

BCN updates sleep study questionnaire in the e-referral system

BCN has updated the sleep study questionnaire in the e-referral system. We've condensed the questionnaire, so you'll have fewer questions to answer. The questionnaire pertains to sleep studies in an outpatient facility or clinic-based setting. It became available in the e-referral system starting Sept. 23, 2018.

We use the updated questionnaire in making utilization management determinations for BCN HMO^SM and BCN Advantage^SM members.

You'll find a link to the updated preview questionnaire and the medical policy titled "Sleep Disorders, Diagnosis and Medical Management" on this website. Click BCN, then click Authorization Requirements & Criteria. Next, look in the "Authorization criteria and preview questionnaires" section.

You'll also find links to these documents on the Sleep Management Program page in the BCN section of this website.

You can look over the preview questionnaire to see what questions you'll need to answer so 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
Line of business: Blue Care Network

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

As a reminder, effective Oct. 1, 2018, BCN is adding the following two drugs to its site-of-care optimization program:

• Prolia
• Xgeva

For both medications, the generic name is denosumab and the HCPCS code is J0897.

The site-of-care requirement applies only to BCN HMO (commercial) members. It does not apply to BCN Advantage^SM members.

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.

If a provider feels a member is not a candidate to receive these drugs at a site other than the outpatient hospital, documentation supporting medical necessity must be provided to the plan for review. Those requests will be evaluated on a case-by-case basis.

Requests for Prolia and Xgeva must meet applicable authorization criteria in addition to the site-of-care requirement. This applies to first-time and current users of these medications.

For additional requirements related to drugs covered under the medical benefit, including all drugs identified as subject to site-of-care requirements, refer to the Medical Benefit Drugs – Pharmacy page in the BCN section of this website. Click Requirements for drugs covered under the medical benefit – BCN HMO under the heading "For BCN HMO (commercial) members."

The new site-of-care requirement for Prolia and has been added to the list.

Posted: September 2018
Line of business: Blue Care Network

Reminder: Starting Oct. 1, additional specialty medications require authorization for BCN Advantage^SM members

For dates of service on or after Oct. 1, 2018, additional specialty medications covered under the Medicare Part B medical benefit require authorization for BCN Advantage members.

We first communicated about this in the article Starting Oct. 1, additional specialty medications require authorization for BCN Advantage members, on page 28 of the July-August 2018 BCN Provider News. Please review the article to see which drugs require authorization starting October 1.

These medications are not self administered. They must be given by injection or infusion by a physician or health care professional in the office or outpatient facility setting.

These medications require authorization when billed as a professional service (via the paper HCFA 1500 claim form or electronically as an 837P transaction) or as an outpatient facility service (via the UB-04 or electronically as an 837I transaction) and one of the following place of service codes is used:

• Physician office (Place of Service code 11)
• Outpatient facility (Place of Service codes 19, 22 and 24)

We also published an update in the article Clarification: Vivaglobin does not require authorization, on page 8 of the September-October 2018 BCN Provider News.

In addition, an updated list of drugs requiring authorization for BCN Advantage members will be available on this website by the end of September. To see the list, click BCN and then click Medical Benefit Drugs – Pharmacy. Finally, click Requirements for drugs covered under the medical benefit – BCN Advantage.

Note: This communication updates earlier ones, including the newsletter articles, which incorrectly stated that authorization is not required for these medications when they are billed on a facility claim form (such as the UB 04) or electronically via an 837I transaction. We apologize for this error.

Posted: September 2018
Line of business: Blue Care Network

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

Please fax all authorization requests to BCN for post-acute care services for BCN HMO^SM (commercial) and BCN Advantage^SM members. This applies to members transitioning to a skilled nursing facility, a rehabilitation facility or a long-term acute care hospital.

Here's what you need to know

• Fax authorization requests to 1-866-534-9994. We accept faxed requests 24 hours a day, seven days a week.


• Normal business hours for BCN post-acute care staff are Monday through Saturday, 8 a.m. to 5 p.m.


• The on-call nurse is available to assist with admissions on Sundays and holidays and at other times outside of normal business hours. During those times, call the on-call nurse at 1- 800-851-3904 and fax the documentation to 1-866-534-9994.

Here's what to fax

For SNF and rehabilitation admissions, fax these documents:

• A completed Rehabilitation Assessment Form
• History and physical from the hospital admission
• Physical medicine and rehabilitation consultation notes, as appropriate

For LTACH admissions, fax these documents:

• A completed LTACH Assessment Form
• History and physical from the hospital admission
• Physical medicine and rehabilitation consultation notes, as appropriate
• Last two days of practitioner progress notes (admission and concurrent)
• Current intravenous and subcutaneous medication lists

The forms are available on this website, on the BCN Forms page.

A summary of these instructions is available on this website. Click BCN and then click Authorization Requirements & Criteria. Finally, click Post-acute care admissions: Submitting authorization requests to BCN.

The Care Management chapter of the BCN Provider Manual is being updated to reflect this information.

Posted: September 2018
Line of business: Blue Care Network

Renflexis^® requires authorization for BCN Advantage^SM starting Oct. 1

For dates of service on or after Oct. 1, 2018, Renflexis requires authorization for BCN Advantage members.

This medication is not self-administered. It must be given by injection or infusion by a physician or health care professional in the office, home or outpatient facility setting.

This medication requires authorization when it is billed on either a professional HCFA 1500 claim form (or submitted electronically using an 837P transaction) or on a facility claim form such as the UB-04 (or submitted electronically using an 837I transaction), for the following places of service:

• Physician office (Place of Service code 11)
• Home (Place of Service code 12)
• Outpatient facility (Place of Service codes 19 and 22)

Submit authorization requests for this medication through the Novologix online tool. Authorization must be obtained prior to the medication being administered.

Posted: September 2018
Line of business: Blue Care Network

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

Starting Sept. 4, 2018, you can submit inpatient continued stay reviews and discharge notifications for BCN HMO^SM (commercial) and BCN Advantage^SM members through the e-referral system. This applies to members admitted for non-behavioral health services.

Currently, these requests are faxed in to BCN. However, starting Nov. 1, 2018, we will no longer accept faxed requests.

This change means that BCN HMO (commercial) and BCN Advantage inpatient discharge notifications and continued stay reviews will be processed through the e-referral system, just like they are for Blue Cross PPO (commercial) and Blue Cross Medicare Plus Blue^SM PPO members.

To request additional days on an inpatient admission

To request additional days, follow the instructions in the e-referral User Guide for extending an inpatient authorization. Here's what it says: To extend service on an existing Inpatient Authorization, begin by locating your authorization. Click the Edit button on the right side of the details page. Scroll down to the Confinement Extension(s) section, click the Create New button and enter your new dates and the number of days.

You must also submit clinical information related to the continued stay. To do that, follow the instructions in the article How to attach clinical information to your authorization request in the e-referral system, on page 44 in the November-December 2016 issue of BCN Provider News.

To submit a discharge notification

To notify us of a member's discharge, enter the discharge date in the e-referral Case Communication field. As an alternative, you can record the discharge date on a discharge summary form and attach it to the case in e-referral.

Sign up for e-referral

If you don't currently have access to the e-referral system, we encourage you to sign up for it now so you'll be ready to use it before November 1, when faxes are no longer accepted. Follow the instructions on the Sign Up or Change a User page on this website.

Posted: August 2018
Line of business: Blue Care Network

How to submit BCN inpatient authorization requests during upcoming holiday closures

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices are closed on the following days:

• Monday, Sept. 3, 2018 (Labor Day holiday)
• Tuesday, Nov. 6, 2018 (Election Day holiday)

During these holiday closures, BCN's inpatient utilization management area remains available to accept inpatient authorization requests for BCN HMO^SM (commercial) and BCN Advantage^SM members.

Here's what you need to know about submitting inpatient authorization requests to BCN when our corporate offices are closed.

Acute initial inpatient admissions. Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week.

Note: These requests may also be submitted through the X12N 278 Health Care Services Review – Request for Review and Response electronic standard transaction.

Post-acute initial and concurrent admission reviews. Follow the current process you use to submit these requests by fax at 1-866-534-9994.

Other authorization requests. The types of requests listed below must be submitted by fax. For these requests, faxes are processed only Mondays through Friday. They are not processed on weekends or on the holidays on which BCN is closed. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

• Acute inpatient concurrent reviews and discharge dates, but only for facilities reimbursed on the basis of DRGs
• Authorization requests for sick or ill newborns
• Authorization requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN After-Hours Care Manager hotline at 1-800-851-3904 and listen to the prompts for help with the following:

• Determining alternatives to inpatient admissions and triage to alternative care settings
• Arranging for emergency home health care, home infusion services and in-home pain control
• Arranging for durable medical equipment
• Handling emergency discharge planning coordination and authorization
• Handing expedited appeals of utilization management decisions

Note: Do not use the after-hours care manager phone number to request authorization for routine inpatient admissions.

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member's medical condition and coordinate care prior to admitting the member.

Posted: August 2018
Line of business: Blue Care Network

Phone numbers change for BCN Case Management and Care Transition programs

The phone numbers for BCN's Case Management and Care Transition to Home programs have changed.

To reach staff in these programs, call 1-800-775-2583. Wait to hear the prompts and press the number for the prompt that matches your request.

Please update your files to show the following:

• Instead of the 1-800-943-9744 number for BCN Case Management, call 1-800-775-2583.


• Instead of the 1-800-728-3010 number for the BCN Care Transition to Home program, call 1- 800-775-2583.

The Care Management and BCN Advantage chapters of the BCN Provider Manual are being updated to reflect the new 1-800-775-2583 phone number.

Posted: August 2018
Line of business: Blue Care Network

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

As a reminder, for dates of service on or after Oct. 1, 2018, AIM Specialty Health will manage the authorization process for cardiology and high-tech radiology procedures for BCN HMO^SM (commercial) and BCN Advantage^SM members. We first communicated about this in the article AIM Specialty Health to manage cardiology and high-tech radiology procedures for BCN starting October 1 in the July-August 2018 issue of BCN Provider News, on page 33.

Here are some important things to know:

• AIM will accept authorization requests starting Sept. 17, 2018, for dates of service on or after Oct. 1. You can submit these requests either through the AIM provider portal or by calling AIM at 1-844-377-1278.


• For dates of service prior to Oct. 1, continue to submit your authorization requests to eviCore healthcare. eviCore will handle all requests for dates of service prior to Oct. 1, including postservice requests.

Codes for procedures AIM will manage

Click here for a list of the procedure codes AIM will manage. You'll be able to find the list of codes on this website by the end of September.

Webinars offered in August, September and October

There's still time to sign up for training webinars to learn how to register for and use the AIM ProviderPortal^SM, an online tool used to request authorization from AIM.

Here are the webinar days and times:

• Wednesday, Aug. 22, 10-11 a.m.
• Thursday, Aug. 23, 2-3 p.m.
• Wednesday, Aug. 29, 10-11 a.m.
• Thursday, Aug. 30, 2-3 p.m.
• Wednesday, Sept. 5, 10-11 a.m.
• Thursday, Sept. 6, 2-3 p.m.
• Wednesday, Oct. 3, 10-11 a.m.

For the instructions on how to register, refer to the article in BCN Provider News.

Posted: August 2018
Line of business: Blue Care Network

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

For dates of service on or after Oct. 1, 2018, AIM Specialty Health will manage the authorization process for cardiology and high-tech radiology procedures for BCN HMO^SM (commercial) and BCN Advantage^SM members. We first communicated about this in the article AIM Specialty Health to manage cardiology and high-tech radiology procedures for BCN starting October 1 in the July-August 2018 issue of BCN Provider News, on page 33.

AIM will accept authorization requests starting Sept. 17, 2018. You can submit these requests either through the AIM provider portal or by calling AIM at 1-844-377-1278.

For dates of service prior to Oct. 1, continue to submit your authorization requests to eviCore healthcare.

Webinars offered in August, September and October

We've scheduled training webinars so you can learn how to register for and use the AIM ProviderPortal^SM, an online tool used to request authorization from AIM.

For the training dates and the instructions on how to register, refer to the article in BCN Provider News.

Codes for procedures AIM will manage

Click here for a list of the procedure codes AIM will manage. The list shows the following categories of procedures:

• Category 1: Procedures that require authorization by eviCore healthcare for dates of service through Sept. 30, 2018, and will continue to require authorization by AIM for dates of service on or after Oct. 1, 2018


• Category 2: Procedures that require authorization by eviCore healthcare for dates of service through Sept. 30, 2018, but will not require authorization by AIM for dates of service on or after Oct. 1, 2018


• Category 3: A few procedures that require authorization by eviCore healthcare for dates of service through Sept. 30, 2018, will require authorization by BCN for dates of service on or after Oct. 1, 2018. Submit authorization requests for these procedures directly to BCN through the e-referral system. Don't submit them to AIM.


• Category 4: Procedures that do not require authorization by eviCore healthcare for dates of service through Sept. 30, 2018, but will require authorization by AIM for dates of service on or after Oct. 1, 2018

You'll be able to find the list of codes on our ereferrals.bcbsm.com website by the end of September.

Posted: July 2018
Line of business: Blue Care Network

Starting Oct. 1, additional specialty medications require authorization for BCN Advantage^SM members

For dates of service on or after Oct. 1, 2018, additional specialty medications covered under the Medicare Part B medical benefit require authorization for BCN Advantage members.

We first communicated about this in the article Starting Oct. 1, additional specialty medications require authorization for BCN Advantage members, on page 28 of the July-August 2018 BCN Provider News.

Please review the article to see which drugs require authorization starting October 1.

Exception: Vivaglobin^® (HCPCS code J1562) will not require authorization because it is being discontinued. This is a change from what we communicated in the newsletter article.

These medications are not self administered. They must be given by injection or infusion by a physician or health care professional in the office or outpatient facility setting.

These medications require authorization when billed as a professional service (via the paper HCFA 1500 claim form or electronically as an 837P transaction) or as an outpatient facility service (via the UB-04 or electronically as an 837I transaction) and one of the following place of service codes is used:

• Physician office (Place of Service code 11)
• Outpatient facility (Place of Service codes 19, 22 and 24)

Note: In the July-August 2018 newsletter article, we mentioned only Place of Service codes 19 and 22 for outpatient facilities, but authorization is also required for Place of Service code 24.

Please review the July-August newsletter article for additional information.

In addition, look for an article in the September-October 2018 BCN Provider News that will clarify these changes.

Posted: July 2018
Line of business: Blue Care Network

How to submit BCN inpatient authorization requests during upcoming holiday closures

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices are closed on the following days:

• Wednesday, July 4, 2018 (Fourth of July holiday)
• Monday, Sept. 3, 2018 (Labor Day holiday)

During these holiday closures, BCN's inpatient utilization management area remains available to accept inpatient authorization requests for BCN HMO^SM (commercial) and BCN Advantage^SM members.

Here's what you need to know about submitting inpatient authorization requests to BCN when our corporate offices are closed.

Acute initial inpatient admissions. Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week.

Note: These requests may also be submitted through the X12N 278 Health Care Services Review – Request for Review and Response electronic standard transaction.

Post-acute initial and concurrent admission reviews. Follow the current process you use to submit these requests by fax at 1-866-534-9994.

Other authorization requests. The types of requests listed below must be submitted by fax. For these requests, faxes are processed only Mondays through Friday. They are not processed on weekends or on the holidays on which BCN is closed. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

• Acute inpatient concurrent reviews and discharge dates, but only for facilities reimbursed on the basis of DRGs
• Authorization requests for sick or ill newborns
• Authorization requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN After-Hours Care Manager hotline at 1-800-851-3904 and listen to the prompts for help with the following:

• Determining alternatives to inpatient admissions and triage to alternative care settings
• Arranging for emergency home health care, home infusion services and in-home pain control
• Arranging for durable medical equipment
• Handling emergency discharge planning coordination and authorization
• Handing expedited appeals of utilization management decisions

Note: Do not use the after-hours care manager phone number to request authorization for routine inpatient admissions.

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member's medical condition and coordinate care prior to admitting the member.

Posted: July 2018
Line of business: Blue Care Network

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

Effective Oct. 1, 2018, BCN is adding the following two drugs to its site-of-care optimization program:

• Prolia
• Xgeva

For both medications, the generic name is denosumab and the HCPCS code is J0897.

The site-of-care requirement applies only to BCN HMO (commercial) members. It does not apply to BCN Advantage^SM members.

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.

If a provider feels a member is not a candidate to receive these drugs at a site other than the outpatient hospital, documentation supporting medical necessity must be provided to the plan for review. Those requests will be evaluated on a case-by-case basis.

Requests for Prolia and Xgeva must meet applicable authorization criteria in addition to the site-of-care requirement. This applies to first-time and current users of these medications.

For additional requirements related to drugs covered under the medical benefit, including all drugs identified as subject to site-of-care requirements, refer to the Medical Benefit Drugs – Pharmacy page in the BCN section of this website. Click Requirements for drugs covered under the medical benefit – BCN HMO under the heading "For BCN HMO (commercial) members."

The new site-of-care requirement for Prolia and Xgeva will be added to the list in late September.

Posted: June 2018
Line of business: Blue Care Network

Effective June 22, submit appeals of eviCore decisions on BCN Advantage^SM requests to BCN, not to eviCore

Effective June 22, 2018, providers must submit appeals of eviCore healthcare's decisions on BCN Advantage authorization requests to the BCN Advantage Grievances and Appeals Unit and not to eviCore. Here's where to submit:

By mail:

Blue Care Network
ATTN: BCN Advantage Grievances and Appeals Unit
P.O. Box 284
Southfield MI 48076-5043

By fax: 1-866-522-7345

BCN will process these appeals using the normal BCN Advantage appeal process for standard and expedited appeals. For information on that process, refer to the BCN Advantage chapter of the BCN Provider Manual. Look in the section titled "BCN Advantage provider appeals."

Appeals of eviCore decisions on BCN HMO^SM (commercial) authorization requests should continue to be submitted to eviCore.

Posted: June 2018
Line of business: Blue Care Network

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

As a reminder, effective July 1, 2018, BCN is adding the following two drugs to its site-of-care optimization program:

This requirement applies only to BCN HMO (commercial) members, for first-time and current users of these medications. It does not apply to BCN Advantage^SM members.

The site-of-care program redirects members receiving select medical benefit 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.

If a provider feels a member is not a candidate to receive these drugs at a site other than the outpatient hospital, documentation supporting medical necessity must be provided to the plan for review. Those requests will be evaluated on a case-by-case basis.

Requests for Krystexxa and Stelara (SQ/IV) must meet applicable authorization criteria in addition to the site-of-care requirement.

For additional requirements related to drugs covered under the medical benefit, including all drugs identified as subject to site-of-care requirements, refer to the Medical Benefit Drugs – Pharmacy page in the BCN section of this website. Click Requirements for drugs covered under the medical benefit – BCN HMO under the heading "For BCN HMO (commercial) members."

The new site-of-care requirement for Krystexxa and Stelara is included in the list that is now available online.

Posted: June 2018
Line of business: Blue Care Network

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

Providers must complete questionnaires in the e-referral system for the following procedures:

• Blepharoplasty and repair of brow ptosis – beginning June 25, 2018, for any date of service
• Hyperbaric oxygen therapy – for dates of service on or after July 1, 2018

The questionnaires will open in the e-referral system when you're submitting authorization requests for BCN HMO^SM (commercial) and BCN Advantage^SM members.

These procedures already require authorization. It's just the questionnaires that are new.

How the questionnaires work

If your responses to the questionnaire in the e-referral system indicate that the procedure meets criteria, the authorization request will automatically be approved. If the criteria are not met, the request will be pended for clinical review by BCN's Utilization Management staff.

For cases that are not automatically approved via e-referral after you complete the questionnaire, you must include additional clinical information. You can type the information directly into the Case Communication section in the e-referral system or you can attach it to the case. The instructions for attaching clinical information to the case are outlined in the article How to attach clinical information to your authorization request in the e-referral system, on page 44 in the November-December 2016 BCN Provider News.

Where to find medical policies and preview questionnaires

The medical policies for these procedures will guide the decisions on these authorization requests. Click to open the policies:

• Blepharoplasty and Repair of Brow Ptosis
• Hyperbaric Oxygen Therapy, Systemic and Topical

The medical policies for these procedures will be posted online before the end of June in the BCN section of this website, on the Authorization Requirements & Criteria page.

You'll also find preview questionnaires at that location. 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: May 2018
Line of business: Blue Care Network

How to submit BCN inpatient authorization requests during upcoming holiday closures

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices are closed on the following days:

• Monday, May 28, 2018 (Memorial Day)
• Wednesday, July 4, 2018 (Fourth of July holiday)

During these holiday closures, BCN's inpatient utilization management area remains available to accept inpatient authorization requests for BCN HMO^SM (commercial) and BCN Advantage^SM members.

Here's what you need to know about submitting inpatient authorization requests to BCN when our corporate offices are closed.

Acute initial inpatient admissions. Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week.

Post-acute initial and concurrent admission reviews. Follow the current process you use to submit these requests by fax at 1-866-534-9994.

Other authorization requests. The types of requests listed below must be submitted by fax. For these requests, faxes are processed only Mondays through Friday. They are not processed on weekends or on the holidays on which BCN is closed. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

• Acute inpatient concurrent reviews and discharge dates, but only for facilities reimbursed on the basis of DRGs
• Authorization requests for sick or ill newborns
• Authorization requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN After-Hours Care Manager hotline at 1-800-851-3904 and listen to the prompts for help with the following:

• Determining alternatives to inpatient admissions and triage to alternative care settings
• Arranging for emergency home health care, home infusion services and in-home pain control
• Arranging for durable medical equipment
• Handling emergency discharge planning coordination and authorization
• Handing expedited appeals of utilization management decisions

Note: Do not use the after-hours care manager phone number to request authorization for routine inpatient admissions.

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member's medical condition and coordinate care prior to admitting the member.

Posted: May 2018
Line of business: Blue Care Network

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

Later this year, providers who currently submit their initial authorization requests for physical, occupational and speech therapy, or for physical medicine services by chiropractors, through the e-referral system or by calling BCN will submit these requests through eviCore healthcare's provider portal instead.

At the same time, requests to authorize follow-up services will also be submitted through the eviCore provider portal instead of through the Landmark Healthcare portal.

This change will apply to requests for BCN HMO^SM (commercial) and BCN Advantage^SM members and to the following providers:

• Facilities
• Therapists performing physical, occupational and speech therapy
• Chiropractors performing physical medicine services
• Referring physicians
• Podiatrists

In addition, BCN is working with eviCore to implement the corePath^SM authorization model for these requests for BCN HMO (commercial) and BCN Advantage members. corePath will streamline the authorization process and make it easier for providers to submit authorization requests. It's the same model that was implemented for Blue Cross Medicare Plus Blue^SM PPO authorization requests starting Jan. 1, 2018.

We first communicated about this change in the article titled eviCore to handle BCN initial and follow-up authorization requests for PT, OT and ST starting later in 2018, on page 42 of the May-June 2018 BCN Provider News.

More details about these changes will be provided in the coming months.

Posted:
Line of business: Blue Care Network

No site-of-care requirement for Brineura^TM for BCN HMO^SM (commercial) members

Brineura (cerliponase alfa), a medication covered under the medical benefit, will not be subject to a site-of-care requirement starting July 1, 2018, for BCN HMO (commercial) members, as we had previously announced.

In April, we communicated that we were adding Brineura to the site-of-care optimization program starting July 1. However, we have decided after additional review that we will not add Brineura to that program.

The document Requirements for drugs covered under the medical benefit – BCN HMO has been updated to reflect this change. However, please check that document for the authorization requirements that do pertain to Brineura and for the requirements that pertain to other drugs covered under the medical benefit for BCN HMO (commercial) members.

Posted: May 2018
Line of business: Blue Care Network

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

For dates of service on or after June 1, 2018, authorization is not required for routine outpatient therapy for mental health and substance use disorders, for contracted behavioral health providers in Michigan. This applies to both BCN HMO^SM (commercial) and BCN Advantage^SM members.

Currently, these services require authorization for all providers and authorization requests are submitted through the e-referral system.

Authorization will continue to be required for:

• Providers who do not belong to the network assigned to a member's plan
• Noncontracted providers, including providers outside of Michigan

In addition, the outpatient services listed here will continue to require authorization through the e-referral system for all providers:

• Autism evaluation and treatment
• Electroconvulsive therapy
• Neurofeedback
• Transcranial magnetic stimulation

We'll be updating the Behavioral Health chapter of the BCN Provider Manual and other documents to reflect the change in authorization requirements.

Posted: April 2018
Line of business: Blue Care Network

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

Effective for dates of service on or after July 1, 2018, multiple sclerosis medications covered under the medical benefit will not require authorization, for Blue Cross PPO (commercial) and BCN HMO^SM (commercial) members. This change applies to the following medications:

For Blue Cross and BCN commercial members with an active authorization for one of these medications, no additional action is required by the member or the provider.

This change does not apply to BCN Advantage^SM, Blue Cross Medicare Plus Blue^SM PPO or Federal Employee Program^® members. The requirements for these products are as follows:

• For BCN Advantage and Federal Employee Program members, no authorization is currently required.
• For Medicare Plus Blue members, authorization is currently required and will continue to be required.

For additional information on the change related to commercial members, look for articles in the following upcoming newsletters:

• May 2018 issue of The Record
• May-June 2018 issue of BCN Provider News

Posted: April 2018
Line of business: Blue Care Network

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

Blue Care Network is helping BCN HMO^SM (commercial) and BCN Advantage^SM members get access to long-acting injectable medications for the treatment of certain psychiatric and substance use disorders.

We've contracted with home health care agencies that can visit the member's home to administer the injections and complete a nursing assessment of the member. The agencies can be used when the primary care physician, psychiatrist or facility is unable to administer these medications.

The newer long-acting injectable medications may be used for the medically assisted treatment of psychiatric and substance use disorders. These medications have fewer side effects and are better tolerated than some of the older formulations. They are also now usually preferred early in treatment and should often be the first line of treatment for certain psychiatric and substance use disorders.

The member just needs a doctor's order to be sent to the home health agency. The doctor also needs to order the medication through AllianceRx Walgreens Prime Specialty Pharmacy on behalf of the member.

By providing this service, we're removing a barrier for members. We're providing a place to get the injection.

For information on how to use this service, refer to the document Administering long-acting injectable medications at home (behavioral health). This document is on the Behavioral Health page in the BCN section of this website, under the "Other resources" heading.

This document shows:

• The steps for initiating and continuing the administration of the medications in the member's home
• A list of some long-acting injectable medications that can be obtained through AllianceRx Walgreens Prime Specialty Pharmacy
• A list of the BCN-contracted home health agencies that provide in-home long-acting injectables

We're also updating the Behavioral Health chapter of the BCN Provider Manual with a link to this document.

Posted: April 2018
Line of business: Blue Care Network

How to submit BCN inpatient authorization requests during upcoming holiday closures

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices are closed on the following days:

• Friday, March 30, 2018 (Good Friday)
• Monday, May 28, 2018 (Memorial Day)

During these holiday closures, BCN's inpatient utilization management area remains available to accept inpatient authorization requests for BCN HMO^SM (commercial) and BCN Advantage^SM members.

Here's what you need to know about submitting inpatient authorization requests to BCN when our corporate offices are closed.

Acute initial inpatient admissions. Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week.

Post-acute initial and concurrent admission reviews. Follow the current process you use to submit these requests by fax at 1-866-534-9994.

Other authorization requests. The types of requests listed below must be submitted by fax. For these requests, faxes are processed only Mondays through Friday. They are not processed on weekends or on the holidays on which BCN is closed. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

• Acute inpatient concurrent reviews and discharge dates, but only for facilities reimbursed on the basis of DRGs
• Authorization requests for sick or ill newborns
• Authorization requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN After-Hours Care Manager hotline at 1-800-851-3904 and listen to the prompts for help with the following:

• Determining alternatives to inpatient admissions and triage to alternative care settings
• Arranging for emergency home health care, home infusion services and in-home pain control
• Arranging for durable medical equipment
• Handling emergency discharge planning coordination and authorization
• Handing expedited appeals of utilization management decisions

Note: Do not use the after-hours care manager phone number to request authorization for routine inpatient admissions.

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member's medical condition and coordinate care prior to admitting the member.

Posted: March 2018
Line of business: Blue Care Network

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

Effective July 1, 2018, BCN is adding the following two drugs to its site-of-care optimization program:

This requirement applies only to BCN HMO (commercial) members, for first-time and current users of these medications. It does not apply to BCN Advantage^SM members.

The site-of-care program redirects members receiving select medical benefit 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.

If a provider feels a member is not a candidate to receive these drugs at a site other than the outpatient hospital, documentation supporting medical necessity must be provided to the plan for review. Those requests will be evaluated on a case-by-case basis.

Requests for Krystexxa and Stelara (SQ/IV) must meet applicable authorization criteria in addition to the site-of-care requirement.

For additional requirements related to drugs covered under the medical benefit, including all drugs identified as subject to site-of-care requirements, refer to the Medical Benefit Drugs – Pharmacy page in the BCN section of this website. Click Requirements for drugs covered under the medical benefit – BCN HMO under the heading "For BCN HMO (commercial) members."

The new site-of-care requirement for Krystexxa and Stelara will be included in the April 2018 version of the list, which will be available online in late March.

Posted: March 2018
Line of business: Blue Care Network

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

Effective March 19, 2018, two fax numbers will change:

• Use the fax number 1-866-392-6465 for BCN Advantage^SM Medicare Part B authorization requests. It's the same fax number you're currently using for Blue Cross Medicare Plus Blue^SM PPO requests.
• Use the fax number 1-877-325-5979 for BCN HMO^SM (commercial) requests. It's the same fax number you're currently using for Blue Cross PPO (commercial) requests.

We encourage you to submit all authorization requests for drugs covered under the medical benefit using the Novologix® electronic system. It's the most efficient way to submit a request and get a determination.

When you need assistance, however, you can call the Pharmacy Help Desk at 1-800-437-3803 or fax your request using the appropriate fax number.

The BCN Provider Manual will be updated with these changes. The Medical Benefit Drugs – Pharmacy page in the BCN section of this website will also be updated. You can find additional information about drugs covered under the medical benefit on that page.

Posted: March 2018
Line of business: Blue Care Network

Mepsevii^TM is subject to a site-of-care requirement for BCN HMO^SM (commercial) members

Effective immediately, BCN is adding Mepsevii (vestronidase alfa-vjbk) to its site-of-care optimization program. This 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.

This requirement applies only to Blue Care Network HMO (commercial) members. It does not apply to BCN Advantage^SM members.

If a provider feels a member is not a candidate to receive this drug at a site other than the outpatient hospital, documentation supporting medical necessity must be provided to the plan for review. Those requests will be evaluated on a case-by-case basis. Requests for Mepsevii must meet applicable authorization criteria in addition to the site-of-care requirement.

For additional requirements related to drugs covered under the medical benefit, including all drugs identified as subject to site-of-care requirements, visit the Medical Benefit Drugs – Pharmacy page in the BCN section of this website. Click Requirements for drugs covered under the medical benefit – BCN HMO (PDF) under the heading "For BCN HMO (commercial) members."

The new Mepsevii site-of-care requirement is included in the March 2018 version of the list, which is available now.

Posted: March 2018
Line of business: Blue Care Network

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

For dates of service on or after April 1, 2018, authorization is required for the two medical benefit drugs shown in the table below, for BCN HMO^SM (commercial) members only.

Providers must submit an authorization request through the NovoLogix electronic system to demonstrate medical necessity. Authorization requests for these drugs should be submitted prior to the start of services.

Medical necessity criteria for these drugs include but are not limited to diagnosis, lab results, dose and frequency of administration. Documentation may also be required that shows the medications previously used to treat the member's condition, including the dose, regimens, dates of therapy and response. Additional pertinent clinical information may also be required.

These new authorization requirements do not apply to BCN Advantage^SM members.

For a full list of drugs that require authorization and for information on how to request authorization, visit the Medical Benefit Drugs–Pharmacy page in the BCN section of this website.

Posted: February 2018
Line of business: Blue Care Network

How to submit BCN inpatient authorization requests during upcoming holiday closures

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices are closed on the following days:

• Monday, Jan. 15, 2018 (Martin Luther King, Jr., Day)
• Friday, March 30, 2018 (Good Friday)

During these holiday closures, BCN's inpatient utilization management area remains available to accept inpatient authorization requests for BCN HMO^SM (commercial) and BCN Advantage^SM members.

Here's what you need to know about submitting inpatient authorization requests to BCN when our corporate offices are closed.

Acute initial inpatient admissions. Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week.

Post-acute initial and concurrent admission reviews. Follow the current process you use to submit these requests by fax at 1-866-534-9994.

Other authorization requests. The types of requests listed below must be submitted by fax. For these requests, faxes are processed only Mondays through Friday. They are not processed on weekends or on the holidays on which BCN is closed. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

• Acute inpatient concurrent reviews and discharge dates, but only for facilities reimbursed on the basis of DRGs
• Authorization requests for sick or ill newborns
• Authorization requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN After-Hours Care Manager hotline at 1-800-851-3904 and listen to the prompts for help with the following:

• Determining alternatives to inpatient admissions and triage to alternative care settings
• Arranging for emergency home health care, home infusion services and in-home pain control
• Arranging for durable medical equipment
• Handling emergency discharge planning coordination and authorization
• Handing expedited appeals of utilization management decisions

Note: Do not use the after-hours care manager phone number to request authorization for routine inpatient admissions.

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member's medical condition and coordinate care prior to admitting the member.

Posted: January 2018
Line of business: Blue Care Network

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

BCN's Utilization Management department (formerly called Care Management) is experiencing high call volumes.

To avoid waiting on the phone line, providers should use the e-referral system to submit or check the status of referrals or authorization requests.

We encourage providers to call 1-800-392-2512 only for urgent requests.

We apologize for the inconvenience caused by the long waiting times on our phone line.

Posted: January 2018
Line of business: Blue Care Network

Submit functional limitation G codes for BCN Advantage^SM therapy services

When billing outpatient physical, occupational and speech therapy services for BCN Advantage members, you must report the functional limitation G codes and their applicable modifiers.

It's important to report the modifiers for the nonpayable G codes as secondary to the modifiers for the primary codes. If you report these modifiers as primary, it will cause an error in our payment system and the claim will be denied.

For instructions on how to report these codes correctly, see the article Providers must submit functional limitation G codes for BCN Advantage PT, OT and ST services, in the January-February 2018 issue of BCN Provider News, on page 37.

The document Outpatient rehabilitation services: Frequently asked questions for rehab providers has been updated with this information. This document and other resources are posted on this website, on BCN's Outpatient PT, OT, ST page.

Posted: January 2018
Line of business: Blue Care Network

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

As a reminder, on Jan. 1, 2018, new authorization requirements take effect for services for BCN HMO^SM (commercial) and BCN Advantage^SM members. These changes apply to various types of procedures.

For the details, please review the news article Changes in authorization requirements are effective Jan. 1, 2018, in the November-December 2017 issue of BCN Provider News, on page 45.

In addition, the following documents have been updated and are now available on BCN's Authorization Requirements & Criteria page on this website:

• Authorization criteria
• Preview questionnaires
• BCN Referral & Authorization Requirements document

Posted: December 2017
Line of business: Blue Care Network

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

Services represented by procedure codes *0482T, *0501T, *0502T, *0503T and *0504T require authorization by eviCore healthcare for dates of service on or after Jan. 1, 2018. This is in addition to the cardiology services that already require authorization by eviCore.

This applies only to services for Blue Care Network HMO^SM (commercial) and BCN Advantage^SM members age 18 and older.

The document Procedures that require authorization by eviCore healthcare will be updated to reflect this change.

You can find additional information about procedures managed by eviCore healthcare on this website. Click BCN. Then click eviCore-Managed Procedures.

As a reminder, eviCore healthcare manages select procedures for BCN HMO (commercial), BCN Advantage, Blue Cross PPO and Blue Cross Medicare Plus Blue^SM PPO.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2016 American Medical Association. All rights reserved.

Posted: December 2017
Line of business: Blue Care Network

New BCN authorization requirements are effective Jan. 1, 2018!

On Jan. 1, 2018, new authorization requirements take effect for services for BCN HMO^SM (commercial) and BCN Advantage^SM members. These changes apply to various types of procedures.

For the details, please review the news article Changes in authorization requirements are effective Jan. 1, 2018, in the November-December 2017 issue of BCN Provider News, on page 45.

Posted: October 2017
Line of business: Blue Care Network

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

Your feedback is important to us. Please complete the 2017 BCN Care 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 Care Management processes.

The survey will be available online through Dec. 31, 2017.

Information about a drawing for two $250 gift certificates is available in the Nov.-Dec. 2017 issue of BCN Provider News, page 44.

Posted: October 2017
Line of business: Blue Care Network

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

Providers must fax the following acute inpatient admission requests to Blue Care Network:

• Concurrent review requests and discharge dates, but only for facilities reimbursed on the basis of DRGs
• Authorization requests for sick or ill newborns
• Requests for enteral and total parenteral nutrition

Faxes are not accepted on holidays when BCN is closed. The upcoming holidays during which BCN is closed are:

• Thursday and Friday, Nov. 23 and 24, 2017 (Thanksgiving holidays)
• Friday, Monday and Tuesday, Dec. 22, 25 and 26, 2017 (Christmas holidays)
• Monday, Jan. 1, 2018 (New Year's Day)

Otherwise, faxes are accepted from midnight on Sunday through 4 p.m. on Friday. Faxes are not accepted on weekends.

The fax numbers to use are:

• BCN HMO^SM (commercial) members: 1-866-313-8433
• BCN Advantage^SM members: 1-866-526-1326

Except for the admission types outlined above, all other authorization requests for acute inpatient admissions must be submitted to BCN through the e-referral system.

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

Posted: September 2017
Line of business: Blue Care Network

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

Note: The news item originally posted on Sept. 1, 2017, is revised to show that providers may use either the updated forms that CMS provides on its website or the forms that BCN Advantage offers on its website.

Effective Aug. 28, 2017, providers must use the updated Important Message from Medicare form and Detailed Notice of Discharge form for BCN Advantage^SM members being discharged from an inpatient hospital stay.

The forms were recently revised by the Centers for Medicare & Medicaid Services and are available at these locations:

• On the CMS website. Click here to access them.
• On this website. Click BCN and then click Forms. Look in the BCN Advantage section of the page under the subheading "Hospitals, for inpatients." These forms have the BCN Advantage logo and contact information for KEPRO, the Quality Improvement Organization for Michigan.

You can use either the CMS forms or the forms specific to BCN Advantage.

The purpose of the forms is to inform BCN Advantage members hospitalized at an inpatient facility that they have special appeal rights if they are dissatisfied with their discharge plan or believe that coverage of their hospital stay is ending too soon.

Additional information about each form is found in the BCN Advantage chapter of the BCN Provider Manual. Look in the section titled "QIO immediate review of hospital discharges."

Posted: September 2017
Line of business: Blue Care Network

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

Effective Aug. 21, 2017, the phone number for the Blue Care Network Behavioral Health Physician Review Line is changing to 1-877-293-2788. This is the number for physician-to-physician reviews of determinations related to medical necessity.

The previous Physician Review Line number, 734-332-2567, will not be working as of that date.

Here's a summary of how to reach a BCN medical director to discuss a behavioral health determination for a BCN member as of August 21:

• During business hours (8 a.m. to 5 p.m., Monday through Friday), call 1-877-293-2788 (the new Physician Review Line number).
• After business hours (for emergent cases only), call 1-800-482-5982. (This is the current number and it is not changing.)

The numbers for calling BCN Behavioral Health during business hours for other purposes are not changing, either. Those are:

• 1-800-482-5982 for BCN HMO^SM (commercial) members
• 1-800-431-1059 for BCN Advantage^SM members

Also effective August 21, the mailing address for BCN Behavioral Health is changing to:

• Blue Care Network
• Behavioral Health
• Mail Code H100
• 26899 Northwestern Highway
• Southfield, MI 48034

Posted: August 2017
Line of business: Blue Care Network

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

This is a reminder that Blue Care Network uses McKesson's InterQual^® criteria as guidelines in reviewing acute inpatient medical admissions and that BCN's medical directors make the final determination about the most appropriate level of care based on their medical judgment.

Additional information about the InterQual criteria and about the process for reviewing these admissions is found in the Care Management chapter of the BCN Provider Manual.

Posted: July 2017
Line of business: Blue Care Network

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

To reduce the time it takes us to respond to authorization requests for initial inpatient admissions, Blue Care Network is asking that hospitals limit the clinical information they send.

Please send only the pertinent parts of the medical record. This applies to both Blue Care Network HMO^SM (commercial) and BCN Advantage^SM members.

Some hospitals send the member's entire clinical record when the request is submitted. This increases the time we spend responding to the request.

The form is optional now

The parts of the record you should send are outlined on the Request for Review of Initial Inpatient Admission form. We recommend that you use the form as a guide.

Submitting the form itself is optional now. (It was required just recently, but we're changing that.)

Hospitals that continue to submit the entire clinical record will ultimately be required to submit the form.

Accessing the form

The form is located in the BCN section of this website, on the Clinical Review & Criteria Charts page. Look under the heading "Referral/clinical review information."

Posted: June 2017
Line of business: Blue Care Network

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

Reminder: Effective July 1, 2017, BCN will add the injectable or infusible drugs listed below to its site-of-care optimization program. This program redirects members receiving these drugs in an outpatient hospital setting to a lower-cost, alternate site of care, such as the physician's office or member's home. This includes members who are currently receiving these drugs and members who are receiving them for the first time.

This requirement applies to Blue Care Network HMO^SM (commercial) members. It does not apply to BCN Advantage^SM members.

The drugs are:

• Benlysta^® (J0490)
• Cimzia^® (J0717)
• Cinqair^® (J2786)
• Entyvio^® (J3380)
• Ilaris^® (J0638)
• Nucala^® (J2182)
• Xolair^® (J2357)

As with other drugs in the site-of-care program, if a provider feels a member is not a candidate to receive a drug on this list at a site other than the outpatient hospital, documentation supporting medical necessity must be provided to the plan for review and will be evaluated on a case-by-case basis.

All drugs listed here must meet applicable authorization criteria in addition to the site-of-care requirement.

For additional details, please review the article titled BCN expanding site of care optimization program on July 1, 2017, on page 37 of the May-June 2017 issue of BCN Provider News.

Additional information, including a complete list of drugs in the site-of-care program, is also available on the Medical Benefit Drugs - Pharmacy page in the BCN section of this website. Click Requirements for drugs covered under the medical benefit - BCN HMO under the heading "For BCN HMO (commercial) members." Look for the new July 1 site-of-care requirements in the July 2017 version of the list, which will be available at the end of June.

Posted: June 2017
Line of business: Blue Care Network

Blue Care Network changes authorization requirements for sleep management studies

Effective July 17, 2017, all requests to authorize outpatient facility and clinic-based sleep management studies for adult members 18 years of age and older will require the submission of evidence from the member's medical record. This evidence must confirm signs and symptoms of obstructive sleep apnea. This applies to both BCN HMO^SM (commercial) and BCN Advantage^SM members.

This is in addition to the requirement to submit evidence of the specific condition the member has that would exclude or contraindicate a home sleep study – a requirement that has been in place since Oct. 3, 2016.

Any documentation from the patient's medical record that is required can be attached to the request within the e-referral system, through the Case Communication field. For instructions on how to attach documentation, refer to the article "How to attach clinical information to your authorization request in the e-referral system," in the November-December 2016 BCN Provider News. These instructions are also in the e-referral User Guide, in the subsection titled "Create New (communication)."

As a reminder, home sleep studies do not require clinical review. For home sleep study requests, you must submit an authorization request to facilitate claims payment, but you are not required to complete a questionnaire for these services in the e-referral system.

Posted: May 2017
Line of business: Blue Care Network

Blue Care Network updates authorization guideline for external ECG monitoring

Blue Care Network has updated its authorization guideline for external electrocardiographic monitoring devices that are used for continuous recording and storage of data on a long-term basis (greater than 48 hours), such as Zio Patch^® and LifeStar ACT.

Effective immediately, the following procedure codes no longer require clinical review for either BCN HMO^SM or BCN Advantage^SM members when the services are ordered and provided by a cardiologist:

• *0295T
• *0296T
• *0297T
• *0298T

In addition, plan notification for this service is not required. However, cardiologists in the East and Southeast regions must have an active global referral on file for BCN HMO (commercial) members.

Patients are still expected to meet the criteria for coverage, which specify that external ECG monitoring is an alternative to Holter monitoring in patients.

Read more about these criteria and get additional information in the article Blue Care Network updates authorization guideline for external ECG monitoring, on page 44 in the May-June 2017 issue of BCN Provider News.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2016 American Medical Association. All rights reserved.

Posted: May 2017
Line of business: Blue Care Network

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

Effective July 1, 2017, BCN will add the injectable or infusible drugs listed below to its site-of-care optimization program. This program redirects members receiving these drugs in an outpatient hospital setting to a lower-cost, alternate site of care, such as the physician's office or member's home. This includes members who are currently receiving these drugs and members who are receiving them for the first time.

This requirement applies to Blue Care Network HMO^SM (commercial) members. It does not apply to BCN Advantage^SM members.

The drugs are:

• Benlysta^® (J0490)
• Cimzia^® (J0717)
• Cinqair^® (J2786)
• Entyvio^® (J3380)
• Ilaris^® (J0638)
• Nucala^® (J2182)
• Xolair^® (J2357)

As with other drugs in the site-of-care program, if a provider feels a member is not a candidate to receive a drug on this list at a site other than the outpatient hospital, documentation supporting medical necessity must be provided to the plan for review and will be evaluated on a case-by-case basis.

All drugs listed here must meet applicable authorization criteria in addition to the site-of-care requirement.

For additional details, please review the article titled BCN expanding site of care optimization program on July 1, 2017, on page 37 of the May-June 2017 issue of BCN Provider News.

Additional information, including a complete list of drugs in the site-of-care program, is also available on the Medical Benefit Drugs - Pharmacy page in the BCN section of this website. Click Requirements for drugs covered under the medical benefit - BCN HMO under the heading "For BCN HMO (commercial) members." Look for the new July 1 site-of-care requirements in the July 2017 version of the list, which will be available at the end of June.

Posted: May 2017
Line of business: Blue Care Network

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

Providers who want to consult with an eviCore healthcare clinical representative on Blue Care Network radiology authorization requests can now schedule phone appointments online without having to wait on hold. This applies only to radiology services reviewed by eviCore healthcare for BCN HMO^SM commercial and BCN Advantage^SM members.

Here's how to schedule an appointment for a phone consultation:

1. Visit evicore.com.
2. Click Providers.
3. In the line "Request Clinical Consultation Online Here," click Here.
4. In the "Select Health Plan" field, select Blue Care Network.
5. In the "Select Solution" field, select Radiology.
6. In the "First name," "Last name," "Email" and "Phone" fields, enter the contact information for the office representative who will set up the appointment.
7. In the "Select Duration Hours" field, enter the two-hour window of time during which a phone appointment can be scheduled with the eviCore physician.
8. In the "Message" field, indicate the name of the clinician in the office who wants to talk to the eviCore physician.
9. Click Submit.

You'll receive a phone call or an email (or both, if you requested both in the "Message" field) that indicates the 15-minute window of time within which the phone appointment is scheduled.

Sometime during that 15 minutes, the eviCore physician will call the clinician whose name you entered in the "Message" field.

Examples of clinical consultations include:

• Questions that arise while you're submitting an authorization request, such as what clinical information must be submitted
• Questions that arise when a request you've submitted is pended or denied

Before this scheduling option was made available, providers had to call eviCore and wait on hold until an eviCore physician was available.

For additional information about reviews performed by eviCore health for BCN commercial and BCN Advantage members, refer to the eviCore-Managed Procedures page in the BCN section at ereferrals.bcbsm.com.

Posted: April 2017
Line of business: Blue Care Network

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

Providers must fax the following acute inpatient admission requests to Blue Care Network:

• Concurrent review requests and discharge dates, but only for facilities reimbursed on the basis of DRGs
• Authorization requests for sick or ill newborns
• Requests for enteral and total parenteral nutrition

Faxes are not accepted on holidays when BCN is closed. The upcoming holidays in 2017 during which BCN is closed are:

• Friday, April 14 (Good Friday)
• Monday, May 29 (Memorial Day)
• Monday and Tuesday, July 3 and 4 (Fourth of July)
• Monday, September 4 (Labor Day)

Faxes are accepted from midnight on Sunday through 4 p.m. on Friday. Faxes are not accepted on weekends.

The fax numbers to use are:

• BCN HMO^SM (commercial) members: 1-866-313-8433
• BCN Advantage^SM members: 1-866-526-1326

Except for the admission types outlined above, all other authorization requests for acute inpatient admissions must be submitted to BCN through the e-referral system.

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

Posted: April 2017
Line of business: Blue Care Network

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

BCN's partnership with providers is important to us. We listened to your concerns and have decided to reinstate BCN's previous inpatient readmission review guidelines.

Effective Jan. 19, 2017, BCN is reviewing inpatient readmissions as follows:

• BCN reviews readmissions that occur within 14 days of discharge for the same or a related condition.
• Readmission reviews are conducted according to the Guidelines for Bundling Admissions document dated November 2013. That document is now available on BCN's web-DENIS Provider Publications and Resources website.

Readmissions within 30 days of discharge that were reviewed from Oct. 1, 2016, through Jan. 18, 2017, will not be revisited, but we will conduct additional research before implementing any further changes.

We apologize for any confusion that may result from these changes.

You can access the Guidelines for Bundling Admissions document by completing the following steps:

1. Visit bcbsm.com/providers and click Login.
2. Log in as a provider, using your user name and password.
3. Click BCN Provider Publications and Resources.
4. Click Billing / Claims.
5. Click Guidelines for Bundling Admissions.

Posted: March 2017
Line of business: Blue Care Network

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

On Jan. 1, 2017, new procedure codes went into effect for physical and occupational therapy evaluations for BCN HMO^SM (commercial) and BCN Advantage^SM members. The new codes are indicated in bold below.

• Physical therapy (physical therapists):
• Service 1: *97110 for treatment
• Service 2: *97161, *97162 or *97163 for evaluation (These codes cannot be used by chiropractors.)


• Occupational therapy:
• Service 1: *97535 for treatment
• Service 2: *97165, *97166 or *97167 for evaluation

The document Procedures that require clinical review by eviCore healthcare has been updated with these codes.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2016 American Medical Association. All rights reserved.

Posted: January 2017
Line of business: Blue Care Network

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

The Centers for Medicare & Medicaid Services requires hospitals to give a Medicare Outpatient Observation Notice to Medicare beneficiaries receiving outpatient observation services for more than 24 hours.

BCN Advantage^SM encourages providers to start giving these notices immediately. A copy of the Medicare Outpatient Observation Notice customized for BCN Advantage members and the instructions for using it are available on the web. These documents are available on the Care Management Forms page in the BCN section of this website, under the BCN Advantage heading.

The Medicare Outpatient Observation Notice is a standard notice that lets the member know that:

• He or she is an outpatient receiving observation services, not an inpatient of the hospital
• The reasons he or she is receiving observation services
• How the observation services affect his or her cost-sharing obligations and post-hospitalization eligibility for coverage of skilled nursing facility services

The notice must be delivered no later than 36 hours after observation services begin, or sooner if the member is transferred, discharged or admitted.

The BCN Advantage chapter of the BCN Provider Manual will be updated with this information. The revised chapter will be available at the end of January on the Provider Manual Chapters page in the BCN section of this website.

Additional information about this requirement is available on the Beneficiary Notices Initiative page of the CMS website.

Posted: January 2017
Line of business: Blue Care Network

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

Obstetrician-gynecologists and gynecologists can refer the Blue Care Network HMO^SM (commercial) and BCN Advantage^SM members in their care for OB-GYN-related specialty services without the members needing to obtain a referral from their primary care physician. OB-GYN providers in the East and Southeast regions should use the e-referral system to refer their patients.

For additional information about this, refer to the article "Obstetrician-gynecologists can refer patients to specialists" in the January-February 2017 issue of BCN Provider News.

Posted: January 2017
Line of business: Blue Care Network

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

Blue Care Network recently announced that authorization would be required for monitored anesthesia care during certain gastrointestinal endoscopies on or after Jan. 8, 2017. This requirement will not go into effect on that date. The need for authorization will be reassessed later in 2017.

For additional information, please refer to the document Anesthesia care for gastrointestinal endoscopy procedures.

Posted: December 2016
Line of business: Blue Care Network

BCN revises codes managed by eviCore healthcare

Blue Care Network has revised its Procedures that require clinical review by eviCore healthcare document.

What's changing?

Interventional pain management services

• Procedure codes *62263, *62264, *64620, *64626 and *64627 were removed from the list because services associated with these codes are managed by BCN and not by eviCore. However, if you enter these procedure codes into the e-referral system, you will get a message — incorrectly — indicating that the request should be submitted to eviCore.
  
  IMPORTANT! Until the e-referral system is updated to accept requests involving these codes, you should call BCN Care Management 1-800-392-2512 to request review of these services.
  
  
• The following new codes were added to the list of epidural and facet joint injections managed by eviCore as of Jan. 1, 2017: *62320, *62321, *62322, *62323, *62324, *62325, *62326 and *62327.
  
  
• The following codes are marked as requiring review by eviCore only from Sept. 1 through Dec. 31, 2016: *62310, *62311, *62318 and *62319. These codes are being retired and will eventually be removed from the list.

Physical, occupational and speech therapy services and physical medicine service provided by chiropractors

Some codes for these services are added to the list — specifically, the codes you enter into the e-referral system.

Additional information

For more information, refer to Procedures that require clinical review by eviCore healthcare.

Posted: December 2016
Line of business: Blue Care Network

Guidelines for submitting acute inpatient admission requests to BCN

Authorization requests submitted to Blue Care Network for acute inpatient admissions are accepted only when they are submitted through the e-referral system.

Requests submitted by fax are not accepted, except for the following types of requests, which must be faxed to BCN:

• For facilities reimbursed on the basis of DRGs, concurrent review requests and discharge dates will be accepted via fax. Facilities reimbursed on a per-diem basis must submit concurrent reviews via e-referral.
• Authorization requests for sick or ill newborns must be faxed to BCN. They cannot be submitted through the e-referral system because the newborn is not a member covered by BCN. The BCN nurse reviewer will create a case for the newborn in the e-referral system and you will be able to see it there.
• Requests for enteral and total parenteral nutrition requests must be faxed to BCN.

Faxes are accepted from midnight on Sunday through 4 p.m. on Friday. Faxes are not accepted on weekends. They are also not accepted on holidays when BCN is closed. The holidays observed at BCN are identified in the BCN Provider News issue published prior to the holiday occurring.

The upcoming holidays during which faxes are not accepted are:

• Friday, Dec. 23 through Monday, Dec. 26
• Friday, Dec. 30 through Monday, Jan. 2
• Monday, Jan. 16

The fax numbers to use are:

• For BCN HMO^SM (commercial) members: 1-866-313-8433
• For BCN Advantage^SM (commercial) members: 1-866-526-1326

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

Posted: December 2016
Line of business: Blue Care Network

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

Starting Jan. 1, 2017, Blue Care Network requires authorization as shown below for the following drugs covered under the medical benefit:

You must submit authorization requests for these drugs using the NovoLogix web tool and must include the following clinical information to support the authorization request:

• Diagnosis
• Lab results
• Names of medications previously used to treat the member's condition, including dose, regimens, dates of therapy and response

You may also be required to submit additional pertinent clinical information and documentation related to the specialty of the prescribing physician and the member's age.

These drugs currently require authorization because they were assigned not-otherwise-specified procedure codes. Starting Jan. 1, these drugs require authorization under the new codes they are assigned.

Information about using the NovoLogix web tool is available on the Medical Benefit Drugs – Pharmacy web page on this website.

Posted: November 2016
Line of business: Blue Care Network

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

Starting Jan. 17, 2017, BCN is changing the guidelines it uses to review inpatient readmissions of BCN HMO^SM (commercial) and BCN Advantage^SM members for billing purposes. Under the updated guidelines, BCN will combine admissions for members readmitted within 30 days for the same or a related condition whether or not discharge criteria were met.

Currently, the admissions are typically billed separately as long as the member met the discharge criteria and had an appropriate discharge plan, even if the readmission was for a new occurrence of the same condition.

The Guidelines for Bundling Admissions document is being updated to reflect this change. The updated document will be available online prior to Jan. 17.

You can access that document by completing the following steps:

1. Visit bcbsm.com/providers and click Login.
2. Log in as a provider, using your user name and password.
3. Click BCN Provider Publications and Resources.
4. Click Billing / Claims.
5. Click Guidelines for Bundling Admissions.

Posted: November 2016
Line of business: Blue Care Network

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

As a reminder, for dates of service on or after Dec. 1, 2016, authorization is required through eviCore healthcare for additional pediatric and adult outpatient interventional pain management services for Blue Care Network HMO^SM (commercial) and BCN Advantage^SM members, for all diagnoses. Currently, eviCore reviews epidural and facet joint injections for BCN.

You can submit authorization requests for these additional procedures as early as Nov. 21 at www.evicore.com. Click Providers and log in to eviCore's provider portal.

The codes for the additional services that eviCore will review are: *0213T, *0214T, *0215T, *0216T, *0217T, *0218T, *0228T, *0229T, *0230T, *0231T, *27096, *62263, *62264, *62280, *64470, *64472, *64475, *64476, *64510, *64520, *64620, *64626, *64627, *64633, *64634, *64635 and *64636. These services include sacroiliac joint injections, epidural adhesiolysis, radio frequency ablation and regional sympathetic blocks.

The list of procedures that require review by eviCore healthcare has been updated to reflect these additional codes.

Authorization from eviCore is required for these outpatient pain management services. Services performed without authorization may be denied for payment.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2015 American Medical Association. All rights reserved.

Posted: November 2016
Line of business: Blue Care Network

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

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

What's changing? For dates of service on or after Dec. 5, 2016, BCN requires authorization for laparoscopic cholecystectomies.

Who's affected? This applies to BCN HMO^SM (commercial) and BCN Advantage^SM members and to services related to procedure codes *47562-*47564.

Where to find more information: The authorization criteria for laparoscopic cholecystectomies is available on the Clinical Review & Criteria Charts page in the BCN section of ereferrals.bcbsm.com. You can also find a preview questionnaire, which shows the questions contained in the questionnaire displayed in the e-referral system. For both these documents, look in the table with the heading "Other procedures."

Also see the article "Update and reminder about clinical review requirements for certain surgeries," published in the September-October 2016 issue of BCN Provider News.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2015 American Medical Association. All rights reserved.

Posted: November 2016
Line of business: Blue Care Network

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

BCN providers requesting authorizations for drugs covered under the medical benefit must use the NovoLogix web tool for these requests beginning Dec. 1.

Dec. 1 is the new changeover date. (This is a change from the earlier date of Oct. 1, which was delayed.)

If you are new to the NovoLogix web tool, there are many resources on the Medical Benefit Drugs (Pharmacy) page in the BCN section of ereferrals.bcbsm.com to help you. These include:

• NovoLogix training video
• NovoLogix user guide for BCN providers
• NovoLogix web-based training

How to log in to the Novologix system. Starting Dec. 1, to log in to the NovoLogix system:

1. Log in as a provider at bcbsm.com.
2. Click BCN Medical Benefit – Prior Authorization on the Provider Secured Services welcome page.
3. Enter your NPI.

This will bring you to the NovoLogix welcome page.

BCN's Pharmacy Help Desk. BCN's Pharmacy Help Desk can also input the request on your behalf. You can call the Help Desk at 1-800-437-3803.

Training webinar on Wednesday, Dec. 7. Sign up for a one-hour training webinar on the NovoLogix web tool. There are two times available on Wednesday, Dec. 7. Select either 10 a.m. or 1 p.m. when you register.

Additional information. BCN will move the current active authorizations from the e-referral system to the NovoLogix system before Dec. 1. These authorizations will not be interrupted when the change in the system occurs.

Posted: November 2016
Line of business: Blue Care Network

Tell us what you think about BCN Care Management Services

Your feedback is important to us. Please complete the 2016 BCN Care 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 Care Management processes.

The survey will be available online through Dec. 31, 2016.

Information about a drawing for two $250 gift certificates is available in the Sept.-Oct. issue of BCN Provider News, Page 22.

Posted: November 2016
Line of business: Blue Care Network

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

As a reminder, effective Nov. 1, 2016, BCN behavioral health providers must submit authorization requests for outpatient electroconvulsive therapy and transcranial magnetic stimulation services via the e-referral system. You'll also need to complete a questionnaire that displays while you're in the authorization request. The questionnaire will be pertinent to the service you're requesting.

We previously reported that you would also be required to complete a form and attach it to the case in the e-referral system, but the form will actually not be required. Please disregard any instructions to complete a form for these services that we included in our earlier messages and in the article in the November-December 2016 issue of BCN Provider News that was just recently published online. The only requirement is that you complete the questionnaire that displays in the e-referral system.

Posted: OCtober 2016
Line of business: Blue Care Network

ALERT: Phone issues on eviCore's BCN provider line

ALERT: Due to the Hurricane Matthew evacuation that's now in progress, eviCore healthcare is experiencing longer-than-normal call times on its BCN provider phone line (1-855-774-1317). There are also periodic phone issues such as messages and phone prompts that cut off early. If you encounter phone issues when trying to reach eviCore, please stay on the line and you will be connected to an eviCore representative.

If you need to submit an authorization request for a BCN member to eviCore, here's what we suggest:

• Submit the request through the evicore.com web portal. This is the most efficient way to initiate a request.
• Call the 1-855-774-1317 number only if absolutely necessary. If you call, stay on the line and you will be connected to an eviCore representative.

eviCore is working to address the phone issues. Also, we're aware that some eviCore call centers have been ordered to evacuate in preparation for Hurricane Matthew. We've been advised by eviCore that calls are being answered in centers not affected by the hurricane evacuation.

Posted: October 2016
Line of business: Blue Care Network

Updated BCN authorization criteria and preview questionnaires now available

Blue Care Network has made updated authorization criteria and preview questionnaires available on this website, on the Clinical Review & Criteria Charts page. These resources are available for the following service types:

• Knee arthroscopy
• Cervical spine surgery
• Joint replacement surgery (knee, hip and shoulder)
• Lumbar spine surgery

We encourage you to review the criteria and preview questionnaires prior to submitting an authorization request for these services in the e-referral system. You can use the questionnaires, in particular, as guides in gathering the clinical information you'll need when you encounter the actual questionnaires that display in the e-referral system.

Posted: September 2016
Line of business: Blue Care Network

BCN's Behavioral Health e-referral User Guide updated

BCN's Behavioral Health e-referral User Guide (PDF) has been updated and is now available on the Training Tools page of this website. The updated guide includes instructions for the following:

• Submitting authorization requests for higher levels of care
• Completing the questionnaire for concurrent review of patients in the higher levels of care
• Attaching the BCN Behavioral Health Discharge Summary form to your case in the e-referral system
• Submitting authorization requests for outpatient electroconvulsive therapy and transcranial magnetic stimulation services

Posted: September 2016
Line of business: Blue Care Network

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

For dates of service on or after Dec. 1, 2016, authorization is required through eviCore healthcare for additional outpatient pain management services for adult and pediatric Blue Care Network HMO^SM (commercial) and BCN Advantage^SM members, for all diagnoses. Currently, eviCore reviews epidural and facet joint injections for BCN.

The codes for the additional services that eviCore will review are: *0213T, *0214T, *0215T, *0216T, *0217T, *0218T, *0228T, *0229T, *0230T, *0231T, *27096, *62263, *62264, *62280, *64470, *64472, *64475, *64476, *64510, *64520, *64620, *64626, *64627, *64633, *64634, *64635 and *64636. These services include sacroiliac joint injections, epidural adhesiolysis, radiofrequency ablation and regional sympathetic blocks.

The list of procedures that require review by eviCore healthcare is being updated to reflect these additional codes.

Authorization from eviCore is required for these outpatient pain management services. Services performed without authorization may be denied for payment.

Look for additional information on this topic in the November-December 2016 issue of BCN Provider News, which will be available online in late October.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2015 American Medical Association. All rights reserved.

Posted: September 2016
Line of business: Blue Care Network

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

As a reminder, effective Oct. 1, 2016, BCN will review readmissions that occur within 30 days of discharge. Currently, readmissions that occur within 14 days of discharge are reviewed.

A determination is made as to whether the readmission should be billed separately or bundled with the previous admission. In some instances, the two admissions are combined into one for purposes of DRG reimbursement.

Questionnaires in the e-referral system. The questionnaires you'll encounter in the e-referral system will reflect the 14-day time frame for awhile. Updated questionnaires that reflect the new 30-day time frame will be available in the e-referral system in the near future. We suggest you answer the existing questionnaires with the 30-day time frame in mind, even though they refer to a 14-day time frame.

Documents are being updated. The documents listed below are being updated to reflect the change to 30 from 14 days. All of the revised documents will be available online by Sept. 30.

• Guidelines for bundling admissions
• The Care Management and Claims chapters of the BCN Provider Manual
• The readmission checklist, which facilities should use to ensure that all necessary documentation is available for the review of a readmission that has occurred within 30 days

You can access all these documents by completing the following steps:

1. Visit bcbsm.com/providers and click Login.
2. Log in to Provider Secured Services using your user ID and password.
3. Click BCN Provider Publications and Resources.
4. Click either Billing/Claims, Provider Manual or Forms, to open the appropriate Web page.

Posted: September 2016
Line of business: Blue Care Network

Changeover to using Novologix web tool is delayed for BCN providers

The effective date for BCN providers to start using the NovoLogix web tool to submit authorization requests for drugs covered under the medical benefit is changing. The date previously announced was Oct. 7, 2016. The new date has not yet been determined.

Providers should continue to submit authorization requests for these services through the e-referral system. Watch for updated information in the news alerts on this website and in web-DENIS messages.

The webinars scheduled for September and October are cancelled. New webinar dates will be announced on this website and in web-DENIS messages once the new changeover date is known.

Additional information about drugs covered under the medical benefit is available on the Medical Benefit Drugs–Pharmacy page on this website.

Posted: September 2016
Line of business: Blue Care Network

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

The e-referral system is displaying updated BCN knee arthroscopy questionnaires for earlier dates of service than expected. The updated questionnaires were intended to display only for dates of service on or after Oct. 3, 2016, but are instead displaying for all dates of service, including those earlier than Oct. 3. This is occurring for providers who request authorization for knee arthroscopy procedures for adult BCN HMO^SM (commercial) and BCN Advantage^SM members 18 years of age and older.

We advise that providers simply complete the updated questionnaire. The e-referral system will either approve or pend the request. If the request pends and BCN cannot authorize it, BCN will contact the provider for additional clinical information.

We apologize for any confusion caused by the updated questionnaires displaying for dates of service prior to Oct. 3.

Updated preview questionnaires and medical necessity criteria are being prepared and will be available on the Clinical Review & Criteria Charts page of this website by the end of September.

Posted: September 2016
Line of business: Blue Care Network

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

Effective Nov. 1, 2016, BCN behavioral providers must submit authorization requests for outpatient electroconvulsive therapy and transcranial magnetic stimulation services via the e-referral system.

While submitting the authorization request through e-referral, you'll be presented with a questionnaire pertinent to the service you're requesting. You'll need to answer the questions on the questionnaire.

You'll also need to complete a form and attach it to the authorization request in the e-referral system. You'll complete a form for one of the following:

• ECT – initial outpatient treatment
• ECT – continuation of outpatient care
• TMS – outpatient

All of these forms will be available on the Behavioral Health page of this website prior to Nov. 1.

Instructions for attaching information to an authorization request in the e-referral system are found in the BCN Behavioral Health e-referral User Guide.

Posted: September 2016
Line of business: Blue Care Network

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

Effective for dates of service on or after Nov. 1, 2016, eviCore healthcare will review authorization requests for additional radiation therapy services, for BCN HMO^SM (commercial) and BCN Advantage^SM members.

These additional services are associated with the following procedure codes: *79101, *79403, A9543, C2616 and Q3001

Here's what you need to know:

• Authorization is required prior to services being given.
• You'll need to submit pertinent clinical information with the authorization request

An updated list of codes reviewed by eviCore, including these additional codes, is available on the eviCore Managed Procedures page on this website.

As a reminder, BCN contracts with eviCore healthcare to review select non-emergent cardiology, interventional pain management, radiation therapy and radiologyprocedures when performed in freestanding diagnostic facilities, outpatient hospital settings, ambulatory surgery centers and physician offices for BCN HMO and BCN Advantage members.

* CPT codes, descriptions and two-digit numeric modifiers only are copyright 2015 American Medical Association. All rights reserved.

Posted: September 2016
Line of business: Blue Care Network

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

The e-referral system is displaying an updated BCN sleep study questionnaire earlier than the intended effective date of Oct. 3, for providers who request authorization for outpatient facility and clinic-based sleep management studies for adult members 18 years of age and older.

Here is what's happening: The updated questionnaire instructs providers to attach evidence from the member's medical record that confirms the specific condition the member has that excludes or contraindicates a home sleep study. This is requested for dates of service prior to Oct. 3, 2016, even though it is required only for dates of service on or after Oct. 3, 2016.

The result is that all cases pend, even for dates of service prior to Oct. 3.

Here's what to do: For requests to authorize these procedures for dates of service prior to Oct. 3, do the following:

1. Complete the questionnaire in the e-referral system. This includes commenting on:
• Symptoms of sleepiness
• Daytime sleepiness determined by an assessment tool (Epworth Sleepiness Scale or the Stanford Sleepiness Scale)
• Level of alertness different times of the day
• Diabetes
• Presence of other health conditions
• Neck circumference


2. For repeat sleep studies, submit the results of the initial sleep study. Attach these results to the authorization request in the e-referral system.

For dates of service prior to Oct. 3, BCN's Care Management staff will review the answers on the questionnaire without requiring evidence from the member's medical record showing that a home sleep study is excluded or contraindicated.

We apologize for any confusion caused by the updated questionnaire appearing for dates of service prior to Oct. 3.

Posted: September 2016
Line of business: Blue Care Network

BCN launches new Medical Benefit Drugs-Pharmacy web page

BCN has launched a new Medical Benefit Drugs-Pharmacy web page on this website. You can go to that page and get all the information you need about drugs covered under the medical benefit.

To open this new page, click the Medical Benefit Drugs-Pharmacy link on the left navigation bar, on the BCN part of this website.

The new page offers the following resources for providers offering drugs covered under the medical benefit:

• Authorization requirements (We've added a link that currently opens the pertinent pages in the BCN Referral and Clinical Review Program document but that will later open an all-in-one document outlining authorization requirements and medical necessity criteria and more.)


• Medical necessity criteria (commercial)


• National Drug Code pricing guidelines (unit of measure guidelines for submitting commercial claims)


• Newsletter articles


• Instructions for accessing information in the Pharmacy chapter of the BCN Provider Manual

Over time, you'll be able to open more documents from this new web page, as they become available.

Also, we've removed medical benefit drug information from the Clinical Review and Criteria Resources web page and moved it to the new page.

Posted: August 2016
Line of business: Blue Care Network

MSU Student and Graduate Assistants Health Plans information

Referrals for the new BCN health plans for Michigan State University students and graduate assistants work differently from what you're used to. If you were unable to attend one of the August webinars, you can view the plan flier (PDF) for more information.

Posted: August 2016 / Updated: September 2016
Line of business: Blue Care Network

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

As a reminder, starting with dates of service on or after Sept. 1, 2016, for BCN HMO^SM (commercial) and BCN Advantage^SM members, eviCore healthcare will manage authorizations for interventional pain management services (epidural and facet joint injections). The details about this change are in the news item titled "eviCore healthcare to review epidural and facet joint procedures for BCN effective September 1," which you'll find among the July 2016 news items on this website.

Sign up for an online orientation. eviCore has scheduled online orientation sessions to assist you and your staff with submitting pain management authorization requests through their electronic system.

You can attend the webinar orientation session that best fits into your schedule. This training is for utilization management and for any other appropriate staff.

To attend one of the sessions, please register in advance. Each session is free and will last approximately one hour.

All session times listed below are Eastern time. Note: The webex schedule displays Central time (Chicago), which is one hour before Eastern time (Michigan).

Click for instructions on how to register. Click the webinar orientation announcement for the instructions on how to register.

eviCore healthcare is an independent company that provides clinical review services for Blue Care Network.

Posted: August 2016
Line of business: Blue Care Network

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

For Blue Care Network providers submitting authorization requests to eviCore healthcare for the cardiology, radiology and radiation therapy services eviCore manages for BCN, a change will take place in mid-August.

Currently, both eviCore's electronic system and BCN's e-referral system show the same number of units authorized by eviCore.

Beginning Aug. 18, 2016, in some instances, you may see 250 units authorized in BCN's e-referral system for each service approved by eviCore. This will be more than the actual number of units authorized by eviCore. It is necessary for the 250 units to be downloaded to BCN's e-referral system to facilitate the payment of claims.

In these instances, the actual number of units authorized by eviCore will be visible in eviCore's electronic system and will be included in the letters eviCore sends.

So, starting Aug. 18, if the e-referral system shows 250 units authorized for your request, you should visit eviCore's electronic system and read the letters eviCore sends, to see the correct number of units authorized. When the e-referral system shows 250 units authorized, these will not be the correct number of units authorized.

As a reminder, eviCore healthcare reviews certain outpatient radiology, cardiology and radiation therapy services for BCN. Separately, eviCore also reviews physical, occupational, and speech therapy, and physical medicine services provided by chiropractors. Starting Sept. 1, eviCore will also review non-emergent pain management services for facet joint and epidural injections.

Additional information is available at ereferrals.bcbsm.com. Click BCN. Finally, click eviCore-Managed Procedures.

Posted: August 2016
Line of business: Blue Care Network

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

Starting Oct. 1, 2016, the requirements for how BCN's behavioral health facilities submit initial authorization requests, concurrent reviews and discharge summaries for inpatient, partial hospital and intensive outpatient services will change. The changes will affect both substance use and mental health cases.

Here's a summary of the changes:

e-referral User Guide will be updated. Prior to October 1, BCN's Behavioral Health e-referral User Guide will be updated to include instructions for the higher levels of care. Watch for the announcement!

You can refer to the updated User Guide for instructions on how to attach the BCN Behavioral Health Discharge Summary form to the case in the e-referral system. The User Guide will also show you how to complete the questionnaire for a concurrent review.

You can access the User Guide on the Training Tools page of this website.

Sign up to use the e-referral system. BCN-contracted facilities that have not already signed up for access to the e-referral system should apply immediately. Each utilization review user at each facility will need his or her own individual access.

To get access to e-referral, you must register to use the Blue Cross/BCN Provider Secured Services portal. To do that, click to open the Sign Up or Change a User page on this website. Follow the instructions under the heading "To sign up as a new e-referral user."

This applies whether your facility is new to Provider Secured Services or you're already signed up for Provider Secured Services and just need access to the e-referral system.

It is critical that you sign up as soon as possible since granting access takes some time and you'll need access prior to October 1.

Posted: August 2016
Line of business: Blue Care Network

e-referral User Guide updated and available

The e-referral User Guide (PDF) has been updated on the Training Tools page. The updated guide now includes:

• How to check a Blue Cross member's eligibility and benefits in web-DENIS
• How to submit authorizations and referrals to the University of Michigan Health System and the Henry Ford Health System
• An example of the Potential Duplicate Referral or Authorization screen
• Instructions on attaching medical record documentation to a request in the Case Communication field
• A section outlining how to submit an emergency/urgent inpatient authorization
• A section discussing how to submit for a sick/ill newborn
• An expansion of how the outpatient authorization questionnaire works

Posted: July 2016
Line of business: Blue Care Network

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

What's changing. Effective with dates of service on or after Sept. 1, 2016, eviCore healthcare will complete clinical reviews for non-emergent pain management services for facet joint and epidural injections. BCN Care Management has reviewed these procedures since April 2011 but with this change, eviCore will manage those services for BCN.

Currently, eviCore reviews certain outpatient radiology, cardiology and radiation therapy services for BCN. Separately, eviCore also reviews physical, occupational, and speech therapy, and physical medicine services provided by chiropractors.

For epidural and facet joint procedures, clinical review will be required for all diagnoses, for both BCN HMO^SM (commercial) and BCN Advantage^SM members. This applies to services associated with the following procedure codes: *62281, *62282, *62310, *62311, *62318, *62319, *64479, *64480, *64483, *64484, *64490, *64491, *64492, *64493, *64494, *64495.

How to submit review requests. Starting September 1, providers will be able to submit requests for clinical review for these procedures in one of two ways:

• Preferred method: online at evicore.com
• By phone at 1-855-774-1317

Starting August 25, providers can call eviCore at 1-855-774-1317 to review requests for services that will begin on or after September 1.

All requests must be reviewed prior to the services being rendered. If a treating physician does not receive a medical necessity determination and authorization number from eviCore prior to performing procedures for which eviCore's review is required, claims may not be reimbursed.

Other information. eviCore's interventional pain guidelines will be made available to providers at evicore.com.

In addition, by the end of August, the document Procedures that require clinical review by eviCore healthcare will be updated to include the pain management procedure codes. This document is available on the eviCore-Managed Procedures page on this website.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2015 American Medical Association. All rights reserved.

Posted: July 2016
Line of business: Blue Care Network

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

Physical therapists, occupational therapists, speech therapists and chiropractors performing physical medicine services for Blue Care Network members should select the correct provider ID in each provider category in BCN's e-referral system and in eviCore healthcare's electronic system. Selecting the correct provider ID helps ensure that authorizations are assigned correctly and that claims pay correctly.

Refer to the article "Therapists and physical medicine providers in a group practice should select correct providers in electronic systems" in the July-August 2016 issue of BCN Provider News, for instructions on how to select the correct provider ID.

Posted: July 2016
Line of business: Blue Care Network

eviCore changes reconsideration process for PTs' utilization categories

Effective immediately, eviCore healthcare has changed the process by which physical therapists request reconsideration of an assigned utilization category. The changes apply to category assignments that are effective Aug. 1, 2016, and affect reconsideration requests that are currently in progress.

If you are a physical therapist who provides services to BCN HMO (commercial) and BCN Advantage^SM members, you'll want to familiarize yourself with the revised process.

For the additional details you'll need to know, read the article "Changes in eviCore's reconsideration process for physical therapists' utilization categories" in the July-August 2016 issue of BCN Provider News.

Posted: July 2016
Line of business: Blue Care Network

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

This story is updated to show that the effective date for this change is Oct. 1, 2016, not Sept. 1, 2016, as reported earlier.

BCN reviews inpatient readmissions from facilities reimbursed by diagnosis-related groups when the member is readmitted with the same or a similar diagnosis.

What's changing? Effective Oct. 1, 2016, BCN will review readmissions that occur within 30 days of discharge. Currently, readmissions that occur within 14 days of discharge are reviewed.

A determination is made as to whether the readmission should be billed separately or bundled with the previous admission. In some instances, the two admissions are combined into one for purposes of DRG reimbursement.

Documents will be updated. The documents listed below will be updated to reflect the change to 30 from 14 days. All of the revised documents will be available online by the end of September:

• Guidelines for bundling admissions
• The Care Management and Claims chapters of the BCN Provider Manual
• The readmission checklist, which facilities should use to ensure that all necessary documentation is available for the review of a readmission that has occurred within 30 days

For additional information, you can access all these documents by completing the following steps:

1. Visit bcbsm.com/providers and click Login.
2. Log in to Provider Secured Services using your user ID and password.
3. Click BCN Provider Publications and Resources.
4. Click either Billing/Claims, Provider Manual or Forms, to open the appropriate Web page.

Posted: August 2016
Line of business: Blue Care Network

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

Services associated with radiology procedure code *75635 need to be authorized by BCN through the e-referral system to allow claims to pay.

Claims involving radiology procedure code *75635 will pay if there's an authorization in the e-referral system that matches the claim submitted. If no authorization is in the system, the claims will be denied.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2015 American Medical Association. All rights reserved.

Posted: June 2016
Line of business: Blue Care Network

UPDATED: Changes in BCN's sleep study requirements

The following changes in Blue Care Network's sleep study requirements are occurring:

Home sleep studies. Effective immediately, home sleep studies do not require clinical review, but an authorization is still needed in the e-referral system so that claims can be paid. This means that there is no longer a need to complete a questionnaire in the e-referral system for home sleep studies.

As a reminder, only providers who have signed a specific sleep testing agreement may provide home sleep studies to BCN members. Hospitals billing for services related to home sleep studies must also execute a specific sleep testing agreement and bill in accordance with BCN requirements.

Sleep studies in outpatient and clinic-based settings. Effective Oct. 3, 2016, all requests to authorize outpatient facility and clinic-based sleep management studies for adult members 18 years of age and older will require the submission of evidence from the member's medical record. This evidence must confirm the specific condition the member has that would exclude or contraindicate a home sleep study. This applies to BCN HMO^SM (commercial) and BCN Advantage^SM members.

Providers can facilitate the authorization request by completing the sleep study questionnaire for outpatient facilities or clinic-based settings in the e-referral system. Any documentation from the patient's medical record that is required can be attached to the request within the e-referral system, through the Case Communication field.

Additional information. Look for more information on this in the July-August 2016 issue of BCN Provider News, which will be available online at the end of June.

Posted: June 2016
Line of business: Blue Care Network

Submit obstetrical admissions one day after discharge – not sooner

The process for submitting information on obstetrical admissions to BCN has not changed.

Please continue to submit obstetrical admissions one day after discharge. Do not submit these admissions sooner than that.

For all deliveries, submit the following information via the e-referral system:

• Admission date, delivery date and discharge date
• Type of delivery
• Whether the baby was born alive
• Whether both mother and baby were discharged alive

The news item published in April about changes in submitting acute inpatient medical / surgical admissions does not apply to obstetrical admissions.

Posted: June 2016
Line of business: Blue Care Network

Some medical drugs no longer require authorization for BCN Advantage^SM members

Authorization is no longer required for BCN Advantage members for the following drugs covered under the medical benefit:

• J0881: Aranesp^®
• J0885: Epogen^® and Procrit^®
• J0178: Eylea^®
• J2778: Lucentis^®
• J2505: Neulasta^®

For a full list of all drugs covered under the medical benefit that require authorization, along with their procedure codes, refer to the BCN Referral and Clinical Review Program, available on this website.

Details on medical necessity criteria are also available on this website. Click Clinical Information for Drugs Covered under the Medical Benefit That Require Medical Necessity Review.

Both of these documents will be updated with the changes outlined in this news item. The revised documents will be available on this website, on the Clinical Review & Criteria Charts page, at the end of June.

Posted: May 2016
Line of business: Blue Care Network

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

While Blue Care Network uses McKesson's InterQual criteria as guidelines in reviewing acute inpatient medical admissions, BCN's medical directors will make the final determination about the most appropriate level of care based on their medical judgment. This will be effective starting May 30, 2016.

Additional information about the InterQual criteria and about the process for reviewing these admissions is found in the Care Management chapter of the BCN Provider Manual.

Posted: May 2016
Line of business: Blue Care Network

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

As announced earlier, Blue Care Network's Care Management staff will begin using the 2016 McKesson Corporation InterQual criteria when making determinations on clinical review requests for members with coverage through BCN HMO^SM and BCN Advantage^SM products. This change is effective on Aug. 1, 2016.

On that date, updated versions of BCN's Local Rules will also go into effect.

Additional information about these criteria updates and BCN's Local Rules will be included in the July-August 2016 issue of BCN Provider News, which will be available in late June.

Posted: May 2016
Line of business: Blue Care Network

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

Effective with dates of service on or after April 1, 2016, balloon ostial dilation services associated with procedure codes *31295, *31296 and *31297 require referral to a provider contracted with BCN regardless of the treatment setting. Claims submitted with no referral on file will deny on the basis that the services are experimental and investigational. This applies to BCN HMO^SM (commercial) and BCN Advantage^SM members.

Balloon ostial dilation does not require clinical review.

The medical policy titled "Balloon Ostial Dilation for Treatment of Chronic Sinusitis" is available on BCN's Medical Policy Manual Web page. To access it, log in to Provider Secured Services, click BCN Provider Publications and Resources and click Medical Policy Manual. The policies are listed alphabetically by name.

* CPT codes, descriptions and two-digit numeric modifiers only are copyright 2015 American Medical Association. All rights reserved.

Posted: April 2016
Line of business: Blue Care Network

New Behavioral Health e-referral User Guide available

A new User Guide has been posted for behavioral health providers on the Training Tools and Behavioral Health pages on this website.

As a reminder, behavioral health providers are required to submit initial requests for authorization using the e-referral system starting May 1, 2016. See the news item "Effective May 1, 2016, BCN behavioral health providers must use e-referral to submit initial requests for authorization, for non-urgent outpatient (clinic / office) services" posted in March.

The new guide includes step-by-step instructions on how to use the e-referral system for submitting and managing authorization requests electronically.

Posted: April 2016
Line of business: Blue Care Network

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

In response to providers' questions, we've published a Q&A document with additional information about the changes that start May 1 for authorization requests submitted for inpatient acute medical / surgical admissions.

The Q&A is available on this website, on the Clinical Review & Criteria Charts page. The Q&A document may be updated from time to time with additional information.

Be sure to read the initial news item "Changes start May 1 for authorization requests submitted for inpatient acute medical / surgical admissions" posted in March 2016.

Posted: April 2016
Line of business: Blue Care Network

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

On Aug. 1, 2016, Blue Care Network's Care Management staff will begin using the 2016 McKesson Corporation InterQual criteria when making determinations on clinical review requests for members with coverage through BCN HMO^SM and BCN Advantage^SM products.

Additional information about these criteria updates will be included the July-August 2016 issue of BCN Provider News, which will be available in late June.

Posted: April 2016
Line of business: Blue Care Network

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

Services associated with procedure codes *0159T and *0190T require clinical review by Blue Care Network even though they are add-on codes. These changes apply to both BCN HMO^SM (commercial) and BCN Advantage^SM members.

We had communicated earlier that these codes were among several that no longer required clinical review through eviCore healthcare when used as an add-on codes, as long as a valid authorization is on file for the primary code.

However, because the *0159T and *0190T codes represent services that are experimental and investigational, they do require clinical review by BCN on their own merits even when they are used as an add-on code and a valid authorization is on file for the primary code. This is effective immediately.

Claims will deny when they show one of these codes used as an add-on code and a valid authorization is not on file for both the primary and the add-on code.

* CPT codes, descriptions and two-digit numeric modifiers only are copyright 2015 American Medical Association. All rights reserved.

Posted: March 2016
Line of business: Blue Care Network

What you need to know about the eviCore 2.0 provider portal

If you have received an email from eviCore healthcare indicating you should register for the eviCore 2.0 provider portal, here's what you need to know:

• For all BCN care management requests that eviCore manages: Continue to use the existing eviCore portal. There's no need to register for eviCore 2.0 for the BCN requests.
• For non-BCN requests: Submit non-BCN requests through eviCore 2.0. Follow the instructions in the email you received from eviCore to register for eviCore 2.0.

If you have questions about eviCore's provider portals, email eviCore at providernewsletter@medsolutions.com.

Posted: March 2016
Line of business: Blue Care Network

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

Starting May 1, 2016, BCN's behavioral health providers will be required to submit initial outpatientrequests for authorization using the e-referral system. This applies only to non-urgent outpatient (clinic or office) services.

What's changing. Many behavioral health providers are submitting the initial outpatient authorization requests for their BCN patients using the Behavioral Health Initial Outpatient Authorization Request Form, which is currently available on the Behavioral Health Web page on this website.

Starting May 1, this form will no longer be available online and requests for initial outpatient authorization requests will be accepted only through the e-referral system.

Sign up to use the e-referral system. BCN-contracted providers who have not already signed up to for access to the e-referral system should apply immediately. To do that requires signing up for the Blue Cross / BCN Provider Secured Services portal, as follows:

1. Click Sign Up or Change a User on this website.
2. Click to open the appropriate forms for your provider type.
3. Complete the forms. Make sure to check that you want access to the e-referral system.
4. Submit the forms. Follow the instructions given on each form.

Learn how to use the e-referral system. Instructions for using the e-referral system are available on this website. Click Training Tools. Select the best training option for you.

In the next few weeks, an e-referral user guide geared specifically toward behavioral health providers will be available. Watch for the announcement!

Posted: March 2016
Line of business: Blue Care Network

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

The following changes will go into effect for authorization requests submitted to Blue Care Network for inpatient acute medical / surgical admissions:

• From May 1 through June 30, 2016, providers are strongly encouraged to submit these authorization requests via the e-referral system. Faxes will be accepted during certain times, however. The details about faxing are outlined later in this news item.
• Beginning July 1, 2016, these authorization requests will be accepted only when they are submitted through the e-referral system. Requests submitted by fax will no longer be accepted.

This applies to all BCN lines of business, including for BCN HMO^SM (commercial) members and BCN Advantage^SM (BCN Medicare Advantage) members.

In addition, the fax numbers to use in submitting requests are changing.

Here are the details you need to know.

Fax time frames. From May 1 through June 30, 2016, faxed requests will be accepted starting at midnight each Monday through noon on the following Friday. Faxes will not be accepted during the following times:

• From noon on Friday through midnight on the following Sunday
• Anytime on the day prior to a holiday on which BCN offices are closed. (The holidays observed at BCN are identified in the BCN Provider News issue published prior to the holiday occurring.)

Requests submitted by fax during these time frames will not be processed.

Fax numbers. The fax numbers to use in submitting requests are changing.

Use these new fax numbers from May 1 through June 30 to submit requests and to provide concurrent reviews and discharge dates:

• For BCN HMO (commercial) members: 1-866-313-8433
• For BCN Advantage members: 1-866-526-1326

The current fax numbers will go out of use starting May 1. These fax numbers are 1-866-652-8985 and 1-866-578-5482. On May 1, please delete references to these fax numbers in the materials you use.

Submit via e-referral. Requests to authorize inpatient acute medical / surgical admissions can be submitted via the e-referral system right now but beginning July 1, 2016, they must be submitted via e-referral. Requests submitted by fax on or after July 1 will not be accepted.

To access the e-referral system, do the following:

1. Click Login on this website.
2. Insert your Provider Secured Services user name and password.
3. Click Login.
4. Click BCN e-referral on the page that opens.

Sign up for e-referral. If you haven't yet signed up for access to the e-referral system, click Sign Up or Change a User on this website. Follow the instructions to complete the appropriate Provider Secured Services application forms.

We encourage you to sign up immediately, since you'll need access to the e-referral system on July 1.

Posted: March 2016
Line of business: Blue Care Network

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

Effective May 2, 2016, Blue Care Network's Care Management staff will begin using additional BCN Local Rules when making determinations on clinical review requests for acute care services and skilled nursing facilities. This applies to members with coverage through BCN HMO^SM (commercial) and BCN Advantage^SM products.

These Local Rules are:

• Infection GI/GU/GYN: Diverticulitis
• Gastrointestinal or biliary: Dehydration or gastroenteritis
• Gastrointestinal or biliary: Jaundice or bilirubin
• Gastrointestinal or biliary: Pancreatitis, chronic
• Genitourinary: Acute kidney injury
• Deep vein thrombosis
• Diabetes
• Syncope
• Infection: General
• Major joint arthroplasty for rehabilitation and skilled nursing facility
• Pain management for skilled nursing facility

These Local Rules will be added to the McKesson Corporation's 2015 InterQual^® criteria now in use. They will be published in the May-June 2016 issue of BCN Provider News, which will be available online at the end of April.

Posted: March 2016
Line of business: Blue Care Network

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

Effective April 1, 2016, BCN will use AMC Health as the vendor for managing high-risk BCN HMO^SM (commercial) and BCN Advantage^SM members with congestive heart failure and BCN Advantage members with chronic obstructive pulmonary disease. BCN will use the current vendor, Alere^TM Health, to manage these members through March 31.

Here's what you need to know about members moving to AMC Health from Alere:

• These members will receive letters in March 2016 letting them know about the transfer.
• AMC Health will contact members who require monitoring to introduce themselves and set up monitoring in early April.
• The primary care physicians for these members will continue to receive reports about these patients.

Members who no longer require telemonitoring will be contacted about enrolling in BCN's Case Management programs.

Currently, BCN HMO and BCN Advantage members in the CHF program use an in-home electronic weight scale and Interactive Voice Response symptom monitoring device that asks questions about how they feel twice a day. Their answers are reviewed by nursing staff and addressed based on the results. AMC Health will continue to use the scale and IVR symptom and behavioral assessment program but, in addition, they will send members a blood pressure machine. Readings from these devices are sent automatically to AMC Health.

BCN Advantage members in the COPD program will now be monitored with a pulse oximeter and inhaler cap. Depending on the member's response to these devices, an IVR automated phone call may take place or nurse assistance may be offered.

Look for additional information about this in the May-June 2016 issue of BCN Provider News, which will be available in late April.

Posted: March 2016
Line of business: Blue Care Network

We want your opinion

Take a short survey and get a chance to win a $25 gift card just for sharing what you think about BCN Provider News.

Participation in the survey is not necessary to win. The drawing is open to all active BCN providers.

Enter by completing the survey no later than March 31, 2016, or by sending an email with your name, phone number and "Survey drawing" in the subject line to BCNProviderNews@bcbsm.com by March 31.

Two winners will be selected in a random drawing from among all eligible entries. Each winner will receive a $25 gift card. The drawing will take place in early April. Winners will be notified by telephone or by email following the drawing.

Posted: March 2016
Line of business: Blue Care Network

Updated nutrition assessment form now available for home infusion providers

An updated Enteral and TPN Nutrition Assessment / Follow-up Form is now available. This form is intended for use only by home infusion providers

Where to get the form. The form opens from the Forms page on this website. At the bottom of the page, under the "Transitional Care Services" heading, click to open the form.

What's changed. The updated Enteral and TPN Nutrition Assessment / Follow-up Form:

• Has fields into which you can type the information about your agency and the patient. Open the form and save it to your hard drive. Then type the data into the fields.
• Includes information for patients getting total parenteral nutrition feedings as well as enteral feedings
• Shows two different fax numbers – one for BCN HMO^SM (commercial) members and one for BCN Advantage^SM members. Faxing the form to BCN using the appropriate fax number will help facilitate your request.

What's important to know. Be aware that:

• The home infusion agency's name, contact person and contact number must be entered into the form. Without that information, BCN cannot complete the authorization process and get the authorization decision back to you in timely fashion.
• You must provide the start-of-care date. That date may be different from the assessment date and the date the form is submitted.
• Enteral and TPN feeding services must be provided by an infusion provider contracted with BCN. You can search for an infusion provider by visiting bcbsm.com/find-a-doctor.
• It is BCN, not Northwood, Inc., that receives and processes requests to authorize home infusion services. The fax numbers you'll use to return the completed form go to BCN, not to Northwood.

What about after-hours calls? If you require discharge planning assistance after hours or on weekends or holidays, contact BCN's after-hours nurse at 1-800-851-3904.

Posted: March 2016
Line of business: Blue Care Network

Updated preview questionnaire is available for excisional breast biopsy

An updated excisional breast biopsy preview questionnaire is now available on the Clinical Review & Criteria Charts page on this website. Look under the "Medical necessity criteria / benefit review requirements" heading.

When you submit a request for clinical review for this procedure through BCN's e-referral system, you'll be prompted to complete a questionnaire on the appropriateness of the service. If the criteria are met, the request is automatically approved. If the criteria are not met, the request will require additional clinical review. For urgent requests, contact BCN Care Management by phone at 1-800-392-2512.

Minor style and grammatical changes were made to the questionnaire within the e-referral system and those are reflected in the preview questionnaire. No changes were made to the criteria for this service.

As a reminder, clinical review is required for excisional breast biopsy for members with Blue Care Network HMO^SM (commercial) products - including self-funded groups - and for members with BCN Advantage^SM products.

Look for additional information about this in the May-June 2016 issue of BCN Provider News, which will be available in late April.

Posted: February 2016
Line of business: Blue Care Network

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

Note: See the later news item published on this topic under the March 2016 heading.

Effective May 1, 2016, Blue Care Network's Care Management staff will begin implementing additional BCN Local Rules when making determinations on clinical review requests for acute care and skilled nursing facilities. This applies to members with coverage through BCN HMO^SM and BCN Advantage^SM products.

Detailed information about the additional Local Rules will be communicated in April.

Posted: February 2016
Line of business: Blue Care Network

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

Effective March 1, 2016, the following two changes go into effect for members with low back pain:

• These members are no longer required to see a physical medicine and rehabilitation provider for evaluation prior to referral to a neurosurgeon or orthopedic surgeon. The requirement for a referral to a physical medicine and rehabilitation provider had been part of BCN's Spine Care Referral Program.


• Clinical review is no longer required for the initial visit to a neurosurgeon or orthopedic surgeon and for office visits and procedures. These visits may require a referral from the member's primary care physician, depending on the region.

These changes apply to BCN HMO^SM (commercial) and BCN Advantage^SM members who have a low back pain condition defined by the select ICD-10 diagnosis codes that were previously subject to these requirements as part of BCN's Spine Care Referral Program.

The Spine Care Referral Program page on this website will reflect this information by March 1.

For additional information on BCN's referral requirements, which vary by region, refer to the BCN Referral / Clinical Review Program, available on the Clinical Review & Criteria Charts page on this website. Information on requirements for clinical review is also available in that document.

Posted: February 2016
Line of business: Blue Care Network

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

The following is a clarification of an earlier news item on this topic.

Requirements for FCA and GM members only (employer groups 100181 and 100355). Effective with therapy that starts on or after Jan. 1, 2016:

• Authorization is required only for BCN commercial (non-Medicare) members with coverage through Fiat Chrysler Automobiles (employer group 100181) and General Motors (employer group 100355) when the drugs listed below are administered at an infusion center with a location code of 19 or 22.


• No authorization is required for these members when the therapy is administered at other locations (at the physician's office, at the member's home or at an infusion center that's not affiliated with a hospital (that is, an infusion center with a location code other than 19 or 22).

The drugs are:

• Orencia^® (procedure code J0129)
• Remicade^® (procedure code J1745)
• Tysabri^® (procedure code J2323)

No authorization is required at all for other (non-FCA and non-GM) BCN members for these drugs.

The BCN Referral/Clinical Review Program is being updated to reflect this new requirement more accurately. The revised document will be available at the end of January at ereferrals.bcbsm.com, on the Clinical Review & Criteria Charts page.

Reminder related to other medications. Authorization is required for a number of other medications covered under the medical benefit for all BCN commercial members, including those covered through FCA and GM. For additional information on the requirements for these medications, please refer to the BCN Referral/Clinical Review Program document.

Posted: January 2016
Line of business: Blue Care Network

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

The authorization requirements have changed for some procedures managed for BCN by eviCore healthcare.

Requirements for pediatric members. Effective immediately, cardiology and radiation therapy procedures no longer require prior authorization for pediatric members under 18 years of age (through 17 years of age) who have BCN HMO^SM (commercial) and BCN Advantage^SM coverage.

Radiology services for pediatric members continue to require prior authorization for those procedure codes included on the list of Procedures that require clinical review by eviCore healthcare. Cardiology, radiation therapy and radiology services for adult members (18 years of age and older) that are included on the list continue to require prior authorization by eviCore.

BCN's referral requirements still apply and vary by region. Refer to the BCN Referral/Clinical Review Program for information on the referral requirements for your region.

Other requirements. Effective Jan. 1, 2016, services associated with the following procedure codes require prior authorization by eviCore healthcare:

• Radiology: CPT codes *74712, *78265 and *78266
• Radiation therapy: CPT codes *0394T, *0395T, *77767, *77768, *77770, *77771 and *77772

These are 2016 codes with the annual code updates for the American Medical Association and Healthcare Common Procedure Coding System. They are within the range of services currently managed by eviCore; they either replace 2015 codes or represent new or expanded codes that were made more specific for reporting purposes.

In addition, effective Oct. 1, 2015, services associated with the following procedure codes also require prior authorization by eviCore healthcare:

• Radiology: CPT codes *75635 and 77022
• Radiation therapy: CPT code *77014

These codes were included in the program implemented on Oct. 1, 2015, but were inadvertently not reflected on the list of procedures that require authorization by eviCore.

Documents to be updated. The following documents will be updated with these changes and will be available on this website by the end of January:

• Procedures that require clinical review by eviCore healthcare. Click eviCore-Managed Procedures to find this document.
• BCN Referral/Clinical Review Program. Click Clinical Review & Criteria Charts to find this document.

* CPT codes, descriptions and two-digit numeric modifiers only are copyright 2015 American Medical Association. All rights reserved.

Posted: January 2016
Line of business: Blue Care Network

BCN Behavioral Health utilization management criteria is changing on January 1

Effective Jan. 1, 2016, BCN Behavioral Health utilization management criteria are changing as outlined here.

InterQual^® criteria. BCN will use McKesson's InterQual Behavioral Health Criteria as utilization management guidelines. InterQual criteria are evidence-based clinical support criteria specifically developed to help move patients safely and efficiently to the appropriate initial and subsequent level of care. The criteria require reviewers to consider the severity of illness as well as episode-specific variables that match the level of care to a patient's current condition.

InterQual Behavioral Health criteria are developed with evidence-based rigor and are validated through the expertise of a multidisciplinary panel of psychiatrists, psychologists, psychiatric nurses and social workers. McKesson comprehensively reviews medical literature and other respected sources to assure that the criteria are current with the latest advances in evidence-based medicine as well as with new terminology and diagnostic classifications.

Providers may request a copy of the specific InterQual criteria used to render a decision on a member's case. To purchase a copy of the InterQual Behavioral Health criteria, call the InterQual Support unit at McKesson Health Solutions at 1-800-274-8374.

BCN's local criteria. In addition, BCN Behavioral Health will continue to use its own, local utilization management criteria for decisions about specific services, as follows:

• Transcranial magnetic stimulation criteria
• Neurofeedback training criteria for attention deficit disorder / attention deficit hyperactivity disorder criteria
• Autism spectrum disorder / applied behavior analysis criteria
• Residential mental health services / adult, adolescent and child criteria

Behavioral Health develops the criteria used for making medical necessity determinations in these areas. National experts, clinical advisory committees and contracted behavioral health clinicians contribute to the development of these criteria. The criteria are reviewed and updated, if appropriate, at least annually and are presented at the Clinical Quality Committee for physician input and approval. Scientific resources for the internal criteria include:

• Diagnostic and Statistical Manual of Mental Disorders
• Peer-reviewed scientific literature
• Available nationally recognized clinical guidelines

These local criteria will be available by January 1 on the Behavioral Health page on this website.

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

If you need assistance in identifying a supplier contracted with Northwood, Inc., call Northwood's customer service department at 1-800-393-6432.

BCN providers (primary care practitioners and specialists) must refer BCN HMO^SM (commercial) and BCN Advantage^SM members to a supplier contracted with Northwood for outpatient nondiabetic durable medical equipment, prosthetics / orthotics and medical supplies. The supplier will submit the request to Northwood for review.

The phone number that providers had previously been asked to use (1-800-667-8496) is for members. BCN providers should no longer use this number to contact Northwood.

The BCN Provider Manual and related documents will be updated over the next few weeks to reflect this information.

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

We have received feedback that there is a technical issue with the Dec. 7, 2015, launch of our latest e-referral upgrade. Some providers are getting an error when they click submit to enter a case. If this happens, providers are instructed to clear their browsing history, including cache and cookies, then log back in to e-referral. See steps below for clearing the browsing history in your web browser. If this action does not correct the problem, please call the Web Support Help Desk at 1-877-258-3932.

Instructions for clearing your browser history:

Google Chrome

1. In the browser bar, enter: chrome://settings/clearBrowserData
2. Select the following:
   • Browsing history
   • Download history
   • Cookies and other site and plug-in data
   • Cached images and files
   From the "Obliterate the following items from:" drop-down menu, you can choose the period of time for which you want to clear cached information. To clear your entire cache, select "the beginning of time."
3. Click "Clear browsing data."
4. Exit and quit all browser windows and reopen the browser.

Firefox

1. From the History menu at the top of the screen, select "Clear Recent History." If the menu bar is hidden, press the Alt key on your keyboard to make it visible.
2. From the "Time range to clear:" drop-down menu, select the desired range. To clear your entire cache, select "Everything."
3. Next to Details, click the down arrow to choose which elements of the history to clear. To clear your entire cache, select all the items.
4. Click "Clear Now."
5. Exit and quit all browser windows and reopen the browser.

Internet Explorer 9 and higher

1. Select Tools (via the Gear Icon at the top, right of the screen), then "Safety," and then "Delete browsing history." If the menu bar is hidden, press Alt to make it visible.
2. Deselect Preserve Favorites website data, and select:
   • Temporary Internet files or Temporary Internet files and website files
   • Cookies or Cookies and website data
   • History
3. Click "Delete." You'll see a confirmation at the bottom of the window when the process is complete.
4. Exit and quit all browser windows and reopen the browser.

Announcing e-referral enhancements beginning Dec. 7, 2015

We are working to make our new electronic referral system more user-friendly. As more provider offices sign-up and log in to use Blue Care Network's e-referral, we're discovering ways to make the system more responsive to providers' needs. Two major enhancements are available beginning Dec. 7, 2015.

Searching for patient eligibility

E-referral users will no longer need to click through a list of view links to locate a member's active coverage span. E-referral will bring up the member's active coverage for today's date. This will allow the provider to see only links to active coverage and will reduce the need to click on multiple view links to locate the active coverage. It will also reduce the number of instances where a referral is submitted under an inactive coverage span, which may cause the request to pend until BCN Care Management can research the issue. The provider also has the option to search for older coverage by entering a specific effective date in the date field.

Searching for a case

When searching for a referral already submitted for a patient, a provider will now have the option to search for specific associated providers or all associated providers. E-referral previously allowed the user the options to search by the provider that was in focus or all associated providers. This enhancement brings up a customized list of referrals based on the user's needs and avoids returning unrequested results. The user can also search by Provider ID or Patient ID and a specific date.

With any new system, it takes time to make it run as efficiently as possible. With this phase of e-referral enhancements, BCN's goal is to help providers choose the most appropriate eligibility information for the date of service and reduce the amount of waiting time for a response from us. We will continue to make improvements as we work with you, our partners in care.

Summary of December 2015 Enhancements

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

Let us know how satisfied you are with Care Management services from Blue Care Network and help us improve our processes. Take our Care Management survey and you could win a $250 gift card.

Please encourage the physicians, nurses, referral coordinators and others in your office to take it, too.

Responses must be submitted no later than Dec. 31, 2015, to be eligible for the random drawing. Two winners will be selected from all eligible entries approximately one week after the close of the survey. The winner will be notified by telephone or email.

Note: This drawing is open to all contracted BCN providers. If you do not wish to participate in the survey but wish to be included in the drawing, you may enter by emailing BCNPhysicianSurvey@bcbsm.com with your entry request. Please include your name, office name, NPI and address. All requests must be emailed no later than Dec. 31, 2015.

Global referral: What it allows a specialist to do

A global referral allows a specialist contracted with Blue Care Network to perform necessary services to diagnose and treat a member in the office as long as those services do not require prior authorization or benefit review. The specialist may also order diagnostic tests and/or schedule elective surgery at a facility as long as those services fall within the date range of the global referral; however, plan notification and prior authorization rules apply.

A separate request must be submitted by the specialist, primary care physician or facility for services requiring plan notification or prior authorization. Without plan notification or prior authorization, when applicable, claims for services at facilities will not pay against a global referral.

Reminder: Only primary care physicians can request global referrals for their members.

Please see the BCN Referral and Clinical Review Program for additional information about global referrals.

Changes in eviCore authorization requirements

Services that no longer require authorization through eviCore. Effective immediately, the following procedures no longer require authorization by eviCore healthcare:

• "Add-on" codes do not require prior authorization. Prior authorization is required only for the primary code. A separate authorization is not needed to bill BCN for add-on codes if there is a valid authorization on file for the primary code. Claims submitted to BCN for add-on codes without authorization for the associated primary code will not be reimbursed. The affected add-on procedure codes are *0159T, *0190T, *19297, *33225, *49412, *75565, *77293, *78020, *78730, *93320, *93321, *93325, *93352, and *93462.


• Select radiation therapy codes also do not require prior authorization. Click here to see a list of the affected radiation therapy codes.


• The unlisted radiation therapy procedure code *77799 is no longer managed by eviCore. Requests to authorize this procedure should be submitted to BCN Care Management.

Services that do require authorization through eviCore. When multiple radiology and cardiology services are to be performed, a separate authorization is needed though eviCore for each procedure code. This occurs when there are both primary and secondary procedures being performed and the secondary codes are not add-on codes. An example is when procedures associated with both the following codes are being performed and both require prior authorization: *78459 and *78491.

Claims information. BCN's systems are being reconfigured to accommodate these changes retroactive to Oct. 1, 2015. Once our systems have been updated, any claims that were denied for no authorization that, per this notice, were for procedures that no longer require prior authorization will be reprocessed. There is no need to re-bill these claims.

Updated documents are available. Refer to the updated list of Procedures that require clinical review by eviCore healthcare. This list, along with additional information, is available on the Procedures Managed by eviCore for BCN Web page on this website.

Reminder. October 1, 2015, was the effective date on which eviCore healthcare (formerly CareCore National) began performing clinical review for select cardiology, radiology and radiation therapy services. This involves select non-emergent outpatient services when performed on or after Oct. 1, 2015, in freestanding diagnostic facilities, outpatient hospital settings, ambulatory surgery centers and physician offices for BCN HMO^SM (commercial) and BCN Advantage^SM members.

* CPT codes, descriptions and two-digit numeric modifiers only are copyright 2014 American Medical Association. All rights reserved.

Add correct servicing provider information when submitting requests to eviCore

Be sure to add the correct servicing provider to the case, including name, NPI, address and other information, when submitting authorization requests to eviCore healthcare. When the correct servicing provider information is in the case, claims will pay. Without that information, the claim will not match the authorization and payment will be delayed.

BCN has experienced several instances in which the servicing provider's information was not entered correctly. Payments for the claims connected to those authorizations were delayed.

Reminder: Prostatic urethral lift procedures require clinical review

As a reminder, prostatic urethral lift procedures for the treatment of benign prostatic hypertrophy require clinical review effective Sept. 1, 2015. This applies to procedure codes *52441 and *52422 and to BCN HMO^SM (commercial) and BCN Advantage^SM members.

More details are available in the Medical Policy Updates section in the September-October 2015 issue of the BCN Provider News.

The BCN Referral and Clinical Review Program was updated to reflect this change.

* CPT codes, descriptions and two-digit numeric modifiers only are copyright 2014 American Medical Association. All rights reserved.

eviCore healthcare Web Portal webinars available

The eviCore healthcare (formerly CareCore National) Web Portal gives providers immediate access to submit authorizations and view patient authorization and eligibility information 24/7. Using the Web Portal for requests is 8x faster than phone requests and located at www.carecorenational.com. eviCore has recently added several new features to improve the experience including:

• Streamlined registration — Users can now register by email address
• Pause/Start feature — Users can return to a case in progress
• Upload PDF/Word files — no more faxing required
• Duplication — Users can duplicate information into a new case

Providers interested in learning more about the Web Portal and its new features are invited to attend one of the upcoming webinar training sessions (approximately 30 minutes long. All sessions Eastern Standard Time):

• Monday, Nov. 2, 2015 at 1 p.m.
• Tuesday, Nov. 3, 2015 at 2 p.m.
• Thursday, Nov. 5, 2015 at 11 a.m.
• Monday, Nov. 9, 2015 at 2:30 p.m.
• Tuesday, Nov. 10, 2015 at 1:30 p.m.
• Wednesday, Nov. 11, 2015 at 11 a.m.
• Tuesday, Nov. 17, 2015 at 1:30 p.m.
• Wednesday, Nov. 18, 2015 at 11 a.m.
• Friday, Nov. 20, 2015 at 1 p.m.
• Monday, Nov. 23, 2015 at 2:30 p.m.
• Tuesday, Nov. 24, 2015 at 1:30 p.m.
• Wednesday, Nov. 25, 2015 at 11 a.m.

To register, follow these steps:

1. Go to carecorenational.webex.com.
2. Click on the "Training Center" tab at the top of the page.
3. Click the "Upcoming" tab in the Live Sessions section.
4. Find the session you want by looking in the "Date & Time" column and for "Web Utilization Overview" in the Topic column.
5. Click "Register" for that session.
6. Enter the registration information.

Updated Spine Care Referral Program questionnaire is now available

An updated questionnaire is now available on the Spine Care Referral Program Web pages on this website. The updated questionnaire includes the ICD-10 diagnosis codes that are comparable to the ICD-9 diagnosis codes previously included in the program. The ICD-10 codes are to be used for dates of service on or after Oct. 1, 2015.

The BCN Spine Care Referral Program is designed to ensure that all members with ongoing low back pain appropriately receive comprehensive and timely nonsurgical evaluation of their symptoms and condition prior to surgical evaluation.

As a reminder, non-emergent and non-urgent referrals for members 18 years of age or older submitted to a neurosurgeon or orthopedic surgeon for low back pain evaluation with these ICD-10 low back pain diagnoses require prior authorization. All members 18 or older with low back pain must be seen by a physical medicine and rehabilitation provider prior to referral to a neurosurgeon or orthopedic surgeon for the conditions represented by these diagnosis codes.

Some providers showing missing or incorrect address in e-referral

An issue has been identified in the e-referral system in which some providers in the In Focus bar (top right of the screen) are showing an incorrect or missing address. This is a known defect and BCN is currently working to permanently remove this field in the near future.

Users experiencing this issue are asked to ignore the empty or incorrect address field. Please contact your provider consultant with any comments or questions.

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

As a reminder, Oct. 1, 2015, is the effective date on which eviCore healthcare (formerly CareCore National) performs clinical review for additional radiology services and for select cardiology and radiation therapy services.

This applies to select non-emergent outpatient services when performed on or after Oct. 1, 2015, in freestanding diagnostic facilities, outpatient hospital settings, ambulatory surgery centers and physician offices for BCN HMO^SM (commercial) and BCN Advantage^SM members.

Refer to the list of procedures that require clinical review by eviCore healthcare.

This list, along with additional information, is available on the Procedures Managed by eviCore for BCN Web page.

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

Please take a few minutes to respond to our Care Management survey and you could win a $250 gift card.

You can find the survey at http://tinyurl.com/2015BCNCM.

Your feedback is important to us because it will help us improve our care management processes. Encourage the physicians, nurses, referral coordinators and others in your office to take it, too.

Responses must be submitted no later than Dec. 31, 2015, to be eligible for the random drawing. Two winners will be selected from all eligible entries approximately one week after the close of the survey. The winner will be notified by telephone or email.

This drawing is open to all contracted BCN providers.

Note: If you do not wish to participate in the survey but wish to be included in the drawing, you may enter by sending an email to BCNPhysicianSurvey@bcbsm.com with your entry request. Please include your name and NPI, and the name and address of your office. All requests must be emailed no later than Dec. 31, 2015.

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

A federal mandate requires all HIPAA-covered entities to adopt ICD-10 by Oct. 1, 2015. The International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) and Procedure Coding System (ICD-10-PCS) are new medical code sets under the Health Insurance Portability and Accountability Act and represent a significant change to the current ICD-9 coding system.

Providers should be aware of the following when entering referrals and authorizations into e-referral:

• Authorizations and referrals submitted into e-referral with an ICD-9 code prior to October 1 with a date of service that spans past October 1 will not need to be resubmitted with an ICD-10 code.


• Authorizations and referrals submitted into e-referral for dates of service October 1 and later should include an ICD-10 code.


• Authorizations and referrals submitted into e-referral for dates of service October 1 and later with an ICD-9 code will see the warning message: "You have selected an inactive (retired) code. Would you like to continue?" Please choose No and select an ICD-10 code.


• If you are using e-referral bookmarks that contain an ICD-9 code, you will not see the warning message. Please delete any ICD-9 codes from your bookmarks.

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

After careful consideration, Blue Cross Blue Shield of Michigan and Blue Care Network have decided that a re-evaluation of applied behavior analysis autism treatment after every three years will be required only in the following instances:

• When a member has shown only minimal progress in autism treatment
• When there is a significant question about the continued accuracy of a member's diagnosis or treatment plan

A component of the state's autism mandate is that insurance companies may require a re-evaluation for members at three-year intervals of ABA autism treatment. Because the mandate began three years ago, in 2012, many members are now approaching the time that the re-evaluation would be required.

Blue Cross and BCN have decided that the mandatory review is not needed for many members who are in ABA autism treatment. We expect that the members who do need re-evaluation and redirection of their ABA treatment will come to our attention through the continuous monitoring, evaluation and utilization management that providers are doing together with our behavioral health care managers. In addition, Blue Cross and BCN may require that a member undergo annual developmental testing as a standardized method of measuring treatment progress.

Additional information on this topic will be included in upcoming issues of the corporation's provider newsletters, as follows:

• The November 2015 issue of The Record, which will be available electronically by Nov. 1, 2015
• The November-December 2015 issue of BCN Provider News, which will be available electronically at the end of October

Providers are encouraged to subscribe to both newsletters in order to get current information about autism policies and other topics. To subscribe, visit bcbsm.com/providers and click Newsletters.

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

You can submit requests for authorization to eviCore healthcare (formerly CareCore National) prior to Oct. 1, 2015, for procedures with dates of service on or after October 1. EviCore can review these requests prior to October 1.

As a reminder, the table below shows the types of requests reviewed by eviCore.

These requirements apply to BCN HMO^SM (commercial) and BCN Advantage^SM members.

Submit requests for authorization of these procedures in one of two ways:

• Preferred method: online at www.evicore.com
• By phone at 1-855-774-131

The requests must be reviewed prior to the services being rendered. If a treating physician does not receive a medical necessity determination and authorization number from eviCore prior to performing procedures for which eviCore's review is required, claims may not be reimbursed.

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

Many injectable or infusible drugs covered under Blue Care Network members' medical benefit can be safely and effectively administered at several different sites of care. The most common sites include the outpatient hospital, physician's office and the member's home.

To help manage the cost of these drugs, BCN is implementing a program that redirects patients receiving select infusion drugs in the hospital setting to alternate sites of care.

Starting Oct. 1, 2015, BCN commercial members who begin therapy with one of the following drugs or drug categories will be required to receive this therapy at an infusion center, at their physician's office or at home.

• Alpha-1 antitrypsin inhibitors (for example, Prolastin^®)
• Immune globulin therapy (for example, Gammagard^®)
• Lysosomal storage therapy (for example, Cerezyme^®)
• Soliris^®

BCN is also reaching out to members currently being treated with these therapies and their physicians to encourage members to use a more cost-effective site of care, such as an infusion center, their physician's office or their home.

The BCN Referral/Clinical Review Program document will be updated by October 1 to reflect this new requirement. That document is available on this website, on the Clinical Review & Criteria Charts page.

Chiropractors may provide some physical therapy services for BCN commercial members

Effective Aug. 1, 2015, chiropractors contracted with BCN may provide some physical therapy services for BCN HMO^SM (commercial) members with coverage through groups that offer standard chiropractic benefits. This applies to services represented by select *97XXX procedure codes, rendered in office and outpatient care settings.

The member's primary care physician must issue a global referral for "office visits" when the member:

• Is from the East or Southeast region


• Has a plan with a designated provider network the chiropractor does not belong to

The chiropractor may then request authorization for an episode of care directly from Landmark Healthcare, who manages these services for members on BCN's behalf.

You'll find additional information about the referral and authorization process for these services in the Care Management chapter of the BCN Provider Manual. Look in the section titled "Therapy management: PT, OT and ST (including chiropractors providing PT services)". This section has been updated to reflect the details that primary care physicians, specialists and chiropractors need to know.

The document Outpatient rehabilitation services: Frequently asked questions has also been updated with these changes.

Both documents are available through hyperlinks on the Outpatient Physical, Occupational and Speech Therapy Management Program page on this website.

* CPT codes, descriptions and two-digit numeric modifiers only are copyright 2014 American Medical Association. All rights reserved.

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

Effective with dates of service on or after Oct. 1, 2015, additional radiology services and select cardiology and radiation therapy procedures will require clinical review. Radiologists, cardiologists, radiation therapists and facilities who provide these procedures are invited to attend a webinar being held starting Sept. 16, where these changes will be discussed. Fill out and submit the webinar invitation (PDF). Instructions for signing into the webinar will be emailed to you prior to the event chosen.

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

Effective Oct. 1, 2015, preventive screening for lung cancer using low-dose computed tomography requires clinical review. For this preventive service, members do not have cost-sharing responsibilities. This is because under the Patient Protection and Affordable Care Act and Medicare's National Coverage Determination process, insurers must cover preventive services with no member cost-sharing.

Here is some important additional information you'll need to know:

• For BCN HMO^SM (commercial) patients, submit both the request for clinical review and the claim using HCPCS procedure code S8032.


• For BCN Advantage^SM patients, use procedure code S8032 temporarily to submit the request for clinical review. As for claims, the Centers for Medicare & Medicaid Services has not yet published the HCPCS code that will be used for Medicare members receiving this service. For now, CMS has advised providers to hold claims until the code is made available. However, submitting the request for clinical review is required even though the billing guidelines are not yet available.

Use *71250 for non-preventive services. For both BCN HMO and BCN Advantage patients, clinical review requests and claims involving non-preventive screening for lung cancer with low-dose computed tomography services should continue to be submitted using procedure code *71250. When you use this code, the member will have cost-sharing responsibilities.

Submit requests to eviCore. All requests for clinical review should be submitted to eviCore healthcare (formerly CareCore National) in one of the following ways:

• Preferred method: online at www.evicore.com
• By phone at 1-855-774-1317

The requests should be submitted prior to services being provided.

Additional information. Look for additional information in the September-October 2015 issue of BCN Provider News, in the Referral Roundup section. This issue will be published at the end of August.

* CPT codes, descriptions and two-digit numeric modifiers only are copyright 2014 American Medical Association. All rights reserved.

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

October 1, 2015, is the new effective date on which eviCore healthcare (formerly CareCore National) will perform clinical review for additional radiology services and for select cardiology and radiation therapy services.

This applies to select non-emergent outpatient services when performed on or after Oct. 1, 2015, in freestanding diagnostic facilities, outpatient hospital settings, ambulatory surgery centers and physician offices for BCN HMO^SM (commercial) and BCN Advantage^SM members.

The date previously announced for the start of the expanded reviews was Sept. 1, 2015.

If a treating physician does not receive a medical necessity determination and authorization number from eviCore prior to performing these procedures, claims may not be reimbursed.

Requests for clinical review can be submitted in one of two ways:

• Preferred method: online at www.evicore.com
• By phone at 1-855-774-1317

A full list of procedures that require clinical review on or after Oct. 1, 2015, will be available by the end of September on the Radiology Management Program page on this website.

e-referral upgrade slated for Aug. 17

The e-referral system is being upgraded Aug. 17. You can find a list of enhancements in the July-August edition (PDF) of BCN Provider News. Please note that the date has changed from the one originally published.

While we upgrade the system, e-referral will be unavailable from 5 p.m. on Thursday, Aug. 13, until 7 a.m. on Monday, Aug. 17. Please hold routine referral and authorization requests during this time and enter them into the upgraded system starting Monday, Aug. 17. For urgent referral and authorization requests, use the numbers below:

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

The 2015 InterQual Home Care Criteria from McKesson Health Solutions is available only in a new Q&A format. It is no longer available in book form or through the McKesson Mobile Delivery^TM application.

Effective Aug. 3, 2015, BCN will use the 2015 Home Care Criteria in the new format, along with the other 2015 InterQual criteria. See the news item already published on this topic.

Providers who wish to access InterQual Home Care Criteria in the Q&A format must download it electronically using McKesson's InterQual View. To do that, visit mhsinfo.mckesson.com.*

*Blue Cross Blue Shield of Michigan and Blue Care Network do not control this website or endorse its general content.

More procedures to be reviewed by eviCore healthcare effective September 1

Effective with dates of service on or after Sept. 1, 2015, additional non-emergent outpatient high-tech radiology services and also many cardiology and radiation therapy services must undergo clinical review by eviCore healthcare (formerly CareCore National). These requirements will apply to BCN HMO^SM (commercial) and BCN Advantage^SM members.

Providers will be able to submit requests for clinical review for these procedures in one of two ways:

• Preferred method: online at www.evicore.com
• By phone at 1-855-774-1317

The requests must be reviewed prior to the services being rendered. If a treating physician does not receive a medical necessity determination and authorization number from eviCore prior to performing procedures for which eviCore's review is required, claims may not be reimbursed.

Currently, review by eviCore is required for certain outpatient CT, MRI and nuclear scans. Prior to the effective date of the new requirements, an updated outpatient high-tech radiology procedure code summary, listing all the radiology procedures reviewed by eviCore, will be available on the Radiology Management Program page on this website. In addition, lists of all the cardiology and radiation therapy procedures reviewed by eviCore will also be available on that page.

The additional radiology procedures that will require eviCore's review include but are not limited to the following:

Radiology

• Positron emission tomography
• Magnetic resonance angiography
• Additional magnetic resonance imaging and computed tomography procedures, including MRI of breast
• Imaging of bone/joint, pulmonary ventilation, brain, kidney, thyroid and bone marrow

The cardiology and radiation therapy procedures that will require eviCore's review include but are not limited to the following:

Cardiology

• Insertion, replacement or upgrade of permanent pacemaker
• Insertion or removal of implantable defibrillator
• Cardiac MRI
• CT of the heart
• CT angiography of the heart
• Cardiac radionuclide angiography
• PET myocardial imaging
• Myocardioperfusion imaging PET
• Echocardiography (transthoracic and Doppler)
• Catheter placement in coronary artery for coronary angiography

Radiation therapy

• Radiation treatment
• Brachytherapy of coronary arteries
• Hyperthermia
• Image-guided radiation therapy
• Neutron radiotherapy
• Proton beam therapy
• Radioimmunotherapy
• Radioactive yttrium-90 microspheres

eviCore healthcare Web address changes July 6

Effective July 6, 2015, providers submitting online clinical review requests for the high-tech radiology procedures that require it must visit www.evicore.com. This Web address replaces the previous one, www.carecorenational.com, as of July 6.

Providers will still be able to submit the requests for clinical review by phone at 1-855-774-1317, but online submission is the preferred method.

The change in Web address is aligned with the change in name from CareCore National to eviCore healthcare. The name change is already in effect.

For more information on the high-tech radiology procedures that require clinical review, refer to the Radiology Management Program page on this website.

Upgrades coming to e-referral

Several new upgrades and changes are coming to the e-referral system. The expected go-live date for these enhancements is Aug. 3, 2015. With the upgrade, users will be able to:

• Create a new case for the same patient from the Case Details page which reduces the work effort needed to create multiple cases for one patient.
• Add attachments to a Case Communication with the Attach File button on an initial request.
• Search for referrals and authorizations across all providers in a set when choosing the new Include All Associated Providers option.
• Search for a provider or facility by their NPI within their associated provider list. (Previously a user could only search for a provider.)
• Search by either a code or description in the same field during a Procedure Code search.
• Manually enter a Patient ID during a Referral/Authorization case search (Previously had to search/select a patient to populate this field.)

Other changes:

• The Add Provider and Add Facility buttons have been replaced by the Add Bookmark button (found in the Bookmarks feature under the Provider tab).
• The From and To dates have been eliminated when searching for a case by Patient.
• The In Focus vertical bar on the left side has been removed to simplify the application.
• The system will accept ICD-10 codes (as well as ICD-9 codes).

These changes can be found in the updated User Guide (PDF) or the User Guide addendum (PDF).

In order to upgrade the system, e-referral will not be available starting late Friday, July 31 through early Monday, Aug. 3. Please see the article on Page 1 of the July-August 2015 BCN Provider News for full details.

2015 InterQual^® criteria to be used effective August 3

On Aug. 3, 2015, Blue Care Network's Care Management staff will begin using the 2015 McKesson Corporation InterQual criteria when making determinations on clinical review requests for members with coverage through BCN HMO^SM and BCN Advantage^SM products. Updated versions of BCN's Local Rules will also go into effect on August 3.

Additional information about these criteria updates and BCN's Local Rules will be included in the July-August 2015 issue of the BCN Provider News, which will be available in late June.

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

Effective with dates of service on or after July 1, 2015, BCN will require prior authorization/clinical review for the medications listed below before these drugs will be covered under the members' medical benefits.

This requirement applies only to BCN HMO^SM (commercial) members. For BCN Advantage^SM members, no prior authorization/clinical review is required for these services.

These prior authorization/clinical review requirements apply only to members who start their medications on or after July 1, 2015. Members who have a paid claim for one of these medications by the end of June 2015 will not be required to seek initial prior authorization/clinical review.

Prior authorization/clinical review criteria include, but are not limited to: diagnosis, lab results, dosing and frequency of administration. We may also require documentation of medications previously used to treat the member's condition, including dosage, regimens, dates of therapy and response, as well as additional pertinent medical information.

To request prior authorization/clinical review for one of these medications, please submit the request through BCN's e-referral system or fax the request to BCN Care Management at 1-800-675-7278. You can also call Care Management at 1-800-392-2512.

As a reminder, all medications represented by codes J3490, J3590 also require prior authorization/clinical review for all members because these codes represent services that are not otherwise classified.

For a full list of all medications and procedure codes subject to prior authorization/clinical review requirements, click Clinical Review & Criteria Charts at the left on this page and then click Blue Care Network Referral and Clinical Review Program.

Additional information on the medical necessity criteria is available on the same Web page. Just scroll down to the medical necessity criteria section and click Clinical Information for Drugs Covered under the Medical Benefit That Require Medical Necessity Review.

Updated versions of these documents will be available on the Web by July 1.

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

Effective with requests submitted on or after April 1, 2015, transplants that require clinical review are subject to the standard clinical review process managed by BCN Care Management staff. Prior to April 1, clinical review was completed by a BCN case manager. This change applies to solid organ and bone marrow evaluations and harvesting (except kidney, skin and cornea), for all members. This also applies to requests to renew or extend an authorization period if the transplant procedure does not occur within the time frame allowed by the authorization.

The preferred method for requesting clinical review is to submit the request through BCN's e-referral system. You can also call in the request to Care Management at 1-800-392-2512. Clinical documentation should be faxed to 1-800-675-7278.

In addition, as a reminder, BCN HMO^SM(commercial) members are required to have their transplants performed at a Blue Distinction^® Center+ for Transplants, if one is available. This requirement is effective May 1, 2015. In Michigan, the only facility that has achieved the Blue Distinction Center+ for Transplants designation is the University of Michigan Hospital System (for most, but not all, types of transplants). If a Blue Distinction Center+ for Transplants facility is not available for the type of transplant the member needs, a Blue Distinction Center for Transplants facility may be used.

BCN Advantage^SM members are required to have their transplants performed in facilities that are approved by the Centers for Medicare & Medicaid Services and are contracted with BCN Advantage. It's preferred that BCN Advantage members be directed to a Blue Distinction Center for Transplants, when one is available.

For additional information, see the article "BCN updates transplant policy for Blue Distinction Centers" in the March-April 2015 issue of BCN Provider News.

Finding home sleep study providers

You can find the names of home sleep study providers contracted with BCN at bcbsm.com/find-a-doctor by typing "home sleep testing" in the What are you looking for? field.

For more specific instructions for finding BCN-contracted home sleep study providers, refer to the document Finding home sleep study providers.

In addition to the home sleep study providers you'll find for the ZIP code you enter, Night Hawk Sleep Systems, Inc., provides home sleep study services for BCN members throughout Michigan. You can call Night Hawk at 1-877-622-2022.

Only providers who are board-certified in sleep medicine and are specifically contracted with BCN for home sleep studies can bill for this service.

Additional information about BCN's Sleep Management Program can be found on the Sleep Management Program page at ereferrals.bcbsm.com.

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

For BCN Advantage^SM members. For BCN Advantage members, neither referral nor clinical review is required for services involving long-term continuous electrocardiographic rhythm recording and storage devices worn on an adhesive patch when supplied by a contracted provider and used for time periods longer than 48 hours, up to 14 days. This applies to devices such as the Zio^® Patch and LifeStar ACT and to procedure codes *0295T through *0298T.

Clinical review is required for all providers not contracted with BCN. This includes the manufacturers of the ECG monitoring devices. If the manufacturer will be billing BCN directly for procedure code *0297T, clinical review is required.

For BCN HMO^SM members. For BCN HMO (commercial) members, clinical review is still required for continuous ECG monitoring using these rhythm recording and storage devices. You can submit your request for review via the e-referral system or by calling BCN Care Management at 1-800-392-2512. For commercial members, the following two clinical review requests need to be entered:

• One request for codes *0295T, *0296T or *0298T to be submitted by the specialist or facility (or both), to hook up the device and interpret the results
• One request for code *0297T to be submitted by the provider of the device, for the device itself

Date span on the request. The date span on requests for all members should be 45 days, to allow time for the various activities associated with these devices, including device hook-up, member instruction, the days the device is actually in use, the return of the device and interpretation of the results.

* CPT codes, descriptions and two-digit numeric modifiers only are copyright 2014 American Medical Association. All rights reserved.

Register now for April 2015 behavioral health webinar

Fill out and submit the registration form to secure your spot in an April 2015 Blue Cross Blue Shield of Michigan and Blue Care Network behavioral health webinar. No need to travel; you can participate in the webinar right at your desk.

The topics covered include:

• Enrollment
• System navigation and resources
• Billing/supervision guidelines
• BCN's Behavioral Health Incentive Program (2015)

You can select one of the following two dates:

• Tuesday, April 21, 2015, 10-11 a.m.
• Thursday, April 23, 2015, 10-11 a.m

The same information will be covered on each webinar date.

Registration closes Friday, April 17, so get your form in right away. The instructions for submitting the registration form are right on the form. We will email you the instructions for signing in to the webinar a day or two prior to the webinar.

The webinar is for behavioral health providers who serve BCBSM and BCN members.