Clinical review requirements suspended until further notice for certain hospitals at higher inpatient bed occupancy

Due to the recent surge in COVID-19 cases, Blue Cross Blue Shield of Michigan and Blue Care Network are temporarily suspending clinical review requirements for all non-elective medical cases for those hospitals most impacted by the pandemic.

Effective Nov. 25, 2020, and until further notice, the following changes apply to Michigan hospitals with a bed occupancy of 85% or higher*. These changes apply to all lines of business, including Blue Cross commercial, Blue Care Network commercial, Medicare Plus Blue^SM and BCN Advantage^SM:

• Clinical review requirements for all non-elective medical cases will be suspended in hospitals with inpatient bed occupancy at 85% or higher.

  *Blue Cross and BCN are evaluating hospital occupancy each Wednesday based on the previous week's data from the Michigan Department of Health & Human Services. This information can be found on the Statewide Available PPE and Bed Tracking webpage** on the Michigan.gov website (see the Patient Census chart at the bottom). Non-elective medical cases will auto-approve beginning on the Monday following Blue Cross and BCN's evaluation. Once a hospital falls below the 85% bed occupancy rate for three consecutive weeks, non-elective medical cases will no longer auto-approve. Please see the Temporary suspension of clinical review requirements document for hospitals who have the clinical review requirements suspended each week. This document can be found within Provider Secured Services by clicking Coronavirus (COVID-19). It is posted under the Utilization management section.

• Admissions to skilled nursing facilities from the hospitals that qualify for accommodations based on bed occupancy will auto-approve the first three days.
• Long-term acute care hospital and inpatient rehabilitation facility admissions from the hospitals who qualify for accommodations based on bed occupancy will receive expedited processing with most decisions made within two hours of the request for discharge during normal business hours. Clinical review is still required.

Note:

• Non-elective admissions with suspended clinical review may be subject to a future audit.
• Hospitals and facilities that qualify for accommodations based on bed occupancy must still submit a plan notification, so an authorization is in our system when we receive the claim. A plan notification is a request for authorization submitted through e-referral for which no clinical documentation is required.
• Hospitals are encouraged to submit plan notifications through the e-referral system.
• Skilled nursing facilities that receive an admission from a hospital that qualifies for accommodations based on bed occupancy are not required to submit clinical documentation until the continued stay review, starting on the fourth day of stay.
• These changes do not apply to elective procedures or outpatient services. All other prior authorization requirements continue.
• These temporary changes do not apply to FlexLink^® groups for which a third-party administrator makes authorization determinations. Facilities should check the back of the member's ID card to determine whether a third-party administrator needs to be contacted prior to an admission.

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

Nov. 26-27 holiday closure: How to submit inpatient authorization requests

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will be closed for the Thanksgiving holiday on these dates:

• Thursday, Nov. 26, 2020
• Friday, Nov. 27, 2020

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

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

• Blue Cross Authorization Requirements & Criteria page
• BCN Authorization Requirements & Criteria page

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

• Christmas Eve: Thursday, December 24
• Christmas Day: Friday, December 25
• New Year's Eve: Thursday, December 31

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

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

From 10 p.m. on Saturday, Nov. 21 to 10 a.m. on Sunday, Nov. 22

Note: All times are Eastern time.

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

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

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

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

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

Accessing the TurningPoint Provider Portal, registering for training and other important information

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

This expansion affects all Blue Cross' PPO fully insured groups, select Blue Cross' PPO administrative service contract groups, all Medicare Plus Blue^SM PPO members, all BCN HMO^SM members and all BCN Advantage^SM members.

We recently published newsletter articles that include information about:

• The procedures that are affected by the TurningPoint program expansion
• Accessing the TurningPoint Provider Portal
• Submitting retrospective authorization requests for procedure codes for which authorization management will transition from eviCore healthcare^® or Medicare Plus Blue Utilization Management to TurningPoint
• Registering for webinar training sessions

You can view the articles here:

• TurningPoint musculoskeletal authorization program to expand in January (PDF) — on page 46 of the November-December issue of BCN Provider News
• TurningPoint musculoskeletal authorization program to expand in January — in the November 2020 issue of The Record

In addition, we updated the following pages of this website and the documents to which these pages link for the changes that are coming on Jan. 1:

• Blue Cross Musculoskeletal Services
• BCN Musculoskeletal Services

Nov. 3 holiday closure: How to submit inpatient authorization requests

On Tuesday, Nov. 3, 2020, Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will be closed for Election Day.

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

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

• Blue Cross Authorization Requirements & Criteria page
• BCN Authorization Requirements & Criteria page

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

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

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

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

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

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

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

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

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

How to bill

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

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

NovoLogix

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

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

List of requirements

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

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

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

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

Note: All times are Eastern time.

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

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

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

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

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

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

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

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

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

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

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

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

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

Are there any changes to the management for these therapies?

There are no changes to the management of these therapies.

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

Submitting prior authorization requests

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

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

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

List of requirements

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

• Blue Cross Pharmacy Benefit Drugs
• BCN Pharmacy Benefit Drugs

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

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

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

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

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

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

• Viltepso^™ (viltolarsen), HCPCS codes J3490, J3590

How to bill

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

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

Important reminder

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

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

List of requirements

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

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

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

In September and October:

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

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

Updated questionnaires

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

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

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

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

Removed questionnaire

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

Preview questionnaires

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

To find the preview questionnaires:

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

Authorization criteria and medical policies

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

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

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

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

This affects BCN HMO^SM, Medicare Plus Blue^SM PPO, BCN Advantage^SM and UAW Retiree Medical Benefits Trust PPO non-Medicare members.

Drug that will no longer require prior authorization

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

• Lartruvo^® (olaratumab), HCPCS code J9285

Drugs that will require prior authorization

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

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

How to submit authorization requests

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

• Through the AIM provider portal*
• By calling the AIM Contact Center at 1-844-377-1278

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

More about the authorization requirements

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

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

• For BCN HMO members
  • Blue Cross and BCN utilization management medical drug list (PDF)
  • Medical Oncology Program (PDF) list
• For Medicare Advantage members: Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members (PDF)
• For UAW Retiree Medical Benefits Trust non-Medicare members: Medical Oncology Prior Authorization List for UAW Retiree Medical Benefits Trust non-Medicare members (PDF)

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

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

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

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

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

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

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

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

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

1. Register now for access to the e-referral system
   We encourage you to register now for access to the e-referral system. It takes some time to process registration requests and we want to make sure everyone has access before Dec. 1.
   
   To register, follow the instructions on the Sign Up or Change a User webpage on this website.
2. Use the online tools to learn the e-referral system — before attending a webinar
   
   Visit the Training Tools page of this website for:
   
   • e-referral User Guide (PDF)
   • Online self-paced learning modules (PDF)

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

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

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

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

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

Note: All times are Eastern time.

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

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

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

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

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

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

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

This applies to SNF claims for Medicare Plus Blue^SM PPO and BCN Advantage^SM members.

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

As a reminder, naviHealth:

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

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

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

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

What this means

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

• For Medicare Plus Blue^SM PPO, BCN HMO^SM and BCN Advantage^SM members:
  • Cardiac resynchronization therapy
  • Implantable cardioverter-defibrillator
• For Medicare Plus Blue members only:
  • Arterial ultrasound

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

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

Watch for more details

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

Additional information

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

• On this website:
  • Blue Cross AIM-Managed Procedures page
  • BCN AIM-Managed Procedures page
• At bcbsm.com/providers, on the Medicare Plus Blue Preauthorization and Utilization Management page

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

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

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

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

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

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

• TurningPoint musculoskeletal authorization program to expand in January (PDF) - on page 33 of the September-October 2020 issue of BCN Provider News.
• TurningPoint musculoskeletal procedure authorization program to expand in January - in the September 2020 issue of The Record.

Additional information

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

• Blue Cross Musculoskeletal Services page
• BCN Musculoskeletal Services page

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

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

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

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

How to submit authorization requests

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

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

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

More about the authorization requirements

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

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

List of requirements

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

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

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

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

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

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

You can access this document on these webpages:

• Blue Cross Authorization Requirements & Criteria page
• BCN Authorization Requirements & Criteria page

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

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

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

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

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

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

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

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

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

Important reminder

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

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

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

List of requirements

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

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

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

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

How to submit authorization requests

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

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

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

More about the authorization requirements

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

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

List of requirements

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

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

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

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

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

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

Note: All times are Eastern time.

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

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

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

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

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

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

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

This means that:

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

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

These changes apply to all Blue Cross' PPO and BCN HMO^SM members.

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

Which medications are preferred?

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

For acute HAE treatment

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

For HAE prevention

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

Additional information

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

• Requirements for drugs covered under the medical benefit (PDF)
• Requirements for drugs covered under the pharmacy benefit (PDF)

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

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

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

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

• The Blue Cross Musculoskeletal Services page
• The BCN Musculoskeletal Services page

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

• Joint procedures for Medicare Plus Blue^SM PPO, BCN HMO^SM and BCN Advantage^SM members
• Spine procedures for BCN HMO and BCN Advantage members.

Medical specialty drug prior authorization lists are changing in September for BCN HMO^SM, Medicare Plus Blue^SM PPO and BCN Advantage^SM members

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

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

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

How to submit authorization requests

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

• Through the AIM provider portal*
• By calling the AIM Contact Center at 1-844-377-1278

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

More about the authorization requirements

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

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

• BCN HMO: Blue Cross and BCN utilization management medical drug list (PDF) and the Medical Oncology Program (PDF) list
• Medicare Advantage: Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members (PDF)

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

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

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

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

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

More about the authorization requirements

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

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

List of requirements

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

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

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

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

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

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

Note: All times are Eastern time.

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

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

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

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

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

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

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

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

Patients should take the preferred drugs when possible

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

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

  The filgrastim products other than Nivestym and Zarxio are:

  • Neupogen^® (filgrastim; HCPCS code J1442)
  • Granix^® (tbo-filgrastim; HCPCS code J1447)
    
    For commercial members, we'll notify those currently taking the nonpreferred drugs and encourage them to discuss treatment options with you.

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

• For Blue Cross' PPO members, the preferred drugs don't require authorization.
• For BCN HMO^SM, Medicare Plus Blue^SM PPO and BCN Advantage^SM members, the preferred drugs require authorization through AIM Specialty Health^®.

Request authorization for patients who must take the nonpreferred drugs

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

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

More about the authorization requirements

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

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

• Blue Cross' PPO and BCN HMO: Blue Cross and BCN utilization management medical drug list (PDF)
• Medicare Advantage: Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members (PDF)

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

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

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

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

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

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

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

How to bill

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

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

Important reminder

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

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

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

List of requirements

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

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

July 3 holiday closure: How to submit inpatient authorization requests

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

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

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

• Blue Cross Authorization Requirements & Criteria page
• BCN Authorization Requirements & Criteria page

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

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

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

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

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

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

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

Updated e-referral questionnaire to open June 28 for BCN and Medicare Plus Blue^SM PPO

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

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

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

To find the preview questionnaire on this website:

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

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

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

We're still working to resolve the issues.

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

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

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

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

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

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

New authorization requirement

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

• J3590, abicipar pegol

Authorization requirement removed

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

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

How to bill

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

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

Important reminder

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

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

List of requirements

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

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

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

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

Note: All times are Eastern time.

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

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

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

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

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

eviCore has updated corePath for physical and occupational therapy authorizations

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

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

Here's what changed

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

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

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

Additional information

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

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

You can find additional information on this website:

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

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

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

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

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

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

What you need to do

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

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

Additional information

eviCore manages authorizations for radiation oncology for most Blue Cross' PPO fully insured groups and for Medicare Plus Blue^SM PPO, BCN HMO^SM and BCN Advantage^SM members.

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

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

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

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

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

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

Providers should do the following:

• Refer to the InterQual criteria for the type of admission and to the associated Blue Cross and BCN Local Rules.

  Note: The Local Rules are available on this website, on the Blue Cross Authorization Requirements & Criteria page and the BCN Authorization Requirements & Criteria page.

• Disregard any information about the two-midnight rule that we may have published in past communications, since that information is no longer current.

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

Updated: More COVID-19-related utilization management changes

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

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

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

Here are the important things you need to know.

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

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

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

Changes extended temporarily, through June 30, 2020:

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

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

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

For elective and non-urgent services:

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

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

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

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

Additional change: Turnaround time on post-acute care determinations

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

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

More information

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

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

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

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

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

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

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

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

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

More about the authorization requirements

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

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

List of requirements

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

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

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

Medical benefit specialty drug prior authorization lists are changing in July and August for Medicare Plus Blue^SM PPO, BCN HMO^SM and BCN Advantage^SM members

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

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

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

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

• Imlygic^® (talimogene laherparepvec, J9325)

How to submit authorization requests

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

• Through the AIM ProviderPortal*
• By calling the AIM Contact Center at 1-844-377-1278

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

More about the authorization requirements

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

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

• BCN HMO: Blue Cross and BCN utilization management medical drug list (PDF) and the Medical Oncology Program (PDF) list
• Medicare Advantage: Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members (PDF)

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

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

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

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

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

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

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

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

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

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

Register for training on TurningPoint's clinical model and more

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

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

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

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

Register for the webinars

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

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

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

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

Additional information

To learn more, see the following articles:

• Reminder: Providers need to submit authorization requests for all surgical procedures related to musculoskeletal conditions to TurningPoint - on page 23 of the May-June issue of BCN Provider News
• Update: Providers must submit authorization requests to TurningPoint for musculoskeletal surgical procedures scheduled on or after July 1 for certain members - in the May issue of The Record

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

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

• Blue Cross Musculoskeletal Services page
• BCN Musculoskeletal Services page

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

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

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

Note: All times are Eastern time.

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

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

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

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

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

Recommendations for submitting authorization requests for medical oncology drugs to AIM

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

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

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

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

• Medicare Advantage plans: Medicare Plus Blue^SM PPO and BCN Advantage^SM
• Commercial plans: BCN HMO^SM and select Blue Cross' PPO groups

How to submit authorization requests

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

• Through the AIM provider portal*
• By calling the AIM Contact Center at 1-844-377-1278

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

Lists of requirements

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

• For Medicare Advantage members: Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members (PDF)
• For commercial members:
  • Medical oncology prior authorization list for Blue Cross' PPO UAW Retiree Medical Benefits Trust members (PDF)
  • Medical oncology prior authorization list for BCN HMO (commercial) members (PDF)

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

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

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

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

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

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

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

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

Starting May 1, 2020, infusions of Tysabri and Lemtrada may not be covered at hospital outpatient facilities.* Before May 1, members should talk to their doctors to make arrangements to receive infusion services at one of the following locations:

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

*Based on Risk Evaluation and Mitigation Strategies, or REMS, program restrictions, administration of Lemtrada and Tysabri is limited to authorized locations. For Lemtrada, we'll restrict transitions to select locations that have safety protocols in place for adverse reactions. To aid in member transition, please refer to the document Lemtrada and Tysabri site-of-care program: Frequently asked questions by providers, which contains additional program information and details on authorized administration sites in Michigan and elsewhere in the U.S..

More about the authorization requirements

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

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

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Requirements for drugs covered under the medical benefit - BCN HMO and Blue Cross PPO document located on our ereferrals.bcbsm.com website:

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

We've updated the requirements list with the new information about Lemtrada and Tysabri.

Hospitals must notify naviHealth before transferring Medicare Advantage members to SNFs

As communicated previously, we waived the requirement to obtain clinical review for the first three days of skilled nursing facility stays for Medicare Plus Blue^SM PPO and BCN Advantage^SM members transferred from acute care hospitals. This is in effect for transfers that take place from April 3 through May 31, 2020.

Hospitals are still obligated to notify naviHealth about transfers.

However, we're finding that some hospitals are transferring our Medicare Advantage members to SNFs without notifying naviHealth.

To avoid problems, we're clarifying what you need to do:

• Notify naviHealth by submitting an authorization request but not attaching clinical documentation. You can do this through:
  • CarePort Care Management (formerly known as Allscripts^®)
  • nH Access^™, the naviHealth provider portal
  • Calling 1-855-851-0843
  • Faxing to 1-844-899-3730
• Submit the following information to naviHealth with your notification:
  • Name and contact information for person notifying the plan
  • Patient demographics (name, date of birth, enrollee ID, etc.)
  • Name of ordering physician
  • Patient diagnosis
  • Name of accepting SNF

  Note: If you need assistance locating a SNF, include a request for assistance when you submit notification to naviHealth. They'll have their clinicians reach out to local facilities.

We're asking SNFs to confirm that naviHealth has received the required notification for each member before they accept the transfer. Once naviHealth receives the notification, they'll provide a three-day authorization to transfer the patient to the SNF.

Failure to notify naviHealth means there's no authorization in our system when we receive the claim from the SNF.

We'll update the COVID-19 utilization management changes document with the details about the information you must send when notifying naviHealth.

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

Due to the COVID-19 pandemic, we're delaying the date on which TurningPoint Healthcare Solutions, LLC will begin managing authorizations for spine and joint replacement surgeries and other related procedures. This applies to Medicare Plus Blue^SM PPO, BCN HMO^SM (commercial) and BCN Advantage^SM members.

TurningPoint will manage musculoskeletal procedure authorizations for dates of service on or after July 1, 2020. You'll be able to begin submitting authorization requests to TurningPoint on June 1.

You don't need to do anything different until June 1. For dates of service prior to July 1, 2020, Medicare Plus Blue Utilization Management and BCN Utilization Management will continue to manage these authorizations, as they do today.

We're also delaying webinars for professional providers and facilities about TurningPoint's clinical model. For professional providers, these webinars will include a demonstration of their Provider Portal. Watch for web-DENIS messages about new webinar dates.

We apologize for any inconvenience, and we'll update our communications to reflect this change.

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

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

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

Note: All times are Eastern time.

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

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

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

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

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

What to do about e-referral error message

Providers are sometimes getting an "Unknown Error" message in the e-referral system. This error message is connected to the e-referral system software upgrade that occurred over this last weekend.

When you get this error message, you're unable to search or submit or otherwise move forward with the referral or the authorization request.

What to do

Refresh your browser window, re-enter the information and continue working. Most of the time, this will resolve the issue.

Working to resolve the issue

We are working to resolve this issue as soon as possible. We apologize for any inconvenience this may cause.

Sarclisa^® will require prior authorization starting May 15 for BCN HMO^SM, Medicare Plus Blue^SM PPO and BCN Advantage^SM members

We're expanding the prior authorization program for specialty drugs covered under the medical benefit for BCN HMO, Medicare Plus Blue and BCN Advantage members.

For dates of service on or after May 15, 2020, Sarclisa (isatuximab-irfc, HCPCS code J3490, J3590, J9999) will require authorization through AIM Specialty Health^®.

How to submit authorization requests

For this drug, submit authorization requests to AIM using one of the following methods:

• Through the AIM provider portal*
• By calling the AIM Contact Center at 1-844-377-1278

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

More about the authorization requirements

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

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

• BCN HMO: Blue Cross and BCN utilization management medical drug list (PDF)
• BCN HMO: Medical Oncology Program (PDF) list
• Medicare Advantage: Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members (PDF)

We'll update the requirements lists with the new information about Sarclisa prior to May 15.

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

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

Due to the COVID-19 pandemic, we're delaying the date on which TurningPoint Healthcare Solutions, LLC will begin managing authorizations for musculoskeletal surgical and other related procedures. Providers won't be able to begin submitting requests to TurningPoint until June 1, 2020, so we removed information about TurningPoint from this message.

Due to the COVID-19 pandemic, the federal government has mandated that providers postpone all elective and non-urgent procedures.

As a result and to reduce your administrative burden, we're making the following changes to authorization requests for elective procedures, including physical, occupational and speech therapy.

• For requests that have already been approved: The approvals will be valid for 180 days from the date on which the authorization was approved.

This change applies to authorization requests that were approved on or after the following dates:

• Blue Cross or BCN utilization management: March 13, 2020
• AIM Specialty Health^®: April 6, 2020
• eviCore healthcare^®: March 26, 2020
• For requests that are received between now and May 31, 2020: If approved, authorizations will be valid for 180 days.

These changes are in effect through May 31, 2020, and apply to in-state and out-of-state providers, for all lines of business, including Blue Cross' PPO, BCN HMO^SM, Medicare Plus Blue^SM PPO and BCN Advantage^SM.

Exception: These changes don't apply to Flexlink^® groups for which a third-party administrator makes authorization determinations. Contact the third-party administrator on the back of the member's ID card for instructions.

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

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will be closed on Friday, April 10, for Good Friday. In addition, the e-referral system will be unavailable this weekend for a software upgrade.

See below for what to do during these occurrences. Note that all times are Eastern time.

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

Reminder: We've suspended clinical review requirements for acute care medical admissions and transfers to skilled nursing facilities through May 31, 2020, due to the COVID-19 crisis.

This means that all authorization requests for acute inpatient medical admissions and transfers to skilled nursing facilities will be approved without clinical review. However, you'll still need to submit an authorization request, which will serve as plan notification. Requests received via phone or fax on the April 10 holiday or over the weekend will be entered into the e-referral system by our Utilization Management staff on Monday. Your approval will be available in the system by Monday night.

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

Fax numbers

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

On Thursday, April 2, we announced that clinical review requirements have been suspended through May 31 for all admissions to acute care hospitals and for transfers to skilled nursing facilities. For acute care hospital facility and transfers to post-acute care admissions, there is one step required - submitting a plan notification for each admission. Here's what you need to know about these plan notifications:

• A plan notification is a request for authorization submitted through e-referral.
• No clinical documentation is required with this submission. This includes any request that pends for review.
• For inpatient hospital admissions for all lines of business: submit via e-referral.
• For Blue Cross' PPO and BCN HMO^SM post-acute requests: submit via e-referral or by fax.
• For Medicare Plus Blue^SM PPO and BCN Advantage^SM requests: submit to naviHealth.
• Some of these submissions will receive real-time approval. Blue Cross Blue Shield of Michigan and Blue Care Network will respond to requests that pend within two hours during normal business hours.
• Some submissions sent after business hours or on weekends will receive real-time approval. Blue Cross and BCN will respond to requests that pend with approval the next business day.

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

To enable inpatient medical facilities to prioritize patient care during this challenging time, we've already suspended the requirement for clinical review of acute care admissions of Blue Cross Blue Shield of Michigan and Blue Care Network members with COVID-19-related diagnoses.

Based on the evolving nature of this crisis, we have approved several other actions, effective immediately:

• Acute care hospitals: Clinical review requirements at all acute care hospitals for all diagnoses are suspended. This applies to all medical admissions.
• Post-acute care facilities: Clinical review requirements for the first three days of all skilled nursing facility admissions are suspended for members who are transferring from an acute care hospital.

How to submit these requests

• For acute care admissions, no clinical review is required.
• There is an important notification step to take. Eligible facilities must submit a plan notification for each admission so that an authorization is in our system when we receive the claim. We strongly encourage facilities to submit plan notifications through our e referral system. When facilities use e referral, they won't wait on hold on the phone. We're updating the e-referral system to automatically approve these requests without clinical review. While we're updating the system, some requests may pend, in error. In those cases, our staff will provide approval to the facility within two hours of submission during normal business hours.

Note: We reserve the right to audit these admissions at a later date.

• For post-acute care admissions:
• There is an important notification step to take. For SNF admissions, we're suspending clinical review requirements for the first three days when patients are transferred from an acute care hospital. However, facilities must submit a plan notification for each admission so that an authorization is in our system when we receive the claim. Facilities are not required to submit clinical documentation until the continued stay review, starting on the fourth day of stay.
• Inpatient rehabilitation and long-term acute care admissions still require clinical review. Blue Cross has adjusted our clinical review process to expedite these requests. A determination will be made within two hours, during normal business hours.
• Continue to submit Blue Cross' PPO and BCN HMO^SM post-acute requests through the e referral system or by fax. A decision will be provided within 2 hours during normal business hours.
• Continue to submit Medicare Plus Blue^SM PPO and BCN Advantage^SM SNF post-acute admission requests to naviHealth. A decision will be provided within 2 hours during normal business hours.

Important!

These changes are in effect through May 31, 2020, and apply to Michigan facilities, for all lines of business, including Blue Cross' PPO, BCN HMO, Medicare Plus Blue and BCN Advantage.

Exception: These changes do not apply to Flexlink^® groups for which a third-party administrator makes authorization determinations. Facilities should check the back of the member's ID card to determine whether a third-party administrator needs to be contacted prior to an admission.

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

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices have extended the closure of their buildings for an additional day, through Tuesday, March 24, 2020.

How to handle requests related to medical services

During this office closure, use the e-referral system to:

• Submit all referrals and authorization requests for medical services that are managed by Blue Cross or BCN Utilization Management
• Attach clinical information to the case as needed
• Check the status of these authorization requests

This applies to requests for all medical services, for all Blue Cross and BCN members.

While our offices are closed, our Utilization Management staff are not available to answer calls related to medical requests.

However, if a case pends and you need a decision in an emergency or an urgent situation, call the Utilization Management after-hours phone at 1-800-851-3904.

Our Utilization Management offices will reopen on at 8:30 am Eastern time on Wednesday, March 25.

For instructions on how to submit requests through the e-referral system and attach clinical information to the case, refer to the e-referral User Guide (PDF). You'll find additional information about the e-referral system and about referral and authorization requirements on this website.

Peer-to-peer reviews on medical cases to be completed but no new ones scheduled during closure

Peer-to-peer reviews on medical cases scheduled for March 24 will be completed. However, no new medical peer-to-peer reviews will be scheduled until we reopen on March 25.

How to handle requests related to behavioral health services

During this office closure, use the e-referral system to submit authorization requests for behavioral health services as well.

Behavioral Health department staff members are available to discuss a case, if needed. To reach a staff member:

• Medicare Plus Blue^SM PPO: Call 1-888-803-4960.
• BCN HMO^SM (commercial): Call 1-800-482-5982.
• BCN Advantage^SM: Call 1-800-431-1059.

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

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

From 10 p.m. on Saturday, March 21 to 10 a.m. on Sunday, March 22

Note: All times are Eastern time.

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

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

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

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

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

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

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

• Friday, March 20, 2020
• Monday, March 23, 2020

How to handle requests related to medical services

During this office closure, use the e-referral system to:

• Submit all referrals and authorization requests for medical services that are managed by Blue Cross or BCN Utilization Management
• Attach clinical information to the case as needed
• Check the status of these authorization requests

This applies to requests for all medical services, for all Blue Cross and BCN members.

While our offices are closed, our Utilization Management staff are not available to answer calls related to medical requests.

However, if a case pends and you need a decision in an emergency or an urgent situation, call the Utilization Management after-hours phone at 1-800-851-3904.

Our Utilization Management offices will reopen on at 8:30 am Eastern time on Tuesday, March 24.

For instructions on how to submit requests through the e-referral system and attach clinical information to the case, refer to the e-referral User Guide (PDF). You'll find additional information about the e-referral system and about referral and authorization requirements on this website.

Peer-to-peer reviews on medical cases to be completed but no new ones scheduled during closure

Peer-to-peer reviews on medical cases scheduled for March 20 and 23 will be completed. However, no new medical peer-to-peer reviews will be scheduled until we reopen on March 24.

How to handle requests related to behavioral health services

During this office closure, use the e-referral system to submit authorization requests for behavioral health services as well.

Behavioral Health department staff members are available to discuss a case, if needed. To reach a staff member:

• Medicare Plus Blue^SM PPO: Call 1-888-803-4960.
• BCN HMO^SM (commercial): Call 1-800-482-5982.
• BCN Advantage^SM: Call 1-800-431-1059.

Authorization requirements eased for COVID-19-related services

Blue Cross Blue Shield of Michigan and Blue Care Network are temporarily reducing some authorization requirements to make it easier for providers - both contracted and noncontracted - to deliver COVID-19-related testing and treatment services to our members.

Some of our contracted vendors are also easing authorization requirements.

See a description of these changes in the document COVID-19 utilization management changes (PDF), which you can access on this website. Do one of the following:

• Click Blue Cross and then click Authorization Requirements & Criteria.
• Click BCN and then click Authorization Requirements & Criteria.

Look for the document on those pages.

The changes described in this document apply to the plans listed below, for any members who are subject to authorization requirements:

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

We encourage you to check the COVID-19 utilization management changes document from time to time; we'll update it as new information becomes available.

Additional information about the COVID-19 coronavirus is available on our "Coronavirus information updates for providers" page, which you can access by logging in to Provider Secured Services and then doing one of the following:

• Clicking BCN Provider Publications and Resources
• Clicking BCBSM Provider Publications and Resources and then clicking Newsletters and Resources

Finally, click the blue Coronavirus information updates for providers box.

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

In April, we're removing authorization requirements for certain infliximab biosimilar drugs and designating preferred infliximab biosimilar drugs for Medicare Plus Blue^SM PPO and BCN Advantage^SM members.

Removing authorization requirements

For dates of service on or after April 3, 2020, we'll no longer require authorization for the following infliximab biosimilars for Remicade^® for Medicare Plus Blue and BCN Advantage members:

• Q5103 Inflectra^®
• Q5104 Renflexis^®

Designating preferred biosimilar drugs

Starting April 20, 2020, we'll designate the following drugs as preferred infliximab biosimilar products for Medicare Plus Blue and BCN Advantage members:

• J3590 Avsola^™
• Q5103 Inflectra
• Q5104 Renflexis

As part of our shared commitment to keeping health care affordable for all, we encourage you to switch members to one of the preferred infliximab biosimilar products before April 20.

Important! Remicade won't be considered a preferred biosimilar and will continue to require authorization for Medicare Plus Blue and BCN Advantage members.

List of requirements

We'll update the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members with these changes prior to the effective dates.

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

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

naviHealth is taking measures to keep Medicare Plus Blue^SM PPO and BCN Advantage^SM members safe in post-acute care settings in response to coronavirus disease, or COVID-19.

In an effort to contain the spread of COVID-19, naviHealth will conduct all care coordination activities remotely, effective immediately. Care coordinators will use telepresence and other remote capabilities to attend meetings and communicate with patients, families of patients and post-acute care personnel.

Care coordinators will continue to perform all typical care coordination activities, including discharge planning.

In post-acute care settings where care coordinators have been working remotely, you won't notice any changes. In settings where care coordinators have been working onsite, they'll return when it's deemed safe to do so.

For more information, see the email message with the subject "COVID 19 - Keeping Patients Safe" that naviHealth sent to post-acute care providers on March 12. naviHealth sent this message to the leaders within interdisciplinary teams at skilled nursing facilities, inpatient rehabilitation facilities and long-term acute hospitals.

Please direct any questions to your naviHealth Provider Relations Manager.

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

We updated this message on March 16, 2020, to remove J3590 Avsola from the list of drugs that will require authorization starting June 15. Avsola won't require prior authorization.

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

For dates of service on or after June 15, 2020, the following medications will require prior authorization through NovoLogix^®:

• J1428 Exondys 51^®
• J3490 Vyondys 53^™
• J3490 Givlaari^®
• J3590 Tepezza^™
• J3590 Vyepti^™

How to bill

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

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

Important reminder

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

• For Medicare Plus Blue, if you have a Type 1 (individual) NPI and you checked the "Medical Drug PA" box when you completed the Provider Secured Access Application form, you already have access to NovoLogix. If you didn't check that box, you can complete an Addendum P form to request access to NovoLogix and fax it to the number on the form.
• For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

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

List of requirements

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

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

The e-referral system software upgrade most recently planned for March 8-9, 2020, will not occur on those dates after all. This means the e-referral system will be available for your use on those dates.

We don't yet know the dates on which the software upgrade will occur, but we'll announce the new dates as soon as we know them.

The only e-referral system downtime currently planned for March 2020 is this one:

• Routine monthly maintenance: The system will be unavailable from 10 p.m. Saturday, March 21 to 10 a.m. Sunday, March 22.

  Note: The e-referral system will not be available at all during these routine maintenance times. On Sunday, the system will be available by 10 a.m. and may be available earlier if maintenance tasks are completed. During the remaining time over the weekend, we expect the system to be available, although you may experience minor performance issues.

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

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

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

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

Professional providers and facilities can now register for training. For professional providers, the training will cover TurningPoint Healthcare Solution's clinical model and working in the TurningPoint Provider Portal. For facilities, the training will cover TurningPoint's clinical model and facility-specific information.

Webinar training sessions are available on various dates in April.

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

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

To learn more, see the following articles:

• TurningPoint begins managing authorizations for musculoskeletal surgical procedures with dates of service on or after June 1 - on page 37 of the March-April issue of BCN Provider News.
• TurningPoint to manage authorizations for musculoskeletal procedures with dates of service on or after June 1 for certain members - in the March issue of The Record

As we communicated previously, TurningPoint will manage authorizations for surgical procedures related to musculoskeletal conditions for Medicare Plus Blue^SM PPO, BCN HMO^SM and BCN Advantage^SM members for dates of service on or after June 1, 2020.

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

• Blue Cross Musculoskeletal Services page
• BCN Musculoskeletal Services page

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

We updated this message to correct the HCPCS code for Palforzia.

We're adding authorization and site-of-care requirements for specialty drugs covered under the medical benefit for Blue Cross' PPO (commercial) and BCN HMO^SM (commercial) members for the following drugs:

• Palforzia (peanut [Arachis hypogaea] allergen powder-dnfp, HCPCS code J3590)
• Tepezza (teprotumumab-trbw, HCPCS code J3590)

For BCN HMO members

• We'll require authorization for Palforzia and Tepezza for members who begin therapy on or after March 1, 2020.
• We'll add Tepezza to the site-of-care program for BCN HMO members effective March 1, 2020.

For Blue Cross' PPO members

We'll require authorization for Palforzia and Tepezza for members who begin therapy on or after May 1, 2020.

More about the authorization requirements

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

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

List of requirements

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

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

We'll update the requirements list for the drugs listed above prior to the effective dates for the changes.

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

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

For dates of service on or after April 1, 2020, the following medications will require authorization through AIM Specialty Health^®.

• J3490, J3590, J9999 Padcev^™
• J3490, J3590, J9999 Enhertu^®
• J3490, J3590, J9999 Ziextenzo^®

How to bill

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

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

How to submit authorization requests

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

• Through the AIM provider portal*
• By calling the AIM Contact Center at 1-844-377-1278

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

List of requirements

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

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

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

Here's what to do to resolve problems if you can't log in to the e-referral system over the next few days:

• Contact the Web Support Help Desk at 1 877 258 3932.
• Clear your browser history and cookies and restart your browser.
• Submit your authorization requests by phone or fax. Refer to the document e-referral system planned downtimes and what to do (PDF) for the phone and fax numbers to use for various types of requests.

Here's some additional information you may find useful:

• Feb. 8 through 10, we moved the data center out of which the e-referral system is operated. The move went well, but the e-referral system is still stabilizing.
• You can get to the document e-referral system planned downtimes and what to do (PDF) from any page of this website. Scroll down the left navigation pane and look for the blue tile at the bottom.

We apologize for any inconvenience you may experience with the e-referral system. We are working hard to resolve the problems and we expect the system to be working smoothly soon.

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

For dates of service on or after May 1, 2020, interventional pain management services associated with procedure codes *64451 and *64625 require authorization by eviCore healthcare.

This applies to all Blue Cross and Blue Care Network members with plans subject to eviCore healthcare authorization requirements:

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

We've updated the document titled Procedures that require clinical review by eviCore healthcare (PDF) to reflect this new requirement.

How to submit authorization requests

Submit authorization requests to eviCore in one of these ways:

• Preferred: Use evicore's provider portal at www.evicore.com.**
• Alternative: Call eviCore at 1-855-774-1317.
• Alternative: Fax to eviCore at 1-800-540-2406.

Additional information

For more information, refer to the document titled eviCore Management Program: Frequently Asked Questions (PDF).

You can find this document and other resources on this website:

• The BCN eviCore-Managed Procedures webpage
• The Blue Cross eviCore-Managed Procedures webpage

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

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

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

The e-referral system will be unavailable for use during three planned downtimes in February. Typically, the system is unavailable during its routine monthly maintenance but in February, we're also moving the data center and upgrading the system's software.

Here are the three planned downtimes for the e-referral system in February 2020:

• Data center move: The system will be unavailable from 3 a.m. Saturday, Feb. 8, to 7 a.m. Monday, Feb. 10.
• Routine monthly maintenance: The system will be unavailable from 10 p.m. Saturday, Feb. 15, to 9 a.m. Sunday, Feb. 16.*

  *The e-referral system will not be available at all during these times. On Sunday, the system will be available by 9 a.m. and may be available earlier if maintenance tasks are completed. During the remaining time over the weekend, we expect the system to be available, although you may experience minor performance issues.

• Software upgrade: The system will be unavailable from 2 a.m. Sunday, Feb. 23, to 6 a.m. Monday, Feb. 24.

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

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

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

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

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

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

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

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

Starting May 1, 2020, infusions of Tysabri and Lemtrada won't be covered at hospital outpatient facilities.* Before May 1, members should talk to their doctors to make arrangements to receive infusion services at one of the following locations:

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

*Based on Risk Evaluation and Mitigation Strategies, or REMS, program restrictions, administration of Lemtrada and Tysabri are limited to authorized locations. We'll post information about in-state and nationally authorized administration sites to this website soon to aid in member transition; we'll provide an update when this information is available.

More about the authorization requirements

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

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

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Requirements for drugs covered under the medical benefit - BCN HMO and Blue Cross PPO (PDF) document located on this website:

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

We'll update the requirements list for the drugs listed above prior to May 1, 2020.

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

In the January-February issue of BCN Provider News (page 41) and in the January issue of The Record, we listed the questionnaires that we expected to release in the e-referral system by Jan. 26, 2020.

Most of the questionnaires listed in the articles were updated on Dec. 8, 2019. However, we had to postpone the release of the following questionnaires to Feb. 2:

• Breast reduction - We'll combine the Breast reduction, adult and the Breast reduction, adolescent questionnaires for BCN HMO^SM and BCN Advantage^SM members into a single questionnaire for both adult and adolescent BCN HMO and BCN Advantage members.
• Spinal cord stimulator or epidural or intrathecal catheter (trial or permanent placement) — We'll replace this questionnaire with the following three questionnaires:
  • Spinal cord stimulator - For BCN HMO members
  • Spinal cord stimulator - For Medicare Plus Blue and BCN Advantage members
  • Intrathecal catheter — For Medicare Plus Blue, BCN HMO and BCN Advantage members

We'll also update the following questionnaire on Feb. 2:

• Sleep studies - Opens only for BCN HMO and BCN Advantage members

Here's some additional information you need to know:

• We'll update the preview questionnaires, authorization criteria and medical policies on this website for the questionnaire updates soon.
• We use our authorization criteria and medical policies and your answers to the questionnaires when making utilization management determinations on your authorization requests.
• For all of these services, you'll soon be able to access preview questionnaires on this website. The preview questionnaires show the questions you'll need to answer in the actual questionnaires that open in the e-referral system. This can help you prepare your answers ahead of time. To find the preview questionnaires:
• For BCN: Click BCN and then click Authorization Requirements & Criteria. Scroll down and look under the "Authorization criteria and preview questionnaires" heading.
• For Medicare Plus Blue: Click Blue Cross and then click Authorization Requirements & Criteria. In the "Medicare Plus Blue PPO members" section, look under the "Authorization criteria and preview questionnaires - Medicare Plus Blue PPO" heading.

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

We're adding authorization and site-of-care requirements for specialty drugs covered under the medical benefit to include Reblozyl (luspatercept-aamt, HCPCS code J3590) for commercial members:

• For BCN HMO^SM (commercial) members: Reblozyl will require authorization and have site-of-care requirements for members who begin therapy on or after Feb. 1, 2020.

• For Blue Cross' PPO (commercial) members: Reblozyl will require authorization for members who begin therapy on or after April 2, 2020.

More about the authorization requirements

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

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

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Requirements for drugs covered under the medical benefit - BCN HMO and Blue Cross PPO document located on the following pages of this website:

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

We'll update the requirements list for the drug listed above prior to the effective dates for the changes.

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

We're removing medications from the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue^SM PPO and BCN Advantage^SM members. These specialty medications are administered in outpatient sites of care, a physician's office, an outpatient facility or a member's home.

For dates of service on or after March 2, 2020, the following medications for osteoporosis, bone metastases due to solid tumors and other diagnoses involving bone health will no longer require authorization:

• J3489 zoledronic acid (Reclast^®, Zometa^®)

Important reminder

NovoLogix allows you to quickly submit authorization requests. It offers real-time status checks and immediate approvals for certain medications. Also note:

• For Medicare Plus Blue, if you have a Type 1 (individual) NPI and you checked the "Medical Drug PA" box when you completed the Provider Secured Services Application form, you already have access to NovoLogix. If you didn't check that box, you can complete an Addendum P form to request access to NovoLogix and fax it to the number on the form.
• For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

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

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Medical Drug and Step Therapy Prior Authorization List.

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

Orientation sessions will be led by eviCore healthcare to help providers understand the changes to the Practitioner Performance Summary and utilization management categories that will be effective on April 1 for physical therapy providers. This is effective for Medicare Plus Blue^SM PPO, BCN HMO^SM and BCN Advantage^SM providers.

We'll cover:

• The new model for provider tiering
• Updated training material related to the PPS scores and reconsideration process

Dates (all Eastern Standard Time)

Online sessions require advance registration

• Feb. 3, 1 p.m.
• Feb. 4, 1 p.m.
• Feb. 5, Noon

How to register

Please read the following instructions to register for and participate in a session:

1. Once you have selected a provider specific session, please go to http://eviCore.webex.com/*
2. Click on the menu bar on the far left hand side, then choose "Webex Training"
3. Under Live Sessions, click the "Upcoming" tab, then enter the desired topic name exactly as below and search: PPS and Utilization Management Categories for BCBSM/BCN
4. Click "Register" next to the sessions with the date and time you wish to attend
5. Complete the registration information

Keep the registration email you receive so you'll have the link to the Web conference and call-in number for your session.

Questions?

Contact the Web Support team by email at portal.support@evicore.com or call 1-800-646-0418.

(Option 2)

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

Musculoskeletal surgical procedures will require authorization by TurningPoint for Medicare Plus Blue^SM PPO and BCN members

TurningPoint Healthcare Solutions will manage authorizations for surgical procedures related to musculoskeletal conditions for Medicare Plus Blue, BCN HMO^SM and BCN Advantage^SM members. These are the dates you need to know:

• June 1, 2020: Services performed on or after this date will require authorization by TurningPoint.
• May 1, 2020: You'll be able to submit authorization requests to TurningPoint.

TurningPoint specializes in utilization management of musculoskeletal surgeries and related procedures. They focus on improving patient outcomes for patients undergoing procedures such as joint replacements.

To learn more, see the following articles:

• Providers will need to submit authorization requests to TurningPoint for musculoskeletal procedures with a date of service on or after June 1 - on page 43 of the January-February 2020 issue of BCN Provider News
• TurningPoint to handle authorization requests for musculoskeletal procedures with dates of service on or after June 1 for Medicare Advantage, BCN members - in the January 2020 issue of The Record

We'll provide additional details in future newsletters and other communications.

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

For dates of service on or after April 1, 2020, services associated with HCPCS code A9590 (iodine i-131, iobenguane, 1 millicurie) require authorization by eviCore healthcare.

This applies to all Blue Cross and Blue Care Network members with plans subject to eviCore healthcare authorization requirements:

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

We've updated the document titled Procedures that require clinical review by eviCore healthcare to reflect this new requirement.

How to submit authorization requests

Submit authorization requests to eviCore in one of these ways:

• Preferred: Use evicore's provider portal at www.evicore.com.*
• Alternative: Call eviCore at 1-855-774-1317.
• Alternative: Fax to eviCore at 1-800-540-2406.

Additional information

For more information, refer to the document titled eviCore Management Program: Frequently Asked Questions.

You can find this document and other resources on this website:

• The BCN eviCore-Managed Procedures webpage
• The Blue Cross eviCore-Managed Procedures webpage

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

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

We're adding authorization and site of care requirements for specialty drugs covered under the medical benefit for the following drugs for Blue Cross' PPO (commercial) and BCN HMO^SM (commercial) members:

• Avsola (infliximab-axxq, HCPCS code J3590)
• Givlaari (givosiran, HCPCS code J3490)

For BCN HMO members

• We'll require authorization for Avsola and Givlaari for members who begin therapy on or after Feb. 6, 2020.
• Avsola and Givlaari will be added to the site of care program for BCN HMO members, effective Feb. 6, 2020.

For Blue Cross' PPO members

We'll require authorization for Avsola and Givlaari for members who begin therapy on or after March 1, 2020.

More about these requirements

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

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

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Requirements for drugs covered under the medical benefit - BCN HMO and Blue Cross PPO document located on this website:

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

We'll update the requirements list for these drugs prior to the effective dates for the changes.

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

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

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

The e-referral system will not be available at all during these times. On Sunday, the system will be available by 10 a.m. and may be available earlier if maintenance tasks are completed. During the remaining time over the weekend, we expect the system to be available, although you may experience minor performance issues.

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

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

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

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

The site of care program for specialty drugs covered under the medical benefit is expanding starting April 1, 2020. This applies to Blue Cross' PPO (commercial) and BCN HMO^SM (commercial) members for the following drugs:

• Hemlibra^® (emicizumab-kxwh, HCPCS code J7170)
• Onpattro^® (patisiran, HCPCS code J0222)

What to do by April 1

Before April 1, 2020, providers should encourage commercial members to select one of the following infusion locations instead of an outpatient hospital facility:

• A doctor's or other health care provider's office
• An ambulatory infusion center
• The member's home, from a home infusion therapy provider

If members currently receive infusions for these drugs at a hospital outpatient facility, providers must:

• Obtain prior authorization for that location
• Check the directory of participating home infusion therapy providers and infusion centers to see where the member may be able to continue infusion therapy

If the infusion therapy provider can accommodate the member, they'll work with the member and the member's practitioner to make this change easy. The member may also contact the ordering practitioner directly for help with the change.

More about the authorization requirements

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

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

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Requirements for drugs covered under the medical benefit – BCN HMO and Blue Cross PPO document located on this website:

• The Blue Cross Medical Benefit Drugs - Pharmacy webpage
• The Blue Care Network Medical Benefit Drugs - Pharmacy webpage

We'll update the requirements list for these drugs prior to April 1.

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

Part B specialty drugs Prolia^® and Xgeva^® have the same generic name, denosumab, and HCPCS code, J0897. Both drugs require authorization for Medicare Plus Blue^SM PPO and BCN Advantage^SM members.

However, the system through which you request authorization varies as follows:

• If you're administering Prolia, which is used to treat osteoporosis, request authorization through the NovoLogix^® online tool.
• If you're administering Xgeva, which is primarily used to treat bone metastases due to solid tumors, request authorization through the AIM ProviderPortal^SM.

Note: Be sure to use the brand name when requesting Xgeva through the AIM ProviderPortal so AIM will know you are ordering the correct medication. Using the generic name, denosumab, can cause delays in the prior authorization process.