Archives 2019




December 2019

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

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

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

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

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

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

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

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

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

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

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

November 2019

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

Provider appeal time frame extended for Blue Cross' PPO admissions

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

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

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

Register for a webinar about hyaluronic acid products for knee injections

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

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

Tell us what you think about our utilization management services

October 2019

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

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

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

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

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

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

September 2019

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

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

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

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

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

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

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

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

How can we improve our online tools?

New webinars available in September and October for BCN

New webinars available in September and October for Blue Cross

August 2019

Providers invited to Medicare Stars events in Michigan

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

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

naviHealth webinars about SNF PDPM payment methodology

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

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

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

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

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

How can we improve our online tools?

Medical record documentation requirements for ABA services are updated

Changes to BCN member transfer request form

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

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

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

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

Requirements for assessments of Medicare Advantage members in skilled nursing facilities

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

July 2019

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

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

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

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

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

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

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

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

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

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

June 2019

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

NovoLogix® user interface enhancements coming soon

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

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

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

Important information about eviCore healthcare therapy authorization requests for BCN

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

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

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

More updated e-referral questionnaires open on June 23

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

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

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

May 2019

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

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

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

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

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

Updated authorization criteria and e-referral questionnaire for ethmoidectomy

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

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

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

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

Learn about Medicare Advantage post-acute care authorization changes

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

April 2019

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

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

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

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

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

March 2019

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

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

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

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

What to do when error messages display in e-referral

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

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

February 2019

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

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

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

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

Clarifying biofeedback and neurofeedback authorization requirements for BCN members

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

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

January 2019

Sign up to receive Blues Brief electronically

Complete the new questionnaires in e-referral for BCN members

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

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


Training Tools

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

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

User guides and documentation

Online training

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

Password information

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

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

BCN Care Management provider call volumes high

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


How to access e-referral with Internet Explorer ® 11

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


Updated BCN provider affiliations codes on e-referral

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

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

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

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

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

Blue Care Network offers Behavioral Health informational webinars

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

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

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

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

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

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

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

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

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

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

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

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

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

New questionnaires available for lumbar spine surgery

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

The changes include but are not limited to:

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

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

New questionnaires available for arthroscopy of the knee

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

The changes include but are not limited to:

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

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

2013 InterQual® acute care criteria take effect November 4

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

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

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

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

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

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

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

Blue Care Network announces date for sleep management program changes

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

Blue Care Network announces questionnaire changes effective August 5

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

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

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

Lumbar spine surgery questionnaire updated effective July 29, 2013

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

Blue Cross Complete announces changes effective August 1

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

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

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

Blue Care Network announces delay in changes for sleep management

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

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

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

Blue Care Network announces changes for frenulum surgery

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

2013 InterQual® criteria take effect July 1

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

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

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

Criteria/Version Application

InterQual Acute – Adult and Pediatrics
Exceptions-local rules

  • Inpatient admissions
  • Continued stay discharge readiness

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

  • Subacute and skilled nursing facility admissions

InterQual Rehabilitation - Adult and Pediatrics
Exceptions-local rules

  • Inpatient admissions
  • Continued stay and discharge readiness

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

  • Long term acute care facility admissions

InterQual Level of Care – Home Care
Exceptions-local rules

  • Home care requests

InterQual Imaging

  • Imaging studies and X-rays

InterQual Procedures – Adult and Pediatrics

  • Surgery and invasive procedures

BCBSM/BCN medical policies

  • Services that require clinical review for medical necessity

Plan developed imaging criteria

  • Imaging studies and X-rays

Blue Care Network reimbursement for intra-articular hyaluronic acid injections

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

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

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

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

Osteoporosis: Intravenous bisphosphonate therapy — Reclast infusion questionnaire

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

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

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

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

Blue Care Network announces questionnaire update for sleep management

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

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

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

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

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

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

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

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

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

Radiology management program changes effective May 1, 2013

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

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

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

Quick Guides
Blue Distinction Centers®

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

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

Blue Distinction Center programs include:

  • Bariatric surgery
  • Cardiac care
  • Cancer care
  • Cellular immunotherapy (CAR-T)
  • Fertility care
  • Gene therapy – ocular disorders
  • Knee and hip replacements
  • Maternity care
  • Spine surgery
  • Substance use treatment and recovery
  • Transplants

For more information, refer to:

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

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

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

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

What to do by April 1

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

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

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

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

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

More about the authorization requirements

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

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

List of requirements

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

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

Posted: December 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

This message was updated to show that authorization requests for Xgeva should be submitted using the brand name and not the generic name of the drug.

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

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

  • If you're administering Prolia, which is used to treat osteoporosis, request authorization through the NovoLogix® online tool.
  • If you're administering Xgeva, which is primarily used to treat bone metastases due to solid tumors, request authorization through the AIM ProviderPortalSM.
  • Note: Be sure to use the brand name when requesting Xgeva through the AIM ProviderPortal so AIM will know you are ordering the correct medication. Using the generic name, denosumab, can cause delays in the prior authorization process.

How to bill

Be sure to enter the following National Drug Code numbers on the claim, along with the HCPCS code J0897, to ensure appropriate and timely reimbursement.

  • Prolia - Enter NDC 55513071001
  • Xgeva - Enter NDC 55513073001

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

  • Electronically through an 837P transaction or on a professional CMS-1500 claim form
  • or

  • Electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x

Important reminder

You can quickly submit authorization requests through the NovoLogix online tool and through AIM Specialty Health.

  • NovoLogix: You can access NovoLogix through Provider Secured Services. It offers real-time status checks and immediate approvals for certain medications. Also note:
    • For Medicare Plus Blue, if you have a Type 1 (individual) NPI and you checked the "Medical Drug PA" box when you completed the Provider Secured Services Application form, you already have access to NovoLogix. If you didn't check that box, you can complete an Addendum P form to request access to NovoLogix and fax it to the number on the form.
    • For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.
  • If you need to request access to Provider Secured Services, complete the Provider Secured Services Application form and fax it to the number on the form.

  • AIM Specialty Health: You can submit authorizations through the AIM ProviderPortal or by calling AIM at 1-844-377-1278.

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

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

Posted: December 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

The prior authorization and site of care program for specialty drugs covered under the medical benefit is expanding to include the following drugs for Blue Cross' PPO (commercial) and BCN HMO (commercial) members:

  • Adakveo® (crizanlizumab-tmca, HCPCS code J3590)
  • Vyondys 53 (golodirsen, HCPCS code J3490)

For Blue Cross' PPO members:
  • We'll require authorization for Adakveo and Vyondys 53 for members who begin therapy on or after Feb. 1, 2020.

For BCN HMO members:

  • We'll require authorization for Adakveo and Vyondys 53 for members who begin therapy on or after Jan. 2, 2020.
  • Adakveo and Vyondys 53 will be added to the site of care program for BCN HMO members effective Jan. 2, 2020.

More about the authorization requirements

The authorization requirements apply only to groups that are currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit.

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

List of requirements

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

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

Posted: December 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

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

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

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

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

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

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

Posted: December 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

We're adding medications to the Medicare Plus BlueSM PPO and BCN AdvantageSM Part B medical specialty prior authorization drug list. These specialty medications are administered in outpatient sites of care, such as a physician's office, an outpatient facility or a member's home.

For dates of service on or after March 16, 2020, you'll need to request authorization for the following medications through the system specified below.

Through the NovoLogix® online tool

  • J3590 Adakveo®
  • J3490 Scenesse®
  • J3490 Reblozyl®

Through the AIM Specialty Health® ProviderPortalSM

  • J9309 Polivy
  • J9036 Belrapzo
  • J9118 Asparlas
  • J9313 Lumoxiti
  • J9356 Herceptin Hylecta
  • Q5116 Trazimera
  • Q5117 Kanjiti
  • Q5118 Zirabev

How to bill

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

  • Electronically through an 837P transaction or on a professional CMS-1500 claim form
  • or

  • Electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x

Important reminder

Depending on the medication, you can quickly submit authorization requests through NovoLogix or through AIM.

  • NovoLogix: You can access NovoLogix through Provider Secured Services. It offers real-time status checks and immediate approvals for certain medications. Also note:
    • For Medicare Plus Blue, if you have a Type 1 (individual) NPI and you checked the "Medical Drug PA" box when you completed the Provider Secured Services Application form, you already have access to NovoLogix. If you didn't check that box, you can complete an Addendum P form to request access to NovoLogix and fax it to the number on the form.
    • For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.
  • If you need to request access to Provider Secured Services, complete the Provider Secured Services Application form and fax it to the number on the form.

  • AIM: You can submit authorizations through the AIM ProviderPortal or by calling AIM at 1-844-377-1278.

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

List of requirements

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

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

Posted: December 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

This is an update to a message originally posted on Nov. 25, 2019.

We updated our systems to resolve the issues we were experiencing with processing some skilled nursing facility claims for Medicare Plus BlueSM PPO and BCN AdvantageSM members.

On Dec. 8, 2019, we resumed regular processing of these SNF claims, and we began processing any SNF claims we'd been holding.

We previously notified you of the following:

  • For Medicare Plus Blue member claims denied with a message stating that you needed to resubmit with a HIPAA valid CPT code, we told you that you didn't need to do anything and that we would reprocess these claims when the issue was fixed.
  • For BCN Advantage member claims denied with a message stating that you need to resubmit with valid codes, we told you to resubmit these claims with the same PDPM levels. We noted that you would have received a letter stating that these claims were denied and would need to be resubmitted with valid codes.

We apologize for any inconvenience.

As a reminder, naviHealth authorizes PDPM levels during the patient's stay (from preservice through discharge) for dates of service on or after Oct. 1, 2019, to align with CMS payment methodology. naviHealth works with SNFs to ensure the biller submits the appropriate PDPM level for reimbursement.

For more information, see the Post-acute care services: Frequently asked questions by providers document.

Posted: December 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

The e-referral system will be unavailable from 8 to 10 a.m. (Eastern time) on Saturday, Dec. 7, 2019, while we do software upgrades.

During the rest of the weekend, we expect the system to be available, although you may experience minor performance issues.

Other planned downtimes and what to do

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

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

We apologize for any inconvenience you may experience while the e-referral system is down.

Posted: December 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

For members receiving physical, occupational or speech therapy in 2019 that needs to continue into 2020, here's some information on how to submit these authorization requests to eviCore healthcare®:

  • You may submit an authorization request for additional visits as early as 14 days prior to or as late as seven days after the requested start date.
  • Waiver visits previously granted through Landmark Healthcare (six visits for Category B providers and three for Category C providers) no longer apply.
  • Category B and C providers must submit clinical information with their requests; the requests will be subject to a medical necessity review.

As a reminder, eviCore manages the following therapy services for non-autism diagnoses:

  • Physical and occupational therapy for Medicare Plus BlueSM PPO, BCN HMOSM (commercial) and BCN AdvantageSM members
  • Speech therapy for BCN HMO (commercial) and BCN Advantage members

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

Posted: December 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

Starting Jan. 7, 2020, board-certified behavior analysts practicing in Michigan must be licensed by the state of Michigan to be eligible for reimbursement from Blue Cross Blue Shield of Michigan and Blue Care Network. BCBAs who aren't licensed aren't eligible for reimbursement for services provided on or after Jan. 7, 2020.

For information on the licensing process, refer to the Behavior Analysts webpage of the Michigan Department of Licensing and Regulatory Affairs website.

Note that we've introduced a Behavioral Health edition of Blues Brief. To add Blues Brief to your subscriptions, click the Manage Subscriptions link at the bottom of your BCN Provider News or The Record newsletter emails. If you haven't subscribed to our publications, go to bcbsm.com/providers, click Our Provider Newsletters, and then click Subscribe to choose your preferred publications.

Posted: December 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

We're expanding the prior authorization program for specialty drugs covered under the medical benefit to include the following drugs for Blue Cross' PPO (commercial) and BCN HMO (commercial) members:

  • Beovu® (brolucizumab, HCPCS code J3490/J3590)
  • Macugen® (pegaptanib, HCPCS code J2503)
  • Scenesse® (afamelanotide, HCPCS code J3490)

For BCN HMO members:

  • We'll require authorization for Beovu and Scenesse for members who begin therapy on or after Nov. 15, 2019.
  • We'll require authorization for Macugen for members who begin therapy on or after Jan. 1, 2020.

For Blue Cross' PPO members:

  • We'll require authorization for Beovu, Macugen and Scenesse for members who begin therapy on or after Jan. 1, 2020.

More about the authorization requirements

The authorization requirements apply only to groups that are currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. These changes don't apply to members covered by Medicare Plus BlueSM PPO, BCN AdvantageSM or the Federal Employee Program® Service Benefit Plan; however, Medicare Plus Blue and BCN AdvantageSM have required authorization for Macugen since 2017 and will require authorization for Beovu starting on Feb. 3, 2020.

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

List of requirements

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

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

Posted: November 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Register for a webinar about hyaluronic acid products for knee injections

As we communicated previously, starting Jan. 1, 2020, Blue Cross Blue Shield of Michigan and Blue Care Network will consider some hyaluronic acid drugs to be preferred or covered and others to be nonpreferred or noncovered. You can find the full details in the article titled Blue Cross and BCN to cover select hyaluronic acid products, starting Jan. 1 in the November 2019 issue of The Record.

We're holding webinars to provide information about hyaluronic acid products for knee injections for Blue Cross' PPO, Medicare Plus BlueSM PPO, BCN HMOSM and BCN AdvantageSM members.

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

Once the host approves your registration, you'll receive a confirmation email with instructions for joining the session.

Note: We first communicated this change on Sept. 30, 2019, via a web-DENIS message and a news item on the ereferrals.bcbsm.com website.

Posted: November 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

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

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

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

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

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

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

Posted: November 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

For acute non-behavioral health non-elective inpatient admissions, the process for requesting a peer-to-peer review with a Blue Cross Blue Shield of Michigan or Blue Care Network medical director is now the same for all lines of business. This applies to inpatient admission authorization requests denied for Blue Cross' PPO, Medicare Plus BlueSM PPO, BCN HMOSM and BCN AdvantageSM members.

Here's what you need to know about peer-to-peer review requests for acute non-behavioral health non-elective inpatient admissions:

  • Submit all requests using the Physician peer-to-peer request form (for non-behavioral health cases). Complete the form and fax it to 1-866-373-9468 during normal business hours of 8 a.m. to 5 p.m. Eastern time (except weekends and holidays).
  • Note: We'll outreach to you the next business day. The peer-to-peer review will be scheduled on business days, Monday through Friday between 9 a.m. and 4 p.m. Eastern time (except holidays).

  • Using the form is optional for now but will be mandatory starting Jan. 1, 2020.
  • Note: Currently, for Blue Cross' PPO and Medicare Plus Blue requests, you call 1-866-346-7299 to request a peer-to-peer review. However, on Jan. 1, 2020, that number will be taken out of service.

  • The request process is not changing for BCN HMO and BCN Advantage. Currently, you submit BCN requests using the form. It's the process for Blue Cross' PPO and Medicare Plus Blue requests that's changing.
  • The form is available on this website, on the Blue Cross Authorization & Requirements & Criteria page and the BCN Authorization & Requirements & Criteria page. The form has been updated for use with all lines of business.

Additional information

For information about requesting peer-to-peer reviews on denied authorization requests for various types of services, refer to the description of the process in the document How to request a peer-to-peer review with a Blue Cross or BCN medical director. This document is also available on the Blue Cross and BCN Authorization Requirements & Criteria pages on this website.

The only process that's changing is the one for requesting acute non-behavioral health non-elective inpatient admissions. The processes for requesting peer-to-peer reviews for other types of services are staying the same.

Posted: November 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Tell us what you think about our utilization management services

Your feedback is important to us. Please complete the 2019 Blue Cross Blue Shield of Michigan and Blue Care Network Utilization Management Survey and encourage your office colleagues to do so as well, including physicians, nurses and referral coordinators. Your input will help us evaluate our efforts and determine other improvements we can make to enhance our utilization management processes.

The survey will be available online through Dec. 31, 2019.

Posted: November 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

We're adding the following medications to the Medicare Plus BlueSM PPO and BCN AdvantageSM Part B specialty prior authorization drug list. These specialty medications are administered in outpatient sites of care, such as a physician's office, an outpatient facility or a member's home.

For dates of service on or after Feb. 3, 2020, the following medications will require authorization:

  • J3490/C9399 Beovu®
  • J3590 Zolgensma®
  • J3590 Skyrizi
  • J3490 Spravato
  • J7170 Hemlibra®
  • J1555 Cuvitru
  • J1599 Panzyga®
  • Q4074 Ventavis®

How to bill

For Medicare Plus Blue and BCN Advantage, we require authorization for these medications for the following sites of care when you bill the medications as a professional service or as an outpatient facility service and you bill electronically through an 837P transaction or on a professional CMS 1500 claim form:

  • Physician office (place of service code 11)
  • Outpatient facility (place of service code 19, 22 or 24)
  • Home (place of service code 12)

We also require authorization when you bill electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x.

Important reminder

You must obtain authorization prior to administering these medications. Use the NovoLogix® online tool to quickly submit your authorization requests. It offers real-time status checks and immediate approvals for certain medications. Also note:

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

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

List of requirements

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

The authorization requirements for these drugs will be reflected on the drug list on Jan. 1, 2020.

Posted: October 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

The following changes are coming for Blue Cross' PPO (commercial) and BCN HMO (commercial) members:

  • For new courses of treatment involving ketoprofen 25 mg that begin on or after Dec. 1, 2019, you'll have to obtain authorization. If you don't obtain authorization, the member may be responsible for the full cost of the drug.
  • Effective March 1, 2020, ketoprofen 25 mg will be limited to four capsules per day or 120 capsules per 30 days. Requests for Blue Cross Blue Shield of Michigan and Blue Care Network to cover greater quantities will need to include documentation showing that the greater quantity is medically necessary.

Members who start taking ketoprofen prior to Dec. 1, 2019, can continue their treatment courses. However, as of March 1, 2020, you'll need to obtain authorization for these members to continue therapy.

For treatment courses starting on or after Dec. 1, 2019, you'll need to obtain authorization before members begin taking ketoprofen.

We'll notify affected members of these changes, and we'll encourage them to talk to you if they have concerns.

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

Note: These requirements don't apply to Medicare Plus BlueSM PPO or BCN AdvantageSM members.

Posted: October 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

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

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

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

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

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

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

Posted: October 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

On Jan. 1, 2020, a utilization management program for medical oncology drugs will begin for Medicare Plus BlueSM PPO and BCN AdvantageSM members. Providers will need to obtain authorizations from AIM Specialty Health® for some medical oncology and supportive care medications.

This program became effective for BCN HMOSM (commercial) members in August 2019.

For details about the program, see page 10 of the September-October 2019 issue of BCN Provider News.

Frequently asked questions

We've updated the Oncology management program: Frequently asked questions for providers document for the addition of Medicare Plus Blue and BCN Advantage members.

Oct. 24 webinar

Learn about the new medical oncology program and how to use the AIM ProviderPortalSM by attending a webinar on Oct. 24 (intended for non-clinical provider staff).

Make sure to view the article in the November-December issue of BCN Provider News (posting on Oct. 23) for more information and additional webinars.

Posted: October 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

Effective Jan. 1, 2020, Blue Cross Blue Shield of Michigan and Blue Care Network will consider the following hyaluronic acid products to be either covered or preferred under the medical benefit:

  • Durolane®
  • Euflexxa®
  • Gelsyn-3
  • Supartz FX

Starting Jan. 1, we'll consider the following to be either noncovered or nonpreferred hyaluronic acid products: Gel-one®, GenVisc 850®, Hyalgan®, Hymovis®, Monovisc®, Orthovisc®, Synvisc®, Synvisc-One®, TriVisc®, Visco-3, Synojoynt and Triluron.

This change will apply to Blue Cross' PPO (commercial), Medicare Plus BlueSM PPO, BCN HMOSM (commercial) and BCN AdvantageSM members. This change won't apply to self-funded General Motors, Fiat Chrysler Automobiles, Ford Motor Company, and UAW Retiree Medical Benefit Trust commercial groups.

Blue Cross' PPO and BCN HMO commercial members

  • Members who began receiving noncovered hyaluronic acid products prior to Jan. 1, 2020, can continue their treatment courses to completion. For future treatment courses that begin on or after Jan. 1, 2020, we encourage providers to talk to their patients about using a covered hyaluronic acid product.
  • For treatment courses that begin on or after Jan. 1, 2020, we'll require members to use a covered hyaluronic acid product; these products don't require authorization.
  • We'll deny claims for noncovered hyaluronic acid drugs.
  • We'll notify affected members of these changes and encourage them to discuss treatment options with you.

Medicare Plus Blue and BCN Advantage members

  • Members who began receiving nonpreferred hyaluronic acid products prior to Jan. 1, 2020, can continue their treatment courses to completion. For future treatment courses that begin on or after Jan. 1, 2020, we encourage providers to talk to their patients about using a preferred hyaluronic acid product.
  • For treatments on or after Jan. 1, 2020, we'll require members to use preferred hyaluronic acid products; these products won't require authorization. If you select a nonpreferred hyaluronic acid product for a member, you will have to obtain authorization.

Additional information

The U.S. Food and Drug Administration has approved 16 hyaluronic acid products. To date, no study has shown that one hyaluronic acid product is superior to others.

Posted: September 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

Starting Jan. 1, 2020, Blue Cross Blue Shield of Michigan and Blue Care Network will change how we cover hemophilia drugs for commercial (PPO and HMO) members. If a member has Blue Cross' PPO or BCN HMO pharmacy coverage, all hemophilia drugs should be billed under his or her pharmacy benefits.

This change doesn't affect all commercial members. For example, if a member has pharmacy coverage through a company other than Blue Cross or BCN, hemophilia drugs will continue to be covered under the medical benefit.

To determine whether this change applies to a specific member:

  • For Blue Cross' PPO members, review the member's benefits in Benefit Explainer.
  • For BCN HMOSM members, review the member's benefits in web-DENIS.

We'll notify affected members of these changes. Members don't have to do anything. Their medication and treatment won't change.

For complete details, see the We'll cover hemophilia drugs under the pharmacy benefit for most commercial members, starting Jan. 1 article in the October 2019 issue of The Record. A similar article will appear in the November-December 2019 issue of BCN Provider News.

Posted: September 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

Starting Sept. 29, 2019, updated questionnaires will open in the e-referral system for certain procedures. In addition, updated preview questionnaires and authorization criteria will be available on this website.

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

Updates to existing questionnaires

Updated questionnaires will open in the e-referral system starting on Sept. 29 for the following services:

  • Cervical spine fusion with artificial disc replacement - opens for BCN HMOSM and BCN AdvantageSM
  • Dental anesthesia or repair of trauma to natural teeth - opens for BCN HMO and BCN Advantage
  • Noncoronary vascular stents - opens for BCN HMO, BCN Advantage and Medicare Plus Blue

Preview questionnaires

For all of these services, you'll soon be able to access preview questionnaires on this website. The preview questionnaires show the questions you'll need to answer in the actual questionnaires that open in the e-referral system. This can help you prepare your answers ahead of time.

To find the preview questionnaires:

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

Authorization criteria

We'll also update the pertinent authorization criteria on the Authorization Requirements & Criteria pages.

Posted: September 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

For Medicare Plus BlueSM PPO and BCN AdvantageSM skilled nursing facility admissions with dates of service on or after Oct. 1, 2019, naviHealth will authorize patient-driven payment model levels during the patient's stay (from preservice through discharge) to align with the Centers for Medicare & Medicaid Services payment methodology. We first communicated this change in late July.

When submitting claims for stays with dates of service starting on or before Sept. 30, 2019, and extending through or beyond Oct. 1, you'll need to include both the resource utilization group levels and the PDPM levels that naviHealth authorized.

Medicare Plus Blue PPO and BCN Advantage follow CMS payment methodology for skilled nursing facilities. As a result, the payment methodology will change from RUG levels to PDPM levels on Oct. 1, 2019.

You can view additional information on The Patient Driven Payment Model (PDPM) - Information and Resources for Provider Partners page of the naviHealth website.*

As a reminder, naviHealth manages authorization requests for Medicare Plus Blue PPO and BCN Advantage members admitted to post-acute care on or after June 1, 2019. For details, see the Post-acute care services: Frequently asked questions by providers document.

*Blue Cross Blue Shield of Michigan and Blue Care Network don't own or control this website.

Posted: September 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

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

From 7 a.m. on Saturday, Sept. 21 to 10 p.m. on Sunday, Sept. 22 (Eastern time)

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

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

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

Posted: September 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

How can we improve our online tools?

Blue Cross Blue Shield of Michigan and Blue Care Network want to know how we can make our online tools easier to use and more useful for you, our partner providers. We specifically want to know about your experience using online provider tools and services, including the tools available when you log in to our secure provider website at bcbsm.com.

Can you spare eight minutes to share your thoughts? Your input will help us focus future improvements that are most helpful to you.

Take survey now.

This survey will be available through the end of September. Thank you for sharing your opinions. Your responses will be confidential.

Posted: September 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Providers invited to Medicare Stars events in Michigan

Providers are invited to attend the Stars Premiere event held in movie theatres across the state in September. The event will include information about the Medicare Star Rating System, HEDIS measures, the Health Outcomes Survey and much more.

See the article in the September Record or the September-October BCN Provider News, Page 15 for dates, times and registration information.

Posted: August 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

BCN AdvantageSM and Medicare Plus BlueSM PPO members sometimes remain in skilled nursing facilities for days beyond the service end date on the Notice of Medicare Non-Coverage form. Sometimes the extended stay is due to a provider's failure either to deliver a completed NOMNC form in a timely manner or to comply with guidelines from Livanta, LLC, the quality improvement organization. This results in days added to the member's stay that may not be medically necessary.

On behalf of Blue Cross Blue Shield of Michigan, naviHealth will issue an administrative denial for these days if they occur because the SNF provider didn't handle the NOMNC in accordance with the Centers for Medicare and Medicaid Services guidelines. In an administrative denial, the authorization is approved but the reimbursement for the extra days is denied.

Examples of improper handling and delivery of the NOMNC include:

  • Late delivery of the NOMNC. Members must receive the NOMNC 48 hours prior to the planned discharge date.

    Note: naviHealth completes as much of the NOMNC as possible and tells the provider when to issue the NOMNC.
  • Failure to fill out the NOMNC in its entirety. All fields in the NOMNC must be completed, including all date and signature fields. For more information, see the Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123*.
  • Not submitting the requested medical information to the QIO in a timely manner, when the member appealed the service end date with the QIO

Note: To view CMS instructions about appropriate delivery of the NOMNC, see sections 260.2 to 260.4.5 of the CMS Manual System: Pub 100-04 Medicare Claims Processing, Transmittal 2711.*

When SNF providers have repeated difficulties handling the NOMNC according to CMS guidelines, their naviHealth care coordinators will reach out to provide education about CMS guidelines and health plan requirements. If, after receiving education, a SNF provider continues to have difficulties, naviHealth will deliver an administrative denial letter to the provider when members stay beyond the end date stated on the NOMNC.

The administrative denial letter will include details on the specific CMS guideline violations. Blue Cross and Blue Care Network will hold the provider responsible for the additional days the member stayed in the SNF. Per CMS guidelines, providers can't bill members for the additional days.

You can find information about CMS guidelines and Medicare Plus Blue and BCN Advantage requirements in the following locations.

As a reminder, naviHealth manages authorization requests for Medicare Plus Blue and BCN Advantage members admitted to post-acute care on or after June 1, 2019. For details, see the Post-acute care services: Frequently asked questions by providers document.

*Blue Cross Blue Shield of Michigan and Blue Care Network don't own or control this website.

Posted: August 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

naviHealth webinars about SNF PDPM payment methodology

For Medicare Advantage skilled nursing facility admissions with service dates on or after Oct. 1, 2019, naviHealth will authorize Patient-Driven Payment Model levels during the patient's stay (from preservice through discharge) to align with the Centers for Medicare & Medicaid payment methodology. We first communicated this change in late July.

To learn how naviHealth has been preparing for the changes to payment methodology with PDPM, register for and attend one of their live webinars, which are scheduled for September 3, 4 and 5.

During the webinars, naviHealth will cover the following:

  • The naviHealth clinical model under PDPM
  • The enhancements that are planned for the nH Predict|Outcome reports and nH Predict|Pulse
  • The process for PDPM level assignment including:
    • The additional clinical information necessary to process a request
    • How to request a level reconsideration
    • A review of claims processing

You can view additional information on The Patient Driven Payment Model (PDPM) - Information and Resources for Provider Partners page of the naviHealth website.*

As a reminder, naviHealth manages authorization requests for Medicare Plus BlueSM PPO and BCN AdvantageSM members admitted to post-acute care on or after June 1, 2019. For details, see the Post-acute care services: Frequently asked questions by providers document.

*Blue Cross Blue Shield of Michigan and Blue Care Network don't own or control this website.

Posted: August 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

We're adding Evenity® (J3111) to the Medicare Plus BlueSM PPO and BCN AdvantageSM Part B medical drug prior authorization list.

For dates of service on or after Nov. 1, 2019, Evenity will require prior authorization.

Medicare Plus Blue PPO

For Medicare Plus Blue, we require authorization for this medication for the following sites of care when you bill the medication electronically through an 837P transaction or on a professional CMS-1500 claim form:

  • Physician office (place of service code 11)
  • Outpatient facility (place of service code 19, 22 or 24)

BCN Advantage

For BCN Advantage, we require authorization for this medication for the following sites of care when you bill the medication as a professional service or as an outpatient facility service, and when you bill electronically through an 837P transaction or on a professional CMS-1500 claim form:

  • Physician office (place of service code 11)
  • Outpatient facility (place of service code 19, 22 or 24)
  • Home (place of service code 12)

We also require authorization when you bill electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x.

Important reminder

You must obtain an authorization before administering this medication. Use the NovoLogix® online tool to quickly submit your authorization requests. It offers real-time status checks and immediate approvals for certain medications.

If you have access to Provider Secured Services but you need access to NovoLogix, do one of the following:

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

Posted: August 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

Starting Jan. 7, 2020, board-certified behavior analysts practicing in Michigan must have a current license from the State of Michigan to be eligible for reimbursement from Blue Cross and Blue Care Network. BCBAs who are not licensed are not eligible to be reimbursed for services provided on or after Jan. 7, 2020.

For information on the licensing process, refer to the Behavior Analysts webpage of the Michigan Department of Licensing and Regulatory Affairs website.

Note: An earlier version of this message indicated that a license is required by Jan. 1, 2020. The actual date on which a license is required is Jan. 7, 2020.

Posted: August 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

Starting Aug. 25, 2019, new and updated questionnaires will open in the e-referral system for certain procedures. In addition, new and updated preview questionnaires, authorization criteria and medical policies will be available on this website.

New questionnaires

Starting August 25, questionnaires will open in the e-referral system for BCN HMOSM and BCN AdvantageSM authorization requests for the procedures listed below, which already require authorization.

Service Age Procedure codes
Bariatric surgery - BCN HMO Adult and adolescents *43644, *43645, *43770, *43771, *43772, *43773, *43774, *43775, *43842, *43843, *43845, *43846, *43847, *43848, *43886, *43887, *43888 and *44130
Bone-anchored hearing aid Adult and pediatric (5 years old and older) *69714, *69715, *69717 and *69718
Cardiac rehabilitation - BCN HMO Adult and pediatric *93797 and *93798 (for select diagnoses)
Cardiac rehabilitation - BCN Advantage
Pregnancy termination - BCN HMO Adult *01966, *59100, *59840, *59841, *59850, *59851, *59852, *59855, *59856, *59857, *59866, *88304, *88305, S0190, S0191, S0199, S2260, S2265, S2266 and S2267
Pregnancy termination - BCN Advantage
Pulmonary rehabilitation Adult and pediatric G0237, G0238, G0239, G0302, G0303, G0304, G0424 and S9473
Radiofrequency ablation, peripheral nerves Adult *64640
Visual training, orthotic and pleoptic Adult and pediatric *92065

Updates to existing questionnaires

In addition, updated questionnaires will open in the e-referral system on August 25 for BCN HMO, BCN Advantage and Medicare Plus Blue authorization requests (unless otherwise noted), for the following services:

  • Cervical spine surgery - opens only for BCN HMO and BCN Advantage
  • Cholecystectomy (laparoscopic) - opens only for BCN HMO and BCN Advantage
  • Endovascular intervention, peripheral artery - The updated questionnaire for this service was originally scheduled to open starting on July 28 for Medicare Plus Blue requests but will actually open starting August 25.
  • Ethmoidectomy
  • Hammertoe correction surgery
  • Hip arthroplasty, total, revision
  • Knee arthroplasty, total, revision
  • Sacral nerve neuromodulation/stimulation
  • Sinusotomy, frontal, endoscopic
  • Sleep studies, outpatient facility or clinic-based setting - opens only for BCN HMO and BCN Advantage
  • Vascular embolization or occlusion of hepatic tumors (TACE/RFA)

Preview questionnaires

We'll make preview questionnaires available on this website soon. To find them:

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

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

Authorization criteria and medical policies

We'll also post links to the pertinent authorization criteria and medical policies on the Authorization Requirements & Criteria pages.

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

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.

Posted: August 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

How can we improve our online tools?

Blue Cross Blue Shield of Michigan and Blue Care Network want to know how we can make our online tools easier to use and more useful for you, our partner providers. We specifically want to know about your experience using online provider tools and services, including the tools available when you log in to our secure provider website at bcbsm.com.

Can you spare eight minutes to share your thoughts? Your input will help us focus future improvements that are most helpful to you.

Take survey now.

This survey will be available through the end of September. Thank you for sharing your opinions. Your responses will be confidential.

Posted: August 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Medical record documentation requirements for ABA services are updated

We updated the medical record documentation requirements for applied behavior analysis services to clarify documentation requirements for services involving tutors and technicians.

These guidelines apply to services for Blue Cross' PPO (commercial) and BCN HMOSM (commercial) members.

You can view the guidelines on this website by clicking BCN or Blue Cross and then clicking Behavioral Health. Finally, click the Documentation requirements for applied behavior analysis services link.

You can also view the guidelines within Provider Secured Services. Here's how:

  1. Visit bcbsm.com/providers.
  2. Click Login and log in to Provider Secured Services.
  3. Click web-DENIS.

To access the guidelines through BCBSM Provider Publications and Resources:

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

To access the guidelines through BCN Provider Publications and Resources:

  1. Click BCN Provider Publications and Resources.
  2. Click Autism.
  3. Click Documentation requirements for applied behavior analysis services.

Posted: August 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

When we deny an authorization request in the e-referral system, we contact your office to inform you of that determination and then we close the case, which means that the case no longer appears in our queues.

We don't receive notification of changes to authorization requests that have been closed.

For this reason, we ask that you don't submit additional clinical documentation or make any other changes on denied requests. Instead, submit the clinical documentation during the appeals process. This will help to ensure that we see and review the additional documentation.

The denial letter includes instructions for submitting an appeal.

Posted: August 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Requirements for assessments of Medicare Advantage members in skilled nursing facilities

Here's some important information about the assessments required for Blue Cross and Blue Care Network Medicare Advantage members admitted to skilled nursing facilities:

  • You must complete an Omnibus Reconciliation Act, or OBRA, assessment for each member.
  • You may opt to complete an additional Prospective Payment System assessment, but you are not required to complete one.

If you complete a PPS assessment:

  • No Resource Utilization Group level is required, because naviHealth will determine the RUG level.
  • A RUG level included in a PPS assessment may not match the level naviHealth assigns. If the levels don't match and you enter the RUG level from a PPS assessment rather than the naviHealth-assigned RUG level, this may cause a claim payment error.
  • You must bill using the RUG level naviHealth assigns, which you'll find in the authorization on nH Access at access.navihealth.com.

If you choose not to complete a PPS assessment, there will be no penalties, even if you're following CMS protocols.

This applies to BCN AdvantageSM and Medicare Plus BlueSM PPO members admitted for skilled nursing care on or after June 1, 2019.

For more information, see the following documents on the Blue Cross Blue Shield of Michigan and Blue Care Network resources page of the naviHealth website*:

If you have questions, contact your naviHealth network manager.

We'll incorporate this information into the Post-acute care services: Frequently asked questions by providers document.

Additional information:

  • Starting Oct. 1, 2019, naviHealth will authorize Patient-Driven Payment Model levels during the patient's stay, which aligns with CMS payment methodology. Before this change takes place, we'll let you know how it will affect the assessments you must complete.
  • As a reminder, naviHealth manages authorization requests for Medicare Plus Blue and BCN Advantage members admitted to post-acute care on or after June 1, 2019.
  • As part of their partnership with Blue Cross Blue Shield of Michigan, naviHealth assigns and authorizes RUG levels for Medicare Advantage members' stays in skilled nursing facilities.

*Blue Cross Blue Shield of Michigan and Blue Care Network don't own or control this website.

Posted: August 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

You may experience performance issues with the e-referral system from midnight to 6 a.m. on these dates:

  • Saturday, August 3
  • Sunday, August 4

This is because we'll be loading a large membership file into the system during these times.

Any problems you experience using the e-referral system during these times should be resolved by the start of business on Monday, August 5.

We're placing a notice about this on the Provider Secured Services landing page, near the e-referral system link.

Posted: August 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

Blue Cross Blue Shield of Michigan and Blue Care Network are making changes to the post-payment audit and recovery process for skilled nursing facilities. The changes apply to Medicare Plus BlueSM PPO and BCN AdvantageSM members.

Here's what you need to know:

  • HMS® no longer performs post-payment SNF audits. Instead, Blue Cross and BCN review paid SNF claims on a quarterly basis. We'll ensure that Resource Utilization Group or Patient-Driven Payment Model levels in the claims match the RUG or PDPM levels on the authorizations.
  • You won't need to submit medical records during the quarterly post-payment review process.
  • Prior to discharge, a naviHealth care coordinator will work with your biller to verify that the authorized RUG or PDPM levels are submitted for reimbursement. When you submit SNF Medicare Advantage claims, make sure the RUG or PDPM levels on each claim match the levels on the authorization connected to the stay.

For complete details, see the We're making changes to the Medicare Advantage SNF post-payment audit, recovery process article in the August 2019 issue of The Record. A similar article will appear in the September-October 2019 issue of BCN Provider News.

Posted: July 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

We're adding the following medications to the Medicare Plus BlueSM PPO and BCN AdvantageSM Part B specialty prior authorization drug list.

For dates of service on or after Oct. 1, 2019, the following medications will require prior authorization:

  • J1599 Asceniv
  • J1301 Radicava®
  • J0584 Crysvita®
  • J0565 Zinplava

Medicare Plus Blue PPO

For Medicare Plus Blue, we require prior authorization for these medications for the following sites of care when you bill the medications electronically through an 837P transaction or on a professional CMS-1500 claim form:

  • Physician office (place of service code 11)
  • Outpatient facility (place of service code 19, 22 or 24)

BCN Advantage

For BCN Advantage, we require prior authorization for these medications for the following sites of care when you bill the medications as a professional service or as an outpatient-facility service and you bill electronically through an 837P transaction or on a professional CMS-1500 claim form:

  • Physician office (place of service code 11)
  • Outpatient facility (place of service code 19, 22 or 24)
  • Home (place of service code 12)

We also require prior authorization when you bill electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x.

Important reminder

You must obtain authorization prior to administering these medications. Use the NovoLogix® online tool to quickly submit your authorization requests. It offers real-time status checks and immediate approvals for certain medications. Also note:

  • For Medicare Plus Blue, you can fax an Addendum P form to gain access to the NovoLogix online tool.
  • For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

Posted: July 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

It recently came to our attention that some of our documents contained an incorrect fax number for sending post-acute care discharge information to naviHealth. We've updated the documents to include the correct fax number, which is 1-844-729-2951. The incorrect fax number contained the last four digits: 2591.

Providers who sent discharge information to the incorrect fax number before July 13, 2019, should be aware that naviHealth didn't receive it. The fax attempt failed and no one received the information.

If you faxed discharge information and you didn't receive a fax confirmation, or you aren't sure that naviHealth received the fax, resend the information. If naviHealth doesn't receive discharge information within the expected time frame, a naviHealth care coordinator will follow up with the facility.

We apologize for any confusion.

As a reminder, naviHealth manages authorization requests for Medicare Plus BlueSM PPO and BCN AdvantageSM members admitted to post-acute care on or after June 1, 2019.

Posted: July 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

As a reminder, we're making changes to the Medicare Plus BlueSM PPO and BCN AdvantageSM Part B specialty prior authorization drug list, as follows:

  • For dates of service on or after July 22, 2019, Darzalex® (J9145) will require prior authorization.

Here's some additional information you need to know about the change for Darzalex.

Medicare Plus Blue PPO

For Medicare Plus Blue, we require prior authorization for Darzalex when you bill electronically through an 837P transaction or on a professional CMS-1500 claim form, for the following sites of care:

  • Physician office (place of service code 11)
  • Outpatient facility (place of service code 19, 22 or 24)

BCN Advantage

For BCN Advantage, we require prior authorization for Darzalex when you bill it as a professional service or an outpatient facility service electronically through an 837P transaction or on a professional CMS-1500 claim form for:

  • Physician office (place of service code 11)
  • Outpatient facility (place of service code 19, 22 or 24)
  • Home (place of service code 12)

We also require prior authorization when you bill electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x.

Important reminder

You must get authorization prior to administering these medications. Use the Novologix® online web tool to quickly submit your requests. It offers real-time status checks and immediate approvals for certain medications. Also note:

  • For Medicare Plus Blue, you can fax an Addendum P form to gain access to the Novologix online web tool.
  • For BCN Advantage, if you have access to Provider Secured Services, you already have access to submit authorization requests through Novologix.

Posted: July 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



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

We're offering several upcoming training opportunities for providers and staff with the following webinars:

Blues 101 – Understanding the Basics

  • Tuesday, July 16, 1 to 2 p.m. Register

Blues 201 – Enrollment

  • Tuesday, July 23, 2 to 4 p.m. Register
  • Thursday, July 25, 10 a.m. to noon Register

Pharmacy Site of Care

  • Wednesday, July 17, 10 to 11 a.m. Register
  • Thursday, July 25, 1:30 to 2:30 p.m. Register

These events can be also be found on Page 2 of the July-August 2019 BCN Provider News.

We're also offering a webinar on Thursday, Aug. 22, noon to 1 p.m., to learn more about the new medical oncology program managed by AIM Specialty Health®. Register here and read more about it on Page 26 of the May-June 2019 BCN Provider News.

Posted: July 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



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

We've developed comprehensive lists of requirements for medical specialty drugs and pharmacy benefit drugs for Blue Cross Blue Shield of Michigan PPO and Blue Care Network HMO commercial members. These lists, which are typically updated monthly, include the most current information on utilization management requirements.

  • Medical benefit drugs: The medical specialty drug list identifies medical drugs targeted in the prior authorization and site-of-care programs, and includes the following information about them:
    • Medical necessity criteria
    • Quantity limits
    • Step therapy requirements
  • Pharmacy benefit drugs: The pharmacy benefit drug list identifies pharmacy drugs targeted in the prior authorization program and includes step therapy requirements.

For more information, see the following articles:

Posted: July 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



NovoLogix® user interface enhancements coming soon

If you use NovoLogix® to submit electronic prior authorizations for certain Part B medical specialty drugs, you'll soon see an enhanced user interface when you log in to the online web tool. The enhancements will streamline the process of creating authorization requests.

The interface changes are minimal and easy to navigate, and you'll be able to switch between the current and enhanced interfaces while you adjust to the changes. We'll provide more information, such as user guides and training videos, as we get closer to the release date.

As a reminder, you can always find information about authorization requirements for these drugs on this website:

Posted: June 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



More updated e-referral questionnaires open on June 23

Starting June 23, 2019, updated questionnaires will open in the e-referral system for authorization requests for the procedures listed below, which already require authorization.

Procedure New codes Line of business
Breast biopsy, excisional No new codes; existing codes are in preview questionnaire
  • BCN HMOSM
  • BCN AdvantageSM
Endovascular intervention, peripheral artery New codes: *34101, *34111, *34151, *34201, *34203, *37184 and *37222
Existing codes are in preview questionnaire
  • BCN HMO
  • BCN Advantage
  • Medicare Plus BlueSM PPO
Otoplasty No new codes; existing codes are in preview questionnaire
  • BCN HMO
  • BCN Advantage
Rhinoplasty No new codes; existing codes are in preview questionnaire
  • BCN HMO
  • BCN Advantage

For some of these procedures, we are also updating the authorization criteria.

We use the criteria and questionnaires when making utilization management determinations on authorization requests submitted for the affected members.

The updated authorization criteria and preview questionnaires are available at ereferrals.bcbsm.com. Here's where to find them:

You can look over the preview questionnaires to see what questions you'll need to answer in the actual questionnaires that open in the e-referral system for these services. Once you know what questions you'll need to answer, you can prepare your answers in advance to cut down on the time it takes to submit the authorization request.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.

Posted: June 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



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

As a reminder, naviHealth manages initial, continued stay and retrospective authorization requests only for Medicare Advantage post-acute care for Medicare Plus BlueSM PPO and BCN AdvantageSM members admitted on or after June 1, 2019. Post-acute care includes skilled nursing facility, inpatient rehabilitation facility and long-term acute hospital care.

To facilitate the timely review of your authorization requests, please do not submit the following requests to naviHealth:

  • Non-post-acute care authorization requests for any member
  • Post-acute care authorization requests for commercial members

Requesting authorization for non-post-acute care services

If you need to request authorization for services unrelated to post-acute care, refer to the Summary of utilization management programs for Michigan providers to determine where to submit the request. Do not submit these requests to naviHealth.

Requesting authorization for Medicare Advantage post-acute care

To submit Medicare Advantage post-acute care authorization requests to naviHealth, refer to the Post-acute care services: Frequently asked questions for providers for information.

Posted: June 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



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

This message, originally published on May 31, 2019, is republished on June 3, 2019, to include information about Zolgensma®.

The prior authorization program for specialty drugs covered under the medical benefit is expanding for BCN and Blue Cross commercial members:

  • Asceniv (immune globulin, HCPCS code J1599)
  • Evenity (rosmosozumab-aqqb, HCPCS code J3590)
  • Zolgensma (onasemnogene abeparvovec-xioi, HCPCS codes J3490/J3590)

For BCN HMO members:

  • Authorization for Asceniv, Evenity and Zolgensma is required for dates of service on or after June 1, 2019.
  • Asceniv and Evenity will be added to the Site of Care Program for BCN HMO members effective June 1, 2019.

For Blue Cross' PPO members:

  • Authorization for Asceniv is required for dates of service on or after June 1, 2019. Asceniv will also be added to the Site of Care Program for Blue Cross' PPO members, effective June 1, 2019.
  • Authorization for Evenity and Zolgensma is required for dates of service on or after Aug. 1, 2019.

More about the authorization requirements

The authorization requirements apply only to groups that are currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. These changes don't apply to BCN AdvantageSM, Medicare Plus BlueSM PPO or Federal Employee Program® members.

A prior authorization approval isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

List of requirements

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

The new prior authorization requirements that took effect on June 1 are included in the requirements list. The requirements that take effect on Aug. 1 will be reflected in the requirements list before that date. Blue Cross Blue Shield of Michigan and Blue Care Network reserve the right to review for medical necessity prior to the effective dates listed in this message.

Posted: June 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



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

Starting June 1, 2019, naviHealth will manage authorizations for admissions for Medicare Plus BlueSM PPO and BCN AdvantageSM members who need skilled nursing, inpatient rehabilitation or long-term acute care. The last webinars for skilled nursing facilities, acute care facilities, inpatient rehabilitation and long-term acute care facilities are on June 5 and 6. For more information, see the June issue of The Record and the May-June issue of BCN Provider News on page 6. You can also review our frequently asked questions document.

Posted: May 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



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

Skilled nursing facilities, inpatient acute rehabilitation centers and long-term acute care hospitals can continue to submit authorization requests for post-acute care services using Allscripts®, now known as CarePort Care Management. Instructions are available in naviHealth's document, Submitting Pre-service Authorization Requests using CarePort Care Management (PDF)*.

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

Posted: May 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



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

On Aug. 1, 2019, Medicare Plus BlueSM PPO, Blue Cross Blue Shield of Michigan's Medicare Advantage plan, and Blue Care Network's commercial and Medicare Advantage plans (BCN HMOSM and BCN AdvantageSM) will begin using the 2019 InterQual® criteria for behavioral health utilization management determinations.

In addition, certain types of determinations will be based on modifications to InterQual criteria or on local rules or medical policies, as shown in the table below:

Line of business Modified 2019 InterQual criteria for: Local rules or medical policies for:
BCN HMO (commercial) and BCN Advantage
  • Substance use disorders: partial hospital program and intensive outpatient program
  • Residential mental health treatment (adult, geriatric, child and adolescent members)
  • Applied behavior analysis for autism spectrum disorder: (for BCN HMO only)
  • Neurofeedback for attention deficit disorder and attention deficit hyperactivity disorder
  • Transcranial magnetic stimulation
  • Telemedicine (telepsychiatry and teletherapy)
Medicare Plus Blue PPO
  • Substance use disorders: partial hospital program and intensive outpatient program
None

Note: Determinations on Blue Cross PPO (commercial) behavioral health authorization requests are handled by New Directions, a Blue Cross vendor.

Links to the updated versions of the modified criteria, local rules and medical policies are available on the Blue Cross Behavioral Health page and the BCN Behavioral Health page on this website.

Posted: May 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

For dates of service on or after June 1, 2019, BCN and Blue Cross are accepting claims for behavior analysis services billed with the following codes:

  • *97151
  • *97152
  • *97153
  • *97154
  • *97155
  • *97156
  • *97157
  • *97158
  • *0362T
  • *0373T

Claims billed with the following codes will still be honored:

  • H0031
  • H0032
  • H2019
  • H2014
  • S5108
  • S5111

This applies to BCN HMOSM and Blue Cross’ PPO members. All services continue to require authorization.

Billing guidelines

We're updating the ABA billing guidelines to reflect the 2019 codes. Look for the updated guidelines sometime in June on the Autism pages within Provider

Secured Services, which you can access by visiting bcbsm.com/providers and logging into Provider Secured Services. Then:

  • To access the BCN Autism page:
    1. Click BCN Provider Publications and Resources (on the right).
    2. Click Autism(in the left navigation).
    3. Click Applied Behavior Analysis Billing Guidelines and Procedure Codes under the "Autism provider resource materials" heading.
  • To access the Blue Cross Autism page:
    1. Click BCBSM Provider Publications and Resources (on the right).
    2. Click Clinical Criteria & Resources(in the left navigation).
    3. Scroll down and click Autism (in the Resources section).
    4. Click Applied Behavior Analysis Billing Guidelines and Procedure Codes under the "Autism provider resource materials" heading.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.

Posted: May 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Updated authorization criteria and e-referral questionnaire for ethmoidectomy

We're making updates to the ethmoidectomy authorization criteria and questionnaire in the e-referral system.

You'll see the updated questionnaire in the e-referral system starting May 26, 2019.

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

  • BCN HMOSM
  • BCN AdvantageSM
  • Medicare Plus BlueSM PPO

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

You can look over the preview questionnaire to see what questions you'll need to answer in the actual questionnaire that opens in the e-referral system for this service. Once you know what questions you'll need to answer, you can prepare your answers ahead of time. This can cut down on the time it takes to submit the authorization request.

Posted: May 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

We're making changes to the Medicare Plus BlueSM PPO and BCN AdvantageSM Part B specialty prior authorization drug list, as follows:

  • For dates of service on or after July 22, 2019, Darzalex® (J9145) will require prior authorization.
  • Effective immediately, Myozyme® (J0220) is removed from the prior authorization list because it is no longer available in the U.S. market.

Here's some additional information you need to know about the change for Darzalex.

Medicare Plus Blue PPO

For Medicare Plus Blue, we require prior authorization for Darzalex when you bill electronically through an 837P transaction or on a professional CMS-1500 claim form, for the following sites of care:

  • Physician office (place of service code 11)
  • Outpatient facility (place of service code 19, 22 or 24)

BCN Advantage

For BCN Advantage, we require prior authorization for Darzalex when you bill it as a professional service or an outpatient facility service electronically through an 837P transaction or on a professional CMS-1500 claim form for:

  • Physician office (place of service code 11)
  • Outpatient facility (place of service code 19, 22 or 24)
  • Home (place of service code 12)

We also require prior authorization when you bill electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x.

Important reminder

You must get authorization prior to administering these medications. Use the Novologix® online web tool to quickly submit your requests. It offers real-time status checks and immediate approvals for certain medications. Also note:

  • For Medicare Plus Blue, you can fax an Addendum P form to gain access to the Novologix online web tool.
  • For BCN Advantage, if you have access to Provider Secured Services, you already have access to submit authorization requests through Novologix.

Posted: May 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Learn about Medicare Advantage post-acute care authorization changes

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

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

Posted: May 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

Effective June 1, 2019, Spravato (esketamine, HCPCS code J3490) will be added to the Medical Drug Prior Authorization Program for Blue Cross Blue Shield of Michigan PPO and BCN HMOSM (commercial) members. This applies to any members covered by commercial plans who are starting therapy on or after June 1.

The authorization requirement only applies to groups that are currently participating in the commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. These changes don't apply to BCN AdvantageSM, Medicare Plus BlueSM PPO or Federal Employee Program® members.

As a reminder, approval of an authorization request isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members. Members are responsible for the full cost of medications not covered under their medical benefit coverage.

The new requirements for Spravato will appear in the list of requirements for drugs covered under the medical benefit - BCN HMO and Blue Cross PPO before the June 1 start date.

For additional information about drugs covered under the medical benefit, visit the ereferrals.bcbsm.com website:

Posted: May 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

Starting July 1, 2019, Blue Cross Blue Shield of Michigan and Blue Care Network will begin covering additional transgender services for University of Michigan employees with Blue Cross PPO (commercial) or BCN HMOSM (commercial) coverage through U-M Premier Care. The additional services, known as facial feminization procedures, include:

  • Facial hair removal
  • Facial feminization surgery
  • Chondrolaryngoplasty (Adam's apple reduction)

An expanded list of included/excluded procedures can be found here. Currently, Michigan Medicine is the only provider in our network that performs most of these services. Prior authorization is required, and members must meet specific criteria to establish medical necessity for services to be covered. These services must be performed by in-network providers.

Posted: April 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

We're making changes to the Medicare Plus BlueSM PPO and BCN AdvantageSM Part B specialty prior authorization drug list. The following medications are being added to the list.

Medicare Plus Blue PPO

For dates of service on or after June 3, 2019, the following medications will require prior authorization:

  • J3590 Ultomiris
  • J9999 (C9044) Libtayo®
  • J3245 Ilumya
  • Q510X Ixifi
  • J3590/J9999 Elzonris
  • J3397 Mepsevii
  • J3490 Tegsedi
  • J9173 Imfinzi®
  • J3304 Zilretta®

For Medicare Plus Blue, we require prior authorization for these medications when you bill them electronically through an 837P transaction or on a professional CMS-1500 claim form, for the following sites of care:

  • Physician office (place of service code 11)
  • Outpatient facility (place of service code 19, 22 or 24)

BCN Advantage

For dates of service on or after June 3, 2019, the following medications will require prior authorization:

  • J3590 Ultomiris
  • J9999 (C9044) Libtayo®
  • J3245 Ilumya
  • Q510X Ixifi
  • J3590/J9999 Elzonris
  • J3397 Mepsevii
  • J3490 Tegsedi
  • J9173 Imfinzi®
  • J3304 Zilretta®

For BCN Advantage, we require prior authorization for these medications when you bill them as a professional service or an outpatient facility service electronically through an 837P transaction or on a professional CMS-1500 claim form for:

  • Physician office (place of service code 11)
  • Outpatient facility (place of service code 19, 22 or 24)
  • Home (place of service code 12)

We also require prior authorization when you bill electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x.

Important reminder

You must get authorization prior to administering these medications. Use the Novologix® online web tool to quickly submit your requests. It offers real-time status checks and immediate approvals for certain medications. Also note:

  • For BCN Advantage, if you have access to Provider Secured Services, you already have access to enter authorization requests through Novologix.
  • For Medicare Plus Blue, you can fax an Addendum P form to gain access to the Novologix online web tool.

Posted: March 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

What to do when error messages display in e-referral

If you're a provider trying to edit one of your cases in the e-referral system, you may see an error message that says:

"The case is unavailable because it's being reviewed. Please try again later."

Recently, e-referral began displaying these messages when a provider tries to edit a case that's locked because our Utilization Management team is working on it.

This error message can appear for any Blue Cross Blue Shield of Michigan or Blue Care Network case in the e-referral system, including commercial and Medicare Advantage cases. If you encounter one of these messages, we ask that you edit the case later to give our team time to review and exit the case.

If you encounter another type of other error message, contact the Web Support Help Desk at 1-877-258-3932.

Posted: March 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

Starting Feb. 25, 2019, e-referral's home-page dashboard will only display new or updated cases from the previous 60 days. This change applies to all Blue Cross Blue Shield of Michigan and Blue Care Network cases in the e-referral system, including commercial and Medicare Advantage.

Important to know:

  • Your cases will display faster on the home page. This will be especially helpful if you typically have a lot of cases.
  • We don't delete cases that are past the 60-day-display time frame. You can access all of your cases by searching for them with the reference number or the member's contract number.

Blue Cross and BCN will continue to make enhancements to the e-referral system to make it easier to use. Watch for future web-DENIS messages and news items on the ereferrals.bcbsm.com website announcing upcoming updates.

Posted: February 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

Starting June 1, 2019, our new vendor, naviHealth, will manage authorizations for Medicare Plus BlueSM PPO and BCN AdvantageSM members who require a transfer from an acute inpatient facility to a skilled nursing, long-term acute care or inpatient rehabilitation facility. naviHealth will be reviewing both in- and out-of-state post-acute care cases.

Look for upcoming articles in The Record and BCN Provider News on training opportunities and how to submit naviHealth requests.

Posted: February 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Sign up to receive Blues Brief electronically

Blues Brief has a new look and is now available via email subscription. Blues Brief is a quick summary of headlines that reference more in-depth articles found in the BCN Provider News or The Record.

To sign up and avoid possible subscription errors, add Blues Brief to your subscriptions by clicking the Manage Subscriptions link at the bottom of your BCN Provider News or The Record newsletter emails. Once you make your changes to your subscription, simply click Update and we'll process your changes. Our system doesn't automatically acknowledge your changes, but we'll be sure to add you to the distribution list. You can also visit the subscription page to choose your preferred Blues Brief versions. These include the:

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

Posted: January 2019
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



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

As a reminder, Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will be closed on these days:

  • Tuesday, Dec. 24 and Wednesday, Dec. 25, for the Christmas holidays
  • Tuesday, Dec. 31 and Wednesday, Jan. 1, for the New Year’s holidays

During these office closures, follow the guidelines outlined below when submitting inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

Acute initial inpatient admissions. Submit these authorization requests as well as concurrent reviews and discharge dates through the e-referral system, which is available 24 hours a day, seven days a week. If the e-referral system is not available, you can fax requests for inpatient admissions and continued stays to BCN HMO (commercial) at 1 866 313 8433 and to BCN Advantage at 1 866 526 1326.

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

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

Post-acute initial and concurrent admission reviews.

Other authorization requests. The types of requests listed below must be submitted by fax. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

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

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

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

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

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

Posted: December 2019
Line of business: Blue Care Network



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

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will be closed on these days:

  • Thursday, Nov. 28 and Friday, Nov. 29, for the Thanksgiving holidays
  • Tuesday, Dec. 24 and Wednesday, Dec. 25, for the Christmas holidays
  • Tuesday, Dec. 31 and Wednesday, Jan. 1, for the New Year’s holidays

During these office closures, follow the guidelines outlined below when submitting inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

Acute initial inpatient admissions. Submit these authorization requests as well as concurrent reviews and discharge dates through the e-referral system, which is available 24 hours a day, seven days a week. If the e-referral system is not available, you can fax requests for inpatient admissions and continued stays to BCN HMO (commercial) at 1 866 313 8433 and to BCN Advantage at 1 866 526 1326.

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

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

Post-acute initial and concurrent admission reviews.

Other authorization requests. The types of requests listed below must be submitted by fax. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

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

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

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

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

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

Posted: November 2019
Line of business: Blue Care Network



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

Effective Jan. 1, 2020, BCN will deny claims for outpatient toxicology laboratory services provided by an out-of-network laboratory without authorization from Joint Venture Hospital Laboratories. This applies to BCN HMOSM (commercial) claims.

BCN contracts with JVHL to provide the statewide provider network for all outpatient laboratory services. This means:

  • Claims for outpatient toxicology laboratory services are eligible for payment only if the service provider is affiliated with JVHL or proper authorization is obtained from JVHL for out-of-network services.
  • Claims for outpatient laboratory services must be submitted to JVHL
  • Referring providers should use JVHL network laboratories.
  • To obtain a service that is not provided by a JVHL laboratory, you must first submit a request for clinical review to JVHL.

Here's additional information you need to know regarding toxicology laboratory testing:

  • It is the responsibility of the physician who orders the toxicology laboratory services to know whether the laboratory is in network and whether the procedure is covered by BCN. This information can be verified by JVHL.
  • The procedure must be properly authorized before the service is provided and before the specimen is directed to an out-of-network laboratory.
  • A BCN member whose toxicology laboratory services are denied as out of network may not be balance-billed.

For assistance in identifying a JVHL network laboratory, call the JVHL administrative offices at 1-800-445-4979. JHVL business hours are 8 a.m. to 4:30 p.m. Monday through Friday; they are closed during the lunch hour, from noon to 1 p.m. (All times are Eastern time.) Messages can be left 24/7 and a return call will be placed during business hours.

Posted: October 2019
Line of business: Blue Care Network



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

Starting Nov. 1, 2019, some changes will occur in the process of authorizing human organ transplants for BCN HMOSM and BCN AdvantageSM members.

Here's what's staying the same:

  • You'll continue to submit these authorization requests either through the e-referral system or by calling BCN Utilization Management at 1-800-392-2512, as you do now.
  • You'll continue to fax your initial clinical information to BCN Utilization Management at 1-800-675-7278, as you do now.

Here's what’s changing:

  • Checklist for additional clinical information, if required. If additional clinical information is needed before a determination can be made on your request, you'll receive a checklist from the corporate Human Organ Transplant Program unit. In that checklist:
    • You'll see the fax number to use when submitting the additional clinical information; the number is 1-866-752-5769.
    • You'll get the phone number for the corporate Human Organ Transplant Program unit; the number is 1-800-242-3504. You'll call that number with questions or for follow up.
  • Two authorization numbers. You'll receive two authorization numbers for approved requests - one for the transplant procedure and one for the inpatient stay. (Currently, you receive only one authorization number that covers both the procedure and the stay.)
  • Where to find the authorization numbers. Once the determination is made, you'll see both authorization numbers in the e-referral system and you'll receive a letter that will show both numbers. We will fax the letter to the person who requested the authorization. (Currently, you see one number in the e-referral system and don't receive any letters.)
  • Attachment A included. For approved authorizations, the letter you receive will include the Human Organ Transplant Program Attachment A: Authorization Form. This will indicate that your claim will be reimbursed with a global rate, which includes payment for both the procedure and the inpatient stay. (Currently, you don't receive this form for BCN authorizations.)
  • Call 1-800-242-3504. You'll call the corporate Human Organ Transplant Program unit at 1-800-242-3504 with any questions or for any follow up needed after you submit the initial authorization request. This number will be included in any faxes and letters you receive. (As noted earlier, you currently call 1-800-392-2512.)
  • You must initiate reauthorization after one year. If the patient does not receive the transplant within one year of the date of the initial authorization, you must request a new authorization either through the e-referral system or by calling BCN Utilization Management at 1-800-392-2512. (Currently, the reauthorization request is handled internally by BCN.)

We're working to minimize any inconvenience to you as we make changes in how we handle the human organ transplant authorization process. If you have any questions or need after-hours assistance, contact the corporate Human Organ Transplant Program unit at 1-800-242-3504.

Posted: October 2019
Line of business: Blue Care Network



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

Effective immediately, plan notification is no longer required for endometrial ablation and excisional breast biopsy procedures for BCN HMOSM (commercial) and BCN AdvantageSM members. However, standard regional referral requirements still apply; for example, a global referral is still required where applicable.

This change applies to the following procedure codes:

  • Endometrial ablation: *58353, *58356 and *58563
  • Excisional breast biopsy: *19101, *19120, *19125 and *19126

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.

Posted: September 2019
Line of business: Blue Care Network



New webinars available in September and October for BCN

Provider Experience is continuing its series of training webinars for health care providers and staff.

September sessions focus on AIM Specialty Health.

October sessions focus on the claims and appeals process for Blue Cross Blue Shield of Michigan, Blue Care Network, Medicare Plus BlueSM and BCN AdvantageSM facility and professional claims.

See the Sept.-Oct. issue of BCN Provider News, Page 4 for dates and registration information.

Posted: September 2019
Line of business: Blue Care Network



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

Effective immediately, authorization and clinical review are not required for endometrial ablation and excisional breast biopsy procedures for BCN HMOSM (commercial) and BCN AdvantageSM members.

As a result, you no longer need to submit clinical documentation for these requests.

However, these procedures require plan notification to facilitate claims payment. Refer to the e-referral User Guide for instructions on how to submit a plan notification.

This applies to the following procedure codes:

  • Endometrial ablation: *58353, *58356 and *58563
  • Excisional breast biopsy: *19101, *19120, *19125 and *19126

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.

Posted: August 2019
Line of business: Blue Care Network



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

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will be closed on Monday, September 2 for the Labor Day holiday.

During this office closure, follow these guidelines when submitting inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

Acute initial inpatient admissions. Submit these authorization requests as well as concurrent reviews and discharge dates through the e-referral system, which is available 24 hours a day, seven days a week. If the e-referral system is not available, you can fax requests for inpatient admissions and continued stays to BCN HMO (commercial) at 1 866 313 8433 and to BCN Advantage at 1 866 526 1326.

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

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

Post-acute initial and concurrent admission reviews.

Other authorization requests. The types of requests listed below must be submitted by fax. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

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

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

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

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

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

Posted: August 2019
Line of business: Blue Care Network



Changes to BCN member transfer request form

We've made the following changes to the form you use to ask us to transfer a member to another BCN primary care physician:

  • You no longer have to enter the medical care group's name, number or region.
  • You must enter the NPI for the current primary care physician assigned to the member.
  • We added a statement that you can check the web-DENIS Member Eligibility/Coverage screen to verify that the member has an active BCN contract, to confirm that you're the primary care physician assigned to this member and to see the date you were assigned to the member.

We've also updated the description of the member transfer request process to reflect these changes.

As a reminder, you can access the process description and the form in a single document posted on BCN's Forms page within Provider Secured Services. Here's how to get to it:

  1. Visit bcbsm.com/providers.
  2. Click Login.
  3. Log in to Provider Secured Services using your user ID and password.
  4. Click BCN Provider Publications and Resources, on the right.
  5. Click Forms.
  6. Click Member Transfer FAQ and Request Form, under the "Member transfer" heading.

We recommend that when you open the form, you download it and save it to your hard drive before entering information into the fields.

Posted: August 2019
Line of business: Blue Care Network



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

You must submit authorization requests for enteral nutrition for BCN members using the e-referral system. We no longer accept these requests when you submit them by fax.

This applies to BCN HMOSM (commercial) and BCN AdvantageSM members, for procedure codes B4034, B4035, B4036, B4081, B4082, B4083, B4087, B4088, B4102, B4103, B4104, B4105, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B9002, B9998, S9341, S9342 and S9343.

Note: You must still submit authorization requests for total parenteral nutrition by fax.

Here's some additional information you need to know:

  • Enteral nutrition requests are approved for a maximum of 90 calendar days. For additional services after 90 days, you must submit a new authorization request through the e-referral system.
  • You'll need to complete the questionnaire that opens in the e-referral system. Refer to the enteral nutrition preview questionnaire, so you can prepare your answers ahead of time.
  • Refer to the e-referral User Guide for instructions on how to submit an outpatient authorization request.
  • You'll find additional resources on how to use the e-referral system on this website, on the Training Tools page.
  • You'll find a link to the enteral nutrition medical policy on BCN's Authorization Requirements & Criteria page on this website.
  • We use our medical policy and your answers to the questionnaire when making utilization management determinations for the authorization requests you submit.
  • We've revised the form you previously used to submit these requests by fax. You should now use that form only for total parenteral nutrition requests.
  • We'll update the Care Management chapter of the BCN Provider Manual in the near future to reflect these changes.

Posted: August 2019
Line of business: Blue Care Network



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

Effective immediately, authorization and clinical review are not required for transcatheter aortic valve implantation and transcatheter aortic valve replacement for BCN HMOSM (commercial) and BCN AdvantageSM members. As a result, you no longer need to submit clinical documentation for these requests.

However, TAVI/TAVR procedures require plan notification to facilitate claims payment. When you submit the plan notification, the request will pend. If the request is for the member to see a contracted provider, we will update the pended request to approved. We are in the process of updating the e-referral system so that these requests will automatically approve in the future.

Refer to the e-referral User Guide for instructions on how to submit a plan notification.

This applies to the following procedures codes, which are for TAVI/TAVR: *33361, *33362, *33363, *33364, *33365, *33366, *33367, *33368 and *33369.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.

Posted: August 2019
Line of business: Blue Care Network



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

Effective for dates of service on or after Aug. 1, 2019, Blue Care Network will implement a new utilization management program for medical oncology drugs for BCN HMO (commercial) members. Authorizations must be obtained from AIM Specialty Health for most medical oncology and supportive care medications.

Learn about the new oncology management program and how to use the AIM ProviderPortalSM by attending a webinar (intended for nonclinical provider staff). Webinar dates and registration links are available on page 26 of the July-August 2019 BCN Provider News.

For more information, see the Oncology Management Program: Frequently asked questions for providers document, which is available on this website.

Posted: July 2019
Line of business: Blue Care Network



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

Effective Oct. 1, 2019, additional medical benefit specialty drugs have authorization and site of care requirements for BCN HMOSM (commercial) members. These changes don't apply to BCN AdvantageSM members.

Prior authorization requirements

For members initiating therapy on or after Oct. 1, 2019, you must request authorization for these drugs:

  • Lemtrada® (alemtuzumab, HCPCS code J0202)
  • Ocrevus® (ocrelizumab, HCPCS code J2350)
  • Tysabri® (natalizumab, HCPCS code J2323)

Members who currently receive these drugs in one of the following locations are authorized to continue treatment through Sept. 30, 2020:

  • Doctor's or other health care provider's office
  • The member's home, from a home infusion therapy provider
  • Ambulatory infusion center
  • Hospital outpatient facility (Lemtrada and Tysabri ONLY)

However, you'll need to request authorization for these members for therapy that begins on or after Oct. 1, 2020, for these services to be eligible for reimbursement.

Site of care requirement for Ocrevus

Ocrevus will also be added to the Site of Care Program, effective Oct. 1, 2019. If your patient currently receives Ocrevus infusions at an outpatient hospital facility, you may need to discuss other infusion options.

As part of our shared commitment to keeping health care affordable for all, we hope you will join us in supporting our members as they move to new therapy locations.

List of requirements

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

We'll update the requirements list to reflect the changes for these drugs.

Blue Cross Blue Shield of Michigan and Blue Care Network reserve the right to review for medical necessity prior to the effective dates listed in this message. A prior authorization approval isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

As a reminder, you can always find information about authorization requirements for these drugs on the Medical Benefit Drugs - Pharmacy page in the BCN section of this website.

Posted: July 2019
Line of business: Blue Care Network



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

Blue Care Network continues to review and modify clinical edits. With these updates, you may notice that claims may receive different edits than they have in the past. And others that previously received edits may not receive any. We take pride in staying up-to-date on current coding standards and national coding guidelines in addition to recommendations from professional societies.

You may notice new edits related to those that review procedure codes to the reported diagnoses. Diagnosis codes should be coded appropriately and to the highest level of specificity to support the service performed. If you do not agree with the clinical edit, please follow our clinical editing appeal process.

Visit bcbsm.com/providers.

  • Log in to Provider Secured Services.
  • Click BCN Provider Publications and Resources on the right.
  • Click Billing/Claims in the left navigation.
  • Click Appealing a BCN clinical editing denial, under the Clinical Editing Resources heading.

Posted: June 2019
Line of business: Blue Care Network



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

Effective immediately, enter retrospective authorization requests for cardiology and radiology services with dates of service prior to Oct. 1, 2018, in the e-referral system for BCN HMOSM (commercial) and BCN AdvantageSM members. As a reminder, eviCore healthcare no longer handles these requests.

Until recently, the e-referral system was programmed to block these requests. We've updated the e-referral system to accept these requests, so you no longer need to call BCN Utilization Management.

As a reminder, AIM Specialty Health manages cardiology and radiology authorizations for BCN HMO (commercial) and BCN Advantage members with dates of service on or after Oct. 1, 2018.

Posted: June 2019
Line of business: Blue Care Network



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

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will be closed on Thursday, July 4 and Friday, July 5 for the Independence Day holiday.

During this office closure, follow these guidelines when submitting inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

Acute initial inpatient admissions. Submit these authorization requests as well as concurrent reviews and discharge dates through the e-referral system, which is available 24 hours a day, seven days a week. If the e-referral system is not available, you can fax requests for inpatient admissions and continued stays to BCN HMO (commercial) at 1 866 313 8433 and to BCN Advantage at 1 866 526 1326.

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

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

Post-acute initial and concurrent admission reviews.

Other authorization requests. The types of requests listed below must be submitted by fax. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

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

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

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

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

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

Posted: June 2019
Line of business: Blue Care Network

Important information about eviCore healthcare therapy authorization requests for BCN

Here's some important information about submitting authorization requests to eviCore healthcare for outpatient physical, occupational and speech therapy and for physical medicine services by chiropractors for BCN HMOSM and BCN AdvantageSM members.

Reminder: Authorization no longer required for initial evaluations for therapies

As of May 27, 2019, initial evaluations for physical, occupational and speech therapy and for physical medicine services by chiropractors no longer require authorization. After completing an initial evaluation, please submit the authorization request for treatment visits to eviCore.

eviCore will void all authorization requests for initial evaluations. These requests will appear in the eviCore system with a status of Y.

For therapists who are affiliated with a group

When submitting authorization requests for physical, occupational and speech therapy, therapists who are affiliated with groups should use their group's NPI as the servicing site. This will enable eviCore to apply the correct category (A, B or C) to the request.

Additional information

You can get additional information in the Outpatient rehabilitation services: Frequently asked questions document, which we've posted on the Outpatient PT, OT, ST webpage in the BCN section of this website.

Posted: June 2019
Line of business: Blue Care Network

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

Blue Care Network will soon begin covering additional medical services for University of Michigan employees who are transgender. This applies to members covered by U-M Premier Care and GradCare plans.

You can identify the BCN members who are eligible for these services by their group number, which is 00124316. The number is on the front of member's University of Michigan-branded ID cards. As always, be sure to check web-DENIS for benefits and eligibility.

Gender-affirming services

The following additional gender-affirming services for University of Michigan members transitioning from male to female will be covered starting July 1, 2019:

  • Face and neck hair removal
  • Facial feminization surgery
  • Chondrolaryngoplasty (Adam's apple reduction)

Services are eligible for coverage if they meet medical necessity criteria and if members use in-network providers. Michigan Medicine, formerly the University of Michigan Health System, is the only provider in our network that currently performs the facial feminization surgical services.

There's a $30,000 lifetime limit per member for these new gender-affirming services.

Submitting authorization requests

These new services require authorization. Starting June 12, 2019, use the e-referral system to submit authorization requests.

Starting June 23, one of the following questionnaires will open in the e-referral system when you submit these authorization requests:

  • Face and neck hair removal
  • Facial feminization surgery/chondrolaryngoplasty

Preview questionnaires will be available on this website soon. Look for them on BCN's Authorization Requirements & Criteria page. We encourage you to use these preview questionnaires to prepare in advance your answers to the questionnaires you'll see in the e-referral system.

Additional information

For more details, see the University of Michigan fact sheet on health plan coverage for gender-affirming services.*

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

Posted: June 2019
Line of business: Blue Care Network

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

Beginning Aug. 1, 2019, Blue Care Network will implement a new utilization management program for medical oncology for BCN commercial members. Authorizations must be obtained from AIM Specialty Health for some medical oncology and supportive care medications.

Learn about the new oncology management program and how to use the AIM ProviderPortalSM by attending a webinar (intended for non-clinical provider staff). Webinar dates and registration links are available on Page 26 of the May-June 2019 BCN Provider News. More information will be available on Page 26 of the July-August 2019 BCN Provider News published on June 26.

Posted: June 2019
Line of business: Blue Care Network

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

Need help submitting authorization requests or finding cases in the eviCore healthcare provider portal? Contact eviCore's Client & Provider Services department to get help.

How to contact eviCore's Client & Provider Services department

Email clientservices@eviCore.com to get eviCore's assistance with authorization requests for outpatient physical, occupational and speech therapy and physical medicine services by chiropractors for BCN HMOSM or BCN AdvantageSM members. For urgent cases, call eviCore at 1-800-646-6418; select option 4.

When you send an email, you'll get a response that includes a ticket number. An eviCore representative will research your request and reach out to help you navigate the system and find what you need.

Additional information

As a reminder, on May 27, 2019, eviCore healthcare started managing all authorization requests for outpatient PT, OT and ST by therapists and physical medicine services by chiropractors for BCN HMO and BCN Advantage members. This includes requests for both initial and follow-up services.

You can get additional information in the Outpatient rehabilitation services: Frequently asked questions document, which we've posted on the PT, OT, ST webpage in the BCN section of this website.

Posted: June 2019
Line of business: Blue Care Network

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

Here's some information you need to know about submitting requests to eviCore healthcare for physical, occupational and speech therapy and physical medicine services by chiropractors:

  • BCN no longer requires authorization for initial evaluations.
  • The initial evaluation should be completed before you request authorization for treatment. If you submit the request before the evaluation, you may not be able to complete all of the required questions in the pathway, which could result in your request being pended.

Who should submit the authorization request

We recommend that the practitioner who will perform the therapy or physical medicine treatment services submit the request to authorize treatment. This is because it is that practitioner who is most familiar with the patient's condition and who can most readily answer the questions posed within the eviCore provider portal.

Additional information

Refer to the document Outpatient rehabilitation services: Frequently asked questions for additional information.

We're also updating the information in the Care Management chapter of the BCN Provider Manual to reflect the recent changes in how eviCore accepts authorization requests starting May 27, 2019.

Posted: June 2019
Line of business: Blue Care Network

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

As a reminder, starting May 27, 2019, eviCore healthcare will manage all authorization requests for outpatient physical, occupational and speech therapy by therapists and physical medicine services by chiropractors.

This applies to BCN HMOSM (commercial) and BCN AdvantageSM members and includes requests for both initial and follow-up services.

The information you need to know is here:

Posted: May 2019
Line of business: Blue Care Network

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

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will close on Monday, May 27, 2019, for the Memorial Day holiday.

During this office closure, BCN's inpatient utilization management area will still accept inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

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

Acute initial inpatient admissions. Submit these authorization requests as well as concurrent reviews and discharge dates through the e-referral system, which is available 24 hours a day, seven days a week. If the e-referral system is not available, you can fax requests for inpatient admissions and continued stays to BCN HMO (commercial) at 1 866 313 8433 and to BCN Advantage at 1 866 526 1326

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

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

Other authorization requests. The types of requests listed below must be submitted by fax. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

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

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

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

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

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

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

Posted: May 2019
Line of business: Blue Care Network

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

Starting June 23, 2019, questionnaires will open in the e-referral system for BCN authorization requests for the procedures listed below, which already require authorization. The questionnaires will open for both BCN HMOSM (commercial) and BCN AdvantageSM requests unless otherwise noted.

Service Age Procedure codes
Artificial heart, total Adult and pediatric *0051T, *0052T, *0053T, *33927, *33928, *33929, *33992 and *33993
Bariatric surgery (for BCN Advantage) Adult *43644, *43645, *43659, *43770, *43771, *43772, *43773, *43774, *43775, *43842, *43843, *43845, *43846, *43847, *43848, *43886, *43887, *43888 and *44130
Biofeedback, non-behavioral health (for BCN Advantage) Adult *90901 and *90911 (for select diagnoses)
Biofeedback, non-behavioral health (for BCN HMO) Adult and pediatric *90901 and *90911 (for select diagnoses)
Breast implant management Adult *19325, *19328 and *19330
Breast reconstruction Adult *11920, *11921, *11922, *19316, *19324, *19340, *19342, *19350, *19355, *19357, *19361, *19364, *19366, *19367, *19368, *19369, *19370, *19380, *19396, S2066, S2067 and S2068
Breast reduction, adolescent Pediatric *19318
Breast reduction, adult Adult *19318
Chemical peels Adult and pediatric *15788, *15789, *15792 and *17362
Cosmetic or reconstructive surgery Adult and pediatric *0479T, *0480T, *0491T, *0492T, *11950, *11951, *11952, *11954, *15775, 15776, *15780, *15781, *15782, *15783, *15786, *15787, *15820, *15821, *15824, *15825, *15826, *15828, *15829, *15876, *15877, *15878, *15879, *17340, *17380, *21083, *21087, *21172, *21275, *21280, *21282, *30620, *36468, *36469, *54660, *56620, *67909, *67911, G0429, Q2026, Q4100 and S0800
Dental anesthesia or repair of trauma to natural teeth Adult and pediatric *00170 and *41899
Enteral nutrition Adult and pediatric B4034, B4035, B4036, B4081, B4082, B4083, B4087, B4088, B4102, B4103, B4104, B4105, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B9002, B9998, S9341, S9342 and S9343
Excess skin removal Adult *15832, *15833, *15834, *15835, *15836, *15837, *15838 and *15839
Mastectomy for gynecomastia Adult *19300
Oral surgery Adult and pediatric *40525, *40527, *40700, *40701, *40702, *40720, *40761, *40808, *40810, *40812, *40816, *40818, *40840, *40842, *40843, *40844, *40845, *40899, *41800, *41805, *41806, *41820, *41821, *41822, *41823, *41825, *41826, *41827, *41828, *41830, *41850, *41870, *41872, *41874, *42200, *42210, *42215, *42220 and *42225
Orthognathic surgery Adult and pediatric *21085, *21120, *21121, *21122, *21123, *21125, *21127, *21141, *21142, *21143, *21144, *21145, *21146, *21147, *21150, *21151, *21154, *21155, *21159, *21160, *21188, *21193, *21194, *21195, *21196, *21198, *21199, *21206, *21208, *21209, *21210, *21215, *21230, *21235, *21244, *21245, *21246, *21247, *21255, *21270, *21295 and *21296
Prostatic urethral lift Adult *52441 and *52442
Spine surgery, minimally invasive Adult G0276
Temporomandibular joint surgery Adult and pediatric *20605, *20606, *21010, *21050, *21060, *21070, *21240, *21242, *21243, *21490 and *29804

Preview questionnaires will be available online

We'll make preview questionnaires available on this website before June 23. To find them, click BCN, then click Authorization Requirements & Criteria. Next, look in the "Authorization criteria and preview questionnaires" section.

The preview questionnaires will show what questions you'll need to answer in the actual questionnaire that opens in the e-referral system for each service. Once you know what questions you'll need to answer, you can prepare your answers ahead of time. This can cut down on the time it takes to submit the authorization request.

Medical policies will be available online

We'll also post links to the medical policies related to these procedures on the Authorization Requirements & Criteria page.

We use our medical policies and your answers to the questionnaires when making utilization management determinations for the authorization requests you submit.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.

Posted: May 2019
Line of business: Blue Care Network

AIM requires post-service authorization requests for certain BCN cardiology procedures

For the outpatient cardiology procedures listed here, you must submit authorization requests to AIM Specialty Health® after, not before, the service is completed. This applies to requests for BCN HMOSM and BCN AdvantageSM members.

  • *92920
  • *92924
  • *92928
  • *92933
  • *92937
  • *92943
  • *93925
  • *93926
  • *93930
  • *93931

Reason for the requirement

AIM requires post-service requests for these procedures to validate the clinical appropriateness of the service. Some of the clinical information obtained while performing the procedure is required as part of the review. If you submit an authorization request prior to the procedure, your request will not be processed or may be denied.

For BCN HMO and BCN Advantage members, the requirement was effective on Oct. 1, 2018, when AIM began managing select cardiology services for BCN.

When to resubmit

If you tried but were not able to complete a post-service authorization request for a BCN member since October 1, please try submitting it again. (If you successfully submitted a post-service request that resulted in a denial, do not resubmit the request.)

Additional information

We've updated the list of procedures that require authorization by AIM Specialty Health for BCN HMO (commercial) and BCN Advantage members to reflect the requirement for post-service requests for these procedures.

As a reminder, the same requirement applies to some of these codes for Medicare Plus BlueSM PPO members. For more details, refer to the web-DENIS message on this topic posted April 2, 2019.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.

Posted: May 2019
Line of business: Blue Care Network

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

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will close on Friday, April 19, 2019, for their corporate Good Friday holiday.

During this office closure, BCN's inpatient utilization management area will still accept inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

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

Acute initial inpatient admissions. Submit these authorization requests as well as concurrent reviews and discharge dates through the e-referral system, which is available 24 hours a day, seven days a week.

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

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

Other authorization requests. The types of requests listed below must be submitted by fax. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

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

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

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

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

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

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

Posted: April 2019
Line of business: Blue Care Network

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

Call BCN Utilization Management at 1-800-392-2512 for retrospective authorization requests for cardiology and radiology services with dates of service prior to Oct. 1, 2018. This applies to requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

eviCore healthcare no longer handles these requests.

The e-referral system is currently programmed to block these requests. If you submit one of these requests to the e-referral system, you'll see a message directing you to submit it to eviCore. This message is incorrect. You should ignore the message and call the request in to BCN.

We're working on updating the e-referral system to accept these requests. We anticipate you'll be able to use e-referral system for these requests in May. We'll notify you when that occurs.

We apologize for any difficulties you've encountered when trying to submit these requests recently.

As a reminder, AIM Specialty Health manages cardiology and radiology authorizations for BCN HMO (commercial) and BCN Advantage members with dates of service on or after Oct. 1, 2018.

Posted: April 2019
Line of business: Blue Care Network

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

Starting June 1, 2019, BCN Advantage will audit claims for members admitted to skilled nursing facilities. In the audit, we'll review the RUG codes to ensure that the codes submitted on the claim and the associated reimbursement amounts are appropriate and reflect the approved RUG levels provided when authorization determination was made for the member's stay.

RUG codes represent the Resource Utilization Groups that the Centers for Medicare & Medicaid Services uses to determine reimbursement for SNF stays.

RUG codes for Medicare Plus BlueSM PPO members in SNFs have been audited for some time. The change is that the auditing process will also be applied to claims for BCN Advantage members in SNFs.

For SNF admissions, naviHealth will authorize RUG levels during the course of the patient's stay, from preservice through discharge. naviHealth will work with SNFs to ensure the provider submits the appropriate RUG level for reimbursement. When you submit claims for Blue Cross Medicare Advantage members admitted to a SNF, make sure the RUG code you use is appropriate for the authorization connected to the stay.

As a reminder, naviHealth will manage authorization requests for Medicare Plus BlueSM PPO and BCN AdvantageSM members admitted to post-acute care on or after June 1, 2019.

Posted: April 2019
Line of business: Blue Care Network

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

Starting May 27, 2019, eviCore healthcare will manage all authorization requests for outpatient physical, occupational and speech therapy by therapists and physical medicine services by chiropractors. This applies to BCN HMOSM (commercial) and BCN AdvantageSM members and includes requests for both initial and follow-up services.

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

Look for training information and more details on these changes in the May-June 2019 issue of BCN Provider News. We'll also post additional web-DENIS messages and news items on this website.

Additional information is available in past newsletter articles:

Posted: March 2019
Line of business: Blue Care Network

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

The behavioral health components of an evaluation done by an approved autism evaluation center do not require authorization for BCN HMOSM (commercial) members. This applies to intake services covered by procedure codes *90791 and *90792.

We're updating the Behavioral Health chapter of the BCN Provider Manual with this information. The revised chapter will be available by the end of April.

Providers who have recently tried to submit an authorization request into the e-referral system for services associated with those codes have received an error message indicating that those services no longer require authorization.

The updated chapter will show the following:

  • For the behavioral health components of the evaluation, authorization is not required.
  • For the medical components of the evaluation, the AAEC needs to identify the medical specialists who will be evaluating the child so that the child's primary care physician can submit a referral for each specialist. A referral from the primary care physician is required for each medical specialist who will see the child during the evaluation process.
  • The results of the multidisciplinary evaluation must be reported on the AAEC Evaluation Results Form. Follow the instructions on the form for faxing it to BCN.

Note: AAECs should submit a claim for the evaluation of each member using procedure codes *99367 and T1023.

This does not apply to members with BCN AdvantageSM, as those members generally don't have an autism benefit.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.

Posted: March 2019
Line of business: Blue Care Network

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

To obtain the review criteria used to make a determination on a specific authorization request for a BCN HMOSM (commercial) or BCN AdvantageSM member, complete the BCN Criteria Request Form (for non-behavioral health cases) and fax it to 1-866-373-9468.

This applies to non-behavioral health authorization requests only.

You can access the BCN Criteria Request Form on this website:

  1. Click BCN.
  2. Click Authorization Requirements & Criteria.
  3. Look under the "Referral and authorization information" heading.

Previously, you called BCN's Utilization Management department to request the criteria. Now you use the form to submit the request. The BCN Provider Manual has been updated to reflect the change.

Posted: March 2019
Line of business: Blue Care Network

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

We're making additional changes to the process of asking for a peer-to-peer review of a denied authorization of a non-behavioral health service for BCN HMOSM (commercial) or BCN AdvantageSM members.

The request for a peer-to-peer review:

  • Must be submitted within the time frame available for filing an appeal for that determination. Once the appeal time frame has expired, you can no longer request a peer-to-peer review.
  • Cannot be submitted if a provider appeal of that denial has already been submitted
  • May be submitted only for denials based on medical necessity
  • Cannot be submitted for a denial of a member's appeal or grievance

We have outlined these requirements - and additional information about them - in Section 1 of the document How to request a peer-to-peer review with a BCN medical director.

These requirements apply to authorization requests for both inpatient and outpatient services. They are in addition to the change we communicated in December 2018, which was that you must use the Physician peer-to-peer request form (for non-behavioral health cases) to submit the peer-to-peer review request.

You can access both documents - the description of the process for submitting a peer-to-peer review request and the form - on this website by completing the following steps:

  1. Click BCN.
  2. Click Authorization Requirements & Criteria.
  3. Look under the "Referral and authorization information" heading.

Posted: March 2019
Line of business: Blue Care Network

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

Starting May 1, 2019, Blue Care Network prefers the infliximab product, Inflectra (infliximab-dyyb), for its adult BCN HMOSM (commercial) members. This change doesn't apply to:

  • Members covered by any other line of business, including BCN AdvantageSM and Blue Cross PPO (commercial) members
  • Pediatric members 15 years old or younger
  • Pediatric members 18 years old or younger weighing 50 kg or less

Please refer to the current medical policy for all criteria, and begin taking steps to:

  • Transition adult members with active authorizations for non-Inflectra infliximab products to Inflectra by May 1, 2019.
  • Prescribe or fill Inflectra when possible instead of Remicade® (infliximab), HCPCS code J1745, or Renflexis® (infliximab-abda), HCPCS code Q5104.
  • Bill Inflectra with HCPCS code Q5103.

Quick links to helpful resources:

Posted: February 2019
Line of business: Blue Care Network

Clarifying biofeedback and neurofeedback authorization requirements for BCN members

When submitting authorization requests for biofeedback and neurofeedback for BCN HMOSM (commercial) and BCN AdvantageSM members, there are things you have to do differently for each. Here's what you need to know.

Biofeedback is covered, when authorized, for specific medical diagnoses and not for behavioral health diagnoses.

  • When you submit your initial request to authorize biofeedback, you must attach all the required clinical documentation to the case in the e-referral system.
  • BCN's Utilization Management staff, not the Behavioral Health staff, make the determination on the request.

In the future, you'll also need to complete a questionnaire for biofeedback in the e-referral system. Look for more information about that in upcoming web-DENIS messages and articles in BCN Provider News.

Neurofeedback is covered, when authorized, for specific behavioral health diagnoses only.

  • Neurofeedback requires an independent evaluation (psychological or neuropsychological testing) confirming that the member has a diagnosis of attention deficit hyperactivity disorder or attention deficit disorder. This must be completed by someone other than the neurofeedback provider.
  • When you submit your initial request to authorize neurofeedback, you must attach the report from the independent evaluation to the case in the e-referral system, along with any additional clinical documentation required.
  • BCN's Behavioral Health staff, not the Utilization Management staff, make the determination on the request.
  • When you submit requests to authorize additional neurofeedback visits, you must complete the questionnaire that opens in the e-referral system.

Instructions for attaching a document from the member's medical record are outlined in the article How to attach clinical information to your authorization request in the e-referral system, in the November-December 2016 BCN Provider News, on page 44. These instructions are also in:

The Care Management and Behavioral Health chapters of the BCN Provider Manual will be updated with these clarifications.

Posted: February 2019
Line of business: Blue Care Network

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

The otoplasty and rhinoplasty questionnaires will open in the e-referral system starting Feb. 10, 2019, for BCN HMOSM and BCN AdvantageSM authorization requests.

These questionnaires were originally intended to open starting Jan. 27, as we communicated in a web-DENIS message in late January, but they've been delayed.

As a reminder, you must complete the questionnaire when submitting a request to authorize these outpatient procedures, which are associated with the following procedure codes:

  • Otoplasty (procedure code *69300)
  • Rhinoplasty (procedure codes *30400, *30410, *30420, *30430, *30435, *30450, *30460 and *30462)

We've made preview questionnaires available on this website. To find them, click BCN, then click Authorization Requirements & Criteria. Look in the "Authorization criteria and preview questionnaires" section.

You can look over the preview questionnaire to see what questions you'll need to answer. Preparing your answers ahead of time can reduce the time it takes to submit the authorization request.

We've also posted links to the medical policies and authorization criteria related to these procedures on the Authorization Requirements & Criteria page.

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

* CPT codes, descriptions and two-digit modifiers only are copyright 2018 American Medical Association. All rights reserved.

Posted: February 2019
Line of business: Blue Care Network

Complete the new questionnaires in e-referral for BCN members

On Jan. 27, 2019, questionnaires will open for BCN authorization requests in the e-referral system for the following outpatient procedures:

  • Abdominoplasty (procedure codes *15830 and *15847)
  • Otoplasty (procedure code *69300)
  • Rhinoplasty (procedure codes *30400, *30410, *30420, *30430, *30435, *30450, *30460 and *30462)

In addition, updated or new questionnaires for the following services began opening for BCN authorization requests in the e-referral system on Nov. 25, 2018:

  • Arthroscopy, knee, diagnostic (procedure code *29870)
  • Arthroscopy, knee (surgical) for chondroplasty (procedure codes *29877, *29879 and G0289)
  • Arthroscopy, knee (surgical) for removal of loose body or foreign body (procedure code *29874)
  • Arthroscopy, knee (surgical) for removal or stabilization of intra-articular osteochondral lesion (procedure codes *29885, *29886 and *29887)
  • Arthroscopy, knee, synovectomy, limited (procedure code *29875)

You must complete the questionnaire when submitting a request to authorize these procedures for the following members:

  • BCN HMOSM (commercial)
  • BCN AdvantageSM

We've made preview questionnaires available on this website, on the BCN Authorization Requirements & Criteria page. Look in the "Authorization criteria and preview questionnaires" section.

You can look over the preview questionnaire for a specific procedure to see what questions you'll need to answer in the actual questionnaire that opens in the e-referral system for that service. Once you know what questions you'll need to answer, you can prepare your answers ahead of time. This can cut down on the time it takes to submit the authorization request.

We've also posted links to the medical policies and authorization criteria related to these procedures on the Authorization Requirements & Criteria page.

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

Posted: January 2019
Line of business: Blue Care Network

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

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will close on Monday, Jan. 21, 2019, for Martin Luther King, Jr., Day.

During this office closure, BCN's inpatient utilization management area will still accept inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

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

Acute initial inpatient admissions. Submit these authorization requests as well as concurrent reviews and discharge dates through the e-referral system, which is available 24 hours a day, seven days a week.

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

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

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

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

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

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

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

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

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

Posted: January 2019
Line of business: Blue Care Network



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

As a reminder, Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will be closed on these days:

  • Tuesday, Dec. 24 and Wednesday, Dec. 25, for the Christmas holidays
  • Tuesday, Dec. 31 and Wednesday, Jan. 1, for the New Year’s holidays

During these office closures, follow the guidelines outlined below when submitting inpatient authorization requests for Blue Cross' PPO (commercial) and Medicare Plus BlueSM PPO members.

Type of service Blue Cross' PPO (commercial) requests Medicare Plus Blue requests
Acute initial inpatient admissions

Submit requests 24/7 through the e-referral system.

If the e-referral system isn't available:

  • For Blue Cross' PPO requests, fax to 1-800-482-1713 or call 1-877-399-1673.
  • For Medicare Plus Blue requests, fax to 1-866-464-8223 or call 1-866 807 4811.

Or, you can submit requests through the X12N 278 Health Care Services Review - Request for Review and Response electronic standard transaction.

Post-acute initial and concurrent admission reviews

Follow the current process:

  • For UAW retiree contracts, fax requests to 1-866-915-9811.
  • For other members, fax requests to 1-866-411-2573.
Submit requests to naviHealth. Refer to the document Post-acute care services: Frequently asked questions for providers.
Other inpatient services

Fax the following types of requests to 1-800-482-1713:

  • Authorization requests for sick or ill newborns
  • Federal Employee Program members with contract eligibility issues
  • Ineligible members or members with no contract
Not applicable
On-call line and for urgent inpatient requests only Call 1-800-851-3904.

You can find additional resources on this website.

Posted: December 2019
Line of business: Blue Cross Blue Shield of Michigan



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

Beginning Jan. 1, 2020, Blue Cross Blue Shield of Michigan is adding site of care requirements for two medical drugs for Blue Cross' PPO members. The following two medical drugs and HCPCS codes are subject to this requirement:

  • Evenity® (romosozumab-aqqg; HCPCS code J3111)
  • Ultomiris® (ravilizumab-cwvz; HCPCS code J1303)

Infusions for these drugs won't be covered at hospital outpatient facilities without prior authorization for an approved location, starting Jan 1. An approved authorization will be payable for any of these professional locations:

  • A doctor's office or other health care provider's office
  • Ambulatory infusion center
  • Your patient's home, with treatment from a home infusion therapy provider

These site of care requirements are already in place for BCN HMOSM members.

This communication doesn't apply to members covered by BCN AdvantageSM, Medicare Plus BlueSM PPO or the Federal Employee Program®.

The authorization requirement applies only to groups that are currently participating in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit.

If providers don't submit the appropriate prior approval requests and receive approval for the outpatient hospital site of care, members will be responsible for the full cost of the medicine.

Tell members to contact any of the infusion therapy providers listed on their member letter. (We're also sending this information to members.) The infusion therapy providers will work with you and with members to make the change easy.

Posted: November 2019
Line of business: Blue Cross Blue Shield of Michigan



Provider appeal time frame extended for Blue Cross' PPO

You now have up to 45 days to submit appeals of denied authorization requests related to admissions of Blue Cross' PPO (commercial) members.

This applies to admissions for:

  • All members with a Blue Cross' PPO contract
  • Care in acute inpatient settings, skilled nursing facilities, long-term acute care hospitals and inpatient rehabilitation settings

You must submit the appeal within 45 days of the date that the initial request was denied.

Changing the appeal submission deadline from 30 to 45 days brings the Blue Cross' PPO appeal deadline requirements into alignment with requirements for other Blue Cross and Blue Care Network products. The Blue Cross' PPO provider manuals will be updated to reflect this change.

We've extended the Blue Cross' PPO time frame to 45 days to accommodate the increased number of requests for peer-to-peer reviews and the time it's taking to schedule those reviews. As a reminder, peer-to-peer review requests must be submitted within 14 days of the denial and prior to an appeal.

For additional information on submitting a request for a peer-to-peer review, refer to the document How to request a peer-to-peer review with a Blue Cross or BCN medical director, which we recently updated.

Posted: November 2019
Line of business: Blue Cross Blue Shield of Michigan



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

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will be closed on these days:

  • Thursday, Nov. 28 and Friday, Nov. 29, for the Thanksgiving holidays
  • Tuesday, Dec. 24 and Wednesday, Dec. 25, for the Christmas holidays
  • Tuesday, Dec. 31 and Wednesday, Jan. 1, for the New Year’s holidays

During these office closures, follow the guidelines outlined below when submitting inpatient authorization requests for Blue Cross' PPO (commercial) and Medicare Plus BlueSM PPO members.

Type of service Blue Cross' PPO (commercial) requests Medicare Plus Blue requests
Acute initial inpatient admissions

Submit requests 24/7 through the e-referral system.

If the e-referral system isn't available:

  • For Blue Cross' PPO requests, fax to 1-800-482-1713 or call 1-877-399-1673.
  • For Medicare Plus Blue requests, fax to 1-866-464-8223 or call 1-866 807 4811.

Or, you can submit requests through the X12N 278 Health Care Services Review - Request for Review and Response electronic standard transaction.

Post-acute initial and concurrent admission reviews

Follow the current process:

  • For UAW retiree contracts, fax requests to 1-866-915-9811.
  • For other members, fax requests to 1-866-411-2573.
Submit requests to naviHealth. Refer to the document Post-acute care services: Frequently asked questions for providers.
Other inpatient services

Fax the following types of requests to 1-800-482-1713:

  • Authorization requests for sick or ill newborns
  • Federal Employee Program members with contract eligibility issues
  • Ineligible members or members with no contract
Not applicable
On-call line and for urgent inpatient requests only Call 1-800-851-3904.

You can find additional resources on this website.

Posted: November 2019
Line of business: Blue Cross Blue Shield of Michigan

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

For dates of service on or after Jan. 1, 2020, Blue Cross Blue Shield of Michigan will add all outpatient sites of care to the Medicare Plus Blue Specialty Medication Prior Authorization Program. This means you'll need to obtain authorization for specialty medications administered in outpatient sites of care, such as a member's home or an outpatient facility.

This change doesn't affect inpatient sites of care.

You can find a complete list of drugs that require authorization in the Medicare Advantage PPO medical drug policies and forms page of the bcbsm.com website. To open this page:

  1. Go to bcbsm.com/providers.
  2. Click Help and then click Frequently Asked Questions.
  3. Click Toolkits.
  4. Click the Learn more link in the "Provider toolkit" section.
  5. Scroll to the "Coverage details" section.
  6. Click Medicare Advantage PPO medical drug policies and forms.

How to bill

For Medicare Plus Blue, you should bill specialty medications that require authorization in the following manner:

  • Electronically through an 837P transaction or on a professional CMS-1500 claim form
  • or

  • Electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x

Important reminder

You must obtain an authorization before administering any medication that requires authorization. Use the NovoLogix® online tool to quickly submit your authorization requests. It offers real-time status checks and immediate approvals for certain medications.

If you have a Type 1 (individual) NPI and you checked the "Medical Drug PA" box when you completed the Provider Secured Services Application form, you already have access to NovoLogix. If you didn't check that box, you can complete an Addendum P form to request access to NovoLogix and fax it to the number on the form.

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

Posted: September 2019
Line of business: Blue Cross Blue Shield of Michigan

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

Effective Jan.1, 2020, you'll have to obtain authorization before Blue Cross' PPO (commercial) members begin receiving the following drugs:

  • Eylea (aflibercept, HCPCS code J0178)
  • Lucentis (ranibizumab, HCPCS code J2778)

The authorization requirement applies to all Blue Cross' PPO members who start receiving these therapies on or after Jan. 1. This requirement applies only to groups that currently participate in the commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit.

To facilitate continuity of care, members who start therapy before Jan. 1 won't be required to obtain authorization to continue therapy.

Note: These drugs currently require authorization for BCN HMOSM (commercial), BCN AdvantageSM and Medicare Plus BlueSM PPO members.

This requirement doesn't apply to Blue Cross' PPO members covered under the Federal Employee Program® Service Benefit Plan.

Authorization isn't a guarantee of payment. Health care providers 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 in the Medical Benefit Drugs - Pharmacy section of this website.

The authorization requirement for Eylea and Lucentis will be reflected in the requirements list on Jan. 1, 2020.

Posted: September 2019
Line of business: Blue Cross Blue Shield of Michigan

New webinars available in September and October for Blue Cross

Provider Experience is continuing its series of training webinars for health care providers and staff.

September sessions focus on AIM Specialty Health.

October sessions focus on the claims and appeals process for Blue Cross Blue Shield of Michigan, Blue Care Network, Medicare Plus BlueSM and BCN AdvantageSM facility and professional claims

See the September Record for dates and registration information.

Posted: September 2019
Line of business: Blue Cross Blue Shield of Michigan

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

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will be closed on Monday, September 2 for the Labor Day holiday.

During this office closure, follow these guidelines when submitting inpatient authorization requests for Blue Cross' PPO (commercial) and Medicare Plus BlueSM PPO members.

Type of service Blue Cross' PPO (commercial) requests Medicare Plus Blue PPO requests
Acute initial inpatient admissions

Submit requests 24/7 through the e-referral system.

If the e-referral system isn't available:

  • For Blue Cross' PPO requests, fax to 1-800-482-1713 or call 1-877-399-1673.
  • For Medicare Plus Blue requests, fax to 1-866-464-8223 or call 1-866 807 4811.

Or, you can submit requests through the X12N 278 Health Care Services Review - Request for Review and Response electronic standard transaction.

Post-acute initial and concurrent admission reviews
  • Follow the current process.
  • Fax requests to 1-866-411-2573.
  • For UAW retiree contracts, fax requests to 1-866-915-9811.
Other inpatient services

Fax the following types of requests to 1-800-482-1713:

  • Authorization requests for sick or ill newborns
  • Federal Employee Program members with contract eligibility issues
  • Ineligible members or members with no contract
Not applicable
Urgent inpatient requests only Call the Blue Cross after-hours urgent hotline at 313-448-3619.

You can find additional resources on this website.

Posted: August 2019
Line of business: Blue Cross Blue Shield of Michigan

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

Blue Cross Blue Shield of Michigan and Blue Care Network use the web-DENIS message platform to communicate information to providers. The intent of these messages is to provide timely communication on an easy-to-access platform, giving both insight and transparency to our initiatives and programs.

Each web-DENIS message includes a "Start date" and an "End date" to let readers know when each message was posted and how long it will be available. These dates don't pertain to or relate to the information in the message. For example, the dates do not relate to initiative start dates.

On July 30, 2019, we posted a web-DENIS message titled "Effective November 1, Inflectra® is the preferred infliximab product for adult Blue Cross' PPO commercial members." The message had a start date of July 30, because that's the date on which we posted it. To avoid any confusion regarding the start date of the message and the start date of the Inflectra initiative, we promptly removed the message and we're working to optimize our web-DENIS messages to ensure clarity and maximize understanding.

You can find information related to our infliximab strategy for adult Blue Cross' PPO (commercial) members on this website. Look for the news item titled "Effective November 1, Inflectra® is the preferred infliximab product for adult Blue Cross' PPO (commercial) members" under the July 2019 heading.

Please note that, on August 8, we also revised and re-posted the original web-DENIS message titled "Effective November 1, Inflectra® is the preferred infliximab product for adult Blue Cross' PPO (commercial) members" regarding the Inflectra initiative.

Posted: August 2019
Line of business: Blue Cross Blue Shield of Michigan

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

Please note that this message replaces the previous message we posted on July 30 and then promptly removed. Please refer to the web-DENIS message titled "Clarification: Preferred infliximab strategy for adult Blue Cross' PPO (commercial) members" that we posted on August 8 regarding the updates to this article.

Starting Nov. 1, 2019, Inflectra (infliximab-dyyb; HCPCS Code Q5103) will be the preferred infliximab product for its adult Blue Cross' PPO (commercial) members.

Action required

As of Nov. 1, 2019, adult Blue Cross' PPO (commercial) members with an active authorization for an infliximab product other than Inflectra must transition to Inflectra.

The infliximab products other than Inflectra are:

  • Remicade® (infliximab) - HCPCS code J1745
  • Renflexis® (infliximab-abda) - HCPCS code Q5104

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.

This change doesn't apply to:

  • Blue Cross' pediatric members 15 years old or younger
  • Blue Cross' pediatric members 18 years old or younger weighing 50 kg or less
  • Any member covered by Medicare Plus BlueSM PPO, BCN AdvantageSM or the Federal Employee Program®.

Note: This change took effect for BCN HMOSM (commercial) members on May 1, 2019.

Quick links to helpful resources

Note: The Inflectra change will be reflected in the requirements list on November 1.

Posted: July 2019
Line of business: Blue Cross Blue Shield of Michigan

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

Starting Oct. 1, 2019, the Medical Drug Prior Authorization and Site of Care programs are expanding for Blue Cross commercial members. These changes don't apply to Medicare Plus Blue PPOSM or Federal Employee Program® members.

Prior authorization requirements

For members initiating therapy on or after Oct. 1, 2019, you must request authorization for these drugs:

  • Lemtrada® (alemtuzumab, HCPCS code J0202)
  • Ocrevus® (ocrelizumab, HCPCS code J2350)
  • Tysabri® (natalizumab, HCPCS code J2323)

Ocrevus will also be added to the Site of Care Program, effective Oct. 1, 2019. We'll publish more information on this subject in the August issue of The Record.

More about 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.

A prior authorization approval isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please click here.

You can also visit the Drugs Covered Under the Medical Benefit page on this website.

The requirements that take effect on Oct. 1 will be reflected in the requirements list before that date.

Posted: July 2019
Line of business: Blue Cross Blue Shield of Michigan

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

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will be closed on Thursday, July 4 and Friday, July 5 for the Independence Day holiday.

During this office closure, follow these guidelines when submitting inpatient authorization requests for Blue Cross PPO (commercial) and Medicare Plus BlueSM PPO members.

Type of request Blue Cross PPO (commercial) Medicare Plus Blue PPO
Acute initial inpatient admissions Submit requests 24/7 through the e-referral system.

If the e-referral system isn't available, fax Blue Cross PPO requests to 1-800-482-1713 or call them in to 1-877-399-1673. For Medicare Plus Blue requests, fax to 1-866-464-8223 or call 1-866 807 4811.

Or, you can submit requests through the X12N 278 Health Care Services Review - Request for Review and Response electronic standard transaction.
Post-acute initial and concurrent admission reviews
  • Follow the current process.
  • Fax requests to 1-866-411-2573.
  • For UAW retiree contracts, fax requests to 1-866-915-9811.
Other inpatient services Fax the following types of requests to 1-800-482-1713:
  • Authorization requests for sick or ill newborns
  • Federal Employee Program members with contract eligibility issues
  • Ineligible members or members with no contract
Not applicable
Urgent inpatient requests only Call the Blue Cross after-hours urgent hotline at 313-448-3619.

Find additional resources on this website.

Posted: June 2019
Line of business: Blue Cross Blue Shield of Michigan

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

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will close on Monday, May 27, 2019, for the Memorial Day holiday.

During this office closure, our inpatient utilization management area will still accept inpatient authorization requests for Blue Cross PPO (commercial) and Medicare Plus BlueSM PPO members. Follow this advice for submitting inpatient authorization requests during corporate office closures:

Type of request Blue Cross PPO (commercial) Medicare Plus Blue PPO
Acute initial inpatient admissions Submit requests 24/7 through the e-referral system. (If the e-referral system is not available, please fax Blue Cross PPO requests to 1-800-482-1713 or call them in to 1-877-399-1673. For Medicare Plus Blue requests, fax to 1-866-464-8223 or call 1-866 807 4811.)
Or, you can submit them through the X12N 278 Health Care Services Review - Request for Review and Response electronic standard transaction.
Post-acute initial and concurrent admission reviews
  • Follow the current process.
  • Fax requests to 1-866-411-2573.
  • Follow the current process.
  • Fax requests to eviCore healthcare at 1-844-407-5293.
Other inpatient services Fax the following types of requests to 1-800-482-1713:
  • Authorization requests for sick or ill newborns
  • Federal Employee Program members with contract eligibility issues
  • Ineligible members or members with no contract
Not applicable
Urgent inpatient requests only Call the Blue Cross after-hours urgent hotline at 313-448-3619.

You can find additional resources on this website.

Posted: May 2019
Line of business: Blue Cross Blue Shield of Michigan

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

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will close on Friday, April 19, 2019, for their Good Friday corporate holiday.

During this office closure, our inpatient utilization management area will still accept inpatient authorization requests for Blue Cross PPO (commercial) and Blue Cross Medicare Plus BlueSM PPO members. Follow this advice for submitting inpatient authorization requests during corporate office closures:

Type of request Blue Cross PPO (commercial) Blue Cross Medicare Plus Blue PPO
Acute initial inpatient admissions Submit requests 24/7 through the e-referral system.
Or, you can submit them through the X12N 278 Health Care Services Review - Request for Review and Response electronic standard transaction.
Post-acute initial and concurrent admission reviews
  • Follow the current process.
  • Fax requests to 1-866-411-2573.
  • Follow the current process.
  • Fax requests to eviCore healthcare at 1-844-407-5293.
Other inpatient services Fax the following types of requests to 1-800-482-1713:
  • Authorization requests for sick or ill newborns
  • Federal Employee Program members with contract eligibility issues
  • Ineligible members or members with no contract
Not applicable
Urgent inpatient requests only Call the Blue Cross after-hours urgent hotline at 313-448-3619.

Find additional e-referral system resources at ereferrals.bcbsm.com.

Posted: April 2019
Line of business: Blue Cross Blue Shield of Michigan

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

Effective July 1, 2019, KhapzoryTM and Fusilev® will be added to the Medical Drug Prior Authorization Program for Blue Cross Blue Shield of Michigan PPO commercial members. This applies to any members starting therapy on or after July 1.

  • Fusilev (levoleucovorin calcium, HCPCS code J0641)
  • Khapzory (levoleucovorin sodium, HCPCS code J3490)

These drugs are currently included in the prior authorization program for Blue Care Network HMOSM commercial members.

The authorization requirement only applies to groups that are currently participating in the commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. These changes don't apply to BCN AdvantageSM, Blue Cross Medicare Plus BlueSM PPO or Federal Employee Program® members.

A prior authorization approval isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members. Members are responsible for the full cost of medications not covered under their medical benefit coverage.

For a list of requirements related to drugs covered under the medical benefit, do the following:

  1. Visit the Medical Benefit Drugs - Pharmacy page in the Blue Cross section at on this website.
  2. Click Requirements for drugs covered under the medical benefit - BCN HMO and Blue Cross PPO under the heading For Blue Cross (commercial) members.

The new prior authorization requirement for Khapzory and Fusilev will be reflected in the requirements list before the July 1 effective date.

Posted: March 2019
Line of business: Blue Cross Blue Shield of Michigan

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

As of March 1, 2019, all UAW Retirees' Medical Benefits Trust's Blue Cross non-Medicare members, regardless of where they live, need prior authorizations through AIM Specialty Health for the services listed below.

Michigan providers must obtain prior authorizations for:

  • High-tech radiology
  • In-lab sleep management*
  • Medical oncology
  • Radiation oncology procedures

Providers outside of Michigan must obtain prior-authorizations for:

  • Radiation oncology
  • Medical oncology
  • High-tech radiology services

*In-lab sleep auths are only required by providers practicing in the state of Michigan.

Reach AIM Specialty Health at 1-800-728-8008 or visit AIMspecialtyhealth.com.

Posted: February 2019
Line of business: Blue Cross Blue Shield of Michigan

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

As of Jan. 28, 2019, Medicare Plus Blue PPO facility claims billed for Prolastin and Aralast (with HCPCS J0256, sent via electronic institutional format 837I or paper UB-04 form) no longer deny for lack of medical documentation. This is regardless of the date of service.

Also, we've begun working on 2019 prior-authorization requirements (for electronic or paper facility claims) for certain specialty medical drugs, including Prolastin and Aralast. We'll share more information about this over the next few months.

Posted: February 2019
Line of business: Blue Cross Blue Shield of Michigan

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

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will close on Monday, Jan. 21, 2019, for Martin Luther King, Jr., Day.

During this office closure, the Blue Cross inpatient utilization management area will still accept inpatient authorization requests for Blue Cross PPO (commercial) and Blue Cross Medicare Plus BlueSM PPO members. Follow this advice for submitting inpatient authorization requests during corporate office closures:

Type of request Blue Cross PPO (commercial) Blue Cross Medicare Plus Blue PPO
Acute initial inpatient admissions Submit requests 24/7 through the e-referral system.
Or, you can submit them through the X12N 278 Health Care Services Review – Request for Review and Response electronic standard transaction.
Post-acute initial and concurrent admission reviews
  • Follow the current process.
  • Fax requests to 1-866-411-2573.
  • Follow the current process.
  • Fax requests to eviCore healthcare at 1-844-407-5293.
Other inpatient services Fax the following requests to 1-800-482-1713:

  • Authorization requests for sick or ill newborns
  • Federal Employee Program members with contract eligibility issues
  • Ineligible members or members with no contract
Not applicable
Urgent inpatient requests only Call the Blue Cross after-hours urgent hotline at 313-448-3619 for any immediate or urgent need.

Find additional e-referral system resources elsewhere on this website.

Posted: January 2019
Line of business: Blue Cross Blue Shield of Michigan