Blue Cross Blue Shield of Michigan


August 2019

e-referral system out of service for maintenance Aug 21-22

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

Michigan board-certified behavior analysts must be licensed starting Jan. 1, 2020, to be reimbursed by Blue Cross and BCN

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

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

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

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

June 2019

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

NovoLogix® user interface enhancements coming soon

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

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

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

Important information about eviCore healthcare therapy authorization requests for BCN

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

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

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

More updated e-referral questionnaires open on June 23

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

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

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

May 2019

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

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

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

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

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

Updated authorization criteria and e-referral questionnaire for ethmoidectomy

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

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

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

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

Learn about Medicare Advantage post-acute care authorization changes

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

April 2019

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

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

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

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

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

March 2019

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

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

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

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

What to do when error messages display in e-referral

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

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

February 2019

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

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

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

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

Clarifying biofeedback and neurofeedback authorization requirements for BCN members

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

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

January 2019

Sign up to receive Blues Brief electronically

Complete the new questionnaires in e-referral for BCN members

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

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

December 2018

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

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

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

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

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

Additional updated authorization criteria and e-referral questionnaires

e-referral User Guides, online eLearning updated

Xgeva® to require authorization for BCN AdvantageSM members

November 2018

eviCore to manage two radiopharmaceutical drugs, starting Feb. 1

Complete the provider specialty questionnaire in the e-referral system

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

Updated authorization criteria and e-referral questionnaires

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

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

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

October 2018

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

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

Additional updated authorization criteria and e-referral questionnaires

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

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

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

Register now for an AIM Specialty Health® ProviderPortalSM webinar

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

Treat Medicare Advantage members with Avastin® before other specialty drugs

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

September 2018

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

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

BCN updates sleep study questionnaire in the e-referral system

Additional updated authorization criteria and e-referral questionnaires

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

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

August 2018

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

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

Renflexis® requires authorization for BCN AdvantageSM starting Oct. 1

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

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

How to submit BCN inpatient authorization requests during upcoming holiday closures

FAQ available about LLPs and LMFTs

Additional updated authorization criteria and e-referral questionnaires in effect

Phone numbers change for BCN Case Management and Care Transition programs

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

Updated authorization criteria and e-referral questionnaires in effect

Error issue resolved in e-referral system

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

July 2018

2018 InterQual® criteria implementation delayed until Aug. 6

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

2018 InterQual® criteria to be implemented starting Aug. 6

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

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

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

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

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

We're updating you on Blue Distinction® Specialty Care

Deleting your browsing history after an e-referral system outage

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

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

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

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

How to submit BCN inpatient authorization requests during upcoming holiday closures

June 2018

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

Updated authorization criteria and e-referral questionnaires are in effect

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

Where to get help in using the e-referral system

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

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

May 2018

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

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

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

How to submit BCN inpatient authorization requests during upcoming holiday closures

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

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

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

April 2018

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

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

Medicare Outpatient Observation Notice requirements clarified

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

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

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

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

March 2018

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

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

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

How to submit BCN inpatient authorization requests during upcoming holiday closures

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

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

Provider forums are coming to a town near you

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

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

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

February 2018

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

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

January 2018

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

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

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

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

How to submit BCN inpatient authorization requests during upcoming holiday closures

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

Submit functional limitation G codes for BCN AdvantageSM therapy services

December 2017

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

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

eviCore accepting Blue Cross PPO authorization requests starting Dec. 22

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

November 2017

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

October 2017

New BCN authorization requirements are effective Jan. 1, 2018

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

e-referral site wins communications awards

Do not refer new patients to MedEQUIP in Ann Arbor

Clarification on Blue Cross inpatient authorization requirements for newborns

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

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

September 2017

2017 InterQual criteria to be implemented starting October 2

New name for Blue Cross® Physician Choice PPO

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

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

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

Blue Cross inpatient authorization requirements clarified

August 2017

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

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

Reminder: 2017 InterQual criteria delayed until October 2017

July 2017

Clarifying authorization requirements for Blue Cross members

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

June 2017

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

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

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

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

May 2017

2017 InterQual criteria delayed until October 2017

Blue Care Network changes authorization requirements for sleep management studies

Blue Care Network updates authorization guideline for external ECG monitoring

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

April 2017

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

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

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

March 2017

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

RC Claim Assist tool is now available

January 2017

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

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

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

December 2016

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

BCN revises codes managed by eviCore healthcare

Guidelines for submitting acute inpatient admission requests to BCN

November 2016

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

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

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

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

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

Tell us what you think about BCN Care Management Services

October 2016

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

ALERT: Phone issues on eviCore's BCN provider line

September 2016

Updated BCN authorization criteria and preview questionnaires now available

BCN's Behavioral Health e-referral User Guide updated

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

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

Online self-paced training modules now available

Changeover to using Novologix web tool is delayed for BCN providers

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

MSU Student and Graduate Assistant Health Plans information

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

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

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

August 2016

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

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

BCN launches new Medical Benefit Drugs-Pharmacy web page

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

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

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

July 2016

e-referral User Guide updated and available

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

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

eviCore changes reconsideration process for PTs' utilization categories

June 2016

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

UPDATED: Changes in BCN's sleep study requirements

Submit BCN obstetrical admissions one day after discharge – not sooner

May 2016

Some medical drugs no longer require authorization for BCN AdvantageSM members

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

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

Welcome to the new referrals.bcbsm.com

We're updating our look

April 2016

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

New Behavioral Health e-referral User Guide available

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

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

March 2016

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

What you need to know about the eviCore 2.0 provider portal

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

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

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

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

We want your opinion

Updated nutrition assessment form now available for home infusion providers

February 2016

Updated preview questionnaire is available for excisional breast biopsy

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

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

January 2016

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

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

December 2015

BCN Behavioral Health utilization management criteria is changing on January 1

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

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

Announcing e-referral enhancements beginning Dec. 7, 2015

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

November 2015

Global referral: What it allows a specialist to do

Changes in eviCore authorization requirements

Add correct servicing provider information when submitting requests to eviCore

Reminder: Prostatic urethral lift procedures require clinical review

October 2015

eviCore healthcare Web Portal webinars available

Updated Spine Care Referral Program questionnaire is now available

Some providers showing missing or incorrect address in e-referral

September 2015

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

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

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

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

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

August 2015

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

Chiropractors may provide some physical therapy services for BCN commercial members

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

July 2015

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

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

e-referral upgrade slated for Aug. 17

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

June 2015

More procedures to be reviewed by eviCore healthcare effective September 1

eviCore healthcare Web address changes July 6

Upgrades coming to e-referral

2015 InterQual® criteria to be used effective August 3

May 2015

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

March 2015

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

Finding home sleep study providers

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

Register now for April 2015 behavioral health webinar

Training Tools

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

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

User guides and documentation

Online training

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

Password information

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

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

BCN Care Management provider call volumes high

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


How to access e-referral with Internet Explorer ® 11

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


Updated BCN provider affiliations codes on e-referral

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

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

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

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

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

Blue Care Network offers Behavioral Health informational webinars

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

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

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

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

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

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

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

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

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

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

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

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

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

New questionnaires available for lumbar spine surgery

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

The changes include but are not limited to:

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

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

New questionnaires available for arthroscopy of the knee

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

The changes include but are not limited to:

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

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

2013 InterQual® acute care criteria take effect November 4

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

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

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

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

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

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

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

Blue Care Network announces date for sleep management program changes

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

Blue Care Network announces questionnaire changes effective August 5

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

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

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

Lumbar spine surgery questionnaire updated effective July 29, 2013

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

Blue Cross Complete announces changes effective August 1

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

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

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

Blue Care Network announces delay in changes for sleep management

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

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

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

Blue Care Network announces changes for frenulum surgery

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

2013 InterQual® criteria take effect July 1

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

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

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

Criteria/Version Application

InterQual Acute – Adult and Pediatrics
Exceptions-local rules

  • Inpatient admissions
  • Continued stay discharge readiness

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

  • Subacute and skilled nursing facility admissions

InterQual Rehabilitation - Adult and Pediatrics
Exceptions-local rules

  • Inpatient admissions
  • Continued stay and discharge readiness

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

  • Long term acute care facility admissions

InterQual Level of Care – Home Care
Exceptions-local rules

  • Home care requests

InterQual Imaging

  • Imaging studies and X-rays

InterQual Procedures – Adult and Pediatrics

  • Surgery and invasive procedures

BCBSM/BCN medical policies

  • Services that require clinical review for medical necessity

Plan developed imaging criteria

  • Imaging studies and X-rays

Blue Care Network reimbursement for intra-articular hyaluronic acid injections

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

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

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

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

Osteoporosis: Intravenous bisphosphonate therapy — Reclast infusion questionnaire

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

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

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

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

Blue Care Network announces questionnaire update for sleep management

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

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

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

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

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

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

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

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

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

Radiology management program changes effective May 1, 2013

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

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

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

Quick Guides
Blue Distinction Centers®

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

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

Blue Distinction Center programs include:

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

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

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

e-referral system out of service for maintenance August 21-22

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

From 10 p.m. August 21 to 2 p.m. August 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: 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



Michigan board-certified behavior analysts must be licensed starting Jan. 1, 2020, to be reimbursed by Blue Cross and BCN

Starting Jan. 1, 2020, board-certified behavior analysts practicing in Michigan must be licensed by the State of Michigan to be eligible for reimbursement from Blue Cross and Blue Care Network. BCBAs who are not licensed are not eligible for reimbursement for services provided on or after Jan. 1, 2020.

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

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



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

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

Blues 101 – Understanding the Basics

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

Blues 201 – Enrollment

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

Pharmacy Site of Care

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

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

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

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



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

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

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

For more information, see the following articles:

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



NovoLogix® user interface enhancements coming soon

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

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

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

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



More updated e-referral questionnaires open on June 23

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

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

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

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

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

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

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

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



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

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

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

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

Requesting authorization for non-post-acute care services

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

Requesting authorization for Medicare Advantage post-acute care

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

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



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

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

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

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

For BCN HMO members:

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

For Blue Cross' PPO members:

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

More about the authorization requirements

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

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

List of requirements

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

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

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



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

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

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



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

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

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

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



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

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

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

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

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

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

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

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

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

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

Claims billed with the following codes will still be honored:

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

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

Billing guidelines

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

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

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

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

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

Updated authorization criteria and e-referral questionnaire for ethmoidectomy

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

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

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

  • BCN HMOSM
  • BCN AdvantageSM
  • Medicare Plus BlueSM PPO

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

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

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

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

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

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

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

Medicare Plus Blue PPO

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

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

BCN Advantage

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

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

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

Important reminder

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

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

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

Learn about Medicare Advantage post-acute care authorization changes

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Medicare Plus Blue PPO

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

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

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

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

BCN Advantage

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

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

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

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

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

Important reminder

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

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

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

What to do when error messages display in e-referral

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

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

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

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

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

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

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

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

Important to know:

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

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

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

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

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

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

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

Sign up to receive Blues Brief electronically

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

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

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

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

e-referral User Guides, online eLearning updated

The e-referral User Guides and Submitting an Outpatient Authorization online eLearning module have been updated on the Training Tools page of ereferrals.bcbsm.com. They are dated November 2018.

These User Guides and eLearning module have been updated to include:

  • The new Place of Service drop-down menu items. The Outpatient Hospital option has now been split into On Campus Outpatient Hospital and Off Campus Outpatient Hospital. Other Unlisted Facility and Telehealth have also been added as choices but providers should not use these.

The updated User Guides also include:

  • A page has been added with instruction on completing a new questionnaire when submitting to a multispecialty group in the Submitting a Global Referral chapter. An e-referral news message has also been posted regarding the questionnaire.

Posted: December 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

eviCore to manage two radiopharmaceutical drugs, starting Feb. 1

For dates of services on or after Feb. 1, 2019, the following radiopharmaceutical drugs require authorization through eviCore healthcare:

  • Lutathera® (lutetium Lu 177 dotatate, HCPCS code C9513)
  • Xofigo® (radium Ra 223 dichloride, HCPCS code A9606)

This applies to members covered by:

  • Blue Cross PPO (commercial) and Blue Cross Medicare Plus BlueSM PPO

    Note: eviCore already manages procedures associated with code A9606 for Blue Cross PPO and Medicare Plus Blue members. eviCore will begin managing procedures associated with code C9513 on Feb. 1.

  • BCN HMOSM (commercial) and BCN AdvantageSM

    Note: Lutathera was previously managed for BCN HMO members under the prior authorization program for drugs covered under the medical benefit. eviCore already manages procedures associated with code C9513 for BCN Advantage members. For BCN HMO members, C codes aren't payable. However, services associated with the administration of an approved treatment plan with Lutathera are payable for BCN HMO members. eviCore will begin managing procedures associated with code A9606 for both BCN HMO and BCN Advantage on Feb. 1.

Submit authorization requests to eviCore online at evicore.com or by telephone at 1-855-774-1317.

We'll update the Procedures that require authorization by eviCore healthcare document prior to the effective date of the change.

Note: These changes do not apply to MESSA members.

Posted: November 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Updated authorization criteria and e-referral questionnaires

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

  • Cervical spine surgery with artificial disc replacement
  • Deep brain stimulation
  • Endometrial ablation
  • Shoulder replacement surgery

For most of these services, you'll see the updated questionnaires in the e-referral system starting Nov. 25, 2018. You'll see the questionnaire for shoulder replacement surgery starting Nov. 11.

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

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

Note: The criteria and questionnaires for endometrial ablation and cervical spine surgery apply to BCN HMO and BCN Advantage members only.

The updated authorization criteria and preview questionnaires will be available on this website shortly before the revised questionnaires are set to open in the e-referral system. Here's where to find them:

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

Posted: November 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

Some updates are coming for the Part B medical specialty medical prior authorization drug list for Blue Cross Medicare Plus BlueSM PPO and BCN AdvantageSM members. These changes include additions and removals from the prior authorization program as follows.

Medicare Plus Blue PPO

    Removals — for dates of service starting Jan. 1, 2019:

    • J0202 Lemtrada®
    • J2323 Tysabri®
    • J2350 Ocrevus®

    Additions — for dates of service starting Feb. 1, 2019:

    • J2840 Kanuma®
    • J2860 Sylvant®
    • J3357 Stelara® SQ
    • J3358 Stelara® IV
    • J3490/C9036 OnpattroTM
    • J1746 TrogarzoTM
    • J9022 Tecentriq®
    • J9023 Bavencio®
    • J9042 Adcetris®
    • J9176 Empliciti®
    • J9308 Cyramza®
    • J9352 Yondelis®

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

  • Physician office (Place of Service Code 11)
  • Outpatient facility (Place of Service Code 19, 22 or 24)

We do not require authorization for these medications when you bill them on a facility claim form (such as a UB04) or electronically via an 837I transaction.

BCN Advantage

    Removals — for dates of service starting Jan. 1, 2019:

    • J9032 Beleodaq®
    • J9310 Rituxan®

    Additions — for dates of service starting Feb. 1, 2019:

    • J2860 Sylvant®
    • J3357 Stelara® SQ
    • J3358 Stelara® IV
    • J3490/C9036 OnpattroTM
    • J1746 TrogarzoTM
    • J9022 Tecentriq®
    • J9023 Bavencio®
    • J9042 Adcetris®
    • J9176 Empliciti®
    • J9352 Yondelis®

For BCN Advantage, we require prior authorization for these medications when you bill them on a professional CMS-1500 claim form (or submit them electronically via an 837P transaction) or on a facility claim form such as a UB04 (or submit them electronically via an 837I transaction), for the following sites of care:

  • Physician office (Place of Service Code 11)
  • Outpatient facility (Place of Service Code 19, 22 or 24)
  • Home (Place of Service Code 12)

Important reminder

You must get authorization prior to administering these medications. Use the Novologix® online web tool to quickly submit your requests.

Posted: November 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Additional updated authorization criteria and e-referral questionnaires

We made updates to the authorization criteria and to the questionnaires in the e-referral system for the following services:

  • Hip replacement surgery procedure, initial
  • Hyperbaric oxygen therapy, outpatient
  • Knee replacement surgery, nonunicondylar, initial
  • Knee replacement surgery, unicondylar, initial
  • Lumbar spine surgery for adults
  • Transcatheter arterial chemoembolization of hepatic tumors (TACE)

You'll see the updated questionnaires in the e-referral system starting Oct. 28, 2018.

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

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

Note: The criteria and questionnaires for hyperbaric oxygen therapy and lumbar spine surgery apply to BCN HMO and BCN Advantage members only.

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

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

Posted: October 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

Learn about the safe and effective use of Avastin for retinal disorders and how to correctly bill Medicare Plus BlueSM PPO and BCN AdvantageSM for maximum reimbursement.

Register for one of the following webinars now:

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

Posted: October 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

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

Brand name / HCPCS code Prior authorization requirements for all dates of service on or after:
OnpattroTM / J3490 HMO – Nov. 1, 2018
PPO – Dec. 1, 2018
Poteligeo® / J9999 HMO – Nov. 1, 2018 (only for members starting treatment on or after that date)
PPO – None required
Signifor LAR® / J2502 HMO – Feb. 1, 2019
PPO – Already required

These changes don't apply to BCN AdvantageSM, Blue Cross Medicare Plus BlueSM PPO or Federal Employee Program® members.

How to submit authorization requests

Submit authorization requests prior to the start of services for medical benefit drugs that require authorization using the NovoLogix® web tool within Provider Secured Services.

Always verify benefits

Approval of a prior authorization request isn't a guarantee of payment. You need to verify each member's eligibility and benefits. Members are responsible for the full cost of medications not covered under their medical benefit coverage.

Posted: October 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

Your feedback is important to us. Please complete the 2018 Blue Cross Blue Shield of Michigan and Blue Care Network Utilization Management Survey and encourage your office colleagues to do so as well, including physicians, nurses and referral coordinators. Your input will help us evaluate our efforts and determine other improvements we can make to enhance our utilization management processes.

The survey will be available online through Dec. 31, 2018.

Information about a drawing for two $250 gift certificates is available on page 18 of the September-October 2018 issue of BCN Provider News.

Posted: October 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

Internet Explorer, Google Chrome and Mozilla Firefox have announced that new versions of their Internet browsers, being introduced on Oct. 16, 2018, will not trust Symantec certificates. The browsers will display a block page explaining that the site is categorized as "untrusted." If you are a Windows 7 user, you may see a certificate error message starting Oct. 16 when you try to access e-referral.

If you do see a certificate error message, please complete the following steps (PDF), reopen your browser and access e-referral.

If you are still experiencing issues after following the steps, please contact your web support team.

Posted: October 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Treat Medicare Advantage members with Avastin® before other specialty drugs

Starting Jan. 1, 2019, when requesting authorization for Eylea®, Lucentis® or Macugen® for Medicare Advantage members, you'll need to show you've already tried eye injections with compounded Avastin (bevacizumab).

If you're currently treating members with wet, neovascular, age-related macular edema, we:

  • Encourage you to start Avastin therapy now
  • Don't require authorization for Avastin injections
  • Reimburse $173 per eye for medical drug claims with compounded Avastin eye injections

Look for more information, including billing instructions, in upcoming issues of The Record and BCN Provider News.

This change follows Centers for Medicare & Medicaid Services guidance for allowing Part B specialty drug step therapy. And, it applies to Blue Cross Medicare Plus BlueSM PPO and BCN AdvantageSM members for dates of service on or after Jan. 1, 2019.

Posted: October 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

In the new year, according to Centers for Medicare & Medicaid Services guidance, certain Medicare Part B specialty drugs will have additional step therapy authorization requirements. This will apply to Medicare Plus BlueSM PPO and BCN AdvantageSM members for dates of service on or after Jan. 1, 2019.

Step therapy is treatment for a medical condition that starts with the most preferred drug therapy and progresses to other drug therapies only if necessary. The goal of step therapy is to encourage better clinical decision-making.

What's changing?

For drugs requiring step therapy, authorization request questions will be different from the ones you currently answer. Some examples of drugs that require step therapy are:

  • Botox® for migraines and overactive bladder
  • Eylea®, Lucentis® and Macugen® for neovascular age-related macular edema
  • Prolia® for osteoporosis

Use NovoLogix® to submit authorization requests

We encourage you to send prior authorization requests for Medicare Part B specialty drugs through the NovoLogix web tool via Provider Secured Services. It's the most efficient way to get a determination.

Look for more information on step therapy requirements in upcoming issues of The Record and BCN Provider News.

Posted: October 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

Refresh your skills with the NovoLogix web tool, and learn how to create provider administered specialty medical drug prior-authorization requests for members with:

  • Blue Cross Medicare Plus BlueSM PPO
  • BCN AdvantageSM
  • Blue Cross PPO
  • BCN HMOSM

Register for a webinar now:

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

Posted: September 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Additional updated authorization criteria and e-referral questionnaires

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

  • Cervical spine surgery
  • Hammertoe correction surgery
  • Sinusotomy, frontal endoscopic

The updated questionnaires will begin opening in the e-referral system starting Sept. 23, 2018.

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

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

Note: The criteria and questionnaire for cervical spine surgery apply to BCN HMO and BCN Advantage members only.

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

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

Posted: September 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

Providers affiliated with Blue Cross Blue Shield of Michigan and Blue Care Network have a contractual obligation to use in-network providers when referring our members for services. This includes referring members for toxicology and drug-of-abuse testing services. And, this applies for members covered by all Blue Cross and BCN products:

  • Blue Cross PPO
  • Blue Cross Medicare Plus BlueSM PPO
  • BCN HMOSM
  • BCN AdvantageSM

A significant number of contracted providers refer members to out-of-network laboratories. This puts members at risk of having to pay higher costs. Since the tests are available at in-network labs, these costs are unnecessary. Please follow the conditions of your provider agreement and the directions in our provider manuals, which require you to refer these members to in-network labs.

Our goal is to:

  • Give your patients convenient access to high-quality, cost-efficient toxicology testing services that properly meet their clinical needs.
  • Help our members avoid higher copayments and other out-of-pocket costs that may result from using out-of-network labs.

Confirm which labs are in-network or out-of-network with these resources

    Blue Cross PPO

    For salaried employees covered through Ford, General Motors and the Michigan Public School Employees' Retirement System, call: Quest DiagnosticsTM – 1-866-697-8378.

    For all other Blue Cross PPO members, use the Blue Cross online provider directory.

    Blue Cross Medicare Plus Blue PPO

    Call either of the following resources:

    • Joint Venture Hospital Laboratories – 1-800-445-4979
    • Quest Diagnostics – 1-866-697-8378

    BCN HMO and BCN Advantage

    Call Joint Venture Hospital Laboratories at 1-800-445-4979.

Need more help?

If you need more help locating an in-network lab or want to discuss specific lab testing needs you may have, please call one of the following Provider Automated Response System numbers during normal business hours:

    Blue Cross PPO, BCN HMO or BCN Advantage

    • Professional providers in Michigan, call 1-800-344-8525.
    • Facility providers in Michigan, call 1-800-249-5103.

    Blue Cross Medicare Plus Blue PPO

    Call 1-866-309-1719.

After confirming member benefits using the automated system, you can speak to someone in Provider Inquiry to get help finding an in-network lab.

Posted: September 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

FAQ available about LLPs and LMFTs

The answers to questions providers have asked about limited licensed psychologists and licensed marriage and family therapists is now available in the document LLPs and LMFTs – Frequently asked questions. You'll find the FAQ document on this website at these locations:

The FAQ document is intended to clarify questions about LLP and LMFT requirements related to providing services to Blue Cross PPO (commercial), BCN HMOSM (commercial) and BCN AdvantageSM members. We announced this change in The Record (March 2018 article) and BCN Provider News (January-February 2018 issue, article on page 1).

A link to the FAQ document is also located on Blue Cross Clinical Criteria & Resources page within Provider Secured Services. To access that page, visit bcbsm.com/providers, log in to Provider Secured Services and click BCBSM Provider Publications and Resources at the lower right. Then click Clinical Criteria & Resources. Finally, scroll down and look in the "Behavioral Health Information" section of the page, under "General Resources."

Posted: August 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Additional updated authorization criteria and e-referral questionnaires in effect

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

  • Endovascular intervention, peripheral artery
  • Ethmoidectomy, endoscopic
  • Sacral nerve stimulation

The updated questionnaires began opening in the e-referral system starting Aug. 26, 2018.

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

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

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

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

Posted: August 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Updated authorization criteria and e-referral questionnaires in effect

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

  • Knee arthroplasty for adults, total revision
  • Noncoronary vascular stents
  • Spinal cord stimulator or epidural or intrathecal catheter (trial or permanent placement)

The updated questionnaires began opening in the e-referral system starting Aug. 12, 2018.

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

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

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

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

Posted: August 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Error issue resolved in e-referral system

Between Aug. 6 and Aug. 10, 2018, we received reports of an issue in the e-referral system that was preventing providers from viewing certain cases. Some providers told us they had received a message that said "Unknown Error. Please contact health plan administrator."

The issue, which occurred when the e-referral system was recently updated to the 2018 InterQual® criteria, has been resolved.

We apologize for any confusion you may have experienced when you got the error message.

Posted: August 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

2018 InterQual® criteria implementation delayed until Aug. 6

We communicated in June that Blue Cross Blue Shield of Michigan and Blue Care Network would implement the 2018 InterQual criteria and local rules starting Aug. 1, 2018, for all levels of care.

However, the implementation of the 2018 criteria was delayed. The new implementation date is Aug. 6.

Until that date, the 2017 InterQual criteria and local rules will continue to be used in making utilization management and care management determinations for the services subject to review.

This affects both behavioral health and non-behavioral health services for the following lines of business, unless otherwise noted:

  • Blue Cross PPO (commercial)
  • Note: Determinations on Blue Cross PPO (commercial) behavioral health services are handled by New Directions, a Blue Cross vendor, and are not affected by these criteria changes.

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

In addition, the e-referral system won't be available from 6 p.m. on Friday, Aug. 3 through 6 a.m. on Monday, Aug. 6, while it's being updated with the new criteria. Here's some information on how to process certain requests while the e-referral system is down:

  • For urgent acute inpatient requests that need to be processed within 24 hours, call the appropriate number below:
    • For Blue Cross requests, call the critical phone line at (313) 448-3619.
    • For BCN requests, call 1-800-392-2512.

  • For BCN post-acute and concurrent admission reviews, follow the current process you use to submit these requests by fax at 1-866-534-9994.

  • For behavioral health requests, call the appropriate number below:
    • For BCN behavioral health requests, call 1-800-482-5982.
    • For Blue Cross Medicare Plus Blue PPO behavioral health requests, call 1-888-803-4960.

  • For non-urgent authorization requests: Please wait to submit those until the e-referral system is available again.

Posted: July 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

Starting Aug. 6, 2018, Blue Care Network and Blue Cross Medicare Plus BlueSM PPO will use the 2018 InterQual® criteria for behavioral health utilization management determinations. The 2017 InterQual criteria will be used until that date.

Note: In earlier messages, we communicated that the 2018 InterQual criteria would be implemented starting Aug. 1, 2018, but that date has been changed to Aug. 6.

For certain services, we will base utilization management decisions on modified 2018 InterQual criteria, local rules or medical policies, instead. These changes will also begin Aug. 6. The services affected by these changes are outlined in this table.

Line of business Modified 2018 InterQual criteria for: Local rules or medical policy for:
BCN HMOSM (commercial) and BCN AdvantageSM
  • Substance use disorders: partial hospital program and intensive outpatient program
  • Residential mental health treatment (adult/geriatric and child/adolescent)
  • Autism spectrum disorder / applied behavior analysis (local rules)
  • Neurofeedback for attention deficit disorder / attention deficit hyperactivity disorder (medical policy)
  • Transcranial magnetic stimulation (medical policy)
Medicare Plus Blue PPO
  • Substance use disorders: partial hospital program and intensive outpatient program
None

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

Links to the updated versions of the modified criteria, local rules and medical policies will be available by Aug. 3 on the Blue Cross Behavioral Health page and the BCN Behavioral Health page on this website. Links to the current criteria are available on those pages until then.

Posted: July 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

2018 InterQual® criteria to be implemented starting Aug. 6

Blue Cross Blue Shield of Michigan and Blue Care Network will implement the 2018 InterQual criteria starting Aug. 6, 2018, for all levels of care. Until that date, the 2017 InterQual criteria will be used.

Note: In earlier messages, we communicated that the 2018 InterQual criteria would be implemented starting Aug. 1, 2018, but that date has been changed to Aug. 6.

The InterQual criteria are used to make utilization management and care management determinations for the services subject to review, for the follow members:

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

Blue Cross and BCN also use local rules – modifications of InterQual criteria – in making utilization management and care management determinations. The 2018 local rules will be implemented as follows:

  • For behavioral health determinations, the 2018 local rules will be used starting Aug. 6. The updated rules will be available by Aug. 3 on the Blue Cross Behavioral Health page and the BCN Behavioral Health page on this website. This applies to BCN HMO (commercial), BCN Advantage and Medicare Plus Blue PPO requests.

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

  • For non-behavioral health determinations, the 2018 local rules will be implemented starting Oct. 1. We'll let you know through our standard communication channels how to access those rules, once they're available.

Until the 2018 local rules are implemented, the 2017 local rules will be used.

Posted: July 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



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

Time is running out to give us your opinion on provider training. You have until July 31 to complete our online survey. Your response will help us improve the way we distribute information to you. Thank you for your time and your input.

Posted: July 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

When you submit an authorization request in the e-referral system, it may take up to a minute to show the authorization results, especially if the system is handling many requests at one time.

While you're waiting to get the decision on an authorization request, the e-referral system may display messages that conflict with each other. For example, the Authorization Details screen may show a status of "pending decision" along with a note in the Actions field that shows the request was approved.

If you encounter conflicting messages such as these, we suggest you make a note of the Reference ID number and use it to check back in a few minutes. This should give the system the time it needs to finish processing the authorization and display the decision without the conflicting messages.

Posted: July 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

We're updating you on Blue Distinction Specialty Care

In an article in the July-August 2018 Hospital and Physician Update, we provided an update on Blue Distinction Specialty Care. This program recognizes health care facilities and providers nationwide that demonstrate proven expertise in delivering high-quality, effective and cost-efficient care for select specialty areas. The article outlines selection criteria and recent program changes, along with information on what's coming next and program results. For complete details, click here.

This information applies to both Blue Cross PPO (commercial) and Blue Care Network HMOSM (commercial) members. The article that was published in Hospital and Physician Update will also be included in the September-October 2018 issue of BCN Provider News, which will be available online in late August.

Posted: July 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Deleting your browsing history after an e-referral system outage

The e-referral system is available again.

After an outage of the e-referral system, you may experience difficulties logging in to the system. Deleting your browsing history may make the login process easier.

Click here for instructions on how to delete your browsing history if you use Internet Explorer 11 as your browser.

If you use a browser other than Internet Explorer 11, contact your IT support staff for instructions or look up how to clear your browsing history on the Internet.

Posted: July 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

Blue Cross Blue Shield of Michigan and Blue Care Network allow onsite physician advisors at contracted facilities to discuss reviews of inpatient admissions with a Blue Cross or BCN medical director. According to our policy, facilities should start peer-to-peer conversations only through their employed physician advisors, and not through third-party advisors or organizations.

This applies to members with coverage with Blue Cross PPO (commercial), BCN HMOSM (commercial), Blue Cross Medicare Plus BlueSM PPO and BCN AdvantageSM products.

The purpose of the peer-to-peer discussion is to exchange information about the clinical nuances of the member's medical condition and the medical necessity of the inpatient admission, not to discuss InterQual® criteria or Blue Cross and BCN local rules.

The peer-to-peer phone lines are open Monday through Friday, 8 a.m. to 5 p.m. Eastern time, except for holidays. We'll return your call within 48 business hours.

Use the following guidelines to request a peer-to-peer review with a Blue Cross or BCN medical director.

Non-behavioral health inpatient admissions

For BCN HMO (commercial) and BCN Advantage members:

  1. Call 248-799-6312.
  2. Select prompt 3 for a peer-to-peer discussion.
  3. Leave a message that includes the:
    • Reason for requesting a peer-to-peer review
    • Member's name, date of birth and contract number
    • Physician advisor's or physician's name and phone number
    • Best date and time to reach the physician advisor or physician

For Blue Cross PPO (commercial) and Medicare Plus Blue members:

  1. Call 1-866-346-7299.
  2. Select prompt 2 for the Facility Precertification department
  3. Select prompt 1 to request a provider peer-to-peer review.
  4. Wait for the prompt to leave a message, then provide the:
    • Reason for requesting a peer-to-peer review
    • Member's name, date of birth and contract number
    • Physician advisor's or physician's name and phone number
    • Best date and time to reach the physician advisor or physician

Behavioral health inpatient admissions

For BCN HMO (commercial), BCN Advantage and Medicare Plus Blue members:

  1. Call 1-877-293-2788.
  2. If a live operator doesn't answer the call, leave a message that includes the:
    • Name of the person calling and a call-back number
    • Member's name, date of birth and contract or case number
    • Specific times the provider is available to discuss the case
    • Physician advisor's or physician's name and phone number

For Blue Cross PPO (commercial) members: Call the behavioral health number on the back of the member's ID card.

Posted: July 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

For dates of service on or after Oct. 1, 2018, Trogarzo and Zilretta will be added to the medical drug prior authorization program for Blue Cross PPO (commercial) and BCN HMOSM (commercial) members.

Trogarzo will also be subject to a site-of-care requirement for BCN HMO (commercial) members only, effective Oct. 1, 2018. The site-of-care program redirects members receiving select drugs in an outpatient hospital setting to a lower-cost, alternate site of care, such as the physician's office or the member's home.

See the table below for a summary of the requirements.

Drug name HCPCS code Prior authorization requirement Site-of-care requirement
Trogarzo (ibalizumab-uiyk) J3590 Blue Cross PPO (commercial) and BCN HMO (commercial) BCN HMO (commercial) only
Zilretta (triamcinolone acetonide extended release) Q9993 Blue Cross PPO (commercial) and BCN HMO (commercial) No

Note:

  • For members currently on Trogarzo, no action is required.

  • For members currently on Zilretta, authorization will be required for dates of service on or after Oct. 1, 2018.

You can refer to the opt-out list to see which groups don't require members to participate in these programs. This applies to Blue Cross PPO (commercial) groups only. To access the list, complete these steps:

  1. Visit bcbsm.com/providers.
  2. Log in to Provider Secured Services.
  3. Click BCBSM Provider Publications and Resources.
  4. Click Newsletters & Resources.
  5. Click Forms.
  6. Click Physician administered medications.
  7. Click BCBSM Medical Drug Prior Authorization Program list of groups that have opted out.

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

Additional information on medical benefit drugs is available at ereferrals.bcbsm.com, on the Blue Cross Medical Benefit Drugs — Pharmacy page and the BCN Medical Benefit Drugs — Pharmacy page.

Posted: July 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Starting Aug. 1, updated utilization management criteria used for behavioral health

Starting Aug. 1, 2018, Blue Care Network and Blue Cross Medicare Plus BlueSM PPO will use the 2018 InterQual® criteria for behavioral health utilization management determinations. The 2017 InterQual criteria will be used through the end of July.

For certain services, we will base utilization management decisions on modified 2018 InterQual criteria, local rules or medical policies, instead. These changes will also begin Aug. 1. The services affected by these changes are outlined in this table.

Line of business Modified 2018 InterQual criteria for: Local rules or medical policy for:
BCN HMOSM (commercial) and BCN AdvantageSM
  • Substance use disorders: partial hospital program and intensive outpatient program
  • Residential mental health treatment (adult/geriatric and child/adolescent)
  • Autism spectrum disorder / applied behavior analysis (local rules)
  • Neurofeedback for attention deficit disorder / attention deficit hyperactivity disorder (medical policy)
  • Transcranial magnetic stimulation (medical policy)
Medicare Plus Blue PPO
  • Substance use disorders: partial hospital program and intensive outpatient program
None

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

Links to the updated versions of the modified criteria, local rules and medical policies will be available at the end of July on the Blue Cross Behavioral Health page and the BCN Behavioral Health page on this website. Links to the current criteria are available on those pages until then.

Posted: June 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Updated authorization criteria and e-referral questionnaires are in effect

For certain services, the authorization criteria and the questionnaires in the e-referral system have been updated. These are used in making utilization management determinations for the following members:

  • BCN HMOSM (commercial)
  • BCN AdvantageSM
  • Blue Cross Medicare Plus BlueSMPPO

Click here for a list of the authorization criteria and questionnaires that were updated in May and June 2018.

The updated authorization criteria and preview questionnaires are available on this website, on these pages:

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

As a reminder, new questionnaires will open in the e-referral system for blepharoplasty and repair of brow ptosis (starting June 25, for any date of service) and hyperbaric oxygen therapy (for dates of service on or after July 1). We first communicated about this in May, in a web-DENIS message and a news item on this website. You'll see these questionnaires included in the list of updated authorization criteria and questionnaires.

Posted: June 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

2018 InterQual® criteria to be implemented starting Aug. 1

Blue Cross Blue Shield of Michigan and Blue Care Network will implement the 2018 InterQual criteria starting Aug. 1, 2018, for all levels of care. Until that date, the 2017 InterQual criteria will be used.

The InterQual criteria are used to make utilization management and care management determinations for the services subject to review, for the follow members:

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

Blue Cross and BCN also use local rules – modifications of InterQual criteria – in making utilization management and care management determinations. The 2018 local rules will be implemented as follows:

  • For behavioral health determinations, the 2018 local rules will be used starting Aug. 1. The updated rules will be available at the end of July on the Blue Cross Behavioral Health page and the BCN Behavioral Health page on this website. This applies to BCN HMO (commercial), BCN Advantage and Medicare Plus Blue PPO requests.

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

  • For non-behavioral health determinations, the 2018 local rules will be implemented starting Oct. 1. We'll let you know through our standard communication channels how to access those rules, once they're available.

Until the 2018 local rules are implemented, the 2017 local rules will be used.

Posted: June 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Where to get help in using the e-referral system

Recently, the Web Support Help Desk has been experiencing an increase in calls for e-referral assistance. As a reminder, the Web Support Help Desk is only available to assist with password reset, navigation and technical help.

Please follow these guidelines for other e-referral issues:

  • For Blue Cross PPO (commercial) members, you can find the appropriate Provider Inquiry phone number in the Blue Cross provider resource guide at a glance document, on the Quick Guides page of this website.

  • For Blue Cross Medicare Plus BlueSM PPO members, you can find the appropriate Provider Inquiry phone number in the Services That Require Authorization – Medicare Plus Blue PPO document, on the Authorization Requirements & Criteria page in the Blue Cross section of this website.

  • For BCN HMOSM (commercial) or BCN AdvantageSM members, please call 1-800-392-2512.

For additional help using e-referral, contact your provider consultant or consult the user guides and online training available on the Training Tools page on this website.

Posted: June 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

For dates of service on or after Aug. 7, 2018, authorization is required for the following Part B specialty drugs covered under the medical benefit:

  • Fasenra (benralizumab)
  • Luxturna (voretigene neparvovec-rzyl)

This authorization requirement applies to Blue Cross Medicare Plus BlueSM PPO and BCN AdvantageSM members.

Note: Authorization is already required for Blue Cross PPO and BCN HMOSM (commercial) members.

For Medicare Plus Blue and BCN Advantage members, authorization is required for these medications when they are billed on a professional HCFA 1500 claim form or by electronic submission via ANSI 837P, for the following sites of care:

  • Physician office (Place of Service 11)
  • Outpatient facility (Place of Service 19, 22 or 24)

Authorization is not required for these medications when they are billed on a facility claim form (such as the UB-92, UB-04 or UCB).

Both medications are billed with HCPCS procedure code J3590.

You must submit authorization requests for these medications through the NovoLogix online tool. Authorization must be obtained prior to the medications being administered.

Posted: May 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

Several new upgrades and changes are coming to the e-referral system. The biggest change is the combining of BCN and BCBSM e-referral systems into one portal.

In order to upgrade the system, e-referral will not be available starting 6 p.m. on Friday, April 27, 2018. At 6 a.m. on Monday, April 30, 2018, users will see only one e-referral link to be used for both Blue Cross and BCN submissions. Please see the article on page 42 of the May-June 2018 BCN Provider News for full details.

Here's some information on how to process certain requests while the e-referral system is down.

For urgent acute inpatient requests that need to be processed within 24 hours, call the appropriate number below:

  • For Blue Cross requests, call the critical phone line at (313) 448-3619.
  • For BCN requests, call the BCN After-Hours Care Manager Hotline at 1-800-851-3904.

For BCN post-acute and concurrent admission reviews, follow the current process you use to submit these requests by fax at 1-866-534-9994.

To reach BCN Behavioral Health, call 1-800-482-5982.

Posted: April 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Medicare Outpatient Observation Notice requirements clarified

We're clarifying the requirements for notifying Medicare Advantage members using the Medicare Outpatient Observation Notice form.

Here's when hospitals need to notify members

Hospitals must use the Medicare Outpatient Observation Notice form, available on the CMS website* under Downloads, to notify Blue Cross Medicare Plus BlueSM PPO and BCN AdvantageSM members that they're receiving outpatient, rather than inpatient, services when a member is:

  • In the emergency department and is being considered for inpatient admission but has not yet been approved for admission by Blue Cross or BCN
  • Being moved to observation status within the hospital from any other status or source
  • In observation status for 24 hours or more, if the member has not already received the form before being admitted for observation

For Medicare Advantage members in these circumstances, hospitals must present the member with a completed Medicare Outpatient Observation Notice. This is a Centers for Medicare & Medicaid Services requirement.

Hospitals should also review the instructions for notifying members using the Medicare Outpatient Observation Notice.

Here's when hospitals do not need to notify members

When Blue Cross or BCN has approved an inpatient admission, there's no need to notify the member using the form. When the member is not being considered for inpatient care, there's no need to notify either the member or the plan.

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

Posted: April 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

For dates of service on or after June 1, 2018, diabetic shoes and inserts will be managed by Northwood, Inc., for Blue Care Network HMOSM (commercial), BCN AdvantageSM and Blue Cross Medicare Plus Blue PPO members. This applies to HCPCS codes A5500 through A5513 and code K0903.

J&B Medical Supply currently manages these items and will manage them for dates of service on or before May 31, 2018.

Here's how to contact these vendors:

  • Northwood: Call Northwood at 1-800-393-6432 to identify a contracted supplier near you. The supplier submits the request to Northwood for review. Northwood representatives are available weekdays from 8:30 a.m. to 5 p.m. Northwood on-call associates are available after normal business hours at the same number.

  • J&B Medical Supply: Call J&B at 1-888-896-6233. J&B representatives are available weekdays from 8 a.m. to 5 p.m. J&B on-call associates are available after normal business hours at the same number.

We'll be updating the BCN and Blue Cross Medicare Plus Blue PPO provider manuals to reflect the changes related to diabetic shoes and inserts.

Posted: April 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

Time is running out to give us your opinion on our provider manuals. Please complete our online survey by April 30. You could win a $25 gift certificate. For more information see recent articles in The Record and page 13 of BCN Provider News.

Posted: April 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

Earlier this year, we notified you and members that Blue Cross and Blue Care Network will no longer cover hyaluronic acids beginning April 1.

After further review, we've decided to continue covering hyaluronic acids while we conduct additional research. We hope to have a final decision in the next few months and will continue to update you on this critical initiative.

Members will receive a letter soon with the updated information.

Posted: March 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

As a reminder, effective for dates of service on or after April 2, 2018, all non-emergency air ambulance transports for Blue Cross Blue Shield of Michigan PPO (commercial) and Blue Care Network HMOSM (commercial) members require authorization.

Requests to authorize non-emergency flights must be submitted to and approved by Alacura Medical Transportation Management, LLC, prior to the flight. This requirement applies to both in-state and out-of-state air ambulance transports.

Emergency flights – when the patient cannot safely wait six hours to take off – do not require authorization. This includes situations that involve delays due to weather or stabilizing the patient. When it's an emergency, just transport the patient.

How to request an authorization for non-emergency flights

To contact Alacura about authorizing a non-emergency flight request, do the following:

  1. Complete the Air ambulance flight information (non-emergency) form and fax it, along with clinical documentation in support of the request, to Alacura at 1-844-608-3572.
  2. Call Alacura at 1-844-608-3676 to obtain an authorization number.

Additional information

You'll find additional information about air ambulance requirements on page 2 of the Air ambulance flight information (non-emergency) form and in upcoming issues of The Record and BCN Provider News. The Blue Cross and BCN provider manuals are also being updated.

The following articles were published in past newsletter issues:

Posted: March 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

We're working to improve our service to you and would like your opinion on our provider manuals. Please complete our online survey by April 30. You could win a $25 gift certificate. For more information, see recent articles in The Record and BCN Provider News.

Posted: March 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

Provider forums are coming to a town near you

Blue Cross Blue Shield of Michigan and Blue Care Network's 2018 provider forums begin in May. You can register for the full day or choose to attend just the morning or afternoon session. Dates, times, locations and registration information can be found on our provider forum flyer (PDF).

The morning sessions will have content specifically geared to physician office staff who are responsible for closing gaps related to quality measures and coding and will include:

  • The patient experience - why it's important to your practice and how you can improve it
  • 2018 CPT updates and coding scenarios for primary care physicians and specialists
  • HEDIS® measures

The afternoon sessions will be geared toward all office personnel and will include:

  • New provider service model
  • eviCore and prior authorizations
  • e-referral
  • The opioid epidemic
  • Behavioral health
  • Provider enrollment and provider inquiry updates

We hope you can join us.

HEDIS® is a registered trademark of the National Committee for Quality Assurance, or NCQA.

Posted: March 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

Effective immediately, the following CAR (chimeric antigen receptor) T-cell therapies require authorization for Blue Cross Medicare Plus BlueSM PPO and BCN AdvantageSM members:

HCPCS code Brand name Generic name
Q2041 YescartaTM axicabtagene ciloleucel
Q2040 KymriahTM tisagenlecleucel

To request authorization for these therapies:

  1. Complete the Medication Authorization Request Form on this page for the medication you're requesting.
  2. Gather the following supporting clinical documentation:
    • The member's eligibility for autologous hematopoietic stem cell transplant
    • Testing for CD19 tumor expression
    • Previous gene therapy
    • Detailed information about the therapies the member has already received
  3. Fax the completed form and the clinical documentation to 1-866-392-6465.

Since these requests require thorough review, we ask that you request an expedited review only if the standard review time frame could place the member's health in serious jeopardy.

Posted: March 2018
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

When submitting authorization requests for knee arthroplasty procedures in an outpatient setting, you may see a message in the e-referral system indicating "Procedure is not appropriate for treatment setting."

Here's what to do: Please ignore the message and proceed with the outpatient authorization request.

This applies to procedure codes *27446 and *27447, for BCN HMOSM (commercial), BCN AdvantageSM and Blue Cross Medicare Plus BlueSM members.

This year, the Centers for Medicare & Medicaid Services began allowing knee arthroplasty procedures to be done in an outpatient setting. The e-referral system will accept those authorization requests but it's displaying the message that makes it seem like it won't. We're getting many calls from providers asking what they should do.

The e-referral system is being adjusted to stop displaying the message, but the update won't be completed until sometime in April. At that time, you'll no longer see the "Procedure is not appropriate for treatment setting" message when submitting outpatient knee arthroplasty authorization requests.

Meanwhile, ignore the message and proceed with the outpatient request.

We appreciate your patience as we update the e-referral system.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2017 American Medical Association. All rights reserved.

Posted: February 2018
Line of business: Blue Cross and Blue Care Network

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

Effective for dates of service on or after April 2, 2018, all non-emergency air ambulance transports for Blue Cross PPO (commercial) and Blue Care Network HMOSM (commercial) members require authorization. Requests for authorization must be submitted to Alacura Medical Transportation Management, LLC, prior to the flight. Information about the process to use in submitting these requests will be made available closer to the April effective date.

This requirement applies to both in-state and out-of-state air ambulance transports.

Blue Cross and BCN are partnering with Alacura to provide review of non-emergency air ambulance flights. Alacura will use the Blue Cross and BCN medical policy titled Air Ambulance Services to determine the appropriateness of non-emergency flights.

There are no changes to member benefits related to air ambulance services. Non-emergency air ambulance services are eligible for reimbursement if the member has the benefit and if Alacura authorizes the flight.

Reason for this change: Air ambulance transports that are not medically necessary or that are flown by noncontracted providers expose Blue Cross and BCN members to significantly greater out-of-pocket costs and are much costlier for the plan. The requirement for authorization prior to non-emergency flights is expected to lower costs for Blue Cross and BCN members and customers.

Billing air ambulance claims: As a reminder, instructions for billing emergency and non-emergency air ambulance services for dates of service on or after Jan. 1, 2017, are now available. For the details, see the web-DENIS message posted Jan. 12, 2018, titled "Air ambulance billing instructions are now available."

Posted: January 2018
Line of business: Blue Cross and Blue Care Network

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

Blue Cross Blue Shield of Michigan PPO (commercial) and Blue Care Network HMOSM (commercial) plans won't cover hyaluronic acids, beginning April 1, 2018.

Hyaluronic acids, also known as viscosupplements, are used to treat osteoarthritis of the knee.

Randomized controlled trials and national guidelines have examined the effect of hyaluronic acids on pain and function. The combined data show:

  • A lack of defined meaningful clinical improvements over placebo
  • Well-characterized biases among trials
  • Publication bias
  • Missing study results

Effective April 1, 2018, the following hyaluronic acids will be considered investigational and won't be covered for Blue Cross and BCN commercial (non-Medicare) members.

J code Drug description
J7320 Hyaluronan or derivative, GenVisc® 850 for intra-articular injection, 1 mg
J7321 Hyaluronan or derivative, Hyalgan® for SupartzTM for intra-articular injection, per dose
J7322 Hyaluronan or derivative, Hymovis® for intra-articular injection, 1 mg
J7323 Hyaluronan or derivative, Euflexxa® for intra-articular injection, per dose
J7324 Hyaluronan or derivative, Orthovisc® for intra-articular injection, per dose
J7325 Hyaluronan or derivative, Synvisc® or Synvisc-One® for intra-articular injection, 1 mg
J7326 Hyaluronan or derivative, Gel-One® for intra-articular injection, per dose
J7327 Hyaluronan or derivative, Monovisc® for intra-articular Injection, per dose
J7328 Hyaluronan or derivative, Gel-SynTM for intra-articular injection, 0.1 mg
Future J codes Future hyaluronan or derivative products, not yet approved by the FDA

Posted: January 2018
Line of business: Blue Cross and Blue Care Network

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

Behavioral health medical record documentation requirements are now available online. These requirements apply across all lines of business (Blue Cross PPO, Blue Cross Medicare Plus BlueSM PPO, BCN HMOSM and BCN AdvantageSM).

The requirements are available on this website, on both the Blue Cross Behavioral Health page and the BCN Behavioral Health page.

Professional, hospital and facility behavioral health providers contracted with Blue Cross or BCN must follow these requirements when documenting behavioral health services provided to our members.

One set of guidelines is for applied behavior analysis services. The other set applies to non-ABA services.

For additional information on these requirements, including why they were put in place, please review the following news articles:

Posted: November 2017
Line of business: Blue Cross and Blue Care Network

e-referral site wins communications awards

The e-referral site was honored recently with two awards from the International Association of Business Communicators.

Locally, the site received a Detroit Renaissance Award of Merit in Digital Communications. The Detroit chapter includes professional communicators from southeast Michigan.

At a regional level, the site received a Silver Quill Award of Merit from the IABC Heritage Region, which includes 17 states and the District of Columbia. The e-referral redesign was the only project from Michigan to receive this prestigious award.

Congratulations to the team behind the award-winning e-referral site.

Posted: October 2017
Line of business: Blue Cross and Blue Care Network

Do not refer new patients to MedEQUIP in Ann Arbor

Michigan Medicine's MedEQUIP provider of durable medical equipment is not accepting new patients as of Oct. 20, 2017. This is a temporary situation. Please see the MedEQUIP website for any exceptions and the latest information.

Posted: October 2017
Line of business: Blue Cross and Blue Care Network

2017 InterQual criteria to be implemented starting October 2

Blue Cross Blue Shield of Michigan and Blue Care Network will implement the 2017 InterQual® criteria starting Oct. 2, 2017, for all levels of care. These criteria are used to make utilization management and care management determinations for the services subject to review.

Until that date, the 2016 InterQual criteria will be used.

In addition, starting October 2, Blue Cross and BCN will implement their local rules. Until that date, the 2016 local rules will be used.

To access the 2017 Blue Cross Local Rules, do the following:

  1. Log in to Provider Secured Services.
  2. Click BCBSM Provider Publications and Resources.
  3. Click Newsletters & Resources.
  4. Click Clinical Criteria & Resources.
  5. Scroll down to the heading "BCBSM modifications to InterQual criteria."
  6. Click 2017 BCBSM modifications to InterQual criteria.

To access the 2017 BCN Local Rules, visit BCN's Clinical Review & Criteria Charts page on this website and click BCN's current Local Rules.

As a reminder, implementation of the 2017 criteria and local rules was delayed due to upgrades being made to the e-referral system.

Posted: September 2017
Line of business: Blue Cross and Blue Care Network

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

While the eviCore call centers, located in Florida and South Carolina, may be affected by Hurricane Irma, the online portal will remain fully operational.

You are encouraged to use the online portal at evicore.com to initiate authorization requests and check case status until the area has recovered. Calls will continue to be answered, but you may experience longer phone hold times or other issues.

Thank you for your patience.

Posted: September 2017
Line of business: Blue Cross and Blue Care Network

Reminder: 2017 InterQual criteria delayed until October 2017

As a reminder, Blue Cross Blue Shield of Michigan and Blue Care Network will delay implementing the 2017 InterQual® criteria until October 2017. This delay is due to upgrades being made to the e-referral system.

Until these upgrades are complete, we will continue to follow the 2016 InterQual criteria for all levels of care.

When we have a new date for implementing the 2017 criteria, we'll let you know through our standard channels of communication.

Posted: August 2017
Line of business: Blue Cross and Blue Care Network

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

Providers who need to contact the Pharmacy Clinical Help Desk about drugs covered under the medical benefit should call 1-800-437-3803, effective July 5, 2017. This applies to members covered through BCN HMOSM (commercial), BCN AdvantageSM and Blue Cross Medicare Plus BlueSM PPO products.

Providers who have been using other numbers to contact the Pharmacy Clinical Help Desk for drugs covered under the medical benefit should begin using the 1-800-437-3803 number effective July 5, 2017. All other numbers to the Pharmacy Clinical Help Desk will be discontinued as of July 5, 2017.

Posted: June 2017
Line of business: Blue Cross and Blue Care Network

2017 InterQual criteria delayed until October 2017

Blue Cross Blue Shield of Michigan and Blue Care Network will delay implementing the 2017 InterQual® criteria until October 2017. This delay is due to upgrades being made to the e-referral system.

Until these upgrades are complete, we will continue to follow the 2016 InterQual criteria for all levels of care.

When we have a new date for implementing the 2017 criteria, we'll let you know through our standard channels of communication.

Posted: May 2017
Line of business: Blue Cross and Blue Care Network

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

Providers who bill for drugs covered under the medical benefit for their Blue Cross and Blue Care Network commercial members are encouraged to review the additional information now available on the RC Claim Assist tool.

On this website, select BCN or Blue Cross and click to open:

The resources available include:

About RC Claim Assist

RC Claim Assist, created by RJ Health Systems, is a free resource now available to Blue Cross Blue Shield of Michigan and Blue Care Network contracted providers who bill for drugs covered under the medical benefit. The tool can help ensure that you are billing:

  • The correct National Drug Code with the billable HCPCS/CPT code
  • The correct NDC quantity
  • The correct unit of measure

Additional webinars to be scheduled later in the year

Additional provider webinars on the RC Claim Assist tool will be scheduled later in 2017. In the meantime, you should review the information currently available, register for the tool and begin using it. Click here to register for RC Claim Assist or to log in, if you are already registered.

Posted: April 2017
Line of business: Blue Cross and Blue Care Network

RC Claim Assist tool is now available

RC Claim Assist, created by RJ Health Systems, is a free resource now available to Blue Cross Blue Shield and Blue Care Network contracted providers who bill for drugs covered under the medical benefit. The tool can help ensure that you are billing:

  • The correct National Drug Code with the billable HCPCS/CPT®* code
  • The correct NDC quantity
  • The correct unit of measure

Training webinar

Click to open our webinar invitation and sign up to attend one of the RC Claim Assist training webinars we're hosting on March 14, 2017.

How do I access RC Claim Assist?

Visit the RC Claim Assist log-in page. Register to use RC Claim Assist by completing the following steps:

  1. Enter your NPI. (Very important!)
  2. Enter your first name and last name.
  3. Create your unique password when you are prompted to do so.

RC Claim Assist should be used only for claims submitted for Blue Cross Blue Shield of Michigan and Blue Care Network commercial members.

Questions?

Here's how to get your questions answered:

  • For questions concerning the data you see on RC Claim Assist, please email info@rjhealthsystems.com
  • For questions about billing or claims, contact Provider Inquiry.
  • For questions about a claim that are contractual or complex in nature, contact your provider consultant.

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

Posted: March 2017
Line of business: Blue Cross and Blue Care Network

Online self-paced training modules now available

You can now train on e-referral at your own speed. Go to the Training Tools page and look for Online self-paced learning modules in the Online training section. While you're there, check out the other training tools available to you.

Posted: September 2016
Line of business: Blue Cross and Blue Care Network



Welcome to the new referrals.bcbsm.com

You've probably already noticed things have changed. On our new site, to find the BCN information you've used in the past, just click "BCN" along the top or at the left of any page. You'll find all of the BCN-related referral and authorization information in the section that opens.

As time goes on, more information will be added to the Blue Cross section of the website.

When you first enter ereferrals.bcbsm.com, you're in the Home area where you’ll find pages like Provider Search and Quick Guides. This is information that may apply to both BCN and Blue Cross. When a page first displays in the Home section, all BCN and Blue Cross information is visible. To see information specific to a certain line of business, click either the Blue Cross or the BCN filter button at the top of the content section. To see all of the information again, click "Show All."

When you access one of these pages from within the BCN or Blue Cross section, though, only the information relevant to that line of business will be displayed and no filter buttons will appear.

The new ereferrals.bcbsm.com site also includes a Search feature. Look in the upper right part of the page. You can choose to search the Full Site or just the BCN or Blue Cross sections of the site. Enter your search term, select where you want to search from the drop-down, and click "Go."

Thank you to those who participated in the survey held earlier this year. Your input was used to determine some of the enhancements made to the site. If you have comments, please send us feedback.

Posted: May 2016
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

We're updating our look

In mid-May, ereferrals.bcbsm.com is launching a makeover. All the news, forms and information you've come to expect from the site will still be available, but we hope you'll find the new colors and photos more appealing. A new search feature will make the site easier to use. We're also adding a new section for Blue Cross content. Here's a sample of what's coming:

Posted: May 2016
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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

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 close on the following holidays:

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

During these office closures, 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: December 2018
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 close on the following holidays:

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

During these office closures, 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: November 2018
Line of business: Blue Cross Blue Shield of Michigan

Register now for an AIM Specialty Health® ProviderPortalSM webinar.

Beginning Jan. 1, 2019, Blue Cross Blue Shield of Michigan will implement two new utilization management programs for oncology services for UAW Retiree Medical Benefits Trust (URMBT), non-Medicare members. With these programs, prior authorization must be obtained through AIM Specialty Health for some outpatient medical and radiation oncology treatments. The programs require prior authorization for radiation oncology and medical oncology services in outpatient settings.

Sign up for a webinar to hear an overview of the program and learn how to access the AIM system and how the submission process works. The webinars listed are split between medical oncology and radiation oncology for clinical and non-clinical staff.

To register, click here. Once the host approves your registration, you'll receive a confirmation email with instructions for joining the session. For more information, see the article in the October 2018 issue of The Record.

Posted: October 2018
Line of business: Blue Cross Blue Shield of Michigan

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

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

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

During these holiday closures, the Blue Cross inpatient utilization management area remains available to accept inpatient authorization requests for Blue Cross PPO (commercial) and Blue Cross Medicare Plus BlueSM PPO members.

See the table below for instructions on submitting inpatient authorization requests when our corporate offices are closed.

Type of request Blue Cross PPO (commercial) Blue Cross Medicare Plus Blue PPO
Acute initial inpatient admissions Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week. These requests may also be submitted through the X12N 278 Health Care Services Review – Request for Review and Response electronic standard transaction Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week. 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 and fax to 1-866-411-2573. Follow the current process and fax to eviCore healthcare 1-844-407-5293.
Other inpatient services The requests listed below must be faxed 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. Call the Blue Cross after-hours urgent hotline at 313-448-3619 for any immediate or urgent need.

Additional resources related to the e-referral system are found elsewhere on this website.

Posted: July 2018
Line of business: Blue Cross Blue Shield of Michigan

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

In this course, you'll refresh your skills with the NovoLogix® web tool, and learn how to create prior-authorization requests for provider-administered specialty medical drugs.

Register for one of the following Blue Cross Medicare Plus BlueSM PPO webinars:

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

*In July 2017, Blue Cross Medicare Plus Blue PPO launched a prior-authorization program for select provider-administered specialty medical drugs.

Posted: August 2018
Line of business: Blue Cross Blue Shield of Michigan

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

In this course, you'll refresh your skills with the NovoLogix® web tool, and learn how to create prior-authorization requests for provider-administered specialty medical drugs.

Register for one of the following Blue Cross Medicare Plus BlueSM PPO webinars:

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

*In July 2017, Blue Cross Medicare Plus Blue PPO launched a prior-authorization program for select provider-administered specialty medical drugs.

Posted: July 2018
Line of business: Blue Cross Blue Shield of Michigan

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

All providers have the right to appeal an adverse decision made by the Blue Cross Medicare Plus Blue PPO utilization management staff on an inpatient admission authorization request.

The instructions for submitting an appeal are within the Blue Cross Medicare Plus Blue PPO Provider Manual (in the Utilization management chapter, and the "Contracted MI Provider Acute Inpatient Admission Appeals" section).

Expedited appeals: You may ask for an expedited appeal when circumstances require that we make a decision in a short period of time. To request an expedited appeal, call 1-866-807-4811.

First-level appeals: Send these to Medicare Plus Blue by fax, email or mail within 45 calendar days of the date noted on the written denial notification. You can submit additional clarifying clinical information to support your request, as follows:

  • Fax: 1-877-495-3755

  • Email: MedicarePlusBlueInpatientAppeals@bcbsm.com

  • Mail:
  • Medicare Plus Blue Inpatient Provider Appeals
    Blue Cross Blue Shield of Michigan
    Mail Code 1516
    600 E. Lafayette Blvd.
    Detroit, MI 48231-26271

Second-level appeals: Send these to us within 21 calendar days of the date noted on the first-level appeal decision.

Look for upcoming articles on this topic in The Record.

Posted: July 2018
Line of business: Blue Cross Blue Shield of Michigan

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

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

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

During these holiday closures, the Blue Cross inpatient utilization management area remains available to accept inpatient authorization requests for Blue Cross PPO (commercial) and Blue Cross Medicare Plus BlueSM PPO members.

See the table below for instructions on submitting inpatient authorization requests when our corporate offices are closed.

Type of request Blue Cross PPO (commercial) Blue Cross Medicare Plus Blue PPO
Acute initial inpatient admissions Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week. Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week.
Post-acute initial and concurrent admission reviews Follow the current process and fax to 1-866-411-2573. Follow the current process and fax to 1-866-464-8223.
Other inpatient services The requests listed below must be faxed 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. Call the Blue Cross after-hours urgent hotline at 313-448-3619 for any immediate or urgent need.

Note: Acute initial inpatient admissions may also be submitted through the X12N 278 Health Care Services Review – Request for Review and Response electronic standard transaction.

Additional resources related to the e-referral system are found elsewhere on this website.

Posted: July 2018
Line of business: Blue Cross Blue Shield of Michigan

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

Recently, an error in the e-referral system has been causing Blue Cross outpatient authorization requests that should not have been entered into the system to pend. Upon submission, providers submitting these authorizations in error receive a case ID and a pending message.

As a reminder, please check requirements before submitting outpatient cases to e-referral:

While this issue is being resolved, we are voiding these cases manually and sending a message to providers why the case has been voided.

Posted: June 2018
Line of business: Blue Cross Blue Shield of Michigan

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

We invite you to register for one of the educational webinars we're hosting about the upcoming changes to the Medicare Plus Blue specialty medication prior authorization program.

What you'll learn at the webinar

You'll learn about how Medicare Plus Blue is expanding its specialty medication authorization requirements to include outpatient facilities that bill with Place of Service 19, 22 or 24. Currently, only providers that bill with Place of Service 11 are subject to these requirements.

We first communicated about this change in a web-DENIS message posted on May 1, 2018.

How to register for the webinar

To sign up for a webinar, decide which webinar day and time is best for you:

  • Tuesday, June 19, 2018, from 9 to 9:30 a.m. (RSVP by Monday, June 18.)
  • Wednesday, June 20, 2018, from 1 to 1:30 p.m. (RSVP by Monday, June 18.)

Then complete the registration form and fax it to 1-866-652-8983 or email it as an attachment to ProviderInvitations@bcbsm.com. Instructions will be emailed to you a day or two prior to the webinar.

Posted: May 2018
Line of business: Blue Cross Blue Shield of Michigan

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

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

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

During these holiday closures, the Blue Cross inpatient utilization management area remains available to accept inpatient authorization requests for Blue Cross PPO (commercial) and Blue Cross Medicare Plus BlueSM PPO members.

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

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

Post-acute initial and concurrent admission reviews. Follow the current process and fax to 1-866-464-8223.

Other authorization requests. The types of requests listed below must be submitted by fax to 1-866-411-2585:

  • Authorization requests for sick or ill newborns
  • Authorization requests for gender reassignment
  • Contract eligibility issues for Federal Employee Program members

Additional information. You can also call the Blue Cross after-hours urgent hotline at 313-448-3619 for any immediate or urgent need.

Additional resources related to the e-referral system are found elsewhere on this website.

Posted: May 2018
Line of business: Blue Cross Blue Shield of Michigan

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

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

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

During these holiday closures, the Blue Cross inpatient utilization management area remains available to accept inpatient authorization requests for Blue Cross PPO (commercial) and Blue Cross Medicare Plus Blue SM PPO members.

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

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

Post-acute initial and concurrent admission reviews. Follow the current process and fax to 1-866-464-8223.

Other authorization requests. The types of requests listed below must be submitted by fax to 1-866-411-2585:

  • Authorization requests for sick or ill newborns
  • Authorization requests for gender reassignment
  • Contract eligibility issues for Federal Employee Program members

Additional information. You can also call the Blue Cross after-hours urgent hotline at 313-448-3619 for any immediate or urgent need.

Additional resources related to the e-referral system are found elsewhere on this website.

Posted: March 2018
Line of business: Blue Cross

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

In December, we told you about an inaccurate response you could receive when submitting an inpatient authorization request through the e-referral system for Blue Cross PPO members from group 71575. This system error has been fixed.

Now only Ascension members will generate an (appropriate) e-referral message instructing you to submit their authorization requests through ABS.

We apologize for the inconvenience caused by the prior systems error.

Posted: January 2018
Line of business: Blue Cross

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

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

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

During these holiday closures, the Blue Cross inpatient utilization management area remains available to accept inpatient authorization requests for Blue Cross PPO (commercial) and BLue Cross Medicare Plus Blue SM PPO members.

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

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

Post-acute initial and concurrent admission reviews. Follow the current process and fax to 1-866-464-8223.

Other authorization requests. The types of requests listed below must be submitted by fax to 1-866-411-2585:

  • Authorization requests for sick or ill newborns
  • Authorization requests for gender reassignment
  • Contract eligibility issues for Federal Employee Program members

Additional information. You can also call the Blue Cross after-hours urgent hotline at 313-448-3619 for any immediate or urgent need.

Additional resources related to the e-referral system are found elsewhere on this website.

Posted: January 2018
Line of business: Blue Cross

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

Effective Dec. 18, 2017, inpatient authorization requests submitted through the e-referral system for Blue Cross PPO members from group 71575 are resulting in an inaccurate response. The response says, "You are not able to submit this request. Requests for Ascension members are managed by ABS. Submit authorization request to ABS PreCert...".

If you see this message, please check the member's group number on the ID card. If the group number is 71575, then that member is not an Ascension member and the request should not be submitted to ABS PreCert.

We are working to fix this systems error and estimate it will be corrected by Jan. 15, 2018. Until then, we ask that you fax inpatient authorization requests for members from group 71575 to 1-866-411-2585. Remember to include member demographic and clinical information and a contact number in case we have questions.

We apologize for the inconvenience caused by this systems error.

Posted: December 2017
Line of business: Blue Cross

eviCore accepting Blue Cross PPO authorization requests starting Dec. 22

For services that require authorization by eviCore healthcare for Blue Cross PPO members for dates of service on or after Jan. 1, 2018, don't submit authorization requests until Friday, Dec. 22, 2017.

An article in the November 2017 issue of The Record had indicated that requests could be submitted as early as Dec. 18, but eviCore's system won't be ready to accept those requests until Dec. 22.

For more information on these authorization requirements, refer to:

Posted: December 2017
Line of business: Blue Cross

Clarification on Blue Cross inpatient authorization requirements for newborns

Only sick newborns—not well babies—require inpatient admission authorization from Blue Cross Blue Shield of Michigan. Since newborns take a few days to get added to their parent's health care coverage, and since the e-referral application doesn't allow for temporary requests until the sick baby has coverage, sick newborn inpatient admission authorization requests should be submitted by fax. Use the Acute Inpatient Fax Assessment Form to submit the request for patients with Blue Cross commercial PPO coverage. If the baby is not yet named, you can use "Baby Boy" or "Baby Girl" or, in the case of multiple births, "Baby Boy 1", "Baby Boy 2" as the baby's first name.

Our October Record article, Here's what you need to know about Blue Cross inpatient authorization requirements, initially caused some confusion. It listed newborn and gender assignment authorization requests as the only exceptions to using e-referral for submitting Blue Cross inpatient admission authorization requests. We should have said that only sick newborns and gender assignment require inpatient authorization via fax. We updated our October article to clarify this. We apologize for the confusion.

Posted: October 2017
Line of business: Blue Cross

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

On Jan. 1, 2017, we launched our eviCore physical therapy program with the intent of partnering with our provider community to foster better health outcomes for our members. We introduced this initiative by implementing an evidence-based tool delivered by eviCore that we felt would allow providers to offer their patients appropriate care at the right time.

We expected the program transition to be a seamless and positive experience for our providers. Unfortunately, the affects of this implementation didn't align with our intent. We apologize for any unnecessary confusion, frustration or inconvenience that you may have experienced during this transition. We truly value your partnership and want to assure you that we've heard your concerns and taken them seriously. As such, we've been working with eviCore to identify solutions to address these concerns.

Effective Oct. 1, 2017, we're implementing an interim solution that we hope you'll find satisfactory. When a member has had recent surgery and requires physical therapy as a part of their treatment plan, he or she will be entitled to receive a minimum of 12 visits within 45 days. This approach will allow these members to have two visits per week over the course of six weeks, and gives our providers more time to request approvals for any additional visits they want to have added to a member's treatment plan without creating a lapse in care.

While our interim solution is just a start, we want you to know there are long-term changes on the horizon. We've posted two documents on the e-referral site that detail the changes eviCore is making through the implementation of its new authorization model called corePathSM, effective Jan. 1, 2018:

If you have any questions regarding the information in this message, please reach out to your provider consultant. Thank you for your continued partnership.

Posted: October 2017
Line of business: Blue Cross

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

Starting Oct. 16, 2017, the way behavioral health facilities submit initial authorization requests, concurrent reviews and discharge summaries for Blue Cross Blue Shield of Michigan Medicare Plus BlueSM PPO members will change.

This applies to inpatient, partial hospital and intensive outpatient services. It applies to both substance use and mental health disorders.

The changes are summarized in an article in the October 2017 issue of The Record. Addition information is available on the Behavioral Health page in the Blue Cross section of this website.

Posted: October 2017
Line of business: Blue Cross

New name for Blue Cross® Physician Choice PPO

Blue Cross® Personal Choice PPO is now called Blue Cross Physician Choice PPO. See the Blue Cross Physician Choice PPO page for more information, including:

  • Online learning
  • Provider flyer
  • Frequently asked questions
  • User Guide

Posted: September 2017
Line of business: Blue Cross

Blue Cross inpatient authorization requirements clarified

As of July 31, 2017, inpatient admission authorization requests for Blue Cross Blue Shield of Michigan commercial PPO and Blue Cross Medicare Plus Blue® PPO must be submitted through e-referral except for newborn and gender reassignment which must be faxed. See the Blue Cross commercial and Medicare Advantage inpatient authorization requirements table on the Blue Cross Authorization Requirements & Criteria webpage for more information.

The application of clinical criteria is required in some cases to receive authorization. Concurrent review will occur for all inpatient admissions for members with Blue Cross Medicare Plus Blue PPO coverage and members with Blue Cross commercial PPO coverage through the UAW Retiree Medical Benefits Trust.

Facilities and providers should request an appropriate number of days when submitting their authorization request based on the member's diagnosis and clinical presentation. Requests for additional days must be submitted through e-referral and must include clinical updates.

If the member is discharged prior to the last covered day, a discharge date should be entered in e-referral. The discharge date and the total number of days the member was inpatient can be added to e-referral as a note. For instructions on how to do this, see the e-referral User Guide (PDF). Go to the Submitting an Inpatient Authorization section, and review the Create New (communication) instructions.

Posted: September 2017
Line of business: Blue Cross

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

A document titled Frequently asked questions about using the e-referral system has been posted to this website that gives providers important details about submitting authorization requests for services for Blue Cross PPO (commercial) and Blue Cross Medicare Plus BlueSM PPO members. It includes questions and answers emanating from an August 2017 webinar that showed providers how to use the system.

We hope this document will prove especially helpful to providers who started making the transition to the e-referral system on July 31, 2017. This was the effective date for submitting Blue Cross authorization requests through the e-referral system instead of through the prenotification system.

Additional information on using the e-referral system, including the e-referral User Guide, is available on the Blue Cross Training Tools page on this website.

Posted: August 2017
Line of business: Blue Cross

Clarifying authorization requirements for Blue Cross members

We are receiving authorization requests through the e-referral system for Blue Cross PPO (commercial) members that do not need to be submitted.

If you are submitting requests for Blue Cross PPO (commercial) members for procedures identified in the list of Services That Require Authorization as requiring authorization as of July 31, 2017, here's what you need to know: This document applies only to Blue Cross Medicare Plus BlueSM members.

Here's a summary of what's required for both sets of members.

For procedures

  • For Blue Cross Medicare Plus Blue members, professional providers must submit authorization requests through the e-referral system for the procedures listed on the Services That Require Authorization document. Authorization criteria related to these procedures are now available on the Blue Cross Authorization Requirements & Criteria page on this website.

  • For Blue Cross PPO (commercial) members, professional providers should continue to request authorization only for procedures that currently require it, such as the radiology procedures submitted through AIM and a few others. Joint replacements and similar procedures, which require authorization for Blue Cross Medicare Plus Blue members starting July 31, do not require authorization for Blue Cross commercial members.

For inpatient admissions

Facility providers should submit authorization requests for inpatient admissions through the e-referral system for dates of service on or after July 31, 2017, instead of using the prenotification system that's been used for these requests in the past.

For issues related to Blue Cross commercial member authorizations, please call 1-800-572-3413.

For Issues related to Blue Cross Medicare Plus Blue member authorizations, please call 1-866-309-1719.

To add a temporary member to Blue Cross commercial, such as a newborn admitted to a NICU, please fax requests to 1-866-411-2585.

Posted: July 2017
Line of business: Blue Cross

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

Beginning July 31, 2017, providers will use the e-referral system instead of the prenotification system for their Blue Cross PPO (commercial) and Blue Cross Medicare Plus BlueSM PPO members.

If you've been using the prenote system for services requiring prior authorization (also called authorization or preauthorization), you'll be switching to e-referral.

Interested providers are invited to attend an upcoming webinar on July 27 or August 31 for e-referral training. Fill out and submit the webinar invitation. Instructions for signing in to the webinar will be emailed to you prior to the event you sign up for.

Posted: June 2017
Line of business: Blue Cross

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

The Blue Cross® Personal Choice PPO page on this website now has expanded information including upcoming webinars, an FAQ document, an e-referral user guide and more.

You can navigate to the Blue Cross Personal Choice PPO page on this site by clicking Blue Cross and then Blue Cross Personal Choice PPO in the Blue Cross Authorizations / Referrals section of the left navigation.

Posted: August 2016
Line of business: Blue Care Network

Register now for a Blue Cross® Personal Choice PPO Webinar

Six one-hour webinars are being held to introduce the Blue Cross Personal Choice PPO. You can find more information, including the invitation and how to register on the Blue Cross Personal Choice PPO page of the e-referral site.

Posted: July 2016
Line of business: Blue Cross Blue Shield of Michigan