Blue Cross Blue Shield of Michigan

October 2017

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

    e-referral Quick Guide (PDF) - A brief overview of what you need to know to start using the e-referral tool.

    BCN Provider Inquiry Contact Information (PDF) - Provider Inquiry phone and fax numbers for all BCN products.

    BCN Provider Resource Guide (PDF) - Offers providers easy access to contact information for various BCN services and functions. Each service or function has a dedicated page that is updated as needed, so that the most current information is always available.

    BCN Provider Resource Guide At-a-Glance (PDF) - One-page summary of key BCN contact information. The At-a-Glance summary helps providers keep phone and fax numbers at their fingertips and is updated as needed, so that the most current information is always available.

    Blue Cross Provider Resource Guide At-a-Glance (PDF) - Two-page summary of key Blue Cross contact information. The At-a-Glance summary helps providers keep phone and fax numbers at their fingertips and is updated as needed, so that the most current information is always available.

    Blue Care Network Member ID Cards (PDF) - Brochure with BCN product information for providers, including images of the various member ID cards.

    Blue Cross and BCN Provider Systems and Web Resources Guide (PDF) - Two-page flyer detailing the computer systems used by provider offices and where to find information on the public and secured websites.

Blue Distinction Centers®

Our centers of excellence in hospital care are called Blue Distinction Centers for Specialty Care®.

Blue Cross and Blue Care Network have awarded the national Blue Distinction Centers for Specialty Care designation to Michigan hospitals that meet strict requirements for delivering quality health care in specific specialties.

Blue Distinction Center programs include:

  • Bariatric surgery
  • Cardiac care
  • Complex and rare cancers
  • 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 e-referral Bariatric Surgery page.

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 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