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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:


Changes in authorization requirements for outpatient facility and clinic-based sleep management studies take effect July 4, 2016

Effective with requests submitted on or after July 4, 2016, all requests to authorize outpatient facility and clinic-based sleep management studies for adult members 18 years of age and older will require the submission of evidence from the member's medical record. This evidence must confirm the specific condition the member has that would exclude or contraindicate a home sleep study.

This applies to BCN HMOSM (commercial) and BCN AdvantageSM members.

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

Detailed information about BCN's Sleep Management Program is available on this website, on the Sleep Management page.


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

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

Balloon ostial dilation does not require clinical review.

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

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


New Behavioral Health e-referral User Guide available

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

As a reminder, behavioral health providers are required to submit initial requests for authorization using the e-referral system starting May 1, 2016. See the news item on this.

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


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

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

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

Be sure to read the initial news item on this topic, also.

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

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

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


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

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

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

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

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

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


What you need to know about the eviCore 2.0 provider portal

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

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


Effective May 1, 2016, BCN behavioral health providers must use e-referral to submit initial requests for authorization, for non-urgent outpatient (clinic / office) services

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

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

Starting May 1, this form will no longer be available online and requests for initial outpatient authorization requests will be accepted only through the e-referral system. Requests to authorize extensions of outpatient treatment must also be submitted through the e-referral system.

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

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

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

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

Additional information. Urgent requests to authorize outpatient (clinic / office) services should continue to be called in to 1-800-482-5982. Requests to authorize other levels of care should be called in to BCN Behavioral Health at the appropriate phone number, as indicated on the Provider Inquiry Contact Information list. For more information, refer to the Behavioral Health chapter of the BCN Provider Manual.


Changes start May 1, 2016, for authorization requests submitted for inpatient acute medical / surgical admissions

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

This applies to all BCN lines of business, including for BCN HMOSM (commercial) members and BCN AdvantageSM (BCN Medicare Advantage) members.

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

Here are the details you need to know.

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

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

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

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

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

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

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

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

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

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


Additional BCN Local Rules for acute care and skilled nursing facility services go into effect May 2, 2016

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

These Local Rules are:

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


AMC Health to manage members with CHF and COPD effective April 1, 2016

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

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

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

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

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

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


We want your opinion

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

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

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

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


Updated nutrition assessment form now available for home infusion providers

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

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

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

What's important to know. Be aware that:

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


Updated preview questionnaire is available for excisional breast biopsy

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

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

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

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

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


Additional Local Rules for acute care and skilled nursing facility requests go into effect May 1, 2016

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

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

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


Care management requirements change for members with low back pain effective March 1, 2016

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

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

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

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


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

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

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

The drugs are:

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

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

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


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

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

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

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

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

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

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

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

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

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

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


BCN Behavioral Health utilization management criteria is changing on January 1, 2016

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

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

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

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

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

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

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


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

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

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

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

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


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

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

Instructions for clearing your browser history:

Google Chrome

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

Firefox

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

Internet Explorer 9 and higher

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


Announcing e-referral enhancements beginning Dec. 7, 2015

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

Searching for patient eligibility

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

Searching for a case

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

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

Summary of December 2015 Enhancements

Enhancement Viewing eligibility Case search
Previous implementation System brings up all eligibility spans, both active and inactive. Users must search through a list of views to locate the active coverage. When searching for a referral already submitted, users could search cases based on the provider in focus or all associate providers.
Issue Challenge to submit a request for members who show multiple incidents of eligibility. Referral is delayed if user chooses an inactive coverage from the list. BCN staff must void and re-enter the case, causing a delay System returned only a limited list of cases based on the provider in focus or a list of cases based on all associate providers.
December 2015 enhancements System will show only active eligibility and will default to today's date. Only active coverage will display vs. active and inactive spans. Users have the option to change the effective date if they are searching for a different date. User can now choose specific providers among the list of associate providers, in addition to the provider in focus, or they can choose "all."
Advantage Users will only see results based on the "eligibility-as-of" date entered in the patient search instead of a list of active and inactive eligibility spans. The enhancement will help users select a member with active coverage and reduce waiting time for a response. Customizes the number of results returned based on user selections. Can also search by Provider ID, Patient ID, and date


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

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

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

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

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



Global referral: What it allows a specialist to do

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

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

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

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



Changes in eviCore authorization requirements

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

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

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

Updated documents are available. Refer to the updated list of Procedures that require clinical review by eviCore healthcare. This list, along with additional information, is available on the Procedures Managed by eviCore for BCN Web page on this website.

Reminder. October 1, 2015, was the effective date on which eviCore healthcare (formerly CareCore National) began performing clinical review for select cardiology, radiology and radiation therapy services. This involves select non-emergent outpatient services when performed on or after Oct. 1, 2015, in freestanding diagnostic facilities, outpatient hospital settings, ambulatory surgery centers and physician offices for BCN HMOSM (commercial) and BCN AdvantageSM members.

* CPT codes, descriptions and two-digit numeric modifiers only are copyright 2014 American Medical Association. All rights reserved.



Add correct servicing provider information when submitting requests to eviCore

Be sure to add the correct servicing provider to the case, including name, NPI, address and other information, when submitting authorization requests to eviCore healthcare. When the correct servicing provider information is in the case, claims will pay. Without that information, the claim will not match the authorization and payment will be delayed.

BCN has experienced several instances in which the servicing provider's information was not entered correctly. Payments for the claims connected to those authorizations were delayed.



Reminder: Prostatic urethral lift procedures require clinical review

As a reminder, prostatic urethral lift procedures for the treatment of benign prostatic hypertrophy require clinical review effective Sept. 1, 2015. This applies to procedure codes *52441 and *52422 and to BCN HMOSM (commercial) and BCN AdvantageSM members.

More details are available in the Medical Policy Updates section in the September-October 2015 issue of the BCN Provider News.

The BCN Referral and Clinical Review Program was updated to reflect this change.

* CPT codes, descriptions and two-digit numeric modifiers only are copyright 2014 American Medical Association. All rights reserved.



eviCore healthcare Web Portal webinars available

The eviCore healthcare (formerly CareCore National) Web Portal gives providers immediate access to submit authorizations and view patient authorization and eligibility information 24/7. Using the Web Portal for requests is 8x faster than phone requests and located at www.carecorenational.com. eviCore has recently added several new features to improve the experience including:

Providers interested in learning more about the Web Portal and its new features are invited to attend one of the upcoming webinar training sessions (approximately 30 minutes long. All sessions Eastern Standard Time):

To register, follow these steps:

  1. Go to carecorenational.webex.com.
  2. Click on the "Training Center" tab at the top of the page.
  3. Click the "Upcoming" tab in the Live Sessions section.
  4. Find the session you want by looking in the "Date & Time" column and for "Web Utilization Overview" in the Topic column.
  5. Click "Register" for that session.
  6. Enter the registration information.



Updated Spine Care Referral Program questionnaire is now available

An updated questionnaire is now available on the Spine Care Referral Program Web pages on this website. The updated questionnaire includes the ICD-10 diagnosis codes that are comparable to the ICD-9 diagnosis codes previously included in the program. The ICD-10 codes are to be used for dates of service on or after Oct. 1, 2015.

The BCN Spine Care Referral Program is designed to ensure that all members with ongoing low back pain appropriately receive comprehensive and timely nonsurgical evaluation of their symptoms and condition prior to surgical evaluation.

As a reminder, non-emergent and non-urgent referrals for members 18 years of age or older submitted to a neurosurgeon or orthopedic surgeon for low back pain evaluation with these ICD-10 low back pain diagnoses require prior authorization. All members 18 or older with low back pain must be seen by a physical medicine and rehabilitation provider prior to referral to a neurosurgeon or orthopedic surgeon for the conditions represented by these diagnosis codes.



Some providers showing missing or incorrect address in e-referral

An issue has been identified in the e-referral system in which some providers in the In Focus bar (top right of the screen) are showing an incorrect or missing address. This is a known defect and BCN is currently working to permanently remove this field in the near future.

Users experiencing this issue are asked to ignore the empty or incorrect address field. Please contact your provider consultant with any comments or questions.



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

As a reminder, Oct. 1, 2015, is the effective date on which eviCore healthcare (formerly CareCore National) performs clinical review for additional radiology services and for select cardiology and radiation therapy services.

This applies to select non-emergent outpatient services when performed on or after Oct. 1, 2015, in freestanding diagnostic facilities, outpatient hospital settings, ambulatory surgery centers and physician offices for BCN HMOSM (commercial) and BCN AdvantageSM members.

Refer to the list of procedures that require clinical review by eviCore healthcare.

This list, along with additional information, is available on the Procedures Managed by eviCore for BCN Web page.



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

Please take a few minutes to respond to our Care Management survey and you could win a $250 gift card.

You can find the survey at http://tinyurl.com/2015BCNCM.

Your feedback is important to us because it will help us improve our care management processes. Encourage the physicians, nurses, referral coordinators and others in your office to take it, too.

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

This drawing is open to all contracted BCN providers.

Note: If you do not wish to participate in the survey but wish to be included in the drawing, you may enter by sending an email to BCNPhysicianSurvey@bcbsm.com with your entry request. Please include your name and NPI, and the name and address of your office. All requests must be emailed no later than Dec. 31, 2015.



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

A federal mandate requires all HIPAA-covered entities to adopt ICD-10 by Oct. 1, 2015. The International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) and Procedure Coding System (ICD-10-PCS) are new medical code sets under the Health Insurance Portability and Accountability Act and represent a significant change to the current ICD-9 coding system.

Providers should be aware of the following when entering referrals and authorizations into e-referral:



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

After careful consideration, Blue Cross Blue Shield of Michigan and Blue Care Network have decided that a re-evaluation of applied behavior analysis autism treatment after every three years will be required only in the following instances:

A component of the state's autism mandate is that insurance companies may require a re-evaluation for members at three-year intervals of ABA autism treatment. Because the mandate began three years ago, in 2012, many members are now approaching the time that the re-evaluation would be required.

Blue Cross and BCN have decided that the mandatory review is not needed for many members who are in ABA autism treatment. We expect that the members who do need re-evaluation and redirection of their ABA treatment will come to our attention through the continuous monitoring, evaluation and utilization management that providers are doing together with our behavioral health care managers. In addition, Blue Cross and BCN may require that a member undergo annual developmental testing as a standardized method of measuring treatment progress.

Additional information on this topic will be included in upcoming issues of the corporation's provider newsletters, as follows:

Providers are encouraged to subscribe to both newsletters in order to get current information about autism policies and other topics. To subscribe, visit bcbsm.com/providers and click Newsletters.



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

You can submit requests for authorization to eviCore healthcare (formerly CareCore National) prior to Oct. 1, 2015, for procedures with dates of service on or after October 1. EviCore can review these requests prior to October 1.

As a reminder, the table below shows the types of requests reviewed by eviCore.

 Dates of service Types of requests Pertinent procedure codes
Dates of service prior to Oct. 1, 2015
  • High-tech radiology procedures
Outpatient high-tech radiology procedure code summary
Dates of service on or after Oct. 1, 2015
  • High-tech radiology procedures
  • Additional radiology procedures
  • Select cardiology procedures
  • Select radiation therapy procedures
Procedures that require clinical review by eviCore healthcare

These requirements apply to BCN HMOSM (commercial) and BCN AdvantageSM members.

Submit requests for authorization of these procedures in one of two ways:

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



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

Many injectable or infusible drugs covered under Blue Care Network members' medical benefit can be safely and effectively administered at several different sites of care. The most common sites include the outpatient hospital, physician's office and the member's home.

To help manage the cost of these drugs, BCN is implementing a program that redirects patients receiving select infusion drugs in the hospital setting to alternate sites of care.

Starting Oct. 1, 2015, BCN commercial members who begin therapy with one of the following drugs or drug categories will be required to receive this therapy at an infusion center, at their physician's office or at home.

BCN is also reaching out to members currently being treated with these therapies and their physicians to encourage members to use a more cost-effective site of care, such as an infusion center, their physician's office or their home.

The BCN Referral/Clinical Review Program document will be updated by October 1 to reflect this new requirement. That document is available on this website, on the Clinical Review & Criteria Charts page.



Chiropractors may provide some physical therapy services for BCN commercial members

Effective Aug. 1, 2015, chiropractors contracted with BCN may provide some physical therapy services for BCN HMOSM (commercial) members with coverage through groups that offer standard chiropractic benefits. This applies to services represented by select *97XXX procedure codes, rendered in office and outpatient care settings.

The member's primary care physician must issue a global referral for "office visits" when the member:

The chiropractor may then request authorization for an episode of care directly from Landmark Healthcare, who manages these services for members on BCN's behalf.

You'll find additional information about the referral and authorization process for these services in the Care Management chapter of the BCN Provider Manual. Look in the section titled "Therapy management: PT, OT and ST (including chiropractors providing PT services)". This section has been updated to reflect the details that primary care physicians, specialists and chiropractors need to know.

The document Outpatient rehabilitation services: Frequently asked questions has also been updated with these changes.

Both documents are available through hyperlinks on the Outpatient Physical, Occupational and Speech Therapy Management Program page on this website.

* CPT codes, descriptions and two-digit numeric modifiers only are copyright 2014 American Medical Association. All rights reserved.



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

Effective with dates of service on or after Oct. 1, 2015, additional radiology services and select cardiology and radiation therapy procedures will require clinical review. Radiologists, cardiologists, radiation therapists and facilities who provide these procedures are invited to attend a webinar being held starting Sept. 16, where these changes will be discussed. Fill out and submit the webinar invitation (PDF). Instructions for signing into the webinar will be emailed to you prior to the event chosen.



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

Effective Oct. 1, 2015, preventive screening for lung cancer using low-dose computed tomography requires clinical review. For this preventive service, members do not have cost-sharing responsibilities. This is because under the Patient Protection and Affordable Care Act and Medicare's National Coverage Determination process, insurers must cover preventive services with no member cost-sharing.

Here is some important additional information you'll need to know:

Use *71250 for non-preventive services. For both BCN HMO and BCN Advantage patients, clinical review requests and claims involving non-preventive screening for lung cancer with low-dose computed tomography services should continue to be submitted using procedure code *71250. When you use this code, the member will have cost-sharing responsibilities.

Submit requests to eviCore. All requests for clinical review should be submitted to eviCore healthcare (formerly CareCore National) in one of the following ways:

The requests should be submitted prior to services being provided.

Additional information. Look for additional information in the September-October 2015 issue of BCN Provider News, in the Referral Roundup section. This issue will be published at the end of August.

* CPT codes, descriptions and two-digit numeric modifiers only are copyright 2014 American Medical Association. All rights reserved.



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

October 1, 2015, is the new effective date on which eviCore healthcare (formerly CareCore National) will perform clinical review for additional radiology services and for select cardiology and radiation therapy services.

This applies to select non-emergent outpatient services when performed on or after Oct. 1, 2015, in freestanding diagnostic facilities, outpatient hospital settings, ambulatory surgery centers and physician offices for BCN HMOSM (commercial) and BCN AdvantageSM members.

The date previously announced for the start of the expanded reviews was Sept. 1, 2015.

If a treating physician does not receive a medical necessity determination and authorization number from eviCore prior to performing these procedures, claims may not be reimbursed.

Requests for clinical review can be submitted in one of two ways:

A full list of procedures that require clinical review on or after Oct. 1, 2015, will be available by the end of September on the Radiology Management Program page on this website.



e-referral upgrade slated for Aug. 17

The e-referral system is being upgraded Aug. 17. You can find a list of enhancements in the July-August edition (PDF) of BCN Provider News. Please note that the date has changed from the one originally published.

While we upgrade the system, e-referral will be unavailable from 5 p.m. on Thursday, Aug. 13, until 7 a.m. on Monday, Aug. 17. Please hold routine referral and authorization requests during this time and enter them into the upgraded system starting Monday, Aug. 17. For urgent referral and authorization requests, use the numbers below:

  Care Management Behavioral Health
Friday, Aug. 14
9:30 a.m. to noon
and
1 to 5 p.m.
1-800-392-2512 BCN members:
1-800-482-5982
BCN Advantage members:
1-800-431-1059
After business hours 1-800-851-3904 BCN members:
1-800-482-5982
BCN Advantage members:
1-800-431-1059

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

The 2015 InterQual Home Care Criteria from McKesson Health Solutions is available only in a new Q&A format. It is no longer available in book form or through the McKesson Mobile DeliveryTM application.

Effective Aug. 3, 2015, BCN will use the 2015 Home Care Criteria in the new format, along with the other 2015 InterQual criteria. See the news item already published on this topic.

Providers who wish to access InterQual Home Care Criteria in the Q&A format must download it electronically using McKesson's InterQual View. To do that, visit mhsinfo.mckesson.com.*

*Blue Cross Blue Shield of Michigan and Blue Care Network do not control this website or endorse its general content.



More procedures to be reviewed by eviCore healthcare effective September 1

Effective with dates of service on or after Sept. 1, 2015, additional non-emergent outpatient high-tech radiology services and also many cardiology and radiation therapy services must undergo clinical review by eviCore healthcare (formerly CareCore National). These requirements will apply to BCN HMOSM (commercial) and BCN AdvantageSM members.

Providers will be able to submit requests for clinical review for these procedures in one of two ways:

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

Currently, review by eviCore is required for certain outpatient CT, MRI and nuclear scans. Prior to the effective date of the new requirements, an updated outpatient high-tech radiology procedure code summary, listing all the radiology procedures reviewed by eviCore, will be available on the Radiology Management Program page on this website. In addition, lists of all the cardiology and radiation therapy procedures reviewed by eviCore will also be available on that page.

The additional radiology procedures that will require eviCore's review include but are not limited to the following:

Radiology

The cardiology and radiation therapy procedures that will require eviCore's review include but are not limited to the following:

Cardiology

Radiation therapy

eviCore healthcare Web address changes July 6

Effective July 6, 2015, providers submitting online clinical review requests for the high-tech radiology procedures that require it must visit www.evicore.com. This Web address replaces the previous one, www.carecorenational.com, as of July 6.

Providers will still be able to submit the requests for clinical review by phone at 1-855-774-1317, but online submission is the preferred method.

The change in Web address is aligned with the change in name from CareCore National to eviCore healthcare. The name change is already in effect.

For more information on the high-tech radiology procedures that require clinical review, refer to the Radiology Management Program page on this website.



Upgrades coming to e-referral

Several new upgrades and changes are coming to the e-referral system. The expected go-live date for these enhancements is Aug. 3, 2015. With the upgrade, users will be able to:

Other changes:

These changes can be found in the updated User Guide (PDF) or the User Guide addendum (PDF).

In order to upgrade the system, e-referral will not be available starting late Friday, July 31 through early Monday, Aug. 3. Please see the article on Page 1 of the July-August 2015 BCN Provider News for full details.



2015 InterQual® criteria to be used effective August 3

On Aug. 3, 2015, Blue Care Network's Care Management staff will begin using the 2015 McKesson Corporation InterQual criteria when making determinations on clinical review requests for members with coverage through BCN HMOSM and BCN AdvantageSM products. Updated versions of BCN's Local Rules will also go into effect on August 3.

Additional information about these criteria updates and BCN's Local Rules will be included in the July-August 2015 issue of the BCN Provider News, which will be available in late June.



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

Effective with dates of service on or after July 1, 2015, BCN will require prior authorization/clinical review for the medications listed below before these drugs will be covered under the members' medical benefits.

This requirement applies only to BCN HMOSM (commercial) members. For BCN AdvantageSM members, no prior authorization/clinical review is required for these services.

J CODE Medication
J0220
  • Myozyme®
J0221
  • Lumizyme®
J0775
  • Xiaflex®
J1458
  • Naglazyme®
J1744
  • Firazyr®
J1931
  • Aldurazyme®
J2504
  • Adagen®
J9043
  • Jevtana®
J9047
  • Kyprolis®
J9228
  • Yervoy®
J9354
  • Kadcyla®

These prior authorization/clinical review requirements apply only to members who start their medications on or after July 1, 2015. Members who have a paid claim for one of these medications by the end of June 2015 will not be required to seek initial prior authorization/clinical review.

Prior authorization/clinical review criteria include, but are not limited to: diagnosis, lab results, dosing and frequency of administration. We may also require documentation of medications previously used to treat the member's condition, including dosage, regimens, dates of therapy and response, as well as additional pertinent medical information.

To request prior authorization/clinical review for one of these medications, please submit the request through BCN's e-referral system or fax the request to BCN Care Management at 1-800-675-7278. You can also call Care Management at 1-800-392-2512.

As a reminder, all medications represented by codes J3490, J3590 also require prior authorization/clinical review for all members because these codes represent services that are not otherwise classified.

For a full list of all medications and procedure codes subject to prior authorization/clinical review requirements, click Clinical Review & Criteria Charts at the left on this page and then click Blue Care Network Referral and Clinical Review Program.

Additional information on the medical necessity criteria is available on the same Web page. Just scroll down to the medical necessity criteria section and click Clinical Information for Drugs Covered under the Medical Benefit That Require Medical Necessity Review.

Updated versions of these documents will be available on the Web by July 1.



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

Effective with requests submitted on or after April 1, 2015, transplants that require clinical review are subject to the standard clinical review process managed by BCN Care Management staff. Prior to April 1, clinical review was completed by a BCN case manager. This change applies to solid organ and bone marrow evaluations and harvesting (except kidney, skin and cornea), for all members. This also applies to requests to renew or extend an authorization period if the transplant procedure does not occur within the time frame allowed by the authorization.

The preferred method for requesting clinical review is to submit the request through BCN's e-referral system. You can also call in the request to Care Management at 1-800-392-2512. Clinical documentation should be faxed to 1-800-675-7278.

In addition, as a reminder, BCN HMOSM(commercial) members are required to have their transplants performed at a Blue Distinction® Center+ for Transplants, if one is available. This requirement is effective May 1, 2015. In Michigan, the only facility that has achieved the Blue Distinction Center+ for Transplants designation is the University of Michigan Hospital System (for most, but not all, types of transplants). If a Blue Distinction Center+ for Transplants facility is not available for the type of transplant the member needs, a Blue Distinction Center for Transplants facility may be used.

BCN AdvantageSM members are required to have their transplants performed in facilities that are approved by the Centers for Medicare & Medicaid Services and are contracted with BCN Advantage. It's preferred that BCN Advantage members be directed to a Blue Distinction Center for Transplants, when one is available.

For additional information, see the article "BCN updates transplant policy for Blue Distinction Centers" in the March-April 2015 issue of BCN Provider News.



Finding home sleep study providers

You can find the names of home sleep study providers contracted with BCN at bcbsm.com/find-a-doctor by typing "home sleep testing" in the What are you looking for? field.

For more specific instructions for finding BCN-contracted home sleep study providers, refer to the document Finding home sleep study providers.

In addition to the home sleep study providers you'll find for the ZIP code you enter, Night Hawk Sleep Systems, Inc., provides home sleep study services for BCN members throughout Michigan. You can call Night Hawk at 1-877-622-2022.

Only providers who are board-certified in sleep medicine and are specifically contracted with BCN for home sleep studies can bill for this service.

Additional information about BCN's Sleep Management Program can be found on the Sleep Management Program page at ereferrals.bcbsm.com.



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

For BCN AdvantageSM members. For BCN Advantage members, neither referral nor clinical review is required for services involving long-term continuous electrocardiographic rhythm recording and storage devices worn on an adhesive patch when supplied by a contracted provider and used for time periods longer than 48 hours, up to 14 days. This applies to devices such as the Zio® Patch and LifeStar ACT and to procedure codes *0295T through *0298T.

Clinical review is required for all providers not contracted with BCN. This includes the manufacturers of the ECG monitoring devices. If the manufacturer will be billing BCN directly for procedure code *0297T, clinical review is required.

For BCN HMOSM members. For BCN HMO (commercial) members, clinical review is still required for continuous ECG monitoring using these rhythm recording and storage devices. You can submit your request for review via the e-referral system or by calling BCN Care Management at 1-800-392-2512. For commercial members, the following two clinical review requests need to be entered:

Date span on the request. The date span on requests for all members should be 45 days, to allow time for the various activities associated with these devices, including device hook-up, member instruction, the days the device is actually in use, the return of the device and interpretation of the results.

* CPT codes, descriptions and two-digit numeric modifiers only are copyright 2014 American Medical Association. All rights reserved.



Register now for April 2015 behavioral health webinar

Fill out and submit the registration form to secure your spot in an April 2015 Blue Cross Blue Shield of Michigan and Blue Care Network behavioral health webinar. No need to travel; you can participate in the webinar right at your desk.

The topics covered include:

You can select one of the following two dates:

The same information will be covered on each webinar date.

Registration closes Friday, April 17, so get your form in right away. The instructions for submitting the registration form are right on the form. We will email you the instructions for signing in to the webinar a day or two prior to the webinar.

The webinar is for behavioral health providers who serve BCBSM and BCN members.



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

Effective with dates of service on or after April 1, 2015, BCN will require prior authorization/clinical review for the medications listed below before these drugs will be covered under the members' medical benefits.

J CODE Medication Prior authorization / clinical review is required for these members
J0180
  • Fabrazyme®
All members except those with BCN AdvantageSM coverage
J0256
  • Aralast NP
  • Prolastin®
  • Zemaira®
J0257
  • Glassia
J0638
  • Ilaris®
J1300
  • Soliris®
J1786
  • Cerezyme®
J1743
  • Elaprase®
J3060
  • ElelysoTM
J3385
  • Vpriv®
J9999 All medications All members

These prior authorization/clinical review requirements apply only to members who start their medications on or after April 1, 2015. Members who have a paid claim for one of these medications by the end of March 2015 will not be required to seek initial prior authorization/clinical review.

Prior authorization/clinical review criteria include, but are not limited to: diagnosis, lab results, dosing and frequency of administration. We may also require documentation of medications previously used to treat the member's condition, including dosage, regimens, dates of therapy and response, as well as additional pertinent medical information.

To request prior authorization/clinical review for one of these medications, please submit the request through BCN's e-referral system or fax the request to BCN Care Management at 1-800-675-7278. You can also call Care Management at 1-800-392-2512.

As a reminder, all medications represented by codes J3490 and J3590 also require prior authorization/clinical review for all members because these codes represent services that are not otherwise classified.

For a full list of all medications and procedure codes subject to prior authorization/clinical review requirements, click Clinical Review & Criteria Charts at the left on this page and then click Blue Care Network Referral and Clinical Review Program.

Additional information on the medical necessity criteria is available on the same Web page. Just scroll down to the medical necessity criteria section and click Clinical Information for Drugs Covered under the Medical Benefit That Require Medical Necessity Review.

Updated versions of these documents will be available on the Web by April 1.



Some e-referral cases pending; BCN Care Management provider call volumes high

An issue has been identified in the e-referral system causing an increase in pending cases that would normally automatically approve. BCN is working diligently to correct the issue and asks providers to refrain from submitting additional, duplicate requests. The BCN Care Management line has been experiencing higher call volumes due to this issue. Please check this page for updates to this issue.



Member compliance required before reauthorizing positive airway pressure devices effective Jan. 1, 2015

Effective with requests for authorization initiated on or after Jan. 1, 2015, BCN HMOSM (commercial) and BCN AdvantageSM members who use positive airway pressure devices must show they're complying with their treatment recommendations in order to use the devices for longer than 90 days.

For members meeting criteria for initial coverage of a device, Northwood, Inc., BCN's durable medical equipment benefit manager, will authorize use of the device only for an initial three-month period.

There are specific activities that have to be completed by the member, the member's practitioner, Northwood and the DME supplier, both at the time the PAP device is prescribed and during the first 90 days the device is used.

Be sure to familiarize yourself with the new process by reading the details in the November-December 2014 BCN Provider News issue, on pages 48 and 49.



Issues and tips document updated

The Current issues and tips (PDF) has been recently updated. New tips have been added for common e-referral submission scenarios including reasons why a submission may pend. Look for the yellow NEW! icon for the latest additions to this document.



Enter to win a $250 gift certificate — Take the 2014 Care Management survey

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 survey for a chance to win one of two $250 gift certificates. Survey responses must be submitted no later than Dec. 31, 2014 to be eligible for the drawing. One entry per person. Winners will be chosen in January 2015.



Current e-referral system issues

We are experiencing issues with the new e-referral system and are working to fix them. Please check the Current issues and tips (PDF) for the latest updates. We thank you for your patience


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).



Issues and tips document now available

We are finding some issues with the new e-referral system that we want to share with you (PDF). Please check back for updates. You can also get to this document by clicking the panel on the right of the home page that says "Click here for issues and tips."

If you find an issue that has not been identified here, please contact your provider consultant for assistance. Thank you for your patience as we improve our e-referral system for you.



New e-referral system now available!

Welcome to the new e-referral! Access to e-referral is now through Provider Secured Services. Please see the Test your e-referral user ID and password flier (PDF) for instructions on how to log in, what to do if you account is not active and obtaining a user ID and password. If additional help is needed, please contact the Web Support Help Desk at 1-877-258-3932.

Training tools are available on the Training Tools page. BCN encourages users to take the online e-referral training (audio required, 45 minutes run time) for an overview of the new e-referral tool.



Are you ready for the new e-referral tool? It's coming Monday, Sept. 29 at 7 a.m.

The transition to Blue Care Network's new e-referral system has begun. Here's a checklist to make sure you're ready for the new tool.

We have posted the new e-referral User Guide, an e-referral Quick Guide, and a frequently asked questions document on the Training Tools page.

Support is available
Need help logging in? Call the Web Support Help Desk at 1-877-258-3932.
Need help with a referral or authorization? Call BCN Care Management at 1-800-392-2512.
Need help with Behavioral Health authorizations? For BCN members, call 1-800-482-5982; for BCN Advantage, call 1-800-431-1059.
For other questions, contact your provider consultant. Go to bcbsm.com/providers and click on Contact Us.


New e-referral online training now available

Online training for the new e-referral tool is now available! Train from your desktop with this step-by-step guide which will prepare you for the new system coming Sept. 29 at 7 a.m. The training can be found on the Training Tools page along with instructions (PDF) on testing your user ID and password before beginning training.

A BCN Alert has also been sent to subscribers of the BCN Provider News regarding this training opportunity. If you are not already subscribed to receive these emails, please visit bcbsm.com/providernews to sign up and receive future information by email.

As a reminder, the current e-referral system will be unavailable starting at noon on Sept. 25. The new e-referral tool will be live on Monday, Sept. 29 at 7 a.m. More information is available in the transition information flier (PDF).



The new e-referral tool coming Sept. 29; training tools now available

A new e-referral tool will be live on Monday, Sept. 29 at 7 a.m. In order to maintain access to e-referral without disruption, please make sure your Provider Secured Services user ID and password (web-DENIS ID) are operational for the sign-on process. For instructions on testing your user ID and password, please see the article on Page 44 in the September-October 2014 BCN Provider News.

The new e-referral tool includes several new features:

Several training tools are available to help you prepare for the new e-referral. Please visit the Training Tools page to download the comprehensive user guide, a quick guide to getting started and a flier. The user guide will be mailed to every active e-referral user. Online training is coming soon.



Care Management phone line unavailable Thursday, Sept. 4 from noon to 1:30 p.m.

The Care Management phone line will be closed on Thursday, Sept. 4 from noon to 1:30 p.m. We apologize for this inconvenience.



Outpatient high-tech radiology requests must now go through CareCore National

BCN and BCN AdvantageSM members who need outpatient high-tech radiology must have clinical review and approval through CareCore National before receiving services. For more information, see page 1 of the July-August 2014 BCN Provider News (PDF). Refer to the Radiology Management page of this website to view the training material, an Authorizations Quick Reference Guide, the list of outpatient high-tech radiology services that require CareCore review and an updated list of frequently asked questions.


CareCore National training presentation now available online

Did you miss the CareCore National training webinars? The presentation is now available for you to review at your convenience. Go to the Radiology Management page and look for the "CareCore National training" section.

On that page, you'll also find some of the questions asked during the completed training sessions. These include how to update your office's information.



2014 InterQual® criteria to be used effective August 4

On Aug. 4, 2014, Blue Care Network's Care Management staff will begin using the 2014 McKesson Corporation InterQual criteria when making determinations on clinical review requests for members with coverage through BCN HMOSM and BCN AdvantageSM products. Updated versions of BCN's local rules will also go into effect on August 4.

Additional information about these criteria updates and BCN's local rules will be included in the July-August 2014 issue of the BCN Provider News, which will be available in late June.



CareCore National training webinars available

As previously announced, BCN will require clinical review for non-emergent, outpatient high-tech radiology services through CareCore National effective for dates of service on or after July 1, 2014. To learn how to register with CareCore, request clinical review, verify the status of the review and more, providers are invited to attend one of the upcoming training webinars:

Providers may download the webinar invitation (PDF), fill out the information and fax back or submit it electronically.

CareCore National will begin taking authorization requests on June 17, 2014, for dates of service on or after July 1, 2014. Providers who do not already have a user ID and password to log in to carecorenational.com can register beginning June 17.

Long-term continuous ECG rhythm recording and storage services require clinical review

Services involving long-term continuous electrocardiographic rhythm recording and storage devices worn on an adhesive patch continue to require clinical review for BCN HMOSM (commercial) and BCN AdvantageSM members. This applies to devices such as the Zio® Patch and to procedure codes *0295T through *0298T. The BCN Referral and Clinical Review Program has been updated with this information.

Clinical review is required for extended cardiac monitoring using devices such as the Zio Patch for time periods longer than 48 hours, up to 14 days for BCN HMO members. BCN Advantage covers this monitoring for up to 21 days.

Continuous ECG monitoring using these rhythm recording and storage devices is no longer considered experimental and investigational starting May 1, 2014, but clinical review is still required.

You can submit your request for review via the e-referral system or by calling BCN Care Management at 1-800-392-2512. Requests for BCN Advantage are pended in e-referral and will be approved by the plan. Requests for BCN HMO members are pended until review is completed.

* CPT codes, descriptions and two-digit numeric modifiers only are copyright 2013 American Medical Association. All rights reserved.

High tech radiology authorization requests must go through CareCore National effective July 1

BCN has contracted with CareCore National, LLC, for prior authorization and medical necessity reviews for outpatient radiology services including MRI, CT, and Nuclear Scans. BCN will require prior authorization for these services performed on or after July 1, 2014, from CareCore National online at carecorenational.com or by phone at 1-855-774-1317.

If a treating physician does not receive a Medical Necessity Determination and Authorization number from CareCore National prior to performing radiology procedures, claims may not be reimbursed.

For more information, please visit the Radiology Management page of e-referral for FAQs, a Quick Guide, and an updated Outpatient high-tech radiology procedure code summary.

Updated BCN Behavioral Health forms now available

Updated forms for use by BCN's behavioral health providers are now available on the e-referral Behavioral Health Web page as follows:

These forms are to be used with BCN HMO (commercial) and BCN Advantage members.

The revisions to the forms include:

The forms are also available on the web-DENIS BCN Provider Publications and Resources page under the Behavioral Health and Forms sections, but providers can readily access them on the e-referral website under Behavioral Health without having to sign in.



Proton beam therapy requires clinical review effective March 1

BCN is revising and formalizing clinical review criteria for proton beam radiation therapy effective March 1, 2014, for both BCN HMOSM (commercial) and BCN AdvantageSM members. This affects procedure codes *77520, *77522-*77523 and *77525. The BCN Referral and Clinical Review Program is updated with these requirements.

Providers should continue to submit clinical review requests for these procedures, either through the e-referral system or by calling BCN Care Management at 1-800-392-2512. As is currently the case, the requests will be pended for review and Care Management will require additional information.

The most significant changes to the criteria for these procedures are:

For a more detailed explanation of the requirements for this therapy, read BCN's updated medical policy titled Charged-Particle (Proton or Helium Ion) Radiation Therapy. To access this policy, log in to Provider Secured Services, click web-DENIS, click BCN Provider Publications and Resources and click Medical Policy Manual. Use the medical policy index to search for this policy under "C."

Additional details on these requirements will also be available in an upcoming issue of the BCN Provider News.

* CPT codes, descriptions and two-digit numeric modifiers only are copyright 2013 American Medical Association. All rights reserved.



BCN Care Management provider call volumes high

BCN Care Management continues to experience 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. We apologize for any inconvenience as we work to improve our telephone response time.



Zoledronic acid - new J code and e-referral questionnaire effective Feb. 3

A sample questionnaire for zoledronic acid (PDF) replaces the Reclast® sample questionnaire on the e-referral Clinical Review & Criteria Charts page, effective Feb. 3, 2014. We updated the questionnaire to reflect the generic name of zoledronic acid and the new J code assigned to the medication, which is J3489.

The J3489 code replaces the following codes:

When requesting authorizations for zoledronic acid (Reclast or Zometa) on e-referral, the system will prompt you to complete a questionnaire to determine the appropriateness of the request. If clinical criteria are met, approval will be granted for one year.

Medication Approved indications Previous code New J code
Reclast (zoledronic acid) 5mg/100ml Postmenopausal osteoporosis J3488 J3489
Zometa (zoledronic acid) 4mg/100ml Multiple myeloma J3487
Bone metastasis from solid tumor
Hypercalcemia of malignancy

We encourage you to review the sample zoledronic acid questionnaire and familiarize yourself with the questions you'll need to answer on the questionnaire in the e-referral system.

Zoledronic acid is part of the Blue Care Network Drug Utilization Management Program and requires clinical review for BCN HMOSM and BCN AdvantageSM members, in order to ensure safe and appropriate use of the medication.



Prior Authorization for CCTA effective Feb. 3

BCN previously communicated that clinical review will be required for CCTA for BCN commercial and BCN AdvantageSM HMO-POS and BCN AdvantageSM HMO members effective Feb. 3, 2014.

Providers may submit requests for clinical review for these procedures to BCN electronically. Users will be prompted to complete an appropriateness questionnaire for clinical review consideration. If the criteria are met, the request will be automatically approved. If the criteria are not met, the request will require further clinical review. Health care providers may also contact BCN's Care Management department at 1-800-392-2512 to request clinical review.

The questionnaire is available on the e-referral Clinical Review & Criteria Charts page under Medical necessity criteria / benefit review requirements.



Updated questionnaires available for epidural and facet joint injections

Blue Care Network has updated the questionnaires for the epidural and facet joint injection procedures with minor verbiage changes. These updates are in effect beginning Jan. 6, 2014.

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



Radiology Management Program Changes effective Jan. 6, 2014

Appropriateness questionnaires for four high-tech radiology procedures have been updated with minor verbiage changes and are available on Sample questionnaires for high-tech radiology procedures. See the Radiology Management page for additional information.



Questionnaires available for breast biopsy (excisional)

Previously communicated, clinical review is required for excisional breast biopsy effective Jan. 6, 2014. BCN covers excisional biopsy in certain situations in which there is a need for an open surgical procedure.

The requirement for clinical review of excisional breast biopsy applies to members with Blue Care Network commercial (including self-funded groups) and BCN AdvantageSM products.

The CPT codes involved are *19101, *19120, *19125 and *19126.

Providers may submit requests for clinical review for these procedures to BCN electronically. Users will be prompted to complete an appropriateness questionnaire for clinical review consideration. If the criteria are met, the request will be automatically approved. If the criteria are not met, the request will require further clinical review. Health care providers may also contact BCN's Care Management department at 1-800-392-2512 to request clinical review.

The questionnaire is available on the e-referral Clinical Review & Criteria Charts page under Medical necessity criteria / benefit review requirements.