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|
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.
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.
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.
Last fall, we announced changes to the global referral process for Blue Care Network and Blue Cross Complete, effective January 1, 2013.
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.
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.
The e-referral system will be unavailable Sunday, March 17 from 5 a.m. until 4 p.m. We apologize for this inconvenience.
Please note that we have changed the global referral process to improve referrals for our members. Please see the March–April issue, Page 46 to read about the change.
Subscribe to BCN Provider News today to get other important referral news from Blue Care Network. Click "Subscribe" and check the box next to BCN Provider News and BCN Alerts.
As communicated in the Jan.–Feb. 2013 BCN Provider News, prior authorization will be required for arthroscopy of the knee and lumbar spine surgery for Blue Care Network adult members.
Appropriateness questionnaires for the following procedures are available on the Clinical Review and Criteria Charts page under Medical necessity criteria / benefit review requirements.
Arthroscopy of the knee:
Lumbar spine surgery:
BCN has revised the e-referral application process to make it easier to get initial access and request changes to access. New sign-up and change forms are available for the following situations:
Go to the Sign up for e-referral or change a user page to find the forms and instructions for each of the above situations.
All of the forms must be completed, printed and signed, then mailed or faxed to the BCBSM Electronic Business Interchange Group. Please do not use old printed hard-copy BCN forms. We can no longer accept them.
Behavioral health providers can now access some widely used screening instruments through the Behavioral Health page on BCN's e-referral website.
Currently, the following five screening instruments are available:
To access these instruments, open the Behavioral Health page on this website and click on Behavioral health screening tools under the "Other resources" heading,
When you click "I Accept" — which means you agree to accept the conditions for accessing the tools through the e-referral website — you'll open a new page and see a table that contains links to the tools and to scoring information.
While we're currently providing access to only five tools, we plan to add to that number over time. Blue Care Network encourages the use of validated behavioral health screening instruments to identify members with undiagnosed disorders, monitor the severity of their ongoing symptoms and assess treatment outcomes.
The LTACH Assessment Form (PDF) (for long-term acute care hospitals) has been revised and is now available on the e-referral Forms page under the Transitional Care Services heading. The LTACH Assessment Form should be used to submit the information required when requesting initial and concurrent authorizations for a member who requires placement in an LTACH level of care.
Here's how the form was updated:
Look for more information on this revised form in the March-April 2013 issue of the BCN Provider News, which will be published in late February.
Blue Care Network has updated the questionnaires for the epidural and facet joint injection procedures that require prior authorization. These updates will be in effect beginning January 28, 2013.
The changes include but are not limited to:
The updated questionnaires are available on the e-referral Clinical Review & Criteria Charts page under Medical necessity criteria / benefit review requirements.
Because Blue Care Network is committed to improving the referral experience for our members, the BCN global referral process has changed. We told providers beginning last October about these changes, which are effective Jan. 1, 2013:
In order to keep this new process on track, BCN will manually change the end dates of any referrals written for less than the minimum 90 days, or less than the minimum 365 days for oncology, rheumatology and renal management. This manual intervention will take time and could slow our response to your referral requests. We are notifying members of end-date extensions as they arise. If the end date of a global referral is changed, you will see this on the e-referral system.
Effective Jan. 1, 2013, there are new procedure codes to use in identifying behavioral health services. As part of the transition to these new codes, several codes previously in use are ending on Dec. 31, 2012. As applicable, claims must be billed with the new codes.
Authorizations already issued with effective dates that extend into 2013 will work with the new procedure codes. For new authorizations, please select *90791 on the e-referral system.
While Blue Care Network does not instruct providers on how to bill, we can provide resources to help you understand the transition to these new codes. Below are some links to resources that professional organizations have made available about the new codes:
An updated Behavioral Health Fee Schedule is available on the web-DENIS Behavioral Health page.
The Blue Care Network global referral process will be simpler for both providers and members beginning Jan. 1, 2013. The process for BCN commercial and Blue Cross Complete members includes these changes:
For more information, please read the article on page 51 of the Nov.-Dec. 2012 BCN Provider News or contact your BCN provider representative.
In early December, MiBCN.com is merging with bcbsm.com. The new, combined website will provide you with improved functionality and an enhanced online experience, but you may find some of the links you use have moved. To ensure continued quick access to e-referral, add the homepage – ereferrals.bcbsm.com – to your browser's favorites or bookmarks now.
Need help setting a browser bookmark or favorite? See our tip sheet (PDF).
After the new website launches, any visitors to MiBCN.com will be redirected to bcbsm.com. If you have any trouble finding what you're looking for on the new bcbsm.com, use the search box or contact your provider representative for assistance.
Intravitreal injection of vascular endothelial growth factor (VEGF) inhibitors Avastin® (bevacizumab), Eylea (aflibercept), and Lucentis (ranizumab) have demonstrated improved visual outcomes and have become first-line therapies for treating various retinal conditions including, but not limited to, neovascular age-related macular degeneration (wet-AMD), diabetic macular edema (DME), and retinal vein occlusion (RVO).
Avastin has not been reviewed by the Food and Drug Administration for the retinal indications because Genentech, the manufacturer of both Avastin and Lucentis, has not chosen to apply for FDA review. Despite this, its use is supported by many clinical trials, compendia such as DRUGDEX Information System, and the American Academy of Ophthalmology.
Effective January 1, 2013, all requests for Eylea and Lucentis will require clinical review for BCN HMO commercial members to ensure safe, cost effective and appropriate utilization of these drugs. The coverage criteria are as follows:
|Drug||Coverage Criteria||Covered Dose|
If criteria are met, authorization will be approved for one year at a time. When therapy with a VEGF-inhibitor is indicated, please consider using Avastin—the most cost effective option.
Please note these drugs will not require clinical review for BCN AdvantageSM members. Providers can initiate clinical review requests by contacting BCN Care Management at 1-800-392-2512.
On Dec. 1, 2012, LandmarkTM Healthcare, Inc., will transition to a collection of new treatment plan forms for physical and occupational therapy authorization requests.
If you're a provider of physical or occupational therapy services, you should read Landmark Treatment Plan Forms (PDF) to find out more about the new forms and what you'll need to do during the transition.
You can find the announcement about the new forms on the e-referral Outpatient Physical, Occupational and Speech Therapy Management Program page. On that page, you'll also find:
Both of these documents are newly published by BCN and Landmark to assist you with the authorization process and with utilization issues that sometimes come up.
Landmark Healthcare oversees non-autism-related outpatient physical, occupational and speech services for BCN members delivered by independent physical therapists, outpatient therapy providers, physician practices and hospital-based outpatient therapy services.
Effective Jan. 1, 2013, the following changes will be made to the Blue Care Network global referral process for BCN commercial and Blue Cross Complete members:
These changes are based on feedback gathered by BCN from both the member and provider satisfaction surveys and are designed to simplify the process for both providers and members.
Blue Cross Blue Shield of Michigan and Blue Care Network will implement the 2012 InterQual Level of Care Acute Adult and Pediatric, Skilled Nursing Facilities, Rehabilitation and Home Health Care criteria Oct. 15.
In July, we told you that we were delaying implementation of the 2012 criteria while McKesson corrected errors in the data. McKesson has corrected the electronic criteria and issued a revised hard copy with "Content Update August 2012" in red on the cover of the Acute Care Adult and Pediatric books.
Don't miss the important information you need to work efficiently with Blue Care Network. Get the latest BCN billing news, referral and authorization information and patient care updates when you read BCN Provider News.
Subscribe today to receive an email notification when each issue is posted. When you subscribe to BCN Provider News, you can select your topic of interest, and your email will contain headlines specifically of interest to you.
Subscribe by Oct. 15 to receive email notification for the November-December 2012 issue of BCN Provider News.
If you have questions, call the Web Support Help Desk at 1-877-258-3932 or your BCN provider representative.
Blue Care Network is moving to a new e-referral tool by the end of 2012. To continue processing your referrals and authorizations fast and efficiently, BCN recommends that your office computer systems have at least the minimum configuration requirements listed below. For the best results, we highly recommend that you work with your IT department to update your system to meet the optimum specifications. If you keep your computer equipment and software current you will have the best performance.
System specifications for new e-referral tool
|Component||Minimum requirement||Optimum capability|
|Web browser||Microsoft Internet Explorer 8.0 or Firefox 3.6 or Firefox 9 or higher||Microsoft Internet Explorer 9.0 or Firefox 12 or higher|
|Operating system||Windows XP||Windows 7 Professional|
|Processor||3.3 GHz Intel Pentium (or comparable)||3.3 GHz Intel Core i3 processor (or comparable)|
|RAM||3 GB memory||4 GB memory|
|Hard drive space||2 GB available||10 GB available|
|Monitor||1280 x 720 pixels||1280 x 720 pixels or higher|
The following Web browsers will also work with the new e-referral tool, but the processing will be slower. If you have one of these browsers, please consider upgrading to Internet Explorer 9.0 or Firefox 12.
If your Web browser is older than any of the versions listed above, you may not be able to run the new e-referral tool successfully. Please upgrade your browser as soon as possible.
Visit this page regularly for updates about our transition to the new e-referral tool.
Blue Cross Blue Shield of Michigan and Blue Care Network will delay the implementation of 2012 InterQual criteria. McKesson has discovered some errors in the 2012 InterQual Condition Specific and General Medical sections of the Acute Adult and Pediatric criteria. Other levels of care are not affected by any errors.
McKesson will correct the electronic version and reissue the hard copy by early September. Until the corrections are complete, we will continue to follow the 2011 criteria for all levels of care. Please keep your 2011 materials until the final 2012 materials are issued. When an exact date is known, we will notify you in the referral news.
The in-person and webinar training classes will still be held as scheduled; the classes teach process, and the instructors will use conditions that are not affected by the content error.
Blue Care Network is moving this year to a single sign-on process for secure Web applications. In preparation for this move, all e-referral users in your office must have their own Provider Secured Services (web-DENIS) ID and password. Once we begin the single sign-on process, you will log in to e-referral with your Provider Secured Services ID.
A representative from the Blues may contact your office in the next few weeks to coordinate user ID changes for your e-referral users.
To sign up for a Provider Secured Services User ID and password, click here to access the secured access application and instructions for your provider type.
Once an application is submitted, you can expect to receive a response from Provider Secured Services within one month.
If you have questions, call the Web Support Help Desk at 1-877-258-3932 or your BCN provider representative.
BlueCaid of Michigan has expanded its service area to include the entire county of Wayne. This is in addition to the current service area of Washtenaw and Livingston counties and the original six ZIP codes in western Wayne County. Individuals enrolling in Medicaid or choosing to change their Medicaid health plan can now select BlueCaid throughout the entire county of Wayne.
BlueCaid is changing its name to Blue Cross Complete of Michigan effective April 1. We announced this in the March-April issue of BCN Provider News (PDF). There are a few important points you need to know:
If you have any questions about our Medicaid program, the Medicaid-specific Provider Inquiry phone number has not changed. It is 1-800-688-3290. Your BCN provider representative can also answer your questions.
Don't miss important referral information in the March-April BCN Provider News.
Upcoming news includes new Q&A document and sample questionnaires for pain management.
Subscribe today to receive a personalized email when the issue posts on Feb. 29.
Blue Care Network has updated the questionnaire for one of the high-tech radiology procedures that requires clinical review — Nuclear Scan of Biliary Tract/Hepatobiliary Duct. Two CPT codes have been added — *78226 and *78227. This update is effective Feb. 24, 2012.
A link to the updated questionnaire is available on the Radiology Management Program page under Resources.
*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2011 American Medical Association. All rights reserved.
Blue Care Network has developed a question-and-answer document to address some common questions providers ask about pain management services and how to handle referrals and clinical review requests in the e-referral system. In addition, the sample questionnaires for epidural and facet joint injections have been updated.
Among other things, these documents offer a definition of a pain management "unit." A unit is, essentially, a trip to the fluoroscopy suite during which one or more spinal injections for pain management may be administered. For epidural injections, the maximum number of units is four visits in 12 months. For facet joint injections, the maximum number of units is nine visits in 12 months.
The Q&A document, titled Understanding BCN's pain management requirements, and the updated questionnaires are available on the Clinical Review & Criteria Charts page, under the heading Medical necessity criteria / benefit review requirements.
Blue Care Network has updated the questionnaires for the high-tech radiology procedures that require clinical review. These updates are effective Feb. 1, 2012. The following five questionnaires had minor changes:
A link to the updated questionnaires is available on the Radiology Management Program page under Resources.
Blue Cross Blue Shield of Michigan, Blue Care Network and Beaumont Health System signed a new contract late Thursday that keeps Beaumont Health System in the hospital network that serves Blue Care Network members, increases reimbursement to the health system and institutes new performance-based standards for paying the health system in the future.
Daniel J. Loepp, Blues president and CEO said, "This agreement is a win-win – not for the health system or the insurer – but for our members and customers. It maintains access to Beaumont facilities for our customers and members. It commits Beaumont, Blue Cross and physicians to work together to achieve high-quality health care and the efficient use of health care dollars. It advances our efforts to deliver innovation in how Michigan pays for health care in the future."
The five-year agreement provides an increase in base reimbursement to Beaumont Health System while also committing Beaumont to a new performance–based hospital payment model sought by the Blues. Under the new model, Beaumont will work closely with its affiliated physician organizations and the Blues to design standards for successful patient health outcomes that will be the basis for part of its reimbursement.
The new contract moves away from the traditional fee-for-service payment approach toward an outcomes-based approach that revolutionizes the ways hospitals are paid. The new pay–for-performance contract terms sought by the Blues and achieved in this agreement represent a new standard for how Michigan hospitals are paid for services, and how the Blues can help hospitals and physician organizations build efficient and coordinated systems of care.
The agreement includes an opportunity for infrastructure improvements needed to better integrate care services between Beaumont and its physicians groups. The performance standards that will be mutually determined by Beaumont and the Blues will financially reward the hospital for maintaining better overall population health and ensuring the efficient use of tests and procedures.
In December, the Blues announced that St. John Providence Health System, and its five acute care hospitals across southeast Michigan, was the first health system in the state to partner with the Blues on a new performance-based reimbursement model. Both the new Beaumont contract and the agreement with the St. John Providence System signal a new era in health care that rewards hospitals for keeping patients healthy and out of the hospital.
BCN has been reviewing service requests for BCN members to Beaumont facilities as a result of Beaumont's announcement that it would leave BCN's network. The agreement between Beaumont and the Blues means that Beaumont will remain in BCN's provider network. Beginning Monday, Jan. 9, BCN will once again process referral and authorization requests for Beaumont as a contracted provider. We know that some of you had to adjust care plans for your patients. If you want to redirect care back to Beaumont, this can be done through BCN's e-referral system by submitting a new service request beginning Monday.
We extend thanks to physicians for their patience during the Beaumont contract negotiations. We recognize that you and your patients may have felt caught in the middle and may have been inconvenienced. We apologize for the uncertainty the situation has caused. We value the relationship we have with you.
Entering the wrong contract number or selecting the wrong member on a contract for a referral may result in the system sending a referral letter to the wrong recipient. Please confirm that you have typed the number correctly and the correct contract information is displayed before generating a referral.
Oximetry Company, LLC, Blue Care Network's contracted provider for home sleep studies, has changed its name to Night Hawk Sleep Systems, Inc. The phone number has not changed. Contact Night Hawk at 1-877-622-2022.
Referral and authorization requests for services at Beaumont will be handled within 24 hours (or the next business day if the request is submitted on a Friday or the day before a holiday) if the service:
Please check e-referral the next business day to receive your determination on these requests.
Remember that urgent requests must always be submitted by phone at 1-800-392-2512. A request is urgent if the treatment is necessary to prevent jeopardizing a patient's life or to alleviate severe pain that cannot be adequately managed without the requested treatment, in the opinion of a physician with knowledge of the member's medical condition.
As you are probably aware, Beaumont Health System gave notice to Blue Care Network that it may no longer participate in the BCN hospital network for BCN commercial (non-Medicare) plans on or after Jan. 12, 2012, if a substantial payment increase is not granted. BCN is hopeful that ongoing negotiations between the Blues and Beaumont will result in a mutually satisfactory agreement before Jan. 12. However, Beaumont has not rescinded its notice so BCN has an obligation to take steps to work with physicians to redirect care for its members. We want to inform physicians of plans for redirecting care for BCN members from Beaumont to other BCN-contracted hospitals if an agreement is not reached.
Beginning Monday, Nov. 14, 2011, service requests for BCN commercial members to Beaumont facilities are now pending for a manual determination by BCN.
The following process will occur:
|If the request is for a service to be performed…||Then…|
|Before Jan. 12, 2012||The determination will follow the standard process for contracted facilities. Beaumont is currently a contracted BCN facility.|
|Across a span of dates that begins prior to and ends after Jan. 12, 2012||If the service is approved for Beaumont, the service dates will be adjusted to end on Jan. 11, 2012.|
|On or after Jan. 12, 2012||The service will be denied and the requesting provider will be instructed to redirect the care to a BCN-contracted facility other than Beaumont.|
Continuity of care for members in an ongoing course of treatment on Jan. 12
BCN is taking steps to permit members to continue an ongoing course of treatment in certain situations for a specified period of time when disruption of the current course of treatment could cause a recurrence or worsening of the condition under treatment and interfere with anticipated outcomes. If the physician believes such a case exists and that care at Beaumont is necessary on or after Jan. 12, 2012, the physician must call BCN Care Management at 1-800-392-2512 to discuss arrangements.
If and when an agreement with Beaumont is reached providers can then submit a request to extend services beyond Jan. 11, 2012 or revise the place of service to Beaumont for services that were redirected to other BCN-contracted facilities.
For more information and the latest Beaumont updates, log in to web-DENIS, click on BCN Provider Publications and Resources and then click on Beaumont Update.
Blue Care Network is experiencing an increase in errors by e-referral users when selecting the appropriate member for a referral or authorization request. These errors may constitute violations of the federal Health Insurance Portability and Accountability Act of 1996, and BCN may be required to treat them as reportable disclosures of protected health information. The majority of errors involve selecting a member under the wrong contract number or selecting the wrong member under the correct contract.
We understand that e-referral users have limited time to complete administrative tasks, but please make sure you have selected the right member under the correct contract before submitting your request. Besides potentially violating federal law, incorrect submissions result in a slowing of our referral process, increased member dissatisfaction and improper claim denials.
Thank you for your assistance in keeping electronic referrals private and efficient.
Get the latest Blue Care Network referral and authorization information updates when you read BCN Provider News.
Here's what we're featuring in the November – December 2011 issue:
Subscribe today to receive an Upcoming news includes new Q&A document and sample questionnaires for pain management. notification for each new issue. When you subscribe to BCN Provider News, you can select a topic of interest, and your emails will contain headlines specifically of interest to you.
Subscribe before Oct. 24 to receive email notification for the November – December issue of BCN Provider News.
As announced in the July-August issue of BCN Provider News, effective Oct. 1 there will be a reimbursement change for the intra-articular hyaluronic acid injections. Blue Care Network will reimburse Euflexxa®, Hyalgan®, Orthovisc®, Supartz®, Synvisc® and Synvisc One® at $100 per equivalent injection. The reimbursement for each specific product will be as follows:
|HCPCS code for billing||Drug||Billing unit/qty||Reimbursement|
Please note: clinical claims editing will apply to ensure appropriate use, including but not limited to, diagnosis, dosing limits and frequency of administration.
Intra-articular HA injections are approved by the U.S. Food and Drug Administration for relief of pain in patients age 21 or older with osteoarthritis of the knee who fail treatment with non-pharmacologic and conservative therapies (for example, acetaminophen or NSAIDs). There are currently five IA-HA products available for treatment. Based on current clinical evidence, differences in efficacy and safety between IA-HA preparations have not been demonstrated.
BCN does not require prior authorization for these drugs. This change will not apply to BlueCaid members. Actual payments will be according to contract terms with the provider.
Benlysta requires prior authorization for Blue Care Network commercial HMO and BCN Advantage HMO-POSSM members. Coverage criteria include:
If criteria are met, coverage will be authorized for an initial dose of 1 mg/kg infusion at two-week intervals for the first three doses and at four-week intervals thereafter. A maximum of 10mg/kg per infusion will be allowed based on medical necessity. Coverage will be provided for 12 months at a time. We will provide renewal when there is documentation of a decrease on the SELENA-SLEDAI of at least 7 points and will review authorization annually thereafter to assess treatment response.
Makena (hydroxyprogesterone caproate injection) requires prior authorization for commercial HMO members that meet FDA-approved criteria. Coverage criteria include:
If criteria are met, coverage will be authorized for weekly injections until week 37 (through 36 weeks 6 days) of gestation or delivery, whichever occurs first.
As permitted by the FDA, a compounded hydroxyprogesterone product is available through the pharmacy benefit and does not require prior authorization. Makena is supplied as a multidose vial that contains five doses (cost per dose = $828).
The previously delayed self-service password reset process goes live July 25. The first time e-referral users log in after this new feature takes effect, there will be a prompt to create a security profile and answer a security question. This will allow users to reset their own password when the need arises. For more information, please see the e-referral Self-Service Password Setup User Guide (PDF)
Blue Care Network has updated the following questionnaires for procedures that require prior authorization.
Changes were made to clarify and streamline the questions and update the references where indicated. These updates are effective July 15, 2011.
Blue Care Network has introduced a new self-referral option, Blue Elect Plus. Members are required to choose a primary care physician from BCN's network. Certain preventive services are covered only when members receive them from their PCP. Referrals are not required, but costs are lower when members remain in network for health care services.
Certain services require prior authorization, whether or not the provider is contracted with BCN. If the provider is not contracted with BCN or is not a BlueCard® participating provider, these services will process with the out-of-network benefit.
BCN's clinical review requirements are available on this website under Clinical Review and Criteria Charts and on web-DENIS in BCN Provider Publications and Resources on the Care Management and Referrals page.
For more information about Blue Elect Plus, please see the article on Page 4 of the July-August BCN Provider News.
Blue Care Network has created a user guide to assist you with navigating e-referral's new self-service password reset process. A link to the user guide is located on the Training Tools page under User Guides.
At some time this summer when logging in to e-referral, users will be automatically directed to a new page to create a user profile. This one-time setup will require users to provide their email address and select and respond to a security question. They can then proceed to e-referral for normal referral or authorization activities. This self-service enhancement will allow users to easily reset a forgotten password.
If you have any questions regarding this change, please contact the Web Support Help Desk at 1-877-258-3932 or your Blue Care Network provider representative.
Blue Care Network previously announced on e-referral and in the March-April BCN Provider News that effective April 4, 2011, prior authorization will be required for cervical or lumbar epidural injections or facet joint injections. This program applies to BCN commercial (including self-funded groups) and BCN Advantage HMO-POSSM members.
A change has been made to this prior authorization process. Effective April 25, 2011, the CPT code *77003 will not require prior authorization.
Samples of the appropriateness questionnaires are available on the Clinical Review and Criteria Charts page under Medical necessity criteria / benefit review requirements.
Based on provider feedback, a quick reference tool for submitting referrals was developed and is available below the questionnaires on the Clinical Review and Criteria Charts page.
*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2010 American Medical Association. All rights reserved.
Don't miss the important information you need to work efficiently with Blue Care Network. Get the latest BCN referral and authorization information, patient care updates and billing news when you read BCN Provider News.
Subscribe today to receive an email notification when each issue is posted. When you subscribe to BCN Provider News, you can select a topic of interest and your email will contain headlines specifically of interest to you.
Subscribe before April 27 to receive email notification for the May-June 2011 issue of BCN Provider News.
There is a wide range of treatment available for back pain depending on the cause and duration of pain. Most pain improves within a few weeks and may be eliminated with conservative treatment such as appropriate anti-inflammatory medications and physical therapy. There may be instances where further medical treatment is indicated, such as epidural injections or facet joint injections.
Effective April 4, 2011, prior authorization will be required for cervical or lumbar epidural injections or facet joint injections. This program will apply to Blue Care Network commercial (including self-funded groups) and BCN Advantage HMO-POSSM members.
For facet joint injections, the CPT codes that apply are *64490, *64491, *64492, *64493, *64494, *64495 and *77003. The diagnosis codes that apply are: 353.0, 353.1, 353.2, 353.4, 355.0, 722.0, 722.10, 722.2, 722.4, 722.52, 722.6, 722.81, 722.83, 723.0, 723.4, 724.02, 724.3, 953.0, 953.2, 953.3, 721.0, 721.3, 723.1, 724.2, 847.0, 847.2, 720.0, 720.2, 724.6, 846.0-846.9, 722.91, 722.93, 723.7, 723.8, 723.9, 724.00, 724.09, 724.5, 724.8, 724.9, 728.85, 728.9, 729.1, 738.4, 738.5.
For epidural injections, the CPT codes that apply are *62281, *62282, *62310, *62311, *62318, *62319, *64479, *64480, *64483 and *64484. The diagnosis codes that apply are: 353.0, 353.1, 353.2, 353.4, 355.0, 722.0, 722.10, 722.2, 722.4, 722.52, 722.6, 722.81, 722.83, 723.0, 723.4, 724.02, 724.3, 953.0, 953.2, 953.3, 722.91, 722.93, 723.7, 723.8, 723.9, 724.00, 724.09, 724.5, 724.8, 724.9, 728.85, 728.9, 729.1, 738.4 and 738.5.
Providers may submit requests for clinical review for these procedures to BCN via e-referral. Users will be prompted to complete an appropriateness questionnaire for clinical review consideration.
Quantity limits apply. For patients who experience pain relief with facet injections, a series of three injections may be given over a six-month period. The maximum number of units that can be requested is nine (allowing for injections at multiple levels as necessary). For patients who experience pain relief with epidural injections, a series of injections at least two weeks apart may be given for a maximum of three injections. The maximum number of units that can be requested is four (allowing for injections at multiple levels as necessary). Requests for greater than these units will pend and the questionnaire will not display for submitters to complete. Submitters will receive a message if the limit has been exceeded and will have an opportunity to modify the request if needed prior to submitting the request. If all questions are answered and the number of units is within the quantity limit, e-referral will either approve or pend the case. If the case pends and BCN cannot authorize it, BCN will contact the provider for additional clinical information.
Health care providers may also contact BCN's Care Management department at 1-800-392-2512 to request clinical review.
Samples of the appropriateness questionnaires will be available April 1 on the Clinical Review and Criteria Charts page under Medical necessity criteria / benefit review requirements.
*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2010 American Medical Association. All rights reserved.
Blue Care Network has updated the following questionnaires for the high-tech radiology procedures that require prior authorization. These updates will be in effect April 4, 2011.
The changes made were to address appropriateness for these procedures for members who have severe pain.
The updated questionnaires will be available on the Radiology Management Program page by April 4.
Blue Care Network has developed processes to comply with the requirements of the Patient Protection and Affordable Care Act's provision that health plans provide a 24-hour turnaround on urgent requests for treatment.
Due to the expedited timeframe, we request that providers use discretion in submitting urgent requests and limit the requests to situations requiring urgent treatment.
For more information, see How we will handle urgent care requests, BCN Provider News, January - February 2011, Page 5.
The diagnosis of 724 (spinal stenosis unspecified) has been removed from the list of diagnosis codes requiring a referral to an orthopedic surgeon or neurosurgeon.
Providers should use the appropriate HCPCS code when billing the following medications for BCN HMO and BCN Advantage members. The codes to use are listed in the table below.
|HCPCS code for billing*|
|Drug®||BCN HMO members||BCN Advantage members|
|*The J codes are effective Jan. 1, 2011. The C codes are effective Oct. 1, 2010.|
In addition, Tysabri claims are also subject to clinical editing. Tysabri should be administered once every 28 days. BCN will allow variability in dates of service of plus or minus seven days when reviewing claims against this criterion. A total number of 13 doses/infusions are allowed per rolling calendar year.
As a reminder, services involving any of these medications require clinical review before being rendered. Providers can initiate clinical review requests by contacting BCN Care Management at 1-800-392-2512.
Effective Jan. 1, 2011, home health care services for BCN HMO and BCN Advantage members assigned to the UAW Retiree Medical Benefits Trust (URMBT) require benefit review for the first 30 services. Home health care visits for URMBT members beyond the first 30 services require clinical review to confirm the medical necessity for the requested services.
Note: This does not apply to BCN 65 members.
Providers should initiate home health care requests by calling BCN Care Management at 1-800-392-2512. Care Management business hours are Monday through Thursday from 8:30 a.m. to noon and 1 to 5 p.m., and Friday from 9:30 a.m. to noon and 1 to 5 p.m.
2009 BENEFIT DESIGN
For U-M Premier care
|Major Diagnosis on List*:|
|Member is eligible for 60 visits over 365-day benefit period.|
|Clinical Review diagnosis*:|
|Diagnosis is subject to clinical review for approval.|
|Diagnosis not on list:|
|Member is eligible for 15 visits over 60-day benefit period.|
*Please refer to e-referral (ereferrals.bcbsm.com) for a list of diagnosis codes (PDF) associated with the new benefit design. Use this list to determine the member's eligibility for benefits.