Update to requirement for treatment of varicose veins

We indicated in the May-June issue of BCN Provider News that procedure codes 37718, 37722, 37766 and 37780 were not appropriate for treatment of varicose veins in the provider office setting. Effective Aug. 16, 2010, procedure code 37766 is now approved for the provider office treatment setting providing all criteria are met. The Varicose Vein Treatment questionnaire has been updated to reflect this change.

New requirement for endometrial ablation and treatment of varicose veins

Effective July 1, 2010, requests for endometrial ablation and treatment of varicose veins will require clinical review for BCN commercial (including self-funded groups) and BCN Advantage members.

Providers may submit requests for clinical review for these procedures to BCN on e-referral. 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 request clinical review by calling BCN’s Care Management department at 1-800-392-2512.

For more information on the new requirements, please refer to pages 17 and 18 in the May-June 2010 BCN Provider News.

Samples of the appropriateness questionnaires for endometrial ablation and varicose vein treatment are available on the Clinical Review & Criteria Charts page.

Please take our satisfaction survey

We value your opinion and would appreciate your feedback on our Care Management services. Please take a few minutes to complete our online survey.

Sleep study questionnaires change

Blue Care Network has updated the medical policy for Sleep Disorders, Diagnosis and Medical Management. The policy applies to BCN commercial, BCN Advantage^SM and BlueCaid members.

You can access the current policy by logging in to web-DENIS and clicking on BCN Provider Publications and Resources. In the Resources section, click on Medical Policy Manual.

Detailed information about BCN’s Sleep Management Program is available on the e-referral home page at ereferrals.bcbsm.com > Sleep Management. The page includes links to the updated sample home and outpatient facility/clinic-based sleep study questionnaires.

Henry Ford renames Grosse Pointe Cottage facility, eliminates inpatient services

Henry Ford Health System is renaming its Henry Ford Cottage Hospital in Grosse Pointe. On April 30, 2010, the facility becomes Henry Ford Medical Center – Cottage and its operations change to a multi-specialty outpatient center with an emergency department. Inpatient services are no longer available at this location, but current outpatient services will continue.

Effective May 1, please use the Henry Ford Hospital NPI – 1134144801 – when making referrals to this facility.

BCN to require clinical review for Cinryze^TM and NPlate^TM

Beginning April 1, 2010, Blue Care Network will require clinical review for Cinryze and NPlate for BCN commercial and BCN Advantage HMO^SM members.

BCN covers Cinryze for the prophylaxis of hereditary angioedema attacks and NPlate for the treatment of chronic immune thrombocytopenic purpura. In addition to the diagnosis, the member must meet specific clinical criteria.

Other uses of these drugs are considered experimental and investigational due to inconclusive or inadequate published data.

Please note that these drugs now have a unique HCPCS code that providers must use when billing:

• Cinryze - J0598
• NPlate - J2796

To submit a prior authorization request for Cinryze or NPlate, please complete the Medical Benefit Drug Request Form - Prior Authorization Request for Commercial and Medicare and fax with supporting documentation to 1-800-675-7278.

Note: In addition to using this form for Cinryze and NPlate, this form should be used for prior authorization for Immune Globulin Therapy (IVIG, SCIG) beginning April 1.

BCN makes change to e-referral inpatient submission process

In an effort to streamline the inpatient loading process, Blue Care Network will eliminate several treatment setting options in the inpatient request tab on e-referral. We will inactivate the following treatment settings in May 2010:

• Basic Nsg. Fac.
• I/P Rehab
• SNF
• SNF-Sub Acute Unit

If you must submit a case for one of the eliminated treatment settings, please contact BCN Care Management at 1-800-392-2512.

Some referrals and authorizations split into two on e-referral

Beginning in January 2010, you may notice a second referral or authorization under a new group number for services previously approved by Blue Care Network. Creation of the second authorization is a temporary internal BCN process that requires no action by the provider. The end date of the referral or authorization will not change. For example, a referral to a specialist that was originally from Oct. 1, 2009, through March 31, 2010, may now show as two separate referrals, one for the period of Oct. 1, 2009, through March 31, 2010, and the other for Jan. 1 through March 31, 2010.

Blue Care Network is splitting referrals and authorizations into two transactions in order to appropriately manage benefits and pay claims in the following situations:

• An employer's group number changes, such as the current transition of benefit administration for approximately 35,000 Big Three auto hourly retirees to the UAW Retiree Medical Benefits Trust
• A change in benefits by an employer, such as selecting a new plan year, that necessitates resetting the accumulators for counting certain benefits, like physical, occupational or speech therapy

If you have any questions about split referrals or authorizations, please call Care Management at 1-800-392-2512.

Effective dates for BlueCaid elimination of select benefits and reduction in provider fees

Benefit reductions: Medicaid coverage eliminations for adults age 21 and older will be effective for BlueCaid members and providers for dates of services on or after Feb. 1, 2010. In accordance with the Michigan Department of Community Health Bulletin MSA 09-28, for members aged 21 and older, the following benefits will be eliminated:

• Services provided by chiropractors: Coverage is eliminated.
• Services provided by podiatrists: Coverage is eliminated.
• Hearing aids: Coverage is eliminated.
• Vision services: Coverage for routine eye exams, eye glasses, contact lenses and other vision supplies and services is eliminated. Coverage for services related to eye trauma and eye disease will continue.
• Medicaid dental services: Coverage for routine examinations, prophylaxis, restorations and dentures is eliminated. Coverage for emergent and urgent services for the relief of pain or infection will continue. (This is for informational purposes only, since the majority of these services are covered by Medicaid rather than BlueCaid.)

BlueCaid will continue to honor existing and new authorizations for the impacted services provided the authorization is dated and the services are rendered no later than Jan. 31, 2010. For current authorizations with end dates that extend beyond Jan. 31, 2010, affected members and servicing providers will be notified in writing that those authorizations will be honored only for services completed on or before Jan. 31, 2010.

As a reminder, these service cutbacks were initially announced by the MDCH as effective for July 1, 2009, to address State of Michigan budget shortfalls, but were postponed by BlueCaid. Providers should refer to the MDCH Bulletin MSA 09-28 dated June 1, 2009 for a detailed explanation of the changes. This bulletin is available at michigan.gov/documents/mdch/MSA-09-28_280899_7.pdf

Fee reduction: In accordance with MDCH Bulletin MSA 09-62, a four percent reduction in provider reimbursement, with some exceptions, will be implemented effective with dates of service on or after Oct. 1, 2009. This is in addition to the fee reduction previously implemented on July 1, 2009 in line with MDCH MSA Bulletin 09-28. Providers should refer to the MDCH Bulletin MSA 09-62 dated Dec. 8, 2009 for a detailed explanation of the most recent fee reduction. This bulletin is available at michigan.gov/documents/mdch/MSA_09-62_303573_7.pdf

Sleep management program page added to e-referral

Blue Care Network has launched a new Sleep Management Program page on e-referral with information and resources to assist providers requesting outpatient sleep study authorizations, including home sleep studies and sleep studies conducted in an outpatient facility or clinic. We revised the sample sleep study questionnaire previously posted on e-referral and renamed it Outpatient Treatment Setting Sleep Study Questionnaire, and we added a new Home Treatment Setting Sleep Study Questionnaire to the sleep study resources. Blue Care Network has contracted with Oximetry Company, LLC, to provide home sleep study services to BCN commercial and BCN Advantage HMO^SM members.

Lansing area providers — Contacts for medical records and billing inquiries for the former BCN Family Health Center now available

Blue Care Network’s Family Health Center on Creyts Road in Lansing is closed. Here’s some contact information you may need.

Medical records requests, including mammogram results and x-rays pertaining to former BCN Family Health Center patients:
Iron Mountain
1500 East Whitcomb Avenue, Suite 300
Madison Heights, MI 48071
Phone: 1-800-934-3453

Billing inquiries:
Rehmann Group
Physician Service Organization
3597 Henry Street Suite 201
Muskegon MI 49441
Phone: 231-780-6076
Fax: 231-780-6093

To send a lab result or contact a physician formerly employed by BCN’s Family Health Center, reference Primary care physicians’ new locations(PDF) for a list of PCPs who continue to serve BCN members from new Lansing locations. If you are unable to locate the physician using this resource, please contact the patient to determine where to send the information.

Blue Care Network now accepting authorization requests for behavioral health treatment continuing in 2010

For BCN members currently in behavioral health treatment whose treatment will continue in 2010, behavioral health providers will need to submit new requests for authorization for visits that begin on or after Jan. 1, 2010. To do this, providers should use the e-referral system, both to submit the authorization request and verify that the authorization is granted.

As an alternative, behavioral health providers may complete the Behavioral Health 2010 Continuing Outpatient Authorization Request Form (PDF), which can be accessed either on the Behavioral Health page of this site or on web-DENIS in BCN Provider Publications and Resources (Behavioral Health and Forms pages). The completed form must be faxed to 734-332-2519. When this form is used to submit the authorization request, the results can be verified via e-referral.

Note: This form should not be used for members who have not been seen in the past six months.

Ten units will be authorized per member, pending verification of benefits and eligibility. Visits beyond 10 require completion of the Behavioral Health Outpatient Treatment Authorization Form(PDF) .

Lansing area providers – BCN Creyts Road Family Health Center physicians provide care in new locations

Effective Sept. 30, 2009, the Blue Care Network Creyts Road Family Health Center in Lansing closes permanently. Many Family Health Center primary care physicians are at new practice locations in the Lansing area. See Primary care physicians’ new locations(PDF) for a list of PCPs who continue to serve BCN members from new Lansing locations.

Blue Care Network to release details of new behavioral health utilization management program this fall

The federal Mental Health Parity and Addiction Equity Act of 2008 will take effect October 3, 2009. Blue Care Network is currently focusing on a redesign of our outpatient behavioral health utilization management process to enhance the effectiveness of our program while ensuring compliance with the legislation. As details of BCN's program become available this fall, we will share them with our behavioral health provider network, including any new forms we will require.

Please refer to Page 10 of the September/October Network News for an overview of the changes and watch for more information in the November/December issue of BCN's all-new electronic newsletter, BCN Provider News. To sign up for a personalized e-mail notification when each new issue of BCN Provider News is available, go to bcbsm.com/providernews.

Posted September 2009

New one-page BCN Provider Resource Guide At-a-Glance now available on e-referral Provider Resource Guide page

The BCN Provider Resource Guide At-a-Glance (PDF), a one-page summary of key BCN contact information, is available via a link on the e-referral Provider Resource Guide page. The concise At-a-Glance summary is designed to help you keep phone and fax numbers at your fingertips. The At-a-Glance is updated as needed, so that the most current information is always available. When a change is made, the specific change and the revision date will appear in red on the page.

The more complete BCN Provider Resource Guide (PDF) is also available on the e-referral Provider Resource Guide page.

Posted September 2009

Medicaid cuts previously announced have been postponed

The Michigan Department of Community Health released Bulletin MSA 09-28 (PDF) on June 1, 2009, announcing Medicaid coverage eliminations and fee reductions for adults age 21 and older effective July 1, 2009. We posted an alert on this page and sent communications to BlueCaid primary care physicians and affected specialists stating that BlueCaid was adopting these changes to be in line with the Medicaid programs and fee changes. The Medicaid cuts announced by MDCH impact chiropractic and podiatric services, hearing aids, vision services and Medicaid dental services.

The effective date of the benefit reductions has now been postponed by BlueCaid. Until further notice, BlueCaid will continue to honor new authorizations for the impacted services provided the services are rendered prior to December 31, 2009. Requests for services that were denied by BlueCaid after July 1, 2009, will be reconsidered for approval through December 31.

We will publish further information as soon as it is available.

Posted August 2009

BCN ready to launch electronic provider newsletter. Network News ends with the September-October issue. Sign up now to receive BCN's new online provider news magazine.

To communicate with you more efficiently and reduce administrative costs, Blue Care Network will switch to an electronic provider newsletter. The September-October issue will be the final print issue of Network News. Beginning with the November-December publication, your BCN provider information will be available in a brand new online news magazine, BCN Provider News. We will continue to bring you the latest news on BCN referrals and authorizations in a user-friendly electronic format.

We invite you to preview the new publication and complete a short survey to let us know what you think by going to MiBCN.com/providernewsbcn.

Important: To keep BCN provider information coming directly to your office, you and members of your staff may register now to receive an e-mail reminder when each issue of BCN Provider News is available. The e-mails can be personalized with direct links to articles in the Referral Roundup section or other topic categories you select. Go to bcbsm.com/providernews.

Posted August 2009

Authorization not required for observation care

Blue Care Network does not require a referral or authorization for observation care.

Observation care typically includes clinically appropriate services in the assessment and management of a patient's condition. Hospitals typically provide these services on a short-term basis. Observation services may be used as an adjunct to emergency department treatment, providing an opportunity to assess the patient prior to making a decision regarding admission. Observation care may also be used on a stand-alone basis (with no emergency department service) for short-term care that may not be able to be provided in an alternate setting; for example, blood transfusions.

Effective August 2009, authorization for observation care is not given for inpatient admission requests that are denied and are subsequently accepted by the provider as an observation. Claims can be submitted without authorization. BCN limits observation coverage for commercial members to 23 hours or less and up to 48 hours for BCN Advantage^SM members.

Note: Please refer to the latest Referral and Clinical Review Program on the Clinical Review & Criteria Charts page of this site for outpatient services that require plan notification or clinical review

Posted August 2009

Phase out of P numbers affecting provider searches

While Blue Care Network transitions to a new provider enrollment and data management system, old BCN provider P numbers are becoming invalid as a provider search option on e-referral. Some e-referral users are receiving the error message "No provider found matching the search criteria" when they select Provider Old ID (P Number) from the drop-down menu to begin a search for a facility provider. Not all P numbers have been retired yet from BCN's provider enrollment data, so some searches using the Provider Old ID (P Number) drop-down option are still successful. The phase-out process for P numbers will continue into 2010.

To avoid receiving an error message in the future when searching for a facility provider on e-referral, you should choose one of the following options from the drop-down box:

• Provider NPI Number (preferred method*)
• Provider PIN Number
• Provider Name (preferred method*)
• Provider ID

*BCN recommends using either the Provider NPI Number or Provider Name search option.

Please note that the Provider PIN number option consists of the same numerals included in the Old Provider ID (P Number) minus the alpha prefix "P." For e-referral users who have used the Old Provider ID (P Number) drop-down option in the past, you can continue to conduct provider searches with the same numeric information included in the old P number if you select the Provider PIN number drop-down option.

Posted July 2009

Prior authorization now required for sleep studies

Effective July 1, 2009, prior authorization is required for all sleep study requests performed in outpatient treatment settings (this includes, clinic, outpatient and home settings) for BCN commercial (including self-funded groups) and BCN Advantage members.

Providers may submit requests for prior authorization of sleep studies to BCN via e-referral. Users will be prompted to complete an appropriateness questionnaire (PDF) for prior authorization consideration. Providers are asked to answer only those questions that apply. A sample of the questionnaire is available on the Forms page accessed by clicking on Forms in the left navigation panel. If the criteria for sleep study are met and the test is being performed in an appropriate treatment setting, the request will be automatically approved. If the criteria are not met or the test is not being requested for the appropriate treatment setting, the request will require further clinical review. Health care providers may also contact BCN's Care Management department at 800-392-2512 to request prior authorization.

Posted July 2009

2009 Referral and Clinical Review Programs are revised and have a new look

The BCN Referral and Clinical Review Program has been revised and updated with a new look. In the past, we published a total of five programs, one for each region and product. The new look of the program combines the regions and products so you have less paperwork to manage.

We have combined the following Referral and Clinical Review Programs:

The BlueCaid Referral and Clinical Review Program is still published separately.

For all programs, we have removed the procedure code lists and posted them separately on the e-referral Clinical Review & Criteria Charts Web page.

Blue Dot change process applied to Referral and Clinical Review Programs

Blue Dot changes make it possible to offer the most up-to-date information about clinical review and referral requirements. To find out more, read About Blue Dot Changes to the Referral and Clinical Review Programs (PDF).

Highlights of changes to the BCN and BlueCaid Referral and Clinical Review Programs

For a summary of the main changes to the Referral and Clinical Review Programs effective July 1, 2009, read Highlights of Changes to BCN and BlueCaid Referral and Clinical Review Programs (PDF).

Posted July 2009

Immune globulin replacement therapies require prior authorization for BCN members

Effective July 1, 2009, immune globulin replacement therapies (intravenous and subcutaneous) require prior authorization through BCN Care Management, for BCN members.

Note: This does not apply to BlueCaid.

To request prior authorization, providers should complete the Immune Globulin Replacement Therapy (PDF) authorization request form and fax it to Care Management at 800-675-7278.

The form is available on the e-referral Forms page.

Providers may call Care Management at 800-392-2512 with any questions.

Posted July 2009

Reductions in BlueCaid benefits and BlueCaid provider fees are effective July 1, 2009

Effective for dates of service on or after July 1, 2009, and in line with Medicaid program and fee changes announced by the Michigan Department of Community Health to address budget shortfalls, the following benefits will be eliminated or reduced for BlueCaid members aged 21 and older:

If prior authorization for an eliminated service is on file prior to July 1, 2009, providers have 180 days from the date the prior authorization was approved to complete the service, in order to be reimbursed for it. No updates or extensions will be granted if the service is not completed within the initial approved service dates.

In addition, a four percent reduction in provider reimbursement, with some exceptions, will be implemented effective with dates of service on or after July 1.

BlueCaid is adopting these Medicaid coverage eliminations and fee reductions as announced by the MDCH in Bulletin MSA 09-28, published June 1, 2009.

Providers should refer to that bulletin for a detailed explanation of the changes. This bulletin is available at michigan.gov/documents/mdch/MSA-09-28_280899_7.pdf

Posted June 2009

BCN Bariatric Center of Excellence bariatric surgeons listed on e-referral

To make the referral process easier when referring members for bariatric surgery, consult this list of bariatric surgeons affiliated with BCN Bariatric Centers of Excellence..

As a reminder, bariatric surgery requires clinical review by BCN and, in order for the service to be covered, it must be performed at a BCN Bariatric Center of Excellence.

Posted June 2009

Additional hospitals receive Center of Excellence designation

Spectrum Health Blodgett Hospital has received designation as a Blue Care Network Bariatric Center of Excellence. This means BCN physicians can continue to request authorization for bariatric surgery at Spectrum Health's Blodgett Campus for BCN members. This is a change to information published in our May-June issue of Network News, which indicated that bariatric surgery authorizations to this hospital would cease July 1. For more information, visit the Bariatric Surgery page on this Web site.

Lakeland Regional Medical Center in St. Joseph and Spectrum Health Butterworth Hospital in Grand Rapids have received designation as Cardiac Centers of Excellence by Blue Cross Blue Shield of Michigan and Blue Care Network.

These hospitals are also designated as Blue Distinction Centers for Specialty Care^®, meeting the standards of the Blue Cross and Blue Shield Association's national program.

Posted May 2009

Home care services referral not required for contracted providers

Note: This article modifies the information published in the BCN and BlueCaid Referral and Clinical Review Program guidelines published in the May-June issue of Network News (Pages 37 to 42).

Effective May 26, 2009, a referral is not required for home care services provided by contracted providers. In the past these services required clinical review. This change applies to Blue Care Network commercial and BCN Advantage^SM coverage. All home care requests for BlueCaid members still require clinical review.

Although a pre-service clinical review is not required, BCN reserves the right to conduct retrospective review on all home care services. BCN will initiate financial recovery for services that do not meet the appropriate criteria. Noncontracted home care providers are still required to obtain clinical review prior to services being rendered by calling 800-392-2512.

For BCN Advantage members, home care providers must continue to provide a signed Notice of Medicare Non-Coverage form. The form must be signed by the member at least two days prior to the services ending. The provider must fax the signed NOMNC to Care Management at 248-799-6995. The NOMNC contains detailed instructions about how members may request an immediate appeal directly to MPRO if he or she disagrees with the decision to end services. The Centers for Medicare & Medicaid Services requires home care providers to provide members with this form. A copy of the NOMNC form language is available on web-DENIS > BCN Provider Publications and Resources > Government Programs.

Posted May 2009

Referral to BCN no longer needed for retinopathy exam for diabetic members in East and Southeast regions

Effective April 1, it is no longer necessary to submit a referral to BCN for a yearly eye exam for retinopathy for a diabetic member when the exam is performed by a contracted BCN provider. This change only impacts BCN's East and Southeast regions; Mid and West region providers currently follow this process.

Blue Care Network members who have diabetes should have a yearly eye exam for retinopathy. Some primary care physicians can conduct the exam in their office, or the member can go to an eye care specialist for this exam. The primary care physician is responsible for coordinating the referral to the contracted specialist.

The referral can take any form. For example, the referral can be a fax, a phone conversation, or written instructions given to the member by the primary care physician on office letterhead or a prescription pad. Regardless of the form the referral takes, both the referring physician and specialist should be sure to keep written documentation of the referral in the member's medical record.

BCN also encourages the following for our diabetic members:

If you have questions, please call the BCN Disease Management department at 800-392-4247.

Posted April 2009

Blue Care Network moves sleep study prior authorization to July 1, 2009

In the January 1, 2009, Referral and Clinical Review Program charts, Blue Care Network reported April 1, 2009, as the date for implementation of a prior authorization requirement for sleep studies. The effective date has now been delayed until July 1, 2009. Please visit this page for updates on the sleep study prior authorization program.

Posted April 2009

Behavioral health resources now include online e-referral tutorial

In addition to the educational resources, forms and contact information for Blue Care Network behavioral health providers already available on e-referral, BCN has added a new online interactive e-referral tutorial. Read more…

Posted April 2009

New radiology management program page added

You can now find information about Blue Care Network's expanded radiology management program on its own page. Click on Radiology Management under BCN Care Management Resources. Learn about the referral requirements for high-tech radiology procedures and find the resources you need to request authorizations for your BCN members.

Posted February 2009

U-M Premier Care therapy benefit changes in effect

Effective Jan. 1, 2009, therapy benefits for U-M Premier Care members have changed. The new benefit design and limits are based on the member's diagnosis. These limits reflect the maximum number of visits and timeframe during which visits could be approved. Members must still meet medical necessity requirements in order to receive these benefits in accordance with the Landmark Healthcare, Inc. provider categorization.

Blue Care Network has contracted with Landmark to provide care management for members receiving physical, occupational and speech therapy services in office, outpatient and hospital settings. Landmark reviewed claims data for BCN contracted providers and established authorization requirements based on utilization.

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.

Posted January 2009