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October 2019

e-referral system out of service for maintenance Oct. 19-20

The oncology management program will include Medicare Advantage plans starting Jan. 1, 2020

September 2019

Starting Jan. 1, 2020, we'll cover select hyaluronic acid products

For Medicare Plus BlueSM PPO, the Specialty Medication Prior Authorization Program is expanding to include all sites of care except inpatient

Effective immediately, plan notification is no longer required for endometrial ablation and excisional breast biopsy procedures for BCN members

Effective Jan. 1, 2020, Eylea® and Lucentis® will require authorization for Blue Cross' PPO (commercial) members

Starting Jan. 1, 2020, Blue Cross' PPO and BCN HMOSM plans will cover hemophilia drugs under members' pharmacy benefits

Updated e-referral questionnaires to open Sept. 29 for BCN and Medicare Plus BlueSM PPO

Reminder: Starting Oct. 1, 2019, naviHealth will authorize PDPM levels for Medicare Advantage SNF admissions

e-referral system out of service for maintenance Sept. 21-22

How can we improve our online tools?

New webinars available in September and October for BCN

New webinars available in September and October for Blue Cross

August 2019

Providers invited to Medicare Stars events in Michigan

Endometrial ablation and excisional breast biopsy procedures for BCN members require plan notification, not authorization

Skilled nursing facilities must follow CMS guidelines for issuing NOMNC forms to Medicare Advantage members

naviHealth webinars about SNF PDPM payment methodology

Evenity® will be added to the Medicare Part B medical drug prior authorization list in November

Update: Board-certified behavior analysts must have current Michigan license by Jan. 7, 2020, to be reimbursed by Blue Cross and BCN

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

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

New and updated e-referral questionnaires to open August 25 for BCN and Medicare Plus BlueSM PPO

How can we improve our online tools?

Medical record documentation requirements for ABA services are updated

Changes to BCN member transfer request form

Submit BCN enteral nutrition authorization requests using the e-referral system

Clarification: Preferred infliximab strategy for adult Blue Cross' PPO (commercial) members

TAVI/TAVR procedures for BCN members require plan notification, not authorization

Don’t add clinical documentation to denied requests in the e-referral system

Requirements for assessments of Medicare Advantage members in skilled nursing facilities

You may experience e-referral system performance issues August 3 and August 4

July 2019

Reminder: Effective August 1, authorizations must be obtained from AIM Specialty Health® for most medical oncology and supportive care medications for BCN HMOSM (commercial) members

We're making changes to the Medicare Advantage SNF post-payment audit and recovery process

Medicare Part B medical specialty drug prior authorization list is changing in October

Effective November 1, Inflectra® is the preferred infliximab product for adult Blue Cross' PPO (commercial) members

Correct fax number for submitting post-acute care discharge information to naviHealth

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

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

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

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

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

June 2019

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

NovoLogix® user interface enhancements coming soon

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

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

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

Important information about eviCore healthcare therapy authorization requests for BCN

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

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

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

More updated e-referral questionnaires open on June 23

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

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

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

May 2019

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

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

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

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

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

Updated authorization criteria and e-referral questionnaire for ethmoidectomy

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

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

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

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

Learn about Medicare Advantage post-acute care authorization changes

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

April 2019

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

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

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

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

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

March 2019

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

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

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

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

What to do when error messages display in e-referral

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

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

February 2019

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

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

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

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

Clarifying biofeedback and neurofeedback authorization requirements for BCN members

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

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

January 2019

Sign up to receive Blues Brief electronically

Complete the new questionnaires in e-referral for BCN members

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

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

December 2018

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

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

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

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

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

Additional updated authorization criteria and e-referral questionnaires

e-referral User Guides, online eLearning updated

Xgeva® to require authorization for BCN AdvantageSM members

November 2018

eviCore to manage two radiopharmaceutical drugs, starting Feb. 1

Complete the provider specialty questionnaire in the e-referral system

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

Updated authorization criteria and e-referral questionnaires

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

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

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

October 2018

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

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

Additional updated authorization criteria and e-referral questionnaires

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

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

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

Register now for an AIM Specialty Health® ProviderPortalSM webinar

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

Treat Medicare Advantage members with Avastin® before other specialty drugs

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

September 2018

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

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

BCN updates sleep study questionnaire in the e-referral system

Additional updated authorization criteria and e-referral questionnaires

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

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

August 2018

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

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

Renflexis® requires authorization for BCN AdvantageSM starting Oct. 1

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

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

How to submit BCN inpatient authorization requests during upcoming holiday closures

FAQ available about LLPs and LMFTs

Additional updated authorization criteria and e-referral questionnaires in effect

Phone numbers change for BCN Case Management and Care Transition programs

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

Updated authorization criteria and e-referral questionnaires in effect

Error issue resolved in e-referral system

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

July 2018

2018 InterQual® criteria implementation delayed until Aug. 6

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

2018 InterQual® criteria to be implemented starting Aug. 6

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

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

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

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

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

We're updating you on Blue Distinction® Specialty Care

Deleting your browsing history after an e-referral system outage

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

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

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

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

How to submit BCN inpatient authorization requests during upcoming holiday closures

June 2018

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

Updated authorization criteria and e-referral questionnaires are in effect

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

Where to get help in using the e-referral system

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

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

May 2018

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

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

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

How to submit BCN inpatient authorization requests during upcoming holiday closures

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

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

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

April 2018

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

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

Medicare Outpatient Observation Notice requirements clarified

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

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

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

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

March 2018

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

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

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

How to submit BCN inpatient authorization requests during upcoming holiday closures

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

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

Provider forums are coming to a town near you

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

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

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

February 2018

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

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

January 2018

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

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

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

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

How to submit BCN inpatient authorization requests during upcoming holiday closures

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

Submit functional limitation G codes for BCN AdvantageSM therapy services

December 2017

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

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

eviCore accepting Blue Cross PPO authorization requests starting Dec. 22

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

November 2017

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

October 2017

New BCN authorization requirements are effective Jan. 1, 2018

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

e-referral site wins communications awards

Do not refer new patients to MedEQUIP in Ann Arbor

Clarification on Blue Cross inpatient authorization requirements for newborns

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

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

September 2017

2017 InterQual criteria to be implemented starting October 2

New name for Blue Cross® Physician Choice PPO

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

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

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

Blue Cross inpatient authorization requirements clarified

August 2017

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

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

Reminder: 2017 InterQual criteria delayed until October 2017

July 2017

Clarifying authorization requirements for Blue Cross members

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

June 2017

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

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

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

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

May 2017

2017 InterQual criteria delayed until October 2017

Blue Care Network changes authorization requirements for sleep management studies

Blue Care Network updates authorization guideline for external ECG monitoring

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

April 2017

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

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

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

March 2017

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

RC Claim Assist tool is now available

January 2017

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

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

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

December 2016

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

BCN revises codes managed by eviCore healthcare

Guidelines for submitting acute inpatient admission requests to BCN

November 2016

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

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

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

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

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

Tell us what you think about BCN Care Management Services

October 2016

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

ALERT: Phone issues on eviCore's BCN provider line

September 2016

Updated BCN authorization criteria and preview questionnaires now available

BCN's Behavioral Health e-referral User Guide updated

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

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

Online self-paced training modules now available

Changeover to using Novologix web tool is delayed for BCN providers

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

MSU Student and Graduate Assistant Health Plans information

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

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

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

August 2016

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

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

BCN launches new Medical Benefit Drugs-Pharmacy web page

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

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

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

July 2016

e-referral User Guide updated and available

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

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

eviCore changes reconsideration process for PTs' utilization categories

June 2016

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

UPDATED: Changes in BCN's sleep study requirements

Submit BCN obstetrical admissions one day after discharge – not sooner

May 2016

Some medical drugs no longer require authorization for BCN AdvantageSM members

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

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

Welcome to the new referrals.bcbsm.com

We're updating our look

April 2016

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

New Behavioral Health e-referral User Guide available

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

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

March 2016

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

What you need to know about the eviCore 2.0 provider portal

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

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

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

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

We want your opinion

Updated nutrition assessment form now available for home infusion providers

February 2016

Updated preview questionnaire is available for excisional breast biopsy

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

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

January 2016

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

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

December 2015

BCN Behavioral Health utilization management criteria is changing on January 1

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

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

Announcing e-referral enhancements beginning Dec. 7, 2015

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

November 2015

Global referral: What it allows a specialist to do

Changes in eviCore authorization requirements

Add correct servicing provider information when submitting requests to eviCore

Reminder: Prostatic urethral lift procedures require clinical review

October 2015

eviCore healthcare Web Portal webinars available

Updated Spine Care Referral Program questionnaire is now available

Some providers showing missing or incorrect address in e-referral

September 2015

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

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

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

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

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

August 2015

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

Chiropractors may provide some physical therapy services for BCN commercial members

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

July 2015

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

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

e-referral upgrade slated for Aug. 17

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

June 2015

More procedures to be reviewed by eviCore healthcare effective September 1

eviCore healthcare Web address changes July 6

Upgrades coming to e-referral

2015 InterQual® criteria to be used effective August 3

May 2015

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

March 2015

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

Finding home sleep study providers

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

Register now for April 2015 behavioral health webinar

Training Tools

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

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

User guides and documentation

Online training

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

Password information

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

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

BCN Care Management provider call volumes high

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


How to access e-referral with Internet Explorer ® 11

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


Updated BCN provider affiliations codes on e-referral

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

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

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

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

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

Blue Care Network offers Behavioral Health informational webinars

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

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

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

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

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

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

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

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

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

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

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

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

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

New questionnaires available for lumbar spine surgery

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

The changes include but are not limited to:

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

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

New questionnaires available for arthroscopy of the knee

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

The changes include but are not limited to:

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

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

2013 InterQual® acute care criteria take effect November 4

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

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

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

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

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

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

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

Blue Care Network announces date for sleep management program changes

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

Blue Care Network announces questionnaire changes effective August 5

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

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

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

Lumbar spine surgery questionnaire updated effective July 29, 2013

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

Blue Cross Complete announces changes effective August 1

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

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

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

Blue Care Network announces delay in changes for sleep management

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

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

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

Blue Care Network announces changes for frenulum surgery

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

2013 InterQual® criteria take effect July 1

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

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

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

Criteria/Version Application

InterQual Acute – Adult and Pediatrics
Exceptions-local rules

  • Inpatient admissions
  • Continued stay discharge readiness

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

  • Subacute and skilled nursing facility admissions

InterQual Rehabilitation - Adult and Pediatrics
Exceptions-local rules

  • Inpatient admissions
  • Continued stay and discharge readiness

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

  • Long term acute care facility admissions

InterQual Level of Care – Home Care
Exceptions-local rules

  • Home care requests

InterQual Imaging

  • Imaging studies and X-rays

InterQual Procedures – Adult and Pediatrics

  • Surgery and invasive procedures

BCBSM/BCN medical policies

  • Services that require clinical review for medical necessity

Plan developed imaging criteria

  • Imaging studies and X-rays

Blue Care Network reimbursement for intra-articular hyaluronic acid injections

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

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

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

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

Osteoporosis: Intravenous bisphosphonate therapy — Reclast infusion questionnaire

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

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

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

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

Blue Care Network announces questionnaire update for sleep management

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

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

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

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

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

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

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

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

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

Radiology management program changes effective May 1, 2013

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

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

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

Quick Guides
Blue Distinction Centers®

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

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

Blue Distinction Center programs include:

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

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

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

e-referral system out of service for maintenance Oct. 19-20

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

From 10 p.m. on Saturday, October 19 to 10 a.m. on Sunday, October 20

The e-referral system will not be available at all during these times. On Sunday, the system will be available by 10 a.m. and may be available earlier if maintenance tasks are completed. During the remaining time over the weekend, we expect the system to be available, although you may experience minor performance issues.

To see more planned downtimes and to learn how to handle requests while the system is down, review the list of e-referral system planned downtimes and what to do.

You can get to this list anytime from any page of this website. Scroll down the left navigation pane and look for the blue tile at the bottom.

We're providing this information so you can plan ahead. We apologize for any inconvenience you may experience while the e-referral system is down.

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

The oncology management program will include Medicare Advantage plans starting Jan. 1, 2020

On Jan. 1, 2020, a utilization management program for medical oncology drugs will begin for Medicare Plus BlueSM PPO and BCN AdvantageSM members. Providers will need to obtain authorizations from AIM Specialty Health® for some medical oncology and supportive care medications.

This program became effective for BCN HMOSM (commercial) members in August 2019.

For details about the program, see page 10 of the September-October 2019 issue of BCN Provider News.

Frequently asked questions

We've updated the Oncology management program: Frequently asked questions for providers document for the addition of Medicare Plus Blue and BCN Advantage members.

Oct. 24 webinar

Learn about the new medical oncology program and how to use the AIM ProviderPortalSM by attending a webinar on Oct. 24 (intended for non-clinical provider staff).

Make sure to view the article in the November-December issue of BCN Provider News (posting on Oct. 23) for more information and additional webinars.

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

Starting Jan. 1, 2020, we'll cover select hyaluronic acid products

Effective Jan. 1, 2020, Blue Cross Blue Shield of Michigan and Blue Care Network will consider the following hyaluronic acid products to be either covered or preferred under the medical benefit:

  • Durolane®
  • Euflexxa®
  • Gelsyn-3
  • Supartz FX

Starting Jan. 1, we'll consider the following to be either noncovered or nonpreferred hyaluronic acid products: Gel-one®, GenVisc 850®, Hyalgan®, Hymovis®, Monovisc®, Orthovisc®, Synvisc®, Synvisc-One®, TriVisc®, Visco-3, Synojoynt and Triluron.

This change will apply to Blue Cross' PPO (commercial), Medicare Plus BlueSM PPO, BCN HMOSM (commercial) and BCN AdvantageSM members. This change won't apply to self-funded General Motors, Fiat Chrysler Automobiles, Ford Motor Company, and UAW Retiree Medical Benefit Trust commercial groups.

Blue Cross' PPO and BCN HMO commercial members

  • Members who began receiving noncovered hyaluronic acid products prior to Jan. 1, 2020, can continue their treatment courses to completion. For future treatment courses that begin on or after Jan. 1, 2020, we encourage providers to talk to their patients about using a covered hyaluronic acid product.
  • For treatment courses that begin on or after Jan. 1, 2020, we'll require members to use a covered hyaluronic acid product; these products don't require authorization.
  • We'll deny claims for noncovered hyaluronic acid drugs.
  • We'll notify affected members of these changes and encourage them to discuss treatment options with you.

Medicare Plus Blue and BCN Advantage members

  • Members who began receiving nonpreferred hyaluronic acid products prior to Jan. 1, 2020, can continue their treatment courses to completion. For future treatment courses that begin on or after Jan. 1, 2020, we encourage providers to talk to their patients about using a preferred hyaluronic acid product.
  • For treatments on or after Jan. 1, 2020, we'll require members to use preferred hyaluronic acid products; these products won't require authorization. If you select a nonpreferred hyaluronic acid product for a member, you will have to obtain authorization.

Additional information

The U.S. Food and Drug Administration has approved 16 hyaluronic acid products. To date, no study has shown that one hyaluronic acid product is superior to others.

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

Starting Jan. 1, 2020, Blue Cross' PPO and BCN HMOSM plans will cover hemophilia drugs under members' pharmacy benefits

Starting Jan. 1, 2020, Blue Cross Blue Shield of Michigan and Blue Care Network will change how we cover hemophilia drugs for commercial (PPO and HMO) members. If a member has Blue Cross' PPO or BCN HMO pharmacy coverage, all hemophilia drugs should be billed under his or her pharmacy benefits.

This change doesn't affect all commercial members. For example, if a member has pharmacy coverage through a company other than Blue Cross or BCN, hemophilia drugs will continue to be covered under the medical benefit.

To determine whether this change applies to a specific member:

  • For Blue Cross' PPO members, review the member's benefits in Benefit Explainer.
  • For BCN HMOSM members, review the member's benefits in web-DENIS.

We'll notify affected members of these changes. Members don't have to do anything. Their medication and treatment won't change.

For complete details, see the We'll cover hemophilia drugs under the pharmacy benefit for most commercial members, starting Jan. 1 article in the October 2019 issue of The Record. A similar article will appear in the November-December 2019 issue of BCN Provider News.

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

Updated e-referral questionnaires to open Sept. 29 for BCN and Medicare Plus BlueSM PPO

Starting Sept. 29, 2019, updated questionnaires will open in the e-referral system for certain procedures. In addition, updated preview questionnaires and authorization criteria will be available on this website.

We use our authorization criteria and medical policies and your answers to the questionnaires when making utilization management determinations on your authorization requests.

Updates to existing questionnaires

Updated questionnaires will open in the e-referral system starting on Sept. 29 for the following services:

  • Cervical spine fusion with artificial disc replacement - opens for BCN HMOSM and BCN AdvantageSM
  • Dental anesthesia or repair of trauma to natural teeth - opens for BCN HMO and BCN Advantage
  • Noncoronary vascular stents - opens for BCN HMO, BCN Advantage and Medicare Plus Blue

Preview questionnaires

For all of these services, you'll soon be able to access preview questionnaires on this website. The preview questionnaires show the questions you'll need to answer in the actual questionnaires that open in the e-referral system. This can help you prepare your answers ahead of time.

To find the preview questionnaires:

  • For BCN: Click BCN and then click Authorization Requirements & Criteria. Scroll down and look under the "Authorization criteria and preview questionnaires" heading.
  • For Medicare Plus Blue: Click Blue Cross and then click Authorization Requirements & Criteria. In the "Medicare Plus Blue PPO members" section, look under the "Authorization criteria and preview questionnaires - Medicare Plus Blue PPO" heading.

Authorization criteria

We'll also update the pertinent authorization criteria on the Authorization Requirements & Criteria pages.

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

Reminder: Starting Oct. 1, 2019, naviHealth will authorize PDPM levels for Medicare Advantage SNF admissions

For Medicare Plus BlueSM PPO and BCN AdvantageSM skilled nursing facility admissions with dates of service on or after Oct. 1, 2019, naviHealth will authorize patient-driven payment model levels during the patient's stay (from preservice through discharge) to align with the Centers for Medicare & Medicaid Services payment methodology. We first communicated this change in late July.

When submitting claims for stays with dates of service starting on or before Sept. 30, 2019, and extending through or beyond Oct. 1, you'll need to include both the resource utilization group levels and the PDPM levels that naviHealth authorized.

Medicare Plus Blue PPO and BCN Advantage follow CMS payment methodology for skilled nursing facilities. As a result, the payment methodology will change from RUG levels to PDPM levels on Oct. 1, 2019.

You can view additional information on The Patient Driven Payment Model (PDPM) - Information and Resources for Provider Partners page of the naviHealth website.*

As a reminder, naviHealth manages authorization requests for Medicare Plus Blue PPO and BCN Advantage members admitted to post-acute care on or after June 1, 2019. For details, see the Post-acute care services: Frequently asked questions by providers document.

*Blue Cross Blue Shield of Michigan and Blue Care Network don't own or control this website.

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

e-referral system out of service for maintenance Sept. 21-22

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

From 7 a.m. on Saturday, Sept. 21 to 10 p.m. on Sunday, Sept. 22 (Eastern time)

To see more planned downtimes and to learn how to handle requests while the system is down, review the list of e-referral system planned downtimes and what to do.

You can get to this list anytime from any page of our ereferrals.bcbsm.com website. Scroll down the left navigation pane and look for the blue tile at the bottom.

We're providing this information so you can plan ahead. We apologize for any inconvenience you may experience while the e-referral system is down.

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

How can we improve our online tools?

Blue Cross Blue Shield of Michigan and Blue Care Network want to know how we can make our online tools easier to use and more useful for you, our partner providers. We specifically want to know about your experience using online provider tools and services, including the tools available when you log in to our secure provider website at bcbsm.com.

Can you spare eight minutes to share your thoughts? Your input will help us focus future improvements that are most helpful to you.

Take survey now.

This survey will be available through the end of September. Thank you for sharing your opinions. Your responses will be confidential.

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

Providers invited to Medicare Stars events in Michigan

Providers are invited to attend the Stars Premiere event held in movie theatres across the state in September. The event will include information about the Medicare Star Rating System, HEDIS measures, the Health Outcomes Survey and much more.

See the article in the September Record or the September-October BCN Provider News, Page 15 for dates, times and registration information.

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

Skilled nursing facilities must follow CMS guidelines for issuing NOMNC forms to Medicare Advantage members

BCN AdvantageSM and Medicare Plus BlueSM PPO members sometimes remain in skilled nursing facilities for days beyond the service end date on the Notice of Medicare Non-Coverage form. Sometimes the extended stay is due to a provider's failure either to deliver a completed NOMNC form in a timely manner or to comply with guidelines from Livanta, LLC, the quality improvement organization. This results in days added to the member's stay that may not be medically necessary.

On behalf of Blue Cross Blue Shield of Michigan, naviHealth will issue an administrative denial for these days if they occur because the SNF provider didn't handle the NOMNC in accordance with the Centers for Medicare and Medicaid Services guidelines. In an administrative denial, the authorization is approved but the reimbursement for the extra days is denied.

Examples of improper handling and delivery of the NOMNC include:

  • Late delivery of the NOMNC. Members must receive the NOMNC 48 hours prior to the planned discharge date.

    Note: naviHealth completes as much of the NOMNC as possible and tells the provider when to issue the NOMNC.
  • Failure to fill out the NOMNC in its entirety. All fields in the NOMNC must be completed, including all date and signature fields. For more information, see the Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123*.
  • Not submitting the requested medical information to the QIO in a timely manner, when the member appealed the service end date with the QIO

Note: To view CMS instructions about appropriate delivery of the NOMNC, see sections 260.2 to 260.4.5 of the CMS Manual System: Pub 100-04 Medicare Claims Processing, Transmittal 2711.*

When SNF providers have repeated difficulties handling the NOMNC according to CMS guidelines, their naviHealth care coordinators will reach out to provide education about CMS guidelines and health plan requirements. If, after receiving education, a SNF provider continues to have difficulties, naviHealth will deliver an administrative denial letter to the provider when members stay beyond the end date stated on the NOMNC.

The administrative denial letter will include details on the specific CMS guideline violations. Blue Cross and Blue Care Network will hold the provider responsible for the additional days the member stayed in the SNF. Per CMS guidelines, providers can't bill members for the additional days.

You can find information about CMS guidelines and Medicare Plus Blue and BCN Advantage requirements in the following locations.

As a reminder, naviHealth manages authorization requests for Medicare Plus Blue and BCN Advantage members admitted to post-acute care on or after June 1, 2019. For details, see the Post-acute care services: Frequently asked questions by providers document.

*Blue Cross Blue Shield of Michigan and Blue Care Network don't own or control this website.

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

naviHealth webinars about SNF PDPM payment methodology

For Medicare Advantage skilled nursing facility admissions with service dates on or after Oct. 1, 2019, naviHealth will authorize Patient-Driven Payment Model levels during the patient's stay (from preservice through discharge) to align with the Centers for Medicare & Medicaid payment methodology. We first communicated this change in late July.

To learn how naviHealth has been preparing for the changes to payment methodology with PDPM, register for and attend one of their live webinars, which are scheduled for September 3, 4 and 5.

During the webinars, naviHealth will cover the following:

  • The naviHealth clinical model under PDPM
  • The enhancements that are planned for the nH Predict|Outcome reports and nH Predict|Pulse
  • The process for PDPM level assignment including:
    • The additional clinical information necessary to process a request
    • How to request a level reconsideration
    • A review of claims processing

You can view additional information on The Patient Driven Payment Model (PDPM) - Information and Resources for Provider Partners page of the naviHealth website.*

As a reminder, naviHealth manages authorization requests for Medicare Plus BlueSM PPO and BCN AdvantageSM members admitted to post-acute care on or after June 1, 2019. For details, see the Post-acute care services: Frequently asked questions by providers document.

*Blue Cross Blue Shield of Michigan and Blue Care Network don't own or control this website.

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

Evenity® will be added to the Medicare Part B medical drug prior authorization list in November

We're adding Evenity® (J3111) to the Medicare Plus BlueSM PPO and BCN AdvantageSM Part B medical drug prior authorization list.

For dates of service on or after Nov. 1, 2019, Evenity will require prior authorization.

Medicare Plus Blue PPO

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

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

BCN Advantage

For BCN Advantage, we require authorization for this medication for the following sites of care when you bill the medication as a professional service or as an outpatient facility service, and when you bill electronically through an 837P transaction or on a professional CMS-1500 claim form:

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

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

Important reminder

You must obtain an authorization before administering this medication. Use the NovoLogix® online tool to quickly submit your authorization requests. It offers real-time status checks and immediate approvals for certain medications.

If you have access to Provider Secured Services but you need access to NovoLogix, do one of the following:

If you need to request access to Provider Secured Services, complete the Provider Secured Services Application form and fax it to the number on the form.

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

Update: Board-certified behavior analysts must have current Michigan license by Jan. 7, 2020, to be reimbursed by Blue Cross and BCN

Starting Jan. 7, 2020, board-certified behavior analysts practicing in Michigan must have a current license from the State of Michigan to be eligible for reimbursement from Blue Cross and Blue Care Network. BCBAs who are not licensed are not eligible to be reimbursed for services provided on or after Jan. 7, 2020.

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

Note: An earlier version of this message indicated that a license is required by Jan. 1, 2020. The actual date on which a license is required is Jan. 7, 2020.

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

New and updated e-referral questionnaires to open August 25 for BCN and Medicare Plus BlueSM PPO

Starting Aug. 25, 2019, new and updated questionnaires will open in the e-referral system for certain procedures. In addition, new and updated preview questionnaires, authorization criteria and medical policies will be available on this website.

New questionnaires

Starting August 25, questionnaires will open in the e-referral system for BCN HMOSM and BCN AdvantageSM authorization requests for the procedures listed below, which already require authorization.

Service Age Procedure codes
Bariatric surgery - BCN HMO Adult and adolescents *43644, *43645, *43770, *43771, *43772, *43773, *43774, *43775, *43842, *43843, *43845, *43846, *43847, *43848, *43886, *43887, *43888 and *44130
Bone-anchored hearing aid Adult and pediatric (5 years old and older) *69714, *69715, *69717 and *69718
Cardiac rehabilitation - BCN HMO Adult and pediatric *93797 and *93798 (for select diagnoses)
Cardiac rehabilitation - BCN Advantage
Pregnancy termination - BCN HMO Adult *01966, *59100, *59840, *59841, *59850, *59851, *59852, *59855, *59856, *59857, *59866, *88304, *88305, S0190, S0191, S0199, S2260, S2265, S2266 and S2267
Pregnancy termination - BCN Advantage
Pulmonary rehabilitation Adult and pediatric G0237, G0238, G0239, G0302, G0303, G0304, G0424 and S9473
Radiofrequency ablation, peripheral nerves Adult *64640
Visual training, orthotic and pleoptic Adult and pediatric *92065

Updates to existing questionnaires

In addition, updated questionnaires will open in the e-referral system on August 25 for BCN HMO, BCN Advantage and Medicare Plus Blue authorization requests (unless otherwise noted), for the following services:

  • Cervical spine surgery - opens only for BCN HMO and BCN Advantage
  • Cholecystectomy (laparoscopic) - opens only for BCN HMO and BCN Advantage
  • Endovascular intervention, peripheral artery - The updated questionnaire for this service was originally scheduled to open starting on July 28 for Medicare Plus Blue requests but will actually open starting August 25.
  • Ethmoidectomy
  • Hammertoe correction surgery
  • Hip arthroplasty, total, revision
  • Knee arthroplasty, total, revision
  • Sacral nerve neuromodulation/stimulation
  • Sinusotomy, frontal, endoscopic
  • Sleep studies, outpatient facility or clinic-based setting - opens only for BCN HMO and BCN Advantage
  • Vascular embolization or occlusion of hepatic tumors (TACE/RFA)

Preview questionnaires

We'll make preview questionnaires available on this website soon. To find them:

  • For BCN: Click BCN and then click Authorization Requirements & Criteria. Scroll down and look under the "Authorization criteria and preview questionnaires" heading.
  • For Medicare Plus Blue: Click Blue Cross and then click Authorization Requirements & Criteria. In the "Medicare Plus Blue PPO members" section, look under the "Authorization criteria and preview questionnaires - Medicare Plus Blue PPO" heading.

The preview questionnaires show the questions you'll need to answer in the actual questionnaires that open in the e-referral system. This will help you prepare your answers ahead of time.

Authorization criteria and medical policies

We'll also post links to the pertinent authorization criteria and medical policies on the Authorization Requirements & Criteria pages.

We use our authorization criteria and medical policies and your answers to the questionnaires when making utilization management determinations on your authorization requests.

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

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

How can we improve our online tools?

Blue Cross Blue Shield of Michigan and Blue Care Network want to know how we can make our online tools easier to use and more useful for you, our partner providers. We specifically want to know about your experience using online provider tools and services, including the tools available when you log in to our secure provider website at bcbsm.com.

Can you spare eight minutes to share your thoughts? Your input will help us focus future improvements that are most helpful to you.

Take survey now.

This survey will be available through the end of September. Thank you for sharing your opinions. Your responses will be confidential.

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

Medical record documentation requirements for ABA services are updated

We updated the medical record documentation requirements for applied behavior analysis services to clarify documentation requirements for services involving tutors and technicians.

These guidelines apply to services for Blue Cross' PPO (commercial) and BCN HMOSM (commercial) members.

You can view the guidelines on this website by clicking BCN or Blue Cross and then clicking Behavioral Health. Finally, click the Documentation requirements for applied behavior analysis services link.

You can also view the guidelines within Provider Secured Services. Here's how:

  1. Visit bcbsm.com/providers.
  2. Click Login and log in to Provider Secured Services.
  3. Click web-DENIS.

To access the guidelines through BCBSM Provider Publications and Resources:

  1. Click BCBSM Provider Publications and Resources.
  2. Click Newsletters & Resources.
  3. Click Clinical Criteria & Resources.
  4. Click Autism under the Resources heading.
  5. Click Documentation requirements for applied behavior analysis services.

To access the guidelines through BCN Provider Publications and Resources:

  1. Click BCN Provider Publications and Resources.
  2. Click Autism.
  3. Click Documentation requirements for applied behavior analysis services.

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

Don't add clinical documentation to denied requests in the e-referral system

When we deny an authorization request in the e-referral system, we contact your office to inform you of that determination and then we close the case, which means that the case no longer appears in our queues.

We don't receive notification of changes to authorization requests that have been closed.

For this reason, we ask that you don't submit additional clinical documentation or make any other changes on denied requests. Instead, submit the clinical documentation during the appeals process. This will help to ensure that we see and review the additional documentation.

The denial letter includes instructions for submitting an appeal.

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

Requirements for assessments of Medicare Advantage members in skilled nursing facilities

Here's some important information about the assessments required for Blue Cross and Blue Care Network Medicare Advantage members admitted to skilled nursing facilities:

  • You must complete an Omnibus Reconciliation Act, or OBRA, assessment for each member.
  • You may opt to complete an additional Prospective Payment System assessment, but you are not required to complete one.

If you complete a PPS assessment:

  • No Resource Utilization Group level is required, because naviHealth will determine the RUG level.
  • A RUG level included in a PPS assessment may not match the level naviHealth assigns. If the levels don't match and you enter the RUG level from a PPS assessment rather than the naviHealth-assigned RUG level, this may cause a claim payment error.
  • You must bill using the RUG level naviHealth assigns, which you'll find in the authorization on nH Access at access.navihealth.com.

If you choose not to complete a PPS assessment, there will be no penalties, even if you're following CMS protocols.

This applies to BCN AdvantageSM and Medicare Plus BlueSM PPO members admitted for skilled nursing care on or after June 1, 2019.

For more information, see the following documents on the Blue Cross Blue Shield of Michigan and Blue Care Network resources page of the naviHealth website*:

If you have questions, contact your naviHealth network manager.

We'll incorporate this information into the Post-acute care services: Frequently asked questions by providers document.

Additional information:

  • Starting Oct. 1, 2019, naviHealth will authorize Patient-Driven Payment Model levels during the patient's stay, which aligns with CMS payment methodology. Before this change takes place, we'll let you know how it will affect the assessments you must complete.
  • As a reminder, naviHealth manages authorization requests for Medicare Plus Blue and BCN Advantage members admitted to post-acute care on or after June 1, 2019.
  • As part of their partnership with Blue Cross Blue Shield of Michigan, naviHealth assigns and authorizes RUG levels for Medicare Advantage members' stays in skilled nursing facilities.

*Blue Cross Blue Shield of Michigan and Blue Care Network don't own or control this website.

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

You may experience e-referral system performance issues August 3 and August 4

You may experience performance issues with the e-referral system from midnight to 6 a.m. on these dates:

  • Saturday, August 3
  • Sunday, August 4

This is because we'll be loading a large membership file into the system during these times.

Any problems you experience using the e-referral system during these times should be resolved by the start of business on Monday, August 5.

We're placing a notice about this on the Provider Secured Services landing page, near the e-referral system link.

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

We're making changes to the Medicare Advantage SNF post-payment audit and recovery process

Blue Cross Blue Shield of Michigan and Blue Care Network are making changes to the post-payment audit and recovery process for skilled nursing facilities. The changes apply to Medicare Plus BlueSM PPO and BCN AdvantageSM members.

Here's what you need to know:

  • HMS® no longer performs post-payment SNF audits. Instead, Blue Cross and BCN review paid SNF claims on a quarterly basis. We'll ensure that Resource Utilization Group or Patient-Driven Payment Model levels in the claims match the RUG or PDPM levels on the authorizations.
  • You won't need to submit medical records during the quarterly post-payment review process.
  • Prior to discharge, a naviHealth care coordinator will work with your biller to verify that the authorized RUG or PDPM levels are submitted for reimbursement. When you submit SNF Medicare Advantage claims, make sure the RUG or PDPM levels on each claim match the levels on the authorization connected to the stay.

For complete details, see the We're making changes to the Medicare Advantage SNF post-payment audit, recovery process article in the August 2019 issue of The Record. A similar article will appear in the September-October 2019 issue of BCN Provider News.

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

Medicare Part B medical specialty drug prior authorization list is changing in October

We're adding the following medications to the Medicare Plus BlueSM PPO and BCN AdvantageSM Part B specialty prior authorization drug list.

For dates of service on or after Oct. 1, 2019, the following medications will require prior authorization:

  • J1599 Asceniv
  • J1301 Radicava®
  • J0584 Crysvita®
  • J0565 Zinplava

Medicare Plus Blue PPO

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

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

BCN Advantage

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

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

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

Important reminder

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

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

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

Correct fax number for submitting post-acute care discharge information to naviHealth

It recently came to our attention that some of our documents contained an incorrect fax number for sending post-acute care discharge information to naviHealth. We've updated the documents to include the correct fax number, which is 1-844-729-2951. The incorrect fax number contained the last four digits: 2591.

Providers who sent discharge information to the incorrect fax number before July 13, 2019, should be aware that naviHealth didn't receive it. The fax attempt failed and no one received the information.

If you faxed discharge information and you didn't receive a fax confirmation, or you aren't sure that naviHealth received the fax, resend the information. If naviHealth doesn't receive discharge information within the expected time frame, a naviHealth care coordinator will follow up with the facility.

We apologize for any confusion.

As a reminder, naviHealth manages authorization requests for Medicare Plus BlueSM PPO and BCN AdvantageSM members admitted to post-acute care on or after June 1, 2019.

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

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

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

  • For dates of service on or after July 22, 2019, Darzalex® (J9145) will require prior authorization.

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

Medicare Plus Blue PPO

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

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

BCN Advantage

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

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

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

Important reminder

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

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

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



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

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

Blues 101 – Understanding the Basics

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

Blues 201 – Enrollment

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

Pharmacy Site of Care

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

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

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

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



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

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

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

For more information, see the following articles:

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



NovoLogix® user interface enhancements coming soon

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

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

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

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



More updated e-referral questionnaires open on June 23

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

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

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

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

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

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

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

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



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

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

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

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

Requesting authorization for non-post-acute care services

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

Requesting authorization for Medicare Advantage post-acute care

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

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



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

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

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

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

For BCN HMO members:

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

For Blue Cross' PPO members:

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

More about the authorization requirements

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

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

List of requirements

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

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

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



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

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

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



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

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

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

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

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

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

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

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

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

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

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

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

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

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

Claims billed with the following codes will still be honored:

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

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

Billing guidelines

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

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

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

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

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

Updated authorization criteria and e-referral questionnaire for ethmoidectomy

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

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

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

  • BCN HMOSM
  • BCN AdvantageSM
  • Medicare Plus BlueSM PPO

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

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

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

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

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

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

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

Medicare Plus Blue PPO

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

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

BCN Advantage

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

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

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

Important reminder

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

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

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

Learn about Medicare Advantage post-acute care authorization changes

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Medicare Plus Blue PPO

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

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

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

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

BCN Advantage

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

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

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

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

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

Important reminder

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

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

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

What to do when error messages display in e-referral

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

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

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

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

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

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

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

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

Important to know:

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

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

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

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

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

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

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

Sign up to receive Blues Brief electronically

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

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

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

e-referral User Guides, online eLearning updated

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

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

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

The updated User Guides also include:

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

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

eviCore to manage two radiopharmaceutical drugs, starting Feb. 1

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

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

This applies to members covered by:

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

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

  • BCN HMOSM (commercial) and BCN AdvantageSM

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

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

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

Note: These changes do not apply to MESSA members.

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

Updated authorization criteria and e-referral questionnaires

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

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

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

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

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

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

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

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

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

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

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

Medicare Plus Blue PPO

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

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

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

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

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

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

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

BCN Advantage

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

    • J9032 Beleodaq®
    • J9310 Rituxan®

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

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

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

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

Important reminder

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

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

Additional updated authorization criteria and e-referral questionnaires

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

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

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

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

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

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

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

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

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

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

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

Register for one of the following webinars now:

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

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

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

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

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

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

How to submit authorization requests

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

Always verify benefits

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

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

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

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

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

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

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

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

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

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

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

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

Treat Medicare Advantage members with Avastin® before other specialty drugs

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

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

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

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

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

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

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

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

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

What's changing?

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

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

Use NovoLogix® to submit authorization requests

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

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

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

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

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

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

Register for a webinar now:

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

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

Additional updated authorization criteria and e-referral questionnaires

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

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

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

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

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

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

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

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

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

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

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

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

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

Our goal is to:

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

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

    Blue Cross PPO

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

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

    Blue Cross Medicare Plus Blue PPO

    Call either of the following resources:

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

    BCN HMO and BCN Advantage

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

Need more help?

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

    Blue Cross PPO, BCN HMO or BCN Advantage

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

    Blue Cross Medicare Plus Blue PPO

    Call 1-866-309-1719.

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

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

FAQ available about LLPs and LMFTs

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

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

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

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

Additional updated authorization criteria and e-referral questionnaires in effect

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

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

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

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

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

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

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

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

Updated authorization criteria and e-referral questionnaires in effect

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

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

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

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

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

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

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

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

Error issue resolved in e-referral system

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

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

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

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

2018 InterQual® criteria implementation delayed until Aug. 6

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

2018 InterQual® criteria to be implemented starting Aug. 6

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

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

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

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

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

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

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

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

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

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



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

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

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

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

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

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

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

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

We're updating you on Blue Distinction Specialty Care

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

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

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

Deleting your browsing history after an e-referral system outage

The e-referral system is available again.

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

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

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

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

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

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

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

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

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

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

Non-behavioral health inpatient admissions

For BCN HMO (commercial) and BCN Advantage members:

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

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

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

Behavioral health inpatient admissions

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

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

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

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

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

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

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

See the table below for a summary of the requirements.

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

Note:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Updated authorization criteria and e-referral questionnaires are in effect

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

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

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

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

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

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

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

2018 InterQual® criteria to be implemented starting Aug. 1

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

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

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

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

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

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

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

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

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

Where to get help in using the e-referral system

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

Please follow these guidelines for other e-referral issues:

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

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

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

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

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

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

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

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

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

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

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

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

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

Both medications are billed with HCPCS procedure code J3590.

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

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

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

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

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

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

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

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

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

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

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

Medicare Outpatient Observation Notice requirements clarified

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

Here's when hospitals need to notify members

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

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

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

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

Here's when hospitals do not need to notify members

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

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

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

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

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

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

Here's how to contact these vendors:

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

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

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

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

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

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

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

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

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

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

Members will receive a letter soon with the updated information.

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

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

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

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

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

How to request an authorization for non-emergency flights

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

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

Additional information

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

The following articles were published in past newsletter issues:

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

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

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

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

Provider forums are coming to a town near you

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

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

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

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

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

We hope you can join us.

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

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

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

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

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

To request authorization for these therapies:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

e-referral site wins communications awards

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

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

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

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

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

Do not refer new patients to MedEQUIP in Ann Arbor

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

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

2017 InterQual criteria to be implemented starting October 2

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

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

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

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

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

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

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

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

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

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

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

Thank you for your patience.

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

Reminder: 2017 InterQual criteria delayed until October 2017

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

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

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

Posted: August 2017
Line of business: Blue Cross and Blue Care Network

For BCN and Blue Cross Medicare Plus Blue PPO, use 1-800-437-3803 to reach the Pharmacy Clinical Help Desk

Providers who need to contact the Pharmacy Clinical Help Desk about drugs covered under the medical benefit should call 1-800-437-3803, effective July 5, 2017. This applies to members covered through BCN HMOSM (commercial), BCN AdvantageSM and Blue Cross Medicare Plus BlueSM PPO products.

Providers who have been using other numbers to contact the Pharmacy Clinical Help Desk for drugs covered under the medical benefit should begin using the 1-800-437-3803 number effective July 5, 2017. All other numbers to the Pharmacy Clinical Help Desk will be discontinued as of July 5, 2017.

Posted: June 2017
Line of business: Blue Cross and Blue Care Network

2017 InterQual criteria delayed until October 2017

Blue Cross Blue Shield of Michigan and Blue Care Network will delay implementing the 2017 InterQual® criteria until October 2017. This delay is due to upgrades being made to the e-referral system.

Until these upgrades are complete, we will continue to follow the 2016 InterQual criteria for all levels of care.

When we have a new date for implementing the 2017 criteria, we'll let you know through our standard channels of communication.

Posted: May 2017
Line of business: Blue Cross and Blue Care Network

Additional information on RC Claim Assist now available to Blue Cross and BCN providers

Providers who bill for drugs covered under the medical benefit for their Blue Cross and Blue Care Network commercial members are encouraged to review the additional information now available on the RC Claim Assist tool.

On this website, select BCN or Blue Cross and click to open:

The resources available include:

About RC Claim Assist

RC Claim Assist, created by RJ Health Systems, is a free resource now available to Blue Cross Blue Shield of Michigan and Blue Care Network contracted providers who bill for drugs covered under the medical benefit. The tool can help ensure that you are billing:

  • The correct National Drug Code with the billable HCPCS/CPT code
  • The correct NDC quantity
  • The correct unit of measure

Additional webinars to be scheduled later in the year

Additional provider webinars on the RC Claim Assist tool will be scheduled later in 2017. In the meantime, you should review the information currently available, register for the tool and begin using it. Click here to register for RC Claim Assist or to log in, if you are already registered.

Posted: April 2017
Line of business: Blue Cross and Blue Care Network

RC Claim Assist tool is now available

RC Claim Assist, created by RJ Health Systems, is a free resource now available to Blue Cross Blue Shield and Blue Care Network contracted providers who bill for drugs covered under the medical benefit. The tool can help ensure that you are billing:

  • The correct National Drug Code with the billable HCPCS/CPT®* code
  • The correct NDC quantity
  • The correct unit of measure

Training webinar

Click to open our webinar invitation and sign up to attend one of the RC Claim Assist training webinars we're hosting on March 14, 2017.

How do I access RC Claim Assist?

Visit the RC Claim Assist log-in page. Register to use RC Claim Assist by completing the following steps:

  1. Enter your NPI. (Very important!)
  2. Enter your first name and last name.
  3. Create your unique password when you are prompted to do so.

RC Claim Assist should be used only for claims submitted for Blue Cross Blue Shield of Michigan and Blue Care Network commercial members.

Questions?

Here's how to get your questions answered:

  • For questions concerning the data you see on RC Claim Assist, please email info@rjhealthsystems.com
  • For questions about billing or claims, contact Provider Inquiry.
  • For questions about a claim that are contractual or complex in nature, contact your provider consultant.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2016 American Medical Association. All rights reserved.

Posted: March 2017
Line of business: Blue Cross and Blue Care Network

Online self-paced training modules now available

You can now train on e-referral at your own speed. Go to the Training Tools page and look for Online self-paced learning modules in the Online training section. While you're there, check out the other training tools available to you.

Posted: September 2016
Line of business: Blue Cross and Blue Care Network



Welcome to the new referrals.bcbsm.com

You've probably already noticed things have changed. On our new site, to find the BCN information you've used in the past, just click "BCN" along the top or at the left of any page. You'll find all of the BCN-related referral and authorization information in the section that opens.

As time goes on, more information will be added to the Blue Cross section of the website.

When you first enter ereferrals.bcbsm.com, you're in the Home area where you’ll find pages like Provider Search and Quick Guides. This is information that may apply to both BCN and Blue Cross. When a page first displays in the Home section, all BCN and Blue Cross information is visible. To see information specific to a certain line of business, click either the Blue Cross or the BCN filter button at the top of the content section. To see all of the information again, click "Show All."

When you access one of these pages from within the BCN or Blue Cross section, though, only the information relevant to that line of business will be displayed and no filter buttons will appear.

The new ereferrals.bcbsm.com site also includes a Search feature. Look in the upper right part of the page. You can choose to search the Full Site or just the BCN or Blue Cross sections of the site. Enter your search term, select where you want to search from the drop-down, and click "Go."

Thank you to those who participated in the survey held earlier this year. Your input was used to determine some of the enhancements made to the site. If you have comments, please send us feedback.

Posted: May 2016
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

We're updating our look

In mid-May, ereferrals.bcbsm.com is launching a makeover. All the news, forms and information you've come to expect from the site will still be available, but we hope you'll find the new colors and photos more appealing. A new search feature will make the site easier to use. We're also adding a new section for Blue Cross content. Here's a sample of what's coming:

Posted: May 2016
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Effective immediately, plan notification is no longer required for endometrial ablation and excisional breast biopsy procedures for BCN members

Effective immediately, plan notification is no longer required for endometrial ablation and excisional breast biopsy procedures for BCN HMOSM (commercial) and BCN AdvantageSM members. However, standard regional referral requirements still apply; for example, a global referral is still required where applicable.

This change applies to the following procedure codes:

  • Endometrial ablation: *58353, *58356 and *58563
  • Excisional breast biopsy: *19101, *19120, *19125 and *19126

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.

Posted: September 2019
Line of business: Blue Care Network



New webinars available in September and October for BCN

Provider Experience is continuing its series of training webinars for health care providers and staff.

September sessions focus on AIM Specialty Health.

October sessions focus on the claims and appeals process for Blue Cross Blue Shield of Michigan, Blue Care Network, Medicare Plus BlueSM and BCN AdvantageSM facility and professional claims.

See the Sept.-Oct. issue of BCN Provider News, Page 4 for dates and registration information.

Posted: September 2019
Line of business: Blue Care Network



Endometrial ablation and excisional breast biopsy procedures for BCN members require plan notification, not authorization

Effective immediately, authorization and clinical review are not required for endometrial ablation and excisional breast biopsy procedures for BCN HMOSM (commercial) and BCN AdvantageSM members.

As a result, you no longer need to submit clinical documentation for these requests.

However, these procedures require plan notification to facilitate claims payment. Refer to the e-referral User Guide for instructions on how to submit a plan notification.

This applies to the following procedure codes:

  • Endometrial ablation: *58353, *58356 and *58563
  • Excisional breast biopsy: *19101, *19120, *19125 and *19126

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.

Posted: August 2019
Line of business: Blue Care Network



How to submit inpatient authorization requests to BCN during upcoming holiday closure

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will be closed on Monday, September 2 for the Labor Day holiday.

During this office closure, follow these guidelines when submitting inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

Acute initial inpatient admissions. Submit these authorization requests as well as concurrent reviews and discharge dates through the e-referral system, which is available 24 hours a day, seven days a week. If the e-referral system is not available, you can fax requests for inpatient admissions and continued stays to BCN HMO (commercial) at 1 866 313 8433 and to BCN Advantage at 1 866 526 1326.

Note: These requests may also be submitted through the X12N 278 Health Care Services Review - Request for Review and Response electronic standard transaction.

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

Post-acute initial and concurrent admission reviews.

Other authorization requests. The types of requests listed below must be submitted by fax. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

  • Authorization requests for sick or ill newborns
  • Requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN After-Hours Care Manager hotline at 1-800-851-3904 and listen to the prompts for help with the following:

  • Determining alternatives to inpatient admissions and triage to alternative care settings
  • Arranging for emergency home health care, home infusion services and in-home pain control
  • Arranging for durable medical equipment
  • Handling emergency discharge planning coordination and authorization
  • Handing expedited appeals of utilization management decisions

Note: Do not use the after-hours care manager phone number to request authorization for routine inpatient admissions.

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member's medical condition and coordinate care prior to admitting the member.

Posted: August 2019
Line of business: Blue Care Network



Changes to BCN member transfer request form

We've made the following changes to the form you use to ask us to transfer a member to another BCN primary care physician:

  • You no longer have to enter the medical care group's name, number or region.
  • You must enter the NPI for the current primary care physician assigned to the member.
  • We added a statement that you can check the web-DENIS Member Eligibility/Coverage screen to verify that the member has an active BCN contract, to confirm that you're the primary care physician assigned to this member and to see the date you were assigned to the member.

We've also updated the description of the member transfer request process to reflect these changes.

As a reminder, you can access the process description and the form in a single document posted on BCN's Forms page within Provider Secured Services. Here's how to get to it:

  1. Visit bcbsm.com/providers.
  2. Click Login.
  3. Log in to Provider Secured Services using your user ID and password.
  4. Click BCN Provider Publications and Resources, on the right.
  5. Click Forms.
  6. Click Member Transfer FAQ and Request Form, under the "Member transfer" heading.

We recommend that when you open the form, you download it and save it to your hard drive before entering information into the fields.

Posted: August 2019
Line of business: Blue Care Network



Submit BCN enteral nutrition authorization requests using the e-referral system

You must submit authorization requests for enteral nutrition for BCN members using the e-referral system. We no longer accept these requests when you submit them by fax.

This applies to BCN HMOSM (commercial) and BCN AdvantageSM members, for procedure codes B4034, B4035, B4036, B4081, B4082, B4083, B4087, B4088, B4102, B4103, B4104, B4105, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B9002, B9998, S9341, S9342 and S9343.

Note: You must still submit authorization requests for total parenteral nutrition by fax.

Here's some additional information you need to know:

  • Enteral nutrition requests are approved for a maximum of 90 calendar days. For additional services after 90 days, you must submit a new authorization request through the e-referral system.
  • You'll need to complete the questionnaire that opens in the e-referral system. Refer to the enteral nutrition preview questionnaire, so you can prepare your answers ahead of time.
  • Refer to the e-referral User Guide for instructions on how to submit an outpatient authorization request.
  • You'll find additional resources on how to use the e-referral system on this website, on the Training Tools page.
  • You'll find a link to the enteral nutrition medical policy on BCN's Authorization Requirements & Criteria page on this website.
  • We use our medical policy and your answers to the questionnaire when making utilization management determinations for the authorization requests you submit.
  • We've revised the form you previously used to submit these requests by fax. You should now use that form only for total parenteral nutrition requests.
  • We'll update the Care Management chapter of the BCN Provider Manual in the near future to reflect these changes.

Posted: August 2019
Line of business: Blue Care Network



TAVI/TAVR procedures for BCN members require plan notification, not authorization

Effective immediately, authorization and clinical review are not required for transcatheter aortic valve implantation and transcatheter aortic valve replacement for BCN HMOSM (commercial) and BCN AdvantageSM members. As a result, you no longer need to submit clinical documentation for these requests.

However, TAVI/TAVR procedures require plan notification to facilitate claims payment. When you submit the plan notification, the request will pend. If the request is for the member to see a contracted provider, we will update the pended request to approved. We are in the process of updating the e-referral system so that these requests will automatically approve in the future.

Refer to the e-referral User Guide for instructions on how to submit a plan notification.

This applies to the following procedures codes, which are for TAVI/TAVR: *33361, *33362, *33363, *33364, *33365, *33366, *33367, *33368 and *33369.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.

Posted: August 2019
Line of business: Blue Care Network



Reminder: Effective August 1, authorizations must be obtained from AIM Specialty Health® for most medical oncology and supportive care medications for BCN HMOSM (commercial) members

Effective for dates of service on or after Aug. 1, 2019, Blue Care Network will implement a new utilization management program for medical oncology drugs for BCN HMO (commercial) members. Authorizations must be obtained from AIM Specialty Health for most medical oncology and supportive care medications.

Learn about the new oncology management program and how to use the AIM ProviderPortalSM by attending a webinar (intended for nonclinical provider staff). Webinar dates and registration links are available on page 26 of the July-August 2019 BCN Provider News.

For more information, see the Oncology Management Program: Frequently asked questions for providers document, which is available on this website.

Posted: July 2019
Line of business: Blue Care Network



Additional medical benefit specialty drugs have authorization and site of care requirements for BCN HMOSM members, effective Oct. 1, 2019

Effective Oct. 1, 2019, additional medical benefit specialty drugs have authorization and site of care requirements for BCN HMOSM (commercial) members. These changes don't apply to BCN AdvantageSM members.

Prior authorization requirements

For members initiating therapy on or after Oct. 1, 2019, you must request authorization for these drugs:

  • Lemtrada® (alemtuzumab, HCPCS code J0202)
  • Ocrevus® (ocrelizumab, HCPCS code J2350)
  • Tysabri® (natalizumab, HCPCS code J2323)

Members who currently receive these drugs in one of the following locations are authorized to continue treatment through Sept. 30, 2020:

  • Doctor's or other health care provider's office
  • The member's home, from a home infusion therapy provider
  • Ambulatory infusion center
  • Hospital outpatient facility (Lemtrada and Tysabri ONLY)

However, you'll need to request authorization for these members for therapy that begins on or after Oct. 1, 2020, for these services to be eligible for reimbursement.

Site of care requirement for Ocrevus

Ocrevus will also be added to the Site of Care Program, effective Oct. 1, 2019. If your patient currently receives Ocrevus infusions at an outpatient hospital facility, you may need to discuss other infusion options.

As part of our shared commitment to keeping health care affordable for all, we hope you will join us in supporting our members as they move to new therapy locations.

List of requirements

For a list of requirements related to drugs covered under the medical benefit, see the Requirements for drugs covered under the medical benefit - BCN HMO and Blue Cross PPO document located on this website.

We'll update the requirements list to reflect the changes for these drugs.

Blue Cross Blue Shield of Michigan and Blue Care Network reserve the right to review for medical necessity prior to the effective dates listed in this message. A prior authorization approval isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

As a reminder, you can always find information about authorization requirements for these drugs on the Medical Benefit Drugs - Pharmacy page in the BCN section of this website.

Posted: July 2019
Line of business: Blue Care Network



We'll continue to update clinical edits to comply with current coding guidelines

Blue Care Network continues to review and modify clinical edits. With these updates, you may notice that claims may receive different edits than they have in the past. And others that previously received edits may not receive any. We take pride in staying up-to-date on current coding standards and national coding guidelines in addition to recommendations from professional societies.

You may notice new edits related to those that review procedure codes to the reported diagnoses. Diagnosis codes should be coded appropriately and to the highest level of specificity to support the service performed. If you do not agree with the clinical edit, please follow our clinical editing appeal process.

Visit bcbsm.com/providers.

  • Log in to Provider Secured Services.
  • Click BCN Provider Publications and Resources on the right.
  • Click Billing/Claims in the left navigation.
  • Click Appealing a BCN clinical editing denial, under the Clinical Editing Resources heading.

Posted: June 2019
Line of business: Blue Care Network



Enter BCN retrospective authorization requests for cardiology and radiology services in e-referral

Effective immediately, enter retrospective authorization requests for cardiology and radiology services with dates of service prior to Oct. 1, 2018, in the e-referral system for BCN HMOSM (commercial) and BCN AdvantageSM members. As a reminder, eviCore healthcare no longer handles these requests.

Until recently, the e-referral system was programmed to block these requests. We've updated the e-referral system to accept these requests, so you no longer need to call BCN Utilization Management.

As a reminder, AIM Specialty Health manages cardiology and radiology authorizations for BCN HMO (commercial) and BCN Advantage members with dates of service on or after Oct. 1, 2018.

Posted: June 2019
Line of business: Blue Care Network



How to submit inpatient authorization requests to BCN during upcoming holiday closure

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will be closed on Thursday, July 4 and Friday, July 5 for the Independence Day holiday.

During this office closure, follow these guidelines when submitting inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

Acute initial inpatient admissions. Submit these authorization requests as well as concurrent reviews and discharge dates through the e-referral system, which is available 24 hours a day, seven days a week. If the e-referral system is not available, you can fax requests for inpatient admissions and continued stays to BCN HMO (commercial) at 1 866 313 8433 and to BCN Advantage at 1 866 526 1326.

Note: These requests may also be submitted through the X12N 278 Health Care Services Review - Request for Review and Response electronic standard transaction.

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

Post-acute initial and concurrent admission reviews.

Other authorization requests. The types of requests listed below must be submitted by fax. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

  • Authorization requests for sick or ill newborns
  • Requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN After-Hours Care Manager hotline at 1-800-851-3904 and listen to the prompts for help with the following:

  • Determining alternatives to inpatient admissions and triage to alternative care settings
  • Arranging for emergency home health care, home infusion services and in-home pain control
  • Arranging for durable medical equipment
  • Handling emergency discharge planning coordination and authorization
  • Handing expedited appeals of utilization management decisions

Note: Do not use the after-hours care manager phone number to request authorization for routine inpatient admissions.

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member's medical condition and coordinate care prior to admitting the member.

Posted: June 2019
Line of business: Blue Care Network

Important information about eviCore healthcare therapy authorization requests for BCN

Here's some important information about submitting authorization requests to eviCore healthcare for outpatient physical, occupational and speech therapy and for physical medicine services by chiropractors for BCN HMOSM and BCN AdvantageSM members.

Reminder: Authorization no longer required for initial evaluations for therapies

As of May 27, 2019, initial evaluations for physical, occupational and speech therapy and for physical medicine services by chiropractors no longer require authorization. After completing an initial evaluation, please submit the authorization request for treatment visits to eviCore.

eviCore will void all authorization requests for initial evaluations. These requests will appear in the eviCore system with a status of Y.

For therapists who are affiliated with a group

When submitting authorization requests for physical, occupational and speech therapy, therapists who are affiliated with groups should use their group's NPI as the servicing site. This will enable eviCore to apply the correct category (A, B or C) to the request.

Additional information

You can get additional information in the Outpatient rehabilitation services: Frequently asked questions document, which we've posted on the Outpatient PT, OT, ST webpage in the BCN section of this website.

Posted: June 2019
Line of business: Blue Care Network

Expanding BCN medical coverage for transgender employees of the University of Michigan

Blue Care Network will soon begin covering additional medical services for University of Michigan employees who are transgender. This applies to members covered by U-M Premier Care and GradCare plans.

You can identify the BCN members who are eligible for these services by their group number, which is 00124316. The number is on the front of member's University of Michigan-branded ID cards. As always, be sure to check web-DENIS for benefits and eligibility.

Gender-affirming services

The following additional gender-affirming services for University of Michigan members transitioning from male to female will be covered starting July 1, 2019:

  • Face and neck hair removal
  • Facial feminization surgery
  • Chondrolaryngoplasty (Adam's apple reduction)

Services are eligible for coverage if they meet medical necessity criteria and if members use in-network providers. Michigan Medicine, formerly the University of Michigan Health System, is the only provider in our network that currently performs the facial feminization surgical services.

There's a $30,000 lifetime limit per member for these new gender-affirming services.

Submitting authorization requests

These new services require authorization. Starting June 12, 2019, use the e-referral system to submit authorization requests.

Starting June 23, one of the following questionnaires will open in the e-referral system when you submit these authorization requests:

  • Face and neck hair removal
  • Facial feminization surgery/chondrolaryngoplasty

Preview questionnaires will be available on this website soon. Look for them on BCN's Authorization Requirements & Criteria page. We encourage you to use these preview questionnaires to prepare in advance your answers to the questionnaires you'll see in the e-referral system.

Additional information

For more details, see the University of Michigan fact sheet on health plan coverage for gender-affirming services.*

*Blue Cross Blue Shield of Michigan doesn't own or control this website.

Posted: June 2019
Line of business: Blue Care Network

Register now for an AIM Specialty Health® oncology management program webinar

Beginning Aug. 1, 2019, Blue Care Network will implement a new utilization management program for medical oncology for BCN commercial members. Authorizations must be obtained from AIM Specialty Health for some medical oncology and supportive care medications.

Learn about the new oncology management program and how to use the AIM ProviderPortalSM by attending a webinar (intended for non-clinical provider staff). Webinar dates and registration links are available on Page 26 of the May-June 2019 BCN Provider News. More information will be available on Page 26 of the July-August 2019 BCN Provider News published on June 26.

Posted: June 2019
Line of business: Blue Care Network

Contact eviCore healthcare's Client & Provider Services for help in using the new eviCore provider portal for BCN PT, OT and ST authorizations

Need help submitting authorization requests or finding cases in the eviCore healthcare provider portal? Contact eviCore's Client & Provider Services department to get help.

How to contact eviCore's Client & Provider Services department

Email clientservices@eviCore.com to get eviCore's assistance with authorization requests for outpatient physical, occupational and speech therapy and physical medicine services by chiropractors for BCN HMOSM or BCN AdvantageSM members. For urgent cases, call eviCore at 1-800-646-6418; select option 4.

When you send an email, you'll get a response that includes a ticket number. An eviCore representative will research your request and reach out to help you navigate the system and find what you need.

Additional information

As a reminder, on May 27, 2019, eviCore healthcare started managing all authorization requests for outpatient PT, OT and ST by therapists and physical medicine services by chiropractors for BCN HMO and BCN Advantage members. This includes requests for both initial and follow-up services.

You can get additional information in the Outpatient rehabilitation services: Frequently asked questions document, which we've posted on the PT, OT, ST webpage in the BCN section of this website.

Posted: June 2019
Line of business: Blue Care Network

No authorization required for BCN initial PT, OT and ST evaluations

Here's some information you need to know about submitting requests to eviCore healthcare for physical, occupational and speech therapy and physical medicine services by chiropractors:

  • BCN no longer requires authorization for initial evaluations.
  • The initial evaluation should be completed before you request authorization for treatment. If you submit the request before the evaluation, you may not be able to complete all of the required questions in the pathway, which could result in your request being pended.

Who should submit the authorization request

We recommend that the practitioner who will perform the therapy or physical medicine treatment services submit the request to authorize treatment. This is because it is that practitioner who is most familiar with the patient's condition and who can most readily answer the questions posed within the eviCore provider portal.

Additional information

Refer to the document Outpatient rehabilitation services: Frequently asked questions for additional information.

We're also updating the information in the Care Management chapter of the BCN Provider Manual to reflect the recent changes in how eviCore accepts authorization requests starting May 27, 2019.

Posted: June 2019
Line of business: Blue Care Network

Reminder: Submit BCN initial and follow-up authorization requests for PT, OT and ST to eviCore starting May 27, 2019

As a reminder, starting May 27, 2019, eviCore healthcare will manage all authorization requests for outpatient physical, occupational and speech therapy by therapists and physical medicine services by chiropractors.

This applies to BCN HMOSM (commercial) and BCN AdvantageSM members and includes requests for both initial and follow-up services.

The information you need to know is here:

Posted: May 2019
Line of business: Blue Care Network

How to submit inpatient authorization requests to BCN during upcoming holiday closures

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will close on Monday, May 27, 2019, for the Memorial Day holiday.

During this office closure, BCN's inpatient utilization management area will still accept inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

Here's what you need to know about submitting inpatient authorization requests when our corporate offices are closed.

Acute initial inpatient admissions. Submit these authorization requests as well as concurrent reviews and discharge dates through the e-referral system, which is available 24 hours a day, seven days a week. If the e-referral system is not available, you can fax requests for inpatient admissions and continued stays to BCN HMO (commercial) at 1 866 313 8433 and to BCN Advantage at 1 866 526 1326

Note: These requests may also be submitted through the X12N 278 Health Care Services Review - Request for Review and Response electronic standard transaction.

Post-acute initial and concurrent admission reviews. Follow the current process you use to submit these requests by fax at 1-866-534-9994. Refer to the document Post-acute care admissions: Submitting authorization requests to BCN for additional information.

Other authorization requests. The types of requests listed below must be submitted by fax. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

  • Authorization requests for sick or ill newborns
  • Requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN After-Hours Care Manager hotline at 1-800-851-3904 and listen to the prompts for help with the following:

  • Determining alternatives to inpatient admissions and triage to alternative care settings
  • Arranging for emergency home health care, home infusion services and in-home pain control
  • Arranging for durable medical equipment
  • Handling emergency discharge planning coordination and authorization
  • Handing expedited appeals of utilization management decisions

Note: Do not use the after-hours care manager phone number to request authorization for routine inpatient admissions.

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member's medical condition and coordinate care prior to admitting the member.

Posted: May 2019
Line of business: Blue Care Network

More BCN questionnaires to open on June 23 in e-referral

Starting June 23, 2019, questionnaires will open in the e-referral system for BCN authorization requests for the procedures listed below, which already require authorization. The questionnaires will open for both BCN HMOSM (commercial) and BCN AdvantageSM requests unless otherwise noted.

Service Age Procedure codes
Artificial heart, total Adult and pediatric *0051T, *0052T, *0053T, *33927, *33928, *33929, *33992 and *33993
Bariatric surgery (for BCN Advantage) Adult *43644, *43645, *43659, *43770, *43771, *43772, *43773, *43774, *43775, *43842, *43843, *43845, *43846, *43847, *43848, *43886, *43887, *43888 and *44130
Biofeedback, non-behavioral health (for BCN Advantage) Adult *90901 and *90911 (for select diagnoses)
Biofeedback, non-behavioral health (for BCN HMO) Adult and pediatric *90901 and *90911 (for select diagnoses)
Breast implant management Adult *19325, *19328 and *19330
Breast reconstruction Adult *11920, *11921, *11922, *19316, *19324, *19340, *19342, *19350, *19355, *19357, *19361, *19364, *19366, *19367, *19368, *19369, *19370, *19380, *19396, S2066, S2067 and S2068
Breast reduction, adolescent Pediatric *19318
Breast reduction, adult Adult *19318
Chemical peels Adult and pediatric *15788, *15789, *15792 and *17362
Cosmetic or reconstructive surgery Adult and pediatric *0479T, *0480T, *0491T, *0492T, *11950, *11951, *11952, *11954, *15775, 15776, *15780, *15781, *15782, *15783, *15786, *15787, *15820, *15821, *15824, *15825, *15826, *15828, *15829, *15876, *15877, *15878, *15879, *17340, *17380, *21083, *21087, *21172, *21275, *21280, *21282, *30620, *36468, *36469, *54660, *56620, *67909, *67911, G0429, Q2026, Q4100 and S0800
Dental anesthesia or repair of trauma to natural teeth Adult and pediatric *00170 and *41899
Enteral nutrition Adult and pediatric B4034, B4035, B4036, B4081, B4082, B4083, B4087, B4088, B4102, B4103, B4104, B4105, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B9002, B9998, S9341, S9342 and S9343
Excess skin removal Adult *15832, *15833, *15834, *15835, *15836, *15837, *15838 and *15839
Mastectomy for gynecomastia Adult *19300
Oral surgery Adult and pediatric *40525, *40527, *40700, *40701, *40702, *40720, *40761, *40808, *40810, *40812, *40816, *40818, *40840, *40842, *40843, *40844, *40845, *40899, *41800, *41805, *41806, *41820, *41821, *41822, *41823, *41825, *41826, *41827, *41828, *41830, *41850, *41870, *41872, *41874, *42200, *42210, *42215, *42220 and *42225
Orthognathic surgery Adult and pediatric *21085, *21120, *21121, *21122, *21123, *21125, *21127, *21141, *21142, *21143, *21144, *21145, *21146, *21147, *21150, *21151, *21154, *21155, *21159, *21160, *21188, *21193, *21194, *21195, *21196, *21198, *21199, *21206, *21208, *21209, *21210, *21215, *21230, *21235, *21244, *21245, *21246, *21247, *21255, *21270, *21295 and *21296
Prostatic urethral lift Adult *52441 and *52442
Spine surgery, minimally invasive Adult G0276
Temporomandibular joint surgery Adult and pediatric *20605, *20606, *21010, *21050, *21060, *21070, *21240, *21242, *21243, *21490 and *29804

Preview questionnaires will be available online

We'll make preview questionnaires available on this website before June 23. To find them, click BCN, then click Authorization Requirements & Criteria. Next, look in the "Authorization criteria and preview questionnaires" section.

The preview questionnaires will show what questions you'll need to answer in the actual questionnaire that opens in the e-referral system for each service. Once you know what questions you'll need to answer, you can prepare your answers ahead of time. This can cut down on the time it takes to submit the authorization request.

Medical policies will be available online

We'll also post links to the medical policies related to these procedures on the Authorization Requirements & Criteria page.

We use our medical policies and your answers to the questionnaires when making utilization management determinations for the authorization requests you submit.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.

Posted: May 2019
Line of business: Blue Care Network

AIM requires post-service authorization requests for certain BCN cardiology procedures

For the outpatient cardiology procedures listed here, you must submit authorization requests to AIM Specialty Health® after, not before, the service is completed. This applies to requests for BCN HMOSM and BCN AdvantageSM members.

  • *92920
  • *92924
  • *92928
  • *92933
  • *92937
  • *92943
  • *93925
  • *93926
  • *93930
  • *93931

Reason for the requirement

AIM requires post-service requests for these procedures to validate the clinical appropriateness of the service. Some of the clinical information obtained while performing the procedure is required as part of the review. If you submit an authorization request prior to the procedure, your request will not be processed or may be denied.

For BCN HMO and BCN Advantage members, the requirement was effective on Oct. 1, 2018, when AIM began managing select cardiology services for BCN.

When to resubmit

If you tried but were not able to complete a post-service authorization request for a BCN member since October 1, please try submitting it again. (If you successfully submitted a post-service request that resulted in a denial, do not resubmit the request.)

Additional information

We've updated the list of procedures that require authorization by AIM Specialty Health for BCN HMO (commercial) and BCN Advantage members to reflect the requirement for post-service requests for these procedures.

As a reminder, the same requirement applies to some of these codes for Medicare Plus BlueSM PPO members. For more details, refer to the web-DENIS message on this topic posted April 2, 2019.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.

Posted: May 2019
Line of business: Blue Care Network

How to submit inpatient authorization requests to BCN during upcoming holiday closure

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will close on Friday, April 19, 2019, for their corporate Good Friday holiday.

During this office closure, BCN's inpatient utilization management area will still accept inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

Here's what you need to know about submitting inpatient authorization requests when our corporate offices are closed.

Acute initial inpatient admissions. Submit these authorization requests as well as concurrent reviews and discharge dates through the e-referral system, which is available 24 hours a day, seven days a week.

Note: These requests may also be submitted through the X12N 278 Health Care Services Review - Request for Review and Response electronic standard transaction.

Post-acute initial and concurrent admission reviews. Follow the current process you use to submit these requests by fax at 1-866-534-9994. Refer to the document Post-acute care admissions: Submitting authorization requests to BCN for additional information.

Other authorization requests. The types of requests listed below must be submitted by fax. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

  • Authorization requests for sick or ill newborns
  • Requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN After-Hours Care Manager hotline at 1-800-851-3904 and listen to the prompts for help with the following:

  • Determining alternatives to inpatient admissions and triage to alternative care settings
  • Arranging for emergency home health care, home infusion services and in-home pain control
  • Arranging for durable medical equipment
  • Handling emergency discharge planning coordination and authorization
  • Handing expedited appeals of utilization management decisions

Note: Do not use the after-hours care manager phone number to request authorization for routine inpatient admissions.

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member's medical condition and coordinate care prior to admitting the member.

Posted: April 2019
Line of business: Blue Care Network

Call BCN for cardiology and radiology authorization requests with dates of service prior to Oct. 1, 2018

Call BCN Utilization Management at 1-800-392-2512 for retrospective authorization requests for cardiology and radiology services with dates of service prior to Oct. 1, 2018. This applies to requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

eviCore healthcare no longer handles these requests.

The e-referral system is currently programmed to block these requests. If you submit one of these requests to the e-referral system, you'll see a message directing you to submit it to eviCore. This message is incorrect. You should ignore the message and call the request in to BCN.

We're working on updating the e-referral system to accept these requests. We anticipate you'll be able to use e-referral system for these requests in May. We'll notify you when that occurs.

We apologize for any difficulties you've encountered when trying to submit these requests recently.

As a reminder, AIM Specialty Health manages cardiology and radiology authorizations for BCN HMO (commercial) and BCN Advantage members with dates of service on or after Oct. 1, 2018.

Posted: April 2019
Line of business: Blue Care Network

BCN AdvantageSM to audit SNF claims for RUG codes starting June 1

Starting June 1, 2019, BCN Advantage will audit claims for members admitted to skilled nursing facilities. In the audit, we'll review the RUG codes to ensure that the codes submitted on the claim and the associated reimbursement amounts are appropriate and reflect the approved RUG levels provided when authorization determination was made for the member's stay.

RUG codes represent the Resource Utilization Groups that the Centers for Medicare & Medicaid Services uses to determine reimbursement for SNF stays.

RUG codes for Medicare Plus BlueSM PPO members in SNFs have been audited for some time. The change is that the auditing process will also be applied to claims for BCN Advantage members in SNFs.

For SNF admissions, naviHealth will authorize RUG levels during the course of the patient's stay, from preservice through discharge. naviHealth will work with SNFs to ensure the provider submits the appropriate RUG level for reimbursement. When you submit claims for Blue Cross Medicare Advantage members admitted to a SNF, make sure the RUG code you use is appropriate for the authorization connected to the stay.

As a reminder, naviHealth will manage authorization requests for Medicare Plus BlueSM PPO and BCN AdvantageSM members admitted to post-acute care on or after June 1, 2019.

Posted: April 2019
Line of business: Blue Care Network

Submit BCN initial and follow-up authorization requests for PT, OT and ST to eviCore starting May 27, 2019

Starting May 27, 2019, eviCore healthcare will manage all authorization requests for outpatient physical, occupational and speech therapy by therapists and physical medicine services by chiropractors. This applies to BCN HMOSM (commercial) and BCN AdvantageSM members and includes requests for both initial and follow-up services.

In addition, BCN is working with eviCore to implement the corePathSM authorization model for these requests. corePath will streamline the authorization process and make it easier for providers to submit authorization requests. It's the same model that was implemented for Blue Cross Medicare Plus BlueSM PPO authorization requests starting Jan. 1, 2018.

Look for training information and more details on these changes in the May-June 2019 issue of BCN Provider News. We'll also post additional web-DENIS messages and news items on this website.

Additional information is available in past newsletter articles:

Posted: March 2019
Line of business: Blue Care Network

Behavioral health components of AAEC evaluation do not require authorization for BCN members

The behavioral health components of an evaluation done by an approved autism evaluation center do not require authorization for BCN HMOSM (commercial) members. This applies to intake services covered by procedure codes *90791 and *90792.

We're updating the Behavioral Health chapter of the BCN Provider Manual with this information. The revised chapter will be available by the end of April.

Providers who have recently tried to submit an authorization request into the e-referral system for services associated with those codes have received an error message indicating that those services no longer require authorization.

The updated chapter will show the following:

  • For the behavioral health components of the evaluation, authorization is not required.
  • For the medical components of the evaluation, the AAEC needs to identify the medical specialists who will be evaluating the child so that the child's primary care physician can submit a referral for each specialist. A referral from the primary care physician is required for each medical specialist who will see the child during the evaluation process.
  • The results of the multidisciplinary evaluation must be reported on the AAEC Evaluation Results Form. Follow the instructions on the form for faxing it to BCN.

Note: AAECs should submit a claim for the evaluation of each member using procedure codes *99367 and T1023.

This does not apply to members with BCN AdvantageSM, as those members generally don't have an autism benefit.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.

Posted: March 2019
Line of business: Blue Care Network

Use form to request criteria for BCN authorization decisions (non-behavioral health)

To obtain the review criteria used to make a determination on a specific authorization request for a BCN HMOSM (commercial) or BCN AdvantageSM member, complete the BCN Criteria Request Form (for non-behavioral health cases) and fax it to 1-866-373-9468.

This applies to non-behavioral health authorization requests only.

You can access the BCN Criteria Request Form on this website:

  1. Click BCN.
  2. Click Authorization Requirements & Criteria.
  3. Look under the "Referral and authorization information" heading.

Previously, you called BCN's Utilization Management department to request the criteria. Now you use the form to submit the request. The BCN Provider Manual has been updated to reflect the change.

Posted: March 2019
Line of business: Blue Care Network

Additional changes to BCN process for requesting peer-to-peer review of non-behavioral health cases

We're making additional changes to the process of asking for a peer-to-peer review of a denied authorization of a non-behavioral health service for BCN HMOSM (commercial) or BCN AdvantageSM members.

The request for a peer-to-peer review:

  • Must be submitted within the time frame available for filing an appeal for that determination. Once the appeal time frame has expired, you can no longer request a peer-to-peer review.
  • Cannot be submitted if a provider appeal of that denial has already been submitted
  • May be submitted only for denials based on medical necessity
  • Cannot be submitted for a denial of a member's appeal or grievance

We have outlined these requirements - and additional information about them - in Section 1 of the document How to request a peer-to-peer review with a BCN medical director.

These requirements apply to authorization requests for both inpatient and outpatient services. They are in addition to the change we communicated in December 2018, which was that you must use the Physician peer-to-peer request form (for non-behavioral health cases) to submit the peer-to-peer review request.

You can access both documents - the description of the process for submitting a peer-to-peer review request and the form - on this website by completing the following steps:

  1. Click BCN.
  2. Click Authorization Requirements & Criteria.
  3. Look under the "Referral and authorization information" heading.

Posted: March 2019
Line of business: Blue Care Network

Start transitioning adult BCN HMO members using infliximab products to Inflectra®

Starting May 1, 2019, Blue Care Network prefers the infliximab product, Inflectra (infliximab-dyyb), for its adult BCN HMOSM (commercial) members. This change doesn't apply to:

  • Members covered by any other line of business, including BCN AdvantageSM and Blue Cross PPO (commercial) members
  • Pediatric members 15 years old or younger
  • Pediatric members 18 years old or younger weighing 50 kg or less

Please refer to the current medical policy for all criteria, and begin taking steps to:

  • Transition adult members with active authorizations for non-Inflectra infliximab products to Inflectra by May 1, 2019.
  • Prescribe or fill Inflectra when possible instead of Remicade® (infliximab), HCPCS code J1745, or Renflexis® (infliximab-abda), HCPCS code Q5104.
  • Bill Inflectra with HCPCS code Q5103.

Quick links to helpful resources:

Posted: February 2019
Line of business: Blue Care Network

Clarifying biofeedback and neurofeedback authorization requirements for BCN members

When submitting authorization requests for biofeedback and neurofeedback for BCN HMOSM (commercial) and BCN AdvantageSM members, there are things you have to do differently for each. Here's what you need to know.

Biofeedback is covered, when authorized, for specific medical diagnoses and not for behavioral health diagnoses.

  • When you submit your initial request to authorize biofeedback, you must attach all the required clinical documentation to the case in the e-referral system.
  • BCN's Utilization Management staff, not the Behavioral Health staff, make the determination on the request.

In the future, you'll also need to complete a questionnaire for biofeedback in the e-referral system. Look for more information about that in upcoming web-DENIS messages and articles in BCN Provider News.

Neurofeedback is covered, when authorized, for specific behavioral health diagnoses only.

  • Neurofeedback requires an independent evaluation (psychological or neuropsychological testing) confirming that the member has a diagnosis of attention deficit hyperactivity disorder or attention deficit disorder. This must be completed by someone other than the neurofeedback provider.
  • When you submit your initial request to authorize neurofeedback, you must attach the report from the independent evaluation to the case in the e-referral system, along with any additional clinical documentation required.
  • BCN's Behavioral Health staff, not the Utilization Management staff, make the determination on the request.
  • When you submit requests to authorize additional neurofeedback visits, you must complete the questionnaire that opens in the e-referral system.

Instructions for attaching a document from the member's medical record are outlined in the article How to attach clinical information to your authorization request in the e-referral system, in the November-December 2016 BCN Provider News, on page 44. These instructions are also in:

The Care Management and Behavioral Health chapters of the BCN Provider Manual will be updated with these clarifications.

Posted: February 2019
Line of business: Blue Care Network

BCN otoplasty and rhinoplasty questionnaires to open on Feb. 10 in e-referral

The otoplasty and rhinoplasty questionnaires will open in the e-referral system starting Feb. 10, 2019, for BCN HMOSM and BCN AdvantageSM authorization requests.

These questionnaires were originally intended to open starting Jan. 27, as we communicated in a web-DENIS message in late January, but they've been delayed.

As a reminder, you must complete the questionnaire when submitting a request to authorize these outpatient procedures, which are associated with the following procedure codes:

  • Otoplasty (procedure code *69300)
  • Rhinoplasty (procedure codes *30400, *30410, *30420, *30430, *30435, *30450, *30460 and *30462)

We've made preview questionnaires available on this website. To find them, click BCN, then click Authorization Requirements & Criteria. Look in the "Authorization criteria and preview questionnaires" section.

You can look over the preview questionnaire to see what questions you'll need to answer. Preparing your answers ahead of time can reduce the time it takes to submit the authorization request.

We've also posted links to the medical policies and authorization criteria related to these procedures on the Authorization Requirements & Criteria page.

We use our medical policies, our authorization criteria and your answers to the questionnaires when making utilization management determinations for the authorization requests you submit.

* CPT codes, descriptions and two-digit modifiers only are copyright 2018 American Medical Association. All rights reserved.

Posted: February 2019
Line of business: Blue Care Network

Complete the new questionnaires in e-referral for BCN members

On Jan. 27, 2019, questionnaires will open for BCN authorization requests in the e-referral system for the following outpatient procedures:

  • Abdominoplasty (procedure codes *15830 and *15847)
  • Otoplasty (procedure code *69300)
  • Rhinoplasty (procedure codes *30400, *30410, *30420, *30430, *30435, *30450, *30460 and *30462)

In addition, updated or new questionnaires for the following services began opening for BCN authorization requests in the e-referral system on Nov. 25, 2018:

  • Arthroscopy, knee, diagnostic (procedure code *29870)
  • Arthroscopy, knee (surgical) for chondroplasty (procedure codes *29877, *29879 and G0289)
  • Arthroscopy, knee (surgical) for removal of loose body or foreign body (procedure code *29874)
  • Arthroscopy, knee (surgical) for removal or stabilization of intra-articular osteochondral lesion (procedure codes *29885, *29886 and *29887)
  • Arthroscopy, knee, synovectomy, limited (procedure code *29875)

You must complete the questionnaire when submitting a request to authorize these procedures for the following members:

  • BCN HMOSM (commercial)
  • BCN AdvantageSM

We've made preview questionnaires available on this website, on the BCN Authorization Requirements & Criteria page. Look in the "Authorization criteria and preview questionnaires" section.

You can look over the preview questionnaire for a specific procedure to see what questions you'll need to answer in the actual questionnaire that opens in the e-referral system for that service. Once you know what questions you'll need to answer, you can prepare your answers ahead of time. This can cut down on the time it takes to submit the authorization request.

We've also posted links to the medical policies and authorization criteria related to these procedures on the Authorization Requirements & Criteria page.

We use our medical policies, our authorization criteria and your answers to the questionnaires when making utilization management determinations for the authorization requests you submit.

Posted: January 2019
Line of business: Blue Care Network

How to submit inpatient authorization requests to BCN during upcoming holiday closure

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will close on Monday, Jan. 21, 2019, for Martin Luther King, Jr., Day.

During this office closure, BCN's inpatient utilization management area will still accept inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

Here's what you need to know about submitting inpatient authorization requests to BCN when our corporate offices are closed.

Acute initial inpatient admissions. Submit these authorization requests as well as concurrent reviews and discharge dates through the e-referral system, which is available 24 hours a day, seven days a week.

Note: These requests may also be submitted through the X12N 278 Health Care Services Review – Request for Review and Response electronic standard transaction.

Post-acute initial and concurrent admission reviews. Follow the current process you use to submit these requests by fax at 1-866-534-9994. Refer to the document Post-acute care admissions: Submitting authorization requests to BCN for additional information.

Other authorization requests. The types of requests listed below must be submitted by fax. For these requests, faxes are processed only Monday through Friday. They are not processed on weekends or on the holidays on which BCN is closed. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

  • Authorization requests for sick or ill newborns
  • Authorization requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN after-hours care manager hotline at 1-800-851-3904 and listen to the prompts for help with the following:

  • Determining alternatives to inpatient admissions and triage to alternative care settings
  • Arranging for emergency home health care, home infusion services and in-home pain control
  • Arranging for durable medical equipment
  • Handling emergency discharge planning coordination and authorization
  • Handing expedited appeals of utilization management decisions

Note: Do not use the after-hours care manager phone number to request authorization for routine inpatient admissions.

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member's medical condition and coordinate care prior to admitting the member.

Posted: January 2019
Line of business: Blue Care Network

Effective April 1, FasenraTM and Radicava® are subject to a site-of-care requirement for BCN HMOSM members

Effective April 1, 2019, BCN is adding the following medications to its site-of-care optimization program, for BCN HMO (commercial) members only:

  • Fasenra (benralizumab, HCPCS code J0517)

  • Radicava (edaravone, HCPCS code J1301)

Note: This requirement does not apply to BCN AdvantageSM members.

The site-of-care program redirects members receiving select drugs in an outpatient hospital setting to a lower-cost, alternate site of care, such as the physician's office or the member's home.

If a provider feels a member is not a candidate to receive these drugs at a site other than the outpatient hospital, documentation supporting medical necessity must be provided to the plan for review. Those requests will be evaluated on a case-by-case basis.

Requests for Fasenra and Radicava must meet applicable authorization criteria in addition to the site-of-care requirement.

For a list of requirements related to drugs covered under the medical benefit, including all drugs identified as subject to a site-of-care requirement, do the following:

  1. Visit the Medical Benefit Drugs – Pharmacy page in the BCN section of this website.

  2. Click Requirements for drugs covered under the medical benefit - BCN HMO and Blue Cross PPO under the heading "For BCN HMO (commercial) members."

The new site-of-care requirement for Fasenra and Radicava will be reflected in the requirements list before the April 1 effective date.

Posted: December 2018
Line of business: Blue Care Network

BCN changes process for requesting a peer-to-peer review for non-behavioral health cases

Effective Jan. 7, 2019, BCN is changing the process for requesting a peer-to-peer review discussion with a BCN medical director related to a non-behavioral health authorization request that was denied. This applies to both BCN HMOSM (commercial) or BCN AdvantageSM members.

To get the details, please review the document How to request a peer-to-peer review with a BCN medical director, as follows:

  • See Section 1 for how to request a peer-to-peer review for non-behavioral health cases. Instead of calling in the request, you'll now fax it in using the Physician peer-to-peer request form (for non-behavioral health cases).

  • See Section 2 for how to request a peer-to-peer review on behavioral health cases. For these cases, the process is not changing. No form is used.

You can access both these documents — the process description and the form for non-behavioral health cases — on this website. Click BCN, then click Authorization Requirements & Criteria. Look under the "Referral and authorization information" heading.

The BCN Provider Manual will be updated to reflect this new information by the end of December.

Posted: December 2018
Line of business: Blue Care Network

Don't issue referrals for BCN AdvantageSM members staying in network

BCN Advantage members don't need a referral to see a specialist within their health plan's network. However, authorizations and plan notifications are still required for certain services. Also, all services with a provider who's not in the member's health plan network require an authorization. More information is available in the Jan-Feb 2019 BCN Provider News.

Posted: December 2018
Line of business: Blue Care Network

How to submit inpatient authorization requests to BCN during upcoming holiday closures

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will close on the following holidays:

  • Monday, Dec. 24 and Tuesday, Dec. 25 for the Christmas holidays
  • Monday, Dec. 31 and Tuesday, Jan. 1 for the New Year

During these office closures, BCN's inpatient utilization management area will still accept inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

Here's what you need to know about submitting inpatient authorization requests to BCN when our corporate offices are closed.

Acute initial inpatient admissions. Submit these authorization requests as well as concurrent reviews and discharge dates through the e-referral system, which is available 24 hours a day, seven days a week.

Note: These requests may also be submitted through the X12N 278 Health Care Services Review – Request for Review and Response electronic standard transaction.

Post-acute initial and concurrent admission reviews. Follow the current process you use to submit these requests by fax at 1-866-534-9994. Refer to the document Post-acute care admissions: Submitting authorization requests to BCN for additional information.

Other authorization requests. The types of requests listed below must be submitted by fax. For these requests, faxes are processed only Monday through Friday. They are not processed on weekends or on the holidays on which BCN is closed. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

  • Authorization requests for sick or ill newborns
  • Authorization requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN after-hours care manager hotline at 1-800-851-3904 and listen to the prompts for help with the following:

  • Determining alternatives to inpatient admissions and triage to alternative care settings
  • Arranging for emergency home health care, home infusion services and in-home pain control
  • Arranging for durable medical equipment
  • Handling emergency discharge planning coordination and authorization
  • Handing expedited appeals of utilization management decisions

Note: Do not use the after-hours care manager phone number to request authorization for routine inpatient admissions.

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member's medical condition and coordinate care prior to admitting the member.

Posted: December 2018
Line of business: Blue Care Network

Additional updated authorization criteria and e-referral questionnaires

We're making updates to the authorization criteria and questionnaires in the e-referral system, for the following services:

  • Cholecystectomy (laparoscopic) for adults
  • Endoscopy, upper gastrointestinal, for gastroesophageal reflux disease
  • Hyperbaric oxygen therapy
  • Varicose vein treatment

For these services, you'll see the updated questionnaires in the e-referral system starting Dec. 16, 2018.

We use these criteria and questionnaires when making utilization management determinations for the following members:

  • BCN HMOSM (commercial)
  • BCN AdvantageSM

The updated authorization criteria and preview questionnaires are available at ereferrals.bcbsm.com. To find them, click BCN, then click Authorization Requirements & Criteria. Next, look in the "Authorization criteria and preview questionnaires" section.

You can look over the preview questionnaires to see what questions you'll need to answer in the actual questionnaire that opens in the e-referral system for each service. Once you know what questions you'll need to answer, you can prepare your answers ahead of time. This can cut down on the time it takes to submit the authorization request.

Posted: December 2018
Line of business: Blue Care Network

Xgeva® to require authorization for BCN AdvantageSM members

Xgeva (J0897) will continue to require authorization for BCN Advantage members in 2019.

On Nov. 1, 2018, a web-DENIS message and a news item at ereferrals.bcbsm.com were posted indicating that Xgeva would not require authorization starting Jan. 1, 2019, for BCN Advantage members.

However, you'll need to continue to submit authorization requests for this drug. We apologize for any inconvenience this may cause.

We've updated the earlier communications, titled "Medicare Part B medical specialty drug prior authorization lists changing in 2019," to reflect the change. You may want to review the earlier communications to refresh your memory on the other changes that will take place.

Additional information

For BCN Advantage, we require prior authorization for Xgeva when you bill it as a professional service or an outpatient facility service based on the following:

Professional CMS-1500 claim form (or electronically via an 837P transaction) for the following sites of care:

  • Physician office (Place of Service Code 11)
  • Home (Place of Service Code 12)

Facility UB04 claim form (or electronically via an 837I transaction):

  • Outpatient facility (Type of Bill 013x)

Important reminder

You must get authorization prior to administering these medications. Use the Novologix® online web tool to quickly submit your requests.

Posted: December 2018
Line of business: Blue Care Network

Complete the provider specialty questionnaire in the e-referral system

We'e added a questionnaire to the e-referral system that asks you to select the specialty of the provider you're referring a member to. That's the only question you'll need to answer.

You'll see this provider specialty questionnaire only when you're submitting a global referral to a multispecialty group. As a reminder, only BCN HMOSM (commercial) members require a global referral.

If you're making a global referral to a multispecialty group, you'll see a prompt asking you to complete the provider specialty questionnaire. Here's what to do:

  1. Click the link to open the questionnaire.
  2. Select the specialty of the provider you're referring to from the drop-down menu.
  3. Click Next to continue submitting your global referral.

Completing the questionnaire will help your referral get to the right provider in the multispecialty group.

The provider specialty questionnaire began opening in the e-referral system on Oct. 28, 2018.

We're updating the e-referral User Guide with information on the provider specialty questionnaire.

Posted: November 2018
Line of business: Blue Care Network

Reminder: Submit BCN authorization requests to AIM for cardiology and high-tech radiology procedures

A new provider training tool is available to give providers a summary of our authorization programs through AIM Specialty Health®. The presentation also explains when a new AIM authorization is required.

The AIM presentation is posted in three areas:

  • On this website, on BCN's AIM-Managed Procedures page
  • On the BCN Provider Publications and Resources website, on the Learning Opportunities page
  • On the BCBSM Provider Publications and Resources website, on the Provider Training page

As a reminder, for dates of service on or after Oct. 1, 2018, you must submit authorization requests for cardiology and high-tech radiology procedures for BCN members to AIM Specialty Health.

Some providers are still submitting these requests to eviCore in error.

Here are some important things to know:

  • AIM started accepting authorization requests on Sept. 17, 2018, for dates of service on or after Oct. 1. You can submit these requests either through the AIM provider portal or by calling AIM at 1-844-377-1278.

  • For dates of service prior to Oct. 1, continue to submit your authorization requests to eviCore healthcare. eviCore will handle all requests for dates of service prior to Oct. 1, including postservice requests.

This applies to BCN HMOSM (commercial) and BCN AdvantageSM members.

Information about what AIM manages for BCN

Look on the new AIM-Managed Procedures page in the BCN section of this website to find:

Posted: November 2018
Line of business: Blue Care Network

How to submit inpatient authorization requests to BCN during upcoming holiday closures

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will close on the following holidays:

  • Tuesday, Nov. 6, 2018 (Election Day)
  • Thursday, Nov. 22, 2018 (Thanksgiving)
  • Friday, Nov. 23, 2018 (day after Thanksgiving)

During these office closures, BCN's inpatient utilization management area will still accept inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

Here's what you need to know about submitting inpatient authorization requests to BCN when our corporate offices are closed.

Acute initial inpatient admissions. Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week.

Note: These requests may also be submitted through the X12N 278 Health Care Services Review – Request for Review and Response electronic standard transaction.

Post-acute initial and concurrent admission reviews. Follow the current process you use to submit these requests by fax at 1-866-534-9994. Refer to the document Post-acute care admissions: Submitting authorization requests to BCN for additional information.

Other authorization requests. The types of requests listed below must be submitted by fax. For these requests, faxes are processed only Monday through Friday. They are not processed on weekends or on the holidays on which BCN is closed. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

  • Authorization requests for sick or ill newborns
  • Authorization requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN after-hours care manager hotline at 1-800-851-3904 and listen to the prompts for help with the following:

  • Determining alternatives to inpatient admissions and triage to alternative care settings
  • Arranging for emergency home health care, home infusion services and in-home pain control
  • Arranging for durable medical equipment
  • Handling emergency discharge planning coordination and authorization
  • Handing expedited appeals of utilization management decisions

Note: Do not use the after-hours care manager phone number to request authorization for routine inpatient admissions.

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member's medical condition and coordinate care prior to admitting the member.

Posted: November 2018
Line of business: Blue Care Network

We're telling BCN AdvantageSM members they don't need referrals

We're letting BCN Advantage members know they don't need a referral from their primary care physician for covered services with a specialist who's in the provider network for the member's health plan. Authorizations are still required for certain services.

For details, see the article in the November-December 2018 BCN Provider News, on page 10.

Posted: October 2018
Line of business: Blue Care Network

Reminder: Submit BCN authorization requests to AIM for cardiology and high-tech radiology procedures

As a reminder, for dates of service on or after Oct. 1, 2018, you must submit authorization requests for cardiology and high-tech radiology procedures for BCN members to AIM Specialty Health®.

Some providers are still submitting these requests to eviCore in error.

Here are some important things to know:

  • AIM started accepting authorization requests on Sept. 17, 2018, for dates of service on or after Oct. 1. You can submit these requests either through the AIM provider portal or by calling AIM at 1-844-377-1278.

  • For dates of service prior to Oct. 1, continue to submit your authorization requests to eviCore healthcare. eviCore will handle all requests for dates of service prior to Oct. 1, including postservice requests.

This applies to BCN HMOSM (commercial) and BCN AdvantageSM members.

Information about what AIM manages for BCN

Look on the new AIM-Managed Procedures page in the BCN section of this website to find:

Posted: October 2018
Line of business: Blue Care Network

Reminder: Starting Oct. 1, AIM Specialty Health® manages cardiology and high-tech radiology for Blue Care Network

As a reminder, for dates of service on or after Oct. 1, 2018, AIM Specialty Health manages the authorization process for cardiology and high-tech radiology procedures for BCN HMOSM (commercial) and BCN AdvantageSM members. We first communicated about this in the article AIM Specialty Health to manage cardiology and high-tech radiology procedures for BCN starting October 1 in the July-August 2018 issue of BCN Provider News, on page 33.

Here are some important things to know:

  • AIM started accepting authorization requests on Sept. 17, 2018, for dates of service on or after Oct. 1. You can submit these requests either through the AIM provider portal or by calling AIM at 1-844-377-1278.
  • For dates of service prior to Oct. 1, continue to submit your authorization requests to eviCore healthcare. eviCore will handle all requests for dates of service prior to Oct. 1, including postservice requests.

Information about what AIM manages for BCN

Look on the new AIM-Managed Procedures page in the BCN section of this website to find:

Webinars offered in October

There's still time to sign up for training webinars to learn how to register for and use the AIM ProviderPortalSM, an online tool used to request authorization from AIM. Here are the days and times for the remaining webinars:

  • Wednesday, Oct. 3, 10-11 a.m.
  • Thursday, Oct. 4, 2-3 p.m.

For the instructions on how to register, see the webinar invitation.

Posted: September 2018
Line of business: Blue Care Network

BCN updates sleep study questionnaire in the e-referral system

BCN has updated the sleep study questionnaire in the e-referral system. We've condensed the questionnaire, so you'll have fewer questions to answer. The questionnaire pertains to sleep studies in an outpatient facility or clinic-based setting. It became available in the e-referral system starting Sept. 23, 2018.

We use the updated questionnaire in making utilization management determinations for BCN HMOSM and BCN AdvantageSM members.

You'll find a link to the updated preview questionnaire and the medical policy titled "Sleep Disorders, Diagnosis and Medical Management" on this website. Click BCN, then click Authorization Requirements & Criteria. Next, look in the "Authorization criteria and preview questionnaires" section.

You'll also find links to these documents on the Sleep Management Program page in the BCN section of this website.

You can look over the preview questionnaire to see what questions you'll need to answer so you can prepare your answers ahead of time. This can cut down on the time it takes to submit the authorization request.

Posted: September 2018
Line of business: Blue Care Network

Reminder: Effective Oct. 1, Prolia® and Xgeva® are subject to a site-of-care requirement for BCN HMOSM members

As a reminder, effective Oct. 1, 2018, BCN is adding the following two drugs to its site-of-care optimization program:

  • Prolia
  • Xgeva

For both medications, the generic name is denosumab and the HCPCS code is J0897.

The site-of-care requirement applies only to BCN HMO (commercial) members. It does not apply to BCN AdvantageSM members.

The site-of-care program redirects members receiving select drugs in an outpatient hospital setting to a lower-cost, alternate site of care, such as the physician's office or the member's home.

If a provider feels a member is not a candidate to receive these drugs at a site other than the outpatient hospital, documentation supporting medical necessity must be provided to the plan for review. Those requests will be evaluated on a case-by-case basis.

Requests for Prolia and Xgeva must meet applicable authorization criteria in addition to the site-of-care requirement. This applies to first-time and current users of these medications.

For additional requirements related to drugs covered under the medical benefit, including all drugs identified as subject to site-of-care requirements, refer to the Medical Benefit Drugs – Pharmacy page in the BCN section of this website. Click Requirements for drugs covered under the medical benefit – BCN HMO under the heading "For BCN HMO (commercial) members."

The new site-of-care requirement for Prolia and has been added to the list.

Posted: September 2018
Line of business: Blue Care Network

Reminder: Starting Oct. 1, additional specialty medications require authorization for BCN AdvantageSM members

For dates of service on or after Oct. 1, 2018, additional specialty medications covered under the Medicare Part B medical benefit require authorization for BCN Advantage members.

We first communicated about this in the article Starting Oct. 1, additional specialty medications require authorization for BCN Advantage members, on page 28 of the July-August 2018 BCN Provider News. Please review the article to see which drugs require authorization starting October 1.

These medications are not self administered. They must be given by injection or infusion by a physician or health care professional in the office or outpatient facility setting.

These medications require authorization when billed as a professional service (via the paper HCFA 1500 claim form or electronically as an 837P transaction) or as an outpatient facility service (via the UB-04 or electronically as an 837I transaction) and one of the following place of service codes is used:

  • Physician office (Place of Service code 11)
  • Outpatient facility (Place of Service codes 19, 22 and 24)

We also published an update in the article Clarification: Vivaglobin does not require authorization, on page 8 of the September-October 2018 BCN Provider News.

In addition, an updated list of drugs requiring authorization for BCN Advantage members will be available on this website by the end of September. To see the list, click BCN and then click Medical Benefit Drugs – Pharmacy. Finally, click Requirements for drugs covered under the medical benefit – BCN Advantage.

Note: This communication updates earlier ones, including the newsletter articles, which incorrectly stated that authorization is not required for these medications when they are billed on a facility claim form (such as the UB 04) or electronically via an 837I transaction. We apologize for this error.

Posted: September 2018
Line of business: Blue Care Network

Fax authorization requests for BCN members moving to a SNF, rehabilitation facility or LTACH

Please fax all authorization requests to BCN for post-acute care services for BCN HMOSM (commercial) and BCN AdvantageSM members. This applies to members transitioning to a skilled nursing facility, a rehabilitation facility or a long-term acute care hospital.

Here's what you need to know

  • Fax authorization requests to 1-866-534-9994. We accept faxed requests 24 hours a day, seven days a week.

  • Normal business hours for BCN post-acute care staff are Monday through Saturday, 8 a.m. to 5 p.m.

  • The on-call nurse is available to assist with admissions on Sundays and holidays and at other times outside of normal business hours. During those times, call the on-call nurse at 1- 800-851-3904 and fax the documentation to 1-866-534-9994.

Here's what to fax

For SNF and rehabilitation admissions, fax these documents:

  • A completed Rehabilitation Assessment Form
  • History and physical from the hospital admission
  • Physical medicine and rehabilitation consultation notes, as appropriate

For LTACH admissions, fax these documents:

  • A completed LTACH Assessment Form
  • History and physical from the hospital admission
  • Physical medicine and rehabilitation consultation notes, as appropriate
  • Last two days of practitioner progress notes (admission and concurrent)
  • Current intravenous and subcutaneous medication lists

The forms are available on this website, on the BCN Forms page.

A summary of these instructions is available on this website. Click BCN and then click Authorization Requirements & Criteria. Finally, click Post-acute care admissions: Submitting authorization requests to BCN.

The Care Management chapter of the BCN Provider Manual is being updated to reflect this information.

Posted: September 2018
Line of business: Blue Care Network

Renflexis® requires authorization for BCN AdvantageSM starting Oct. 1

For dates of service on or after Oct. 1, 2018, Renflexis requires authorization for BCN Advantage members.

This medication is not self-administered. It must be given by injection or infusion by a physician or health care professional in the office, home or outpatient facility setting.

This medication requires authorization when it is billed on either a professional HCFA 1500 claim form (or submitted electronically using an 837P transaction) or on a facility claim form such as the UB-04 (or submitted electronically using an 837I transaction), for the following places of service:

  • Physician office (Place of Service code 11)
  • Home (Place of Service code 12)
  • Outpatient facility (Place of Service codes 19 and 22)

Submit authorization requests for this medication through the Novologix online tool. Authorization must be obtained prior to the medication being administered.

Posted: September 2018
Line of business: Blue Care Network

BCN to accept inpatient continued stay reviews and discharge notifications through the e-referral system starting Sept. 4

Starting Sept. 4, 2018, you can submit inpatient continued stay reviews and discharge notifications for BCN HMOSM (commercial) and BCN AdvantageSM members through the e-referral system. This applies to members admitted for non-behavioral health services.

Currently, these requests are faxed in to BCN. However, starting Nov. 1, 2018, we will no longer accept faxed requests.

This change means that BCN HMO (commercial) and BCN Advantage inpatient discharge notifications and continued stay reviews will be processed through the e-referral system, just like they are for Blue Cross PPO (commercial) and Blue Cross Medicare Plus BlueSM PPO members.

To request additional days on an inpatient admission

To request additional days, follow the instructions in the e-referral User Guide for extending an inpatient authorization. Here's what it says: To extend service on an existing Inpatient Authorization, begin by locating your authorization. Click the Edit button on the right side of the details page. Scroll down to the Confinement Extension(s) section, click the Create New button and enter your new dates and the number of days.

You must also submit clinical information related to the continued stay. To do that, follow the instructions in the article How to attach clinical information to your authorization request in the e-referral system, on page 44 in the November-December 2016 issue of BCN Provider News.

To submit a discharge notification

To notify us of a member's discharge, enter the discharge date in the e-referral Case Communication field. As an alternative, you can record the discharge date on a discharge summary form and attach it to the case in e-referral.

Sign up for e-referral

If you don't currently have access to the e-referral system, we encourage you to sign up for it now so you'll be ready to use it before November 1, when faxes are no longer accepted. Follow the instructions on the Sign Up or Change a User page on this website.

Posted: August 2018
Line of business: Blue Care Network

How to submit BCN inpatient authorization requests during upcoming holiday closures

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices are closed on the following days:

  • Monday, Sept. 3, 2018 (Labor Day holiday)
  • Tuesday, Nov. 6, 2018 (Election Day holiday)

During these holiday closures, BCN's inpatient utilization management area remains available to accept inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

Here's what you need to know about submitting inpatient authorization requests to BCN when our corporate offices are closed.

Acute initial inpatient admissions. Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week.

Note: These requests may also be submitted through the X12N 278 Health Care Services Review – Request for Review and Response electronic standard transaction.

Post-acute initial and concurrent admission reviews. Follow the current process you use to submit these requests by fax at 1-866-534-9994.

Other authorization requests. The types of requests listed below must be submitted by fax. For these requests, faxes are processed only Mondays through Friday. They are not processed on weekends or on the holidays on which BCN is closed. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

  • Acute inpatient concurrent reviews and discharge dates, but only for facilities reimbursed on the basis of DRGs
  • Authorization requests for sick or ill newborns
  • Authorization requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN After-Hours Care Manager hotline at 1-800-851-3904 and listen to the prompts for help with the following:

  • Determining alternatives to inpatient admissions and triage to alternative care settings
  • Arranging for emergency home health care, home infusion services and in-home pain control
  • Arranging for durable medical equipment
  • Handling emergency discharge planning coordination and authorization
  • Handing expedited appeals of utilization management decisions

Note: Do not use the after-hours care manager phone number to request authorization for routine inpatient admissions.

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member's medical condition and coordinate care prior to admitting the member.

Posted: August 2018
Line of business: Blue Care Network

Phone numbers change for BCN Case Management and Care Transition programs

The phone numbers for BCN's Case Management and Care Transition to Home programs have changed.

To reach staff in these programs, call 1-800-775-2583. Wait to hear the prompts and press the number for the prompt that matches your request.

Please update your files to show the following:

  • Instead of the 1-800-943-9744 number for BCN Case Management, call 1-800-775-2583.

  • Instead of the 1-800-728-3010 number for the BCN Care Transition to Home program, call 1- 800-775-2583.

The Care Management and BCN Advantage chapters of the BCN Provider Manual are being updated to reflect the new 1-800-775-2583 phone number.

Posted: August 2018
Line of business: Blue Care Network

Reminder: Starting Oct. 1, AIM Specialty Health® to manage cardiology and high-tech radiology for Blue Care Network

As a reminder, for dates of service on or after Oct. 1, 2018, AIM Specialty Health will manage the authorization process for cardiology and high-tech radiology procedures for BCN HMOSM (commercial) and BCN AdvantageSM members. We first communicated about this in the article AIM Specialty Health to manage cardiology and high-tech radiology procedures for BCN starting October 1 in the July-August 2018 issue of BCN Provider News, on page 33.

Here are some important things to know:

  • AIM will accept authorization requests starting Sept. 17, 2018, for dates of service on or after Oct. 1. You can submit these requests either through the AIM provider portal or by calling AIM at 1-844-377-1278.

  • For dates of service prior to Oct. 1, continue to submit your authorization requests to eviCore healthcare. eviCore will handle all requests for dates of service prior to Oct. 1, including postservice requests.

Codes for procedures AIM will manage

Click here for a list of the procedure codes AIM will manage. You'll be able to find the list of codes on this website by the end of September.

Webinars offered in August, September and October

There's still time to sign up for training webinars to learn how to register for and use the AIM ProviderPortalSM, an online tool used to request authorization from AIM.

Here are the webinar days and times:

  • Wednesday, Aug. 22, 10-11 a.m.
  • Thursday, Aug. 23, 2-3 p.m.
  • Wednesday, Aug. 29, 10-11 a.m.
  • Thursday, Aug. 30, 2-3 p.m.
  • Wednesday, Sept. 5, 10-11 a.m.
  • Thursday, Sept. 6, 2-3 p.m.
  • Wednesday, Oct. 3, 10-11 a.m.

For the instructions on how to register, refer to the article in BCN Provider News.

Posted: August 2018
Line of business: Blue Care Network

Starting Oct. 1, AIM Specialty Health® to manage cardiology and high-tech radiology services for Blue Care Network

For dates of service on or after Oct. 1, 2018, AIM Specialty Health will manage the authorization process for cardiology and high-tech radiology procedures for BCN HMOSM (commercial) and BCN AdvantageSM members. We first communicated about this in the article AIM Specialty Health to manage cardiology and high-tech radiology procedures for BCN starting October 1 in the July-August 2018 issue of BCN Provider News, on page 33.

AIM will accept authorization requests starting Sept. 17, 2018. You can submit these requests either through the AIM provider portal or by calling AIM at 1-844-377-1278.

For dates of service prior to Oct. 1, continue to submit your authorization requests to eviCore healthcare.

Webinars offered in August, September and October

We've scheduled training webinars so you can learn how to register for and use the AIM ProviderPortalSM, an online tool used to request authorization from AIM.

For the training dates and the instructions on how to register, refer to the article in BCN Provider News.

Codes for procedures AIM will manage

Click here for a list of the procedure codes AIM will manage. The list shows the following categories of procedures:

  • Category 1: Procedures that require authorization by eviCore healthcare for dates of service through Sept. 30, 2018, and will continue to require authorization by AIM for dates of service on or after Oct. 1, 2018

  • Category 2: Procedures that require authorization by eviCore healthcare for dates of service through Sept. 30, 2018, but will not require authorization by AIM for dates of service on or after Oct. 1, 2018

  • Category 3: A few procedures that require authorization by eviCore healthcare for dates of service through Sept. 30, 2018, will require authorization by BCN for dates of service on or after Oct. 1, 2018. Submit authorization requests for these procedures directly to BCN through the e-referral system. Don't submit them to AIM.

  • Category 4: Procedures that do not require authorization by eviCore healthcare for dates of service through Sept. 30, 2018, but will require authorization by AIM for dates of service on or after Oct. 1, 2018

You'll be able to find the list of codes on our ereferrals.bcbsm.com website by the end of September.

Posted: July 2018
Line of business: Blue Care Network

Starting Oct. 1, additional specialty medications require authorization for BCN AdvantageSM members

For dates of service on or after Oct. 1, 2018, additional specialty medications covered under the Medicare Part B medical benefit require authorization for BCN Advantage members.

We first communicated about this in the article Starting Oct. 1, additional specialty medications require authorization for BCN Advantage members, on page 28 of the July-August 2018 BCN Provider News.

Please review the article to see which drugs require authorization starting October 1.

Exception: Vivaglobin® (HCPCS code J1562) will not require authorization because it is being discontinued. This is a change from what we communicated in the newsletter article.

These medications are not self administered. They must be given by injection or infusion by a physician or health care professional in the office or outpatient facility setting.

These medications require authorization when billed as a professional service (via the paper HCFA 1500 claim form or electronically as an 837P transaction) or as an outpatient facility service (via the UB-04 or electronically as an 837I transaction) and one of the following place of service codes is used:

  • Physician office (Place of Service code 11)
  • Outpatient facility (Place of Service codes 19, 22 and 24)
  • Note: In the July-August 2018 newsletter article, we mentioned only Place of Service codes 19 and 22 for outpatient facilities, but authorization is also required for Place of Service code 24.

Please review the July-August newsletter article for additional information.

In addition, look for an article in the September-October 2018 BCN Provider News that will clarify these changes.

Posted: July 2018
Line of business: Blue Care Network

How to submit BCN inpatient authorization requests during upcoming holiday closures

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices are closed on the following days:

  • Wednesday, July 4, 2018 (Fourth of July holiday)
  • Monday, Sept. 3, 2018 (Labor Day holiday)

During these holiday closures, BCN's inpatient utilization management area remains available to accept inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

Here's what you need to know about submitting inpatient authorization requests to BCN when our corporate offices are closed.

Acute initial inpatient admissions. Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week.

Note: These requests may also be submitted through the X12N 278 Health Care Services Review – Request for Review and Response electronic standard transaction.

Post-acute initial and concurrent admission reviews. Follow the current process you use to submit these requests by fax at 1-866-534-9994.

Other authorization requests. The types of requests listed below must be submitted by fax. For these requests, faxes are processed only Mondays through Friday. They are not processed on weekends or on the holidays on which BCN is closed. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

  • Acute inpatient concurrent reviews and discharge dates, but only for facilities reimbursed on the basis of DRGs
  • Authorization requests for sick or ill newborns
  • Authorization requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN After-Hours Care Manager hotline at 1-800-851-3904 and listen to the prompts for help with the following:

  • Determining alternatives to inpatient admissions and triage to alternative care settings
  • Arranging for emergency home health care, home infusion services and in-home pain control
  • Arranging for durable medical equipment
  • Handling emergency discharge planning coordination and authorization
  • Handing expedited appeals of utilization management decisions

Note: Do not use the after-hours care manager phone number to request authorization for routine inpatient admissions.

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member's medical condition and coordinate care prior to admitting the member.

Posted: July 2018
Line of business: Blue Care Network

Effective Oct. 1, Prolia® and Xgeva® are subject to a site-of-care requirement for BCN HMOSM members

Effective Oct. 1, 2018, BCN is adding the following two drugs to its site-of-care optimization program:

  • Prolia
  • Xgeva

For both medications, the generic name is denosumab and the HCPCS code is J0897.

The site-of-care requirement applies only to BCN HMO (commercial) members. It does not apply to BCN AdvantageSM members.

The site-of-care program redirects members receiving select drugs in an outpatient hospital setting to a lower-cost, alternate site of care, such as the physician's office or the member's home.

If a provider feels a member is not a candidate to receive these drugs at a site other than the outpatient hospital, documentation supporting medical necessity must be provided to the plan for review. Those requests will be evaluated on a case-by-case basis.

Requests for Prolia and Xgeva must meet applicable authorization criteria in addition to the site-of-care requirement. This applies to first-time and current users of these medications.

For additional requirements related to drugs covered under the medical benefit, including all drugs identified as subject to site-of-care requirements, refer to the Medical Benefit Drugs – Pharmacy page in the BCN section of this website. Click Requirements for drugs covered under the medical benefit – BCN HMO under the heading "For BCN HMO (commercial) members."

The new site-of-care requirement for Prolia and Xgeva will be added to the list in late September.

Posted: June 2018
Line of business: Blue Care Network

Effective June 22, submit appeals of eviCore decisions on BCN AdvantageSM requests to BCN, not to eviCore

Effective June 22, 2018, providers must submit appeals of eviCore healthcare's decisions on BCN Advantage authorization requests to the BCN Advantage Grievances and Appeals Unit and not to eviCore. Here's where to submit:

By mail:

Blue Care Network
ATTN: BCN Advantage Grievances and Appeals Unit
P.O. Box 284
Southfield MI 48076-5043

By fax: 1-866-522-7345

BCN will process these appeals using the normal BCN Advantage appeal process for standard and expedited appeals. For information on that process, refer to the BCN Advantage chapter of the BCN Provider Manual. Look in the section titled "BCN Advantage provider appeals."

Appeals of eviCore decisions on BCN HMOSM (commercial) authorization requests should continue to be submitted to eviCore.

Posted: June 2018
Line of business: Blue Care Network

Reminder: Effective July 1, Krystexxa® and Stelara® (SQ/IV) are subject to a site-of-care requirement for BCN HMOSM (commercial) members

As a reminder, effective July 1, 2018, BCN is adding the following two drugs to its site-of-care optimization program:

Brand name HCPCS code Generic name
Krystexxa J2507 pegloticase
Stelara (SQ/IV) J3357, J3358 ustekinumab

This requirement applies only to BCN HMO (commercial) members, for first-time and current users of these medications. It does not apply to BCN AdvantageSM members.

The site-of-care program redirects members receiving select medical benefit drugs in an outpatient hospital setting to a lower-cost, alternate site of care, such as the physician's office or the member's home.

If a provider feels a member is not a candidate to receive these drugs at a site other than the outpatient hospital, documentation supporting medical necessity must be provided to the plan for review. Those requests will be evaluated on a case-by-case basis.

Requests for Krystexxa and Stelara (SQ/IV) must meet applicable authorization criteria in addition to the site-of-care requirement.

For additional requirements related to drugs covered under the medical benefit, including all drugs identified as subject to site-of-care requirements, refer to the Medical Benefit Drugs – Pharmacy page in the BCN section of this website. Click Requirements for drugs covered under the medical benefit – BCN HMO under the heading "For BCN HMO (commercial) members."

The new site-of-care requirement for Krystexxa and Stelara is included in the list that is now available online.

Posted: June 2018
Line of business: Blue Care Network

Complete the e-referral questionnaires for blepharoplasty and hyperbaric oxygen therapy for BCN members

Providers must complete questionnaires in the e-referral system for the following procedures:

  • Blepharoplasty and repair of brow ptosis – beginning June 25, 2018, for any date of service
  • Hyperbaric oxygen therapy – for dates of service on or after July 1, 2018

The questionnaires will open in the e-referral system when you're submitting authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

These procedures already require authorization. It's just the questionnaires that are new.

How the questionnaires work

If your responses to the questionnaire in the e-referral system indicate that the procedure meets criteria, the authorization request will automatically be approved. If the criteria are not met, the request will be pended for clinical review by BCN's Utilization Management staff.

For cases that are not automatically approved via e-referral after you complete the questionnaire, you must include additional clinical information. You can type the information directly into the Case Communication section in the e-referral system or you can attach it to the case. The instructions for attaching clinical information to the case are outlined in the article How to attach clinical information to your authorization request in the e-referral system, on page 44 in the November-December 2016 BCN Provider News.

Where to find medical policies and preview questionnaires

The medical policies for these procedures will guide the decisions on these authorization requests. Click to open the policies:

The medical policies for these procedures will be posted online before the end of June in the BCN section of this website, on the Authorization Requirements & Criteria page.

You'll also find preview questionnaires at that location. You can look over the preview questionnaires to see what questions you'll need to answer in the actual questionnaire that opens in the e-referral system for each service. Once you know what questions you'll need to answer, you can prepare your answers ahead of time. This can cut down on the time it takes to submit the authorization request.

Posted: May 2018
Line of business: Blue Care Network

How to submit BCN inpatient authorization requests during upcoming holiday closures

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices are closed on the following days:

  • Monday, May 28, 2018 (Memorial Day)
  • Wednesday, July 4, 2018 (Fourth of July holiday)

During these holiday closures, BCN's inpatient utilization management area remains available to accept inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

Here's what you need to know about submitting inpatient authorization requests to BCN when our corporate offices are closed.

Acute initial inpatient admissions. Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week.

Post-acute initial and concurrent admission reviews. Follow the current process you use to submit these requests by fax at 1-866-534-9994.

Other authorization requests. The types of requests listed below must be submitted by fax. For these requests, faxes are processed only Mondays through Friday. They are not processed on weekends or on the holidays on which BCN is closed. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

  • Acute inpatient concurrent reviews and discharge dates, but only for facilities reimbursed on the basis of DRGs
  • Authorization requests for sick or ill newborns
  • Authorization requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN After-Hours Care Manager hotline at 1-800-851-3904 and listen to the prompts for help with the following:

  • Determining alternatives to inpatient admissions and triage to alternative care settings
  • Arranging for emergency home health care, home infusion services and in-home pain control
  • Arranging for durable medical equipment
  • Handling emergency discharge planning coordination and authorization
  • Handing expedited appeals of utilization management decisions

Note: Do not use the after-hours care manager phone number to request authorization for routine inpatient admissions.

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member's medical condition and coordinate care prior to admitting the member.

Posted: May 2018
Line of business: Blue Care Network

eviCore to handle BCN initial and follow-up authorization requests for PT, OT and ST starting later in 2018

Later this year, providers who currently submit their initial authorization requests for physical, occupational and speech therapy, or for physical medicine services by chiropractors, through the e-referral system or by calling BCN will submit these requests through eviCore healthcare's provider portal instead.

At the same time, requests to authorize follow-up services will also be submitted through the eviCore provider portal instead of through the Landmark Healthcare portal.

This change will apply to requests for BCN HMOSM (commercial) and BCN AdvantageSM members and to the following providers:

  • Facilities
  • Therapists performing physical, occupational and speech therapy
  • Chiropractors performing physical medicine services
  • Referring physicians
  • Podiatrists

In addition, BCN is working with eviCore to implement the corePathSM authorization model for these requests for BCN HMO (commercial) and BCN Advantage members. corePath will streamline the authorization process and make it easier for providers to submit authorization requests. It's the same model that was implemented for Blue Cross Medicare Plus BlueSM PPO authorization requests starting Jan. 1, 2018.

We first communicated about this change in the article titled eviCore to handle BCN initial and follow-up authorization requests for PT, OT and ST starting later in 2018, on page 42 of the May-June 2018 BCN Provider News.

More details about these changes will be provided in the coming months.

Posted:
Line of business: Blue Care Network

No site-of-care requirement for BrineuraTM for BCN HMOSM (commercial) members

Brineura (cerliponase alfa), a medication covered under the medical benefit, will not be subject to a site-of-care requirement starting July 1, 2018, for BCN HMO (commercial) members, as we had previously announced.

In April, we communicated that we were adding Brineura to the site-of-care optimization program starting July 1. However, we have decided after additional review that we will not add Brineura to that program.

The document Requirements for drugs covered under the medical benefit – BCN HMO has been updated to reflect this change. However, please check that document for the authorization requirements that do pertain to Brineura and for the requirements that pertain to other drugs covered under the medical benefit for BCN HMO (commercial) members.

Posted: May 2018
Line of business: Blue Care Network

Starting June 1, no authorization is required for BCN routine outpatient behavioral health therapy

For dates of service on or after June 1, 2018, authorization is not required for routine outpatient therapy for mental health and substance use disorders, for contracted behavioral health providers in Michigan. This applies to both BCN HMOSM (commercial) and BCN AdvantageSM members.

Currently, these services require authorization for all providers and authorization requests are submitted through the e-referral system.

Authorization will continue to be required for:

  • Providers who do not belong to the network assigned to a member's plan
  • Noncontracted providers, including providers outside of Michigan

In addition, the outpatient services listed here will continue to require authorization through the e-referral system for all providers:

  • Autism evaluation and treatment
  • Electroconvulsive therapy
  • Neurofeedback
  • Transcranial magnetic stimulation

We'll be updating the Behavioral Health chapter of the BCN Provider Manual and other documents to reflect the change in authorization requirements.

Posted: April 2018
Line of business: Blue Care Network

Effective July 1, no authorization is required for multiple sclerosis medications for Blue Cross, BCN commercial members

Effective for dates of service on or after July 1, 2018, multiple sclerosis medications covered under the medical benefit will not require authorization, for Blue Cross PPO (commercial) and BCN HMOSM (commercial) members. This change applies to the following medications:

Brand name Generic name HCPCS code
LemtradaTM alemtuzumab J0202
OcrevusTM ocrelizumab J2350
Tysabri® natalizumab J2323

For Blue Cross and BCN commercial members with an active authorization for one of these medications, no additional action is required by the member or the provider.

This change does not apply to BCN AdvantageSM, Blue Cross Medicare Plus BlueSM PPO or Federal Employee Program® members. The requirements for these products are as follows:

  • For BCN Advantage and Federal Employee Program members, no authorization is currently required.
  • For Medicare Plus Blue members, authorization is currently required and will continue to be required.

For additional information on the change related to commercial members, look for articles in the following upcoming newsletters:

  • May 2018 issue of The Record
  • May-June 2018 issue of BCN Provider News

Posted: April 2018
Line of business: Blue Care Network

BCN members can now get long-acting injectable medications at home

Blue Care Network is helping BCN HMOSM (commercial) and BCN AdvantageSM members get access to long-acting injectable medications for the treatment of certain psychiatric and substance use disorders.

We've contracted with home health care agencies that can visit the member's home to administer the injections and complete a nursing assessment of the member. The agencies can be used when the primary care physician, psychiatrist or facility is unable to administer these medications.

The newer long-acting injectable medications may be used for the medically assisted treatment of psychiatric and substance use disorders. These medications have fewer side effects and are better tolerated than some of the older formulations. They are also now usually preferred early in treatment and should often be the first line of treatment for certain psychiatric and substance use disorders.

The member just needs a doctor's order to be sent to the home health agency. The doctor also needs to order the medication through AllianceRx Walgreens Prime Specialty Pharmacy on behalf of the member.

By providing this service, we're removing a barrier for members. We're providing a place to get the injection.

For information on how to use this service, refer to the document Administering long-acting injectable medications at home (behavioral health). This document is on the Behavioral Health page in the BCN section of this website, under the "Other resources" heading.

This document shows:

  • The steps for initiating and continuing the administration of the medications in the member's home
  • A list of some long-acting injectable medications that can be obtained through AllianceRx Walgreens Prime Specialty Pharmacy
  • A list of the BCN-contracted home health agencies that provide in-home long-acting injectables

We're also updating the Behavioral Health chapter of the BCN Provider Manual with a link to this document.

Posted: April 2018
Line of business: Blue Care Network

How to submit BCN inpatient authorization requests during upcoming holiday closures

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices are closed on the following days:

  • Friday, March 30, 2018 (Good Friday)
  • Monday, May 28, 2018 (Memorial Day)

During these holiday closures, BCN's inpatient utilization management area remains available to accept inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

Here's what you need to know about submitting inpatient authorization requests to BCN when our corporate offices are closed.

Acute initial inpatient admissions. Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week.

Post-acute initial and concurrent admission reviews. Follow the current process you use to submit these requests by fax at 1-866-534-9994.

Other authorization requests. The types of requests listed below must be submitted by fax. For these requests, faxes are processed only Mondays through Friday. They are not processed on weekends or on the holidays on which BCN is closed. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

  • Acute inpatient concurrent reviews and discharge dates, but only for facilities reimbursed on the basis of DRGs
  • Authorization requests for sick or ill newborns
  • Authorization requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN After-Hours Care Manager hotline at 1-800-851-3904 and listen to the prompts for help with the following:

  • Determining alternatives to inpatient admissions and triage to alternative care settings
  • Arranging for emergency home health care, home infusion services and in-home pain control
  • Arranging for durable medical equipment
  • Handling emergency discharge planning coordination and authorization
  • Handing expedited appeals of utilization management decisions

Note: Do not use the after-hours care manager phone number to request authorization for routine inpatient admissions.

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member's medical condition and coordinate care prior to admitting the member.

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Posted: March 2018
Line of business: Blue Care Network

Effective July 1, Krystexxa® and Stelara® (SQ/IV) are subject to a site-of-care requirement for BCN HMOSM (commercial) members

Effective July 1, 2018, BCN is adding the following two drugs to its site-of-care optimization program:

Brand name HCPCS code Generic name
Krystexxa J2507 pegloticase
Stelara (SQ/IV) J3357, J3358 ustekinumab

This requirement applies only to BCN HMO (commercial) members, for first-time and current users of these medications. It does not apply to BCN AdvantageSM members.

The site-of-care program redirects members receiving select medical benefit drugs in an outpatient hospital setting to a lower-cost, alternate site of care, such as the physician's office or the member's home.

If a provider feels a member is not a candidate to receive these drugs at a site other than the outpatient hospital, documentation supporting medical necessity must be provided to the plan for review. Those requests will be evaluated on a case-by-case basis.

Requests for Krystexxa and Stelara (SQ/IV) must meet applicable authorization criteria in addition to the site-of-care requirement.

For additional requirements related to drugs covered under the medical benefit, including all drugs identified as subject to site-of-care requirements, refer to the Medical Benefit Drugs – Pharmacy page in the BCN section of this website. Click Requirements for drugs covered under the medical benefit – BCN HMO under the heading "For BCN HMO (commercial) members."

The new site-of-care requirement for Krystexxa and Stelara will be included in the April 2018 version of the list, which will be available online in late March.

Posted: March 2018
Line of business: Blue Care Network

Effective March 19, fax numbers are changing for BCN medical benefit drug authorization requests

Effective March 19, 2018, two fax numbers will change:

  • Use the fax number 1-866-392-6465 for BCN AdvantageSM Medicare Part B authorization requests. It's the same fax number you're currently using for Blue Cross Medicare Plus BlueSM PPO requests.
  • Use the fax number 1-877-325-5979 for BCN HMOSM (commercial) requests. It's the same fax number you're currently using for Blue Cross PPO (commercial) requests.

We encourage you to submit all authorization requests for drugs covered under the medical benefit using the Novologix® electronic system. It's the most efficient way to submit a request and get a determination.

When you need assistance, however, you can call the Pharmacy Help Desk at 1-800-437-3803 or fax your request using the appropriate fax number.

The BCN Provider Manual will be updated with these changes. The Medical Benefit Drugs – Pharmacy page in the BCN section of this website will also be updated. You can find additional information about drugs covered under the medical benefit on that page.

Posted: March 2018
Line of business: Blue Care Network

MepseviiTM is subject to a site-of-care requirement for BCN HMOSM (commercial) members

Effective immediately, BCN is adding Mepsevii (vestronidase alfa-vjbk) to its site-of-care optimization program. This program redirects members receiving select drugs in an outpatient hospital setting to a lower-cost, alternate site of care, such as the physician's office or the member's home.

This requirement applies only to Blue Care Network HMO (commercial) members. It does not apply to BCN AdvantageSM members.

If a provider feels a member is not a candidate to receive this drug at a site other than the outpatient hospital, documentation supporting medical necessity must be provided to the plan for review. Those requests will be evaluated on a case-by-case basis. Requests for Mepsevii must meet applicable authorization criteria in addition to the site-of-care requirement.

For additional requirements related to drugs covered under the medical benefit, including all drugs identified as subject to site-of-care requirements, visit the Medical Benefit Drugs – Pharmacy page in the BCN section of this website. Click Requirements for drugs covered under the medical benefit – BCN HMO (PDF) under the heading "For BCN HMO (commercial) members."

The new Mepsevii site-of-care requirement is included in the March 2018 version of the list, which is available now.

Posted: March 2018
Line of business: Blue Care Network

Two additional medical benefit drugs require authorization for BCN effective April 1, 2018

For dates of service on or after April 1, 2018, authorization is required for the two medical benefit drugs shown in the table below, for BCN HMOSM (commercial) members only.

Drug name Procedure code Additional information
MakenaTM J1726 Applies only to BCN HMO (commercial) members who start this drug on or after April 1, 2018
Tysabri® J2323 Applies to BCN HMO (commercial) members who start this drug on or after April 1, 2018, and those who currently take this drug

Providers must submit an authorization request through the NovoLogix electronic system to demonstrate medical necessity. Authorization requests for these drugs should be submitted prior to the start of services.

Medical necessity criteria for these drugs include but are not limited to diagnosis, lab results, dose and frequency of administration. Documentation may also be required that shows the medications previously used to treat the member's condition, including the dose, regimens, dates of therapy and response. Additional pertinent clinical information may also be required.

These new authorization requirements do not apply to BCN AdvantageSM members.

For a full list of drugs that require authorization and for information on how to request authorization, visit the Medical Benefit Drugs–Pharmacy page in the BCN section of this website.

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Posted: February 2018
Line of business: Blue Care Network

How to submit BCN inpatient authorization requests during upcoming holiday closures

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices are closed on the following days:

  • Monday, Jan. 15, 2018 (Martin Luther King, Jr., Day)
  • Friday, March 30, 2018 (Good Friday)

During these holiday closures, BCN's inpatient utilization management area remains available to accept inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

Here's what you need to know about submitting inpatient authorization requests to BCN when our corporate offices are closed.

Acute initial inpatient admissions. Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week.

Post-acute initial and concurrent admission reviews. Follow the current process you use to submit these requests by fax at 1-866-534-9994.

Other authorization requests. The types of requests listed below must be submitted by fax. For these requests, faxes are processed only Mondays through Friday. They are not processed on weekends or on the holidays on which BCN is closed. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

  • Acute inpatient concurrent reviews and discharge dates, but only for facilities reimbursed on the basis of DRGs
  • Authorization requests for sick or ill newborns
  • Authorization requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN After-Hours Care Manager hotline at 1-800-851-3904 and listen to the prompts for help with the following:

  • Determining alternatives to inpatient admissions and triage to alternative care settings
  • Arranging for emergency home health care, home infusion services and in-home pain control
  • Arranging for durable medical equipment
  • Handling emergency discharge planning coordination and authorization
  • Handing expedited appeals of utilization management decisions

Note: Do not use the after-hours care manager phone number to request authorization for routine inpatient admissions.

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member's medical condition and coordinate care prior to admitting the member.

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Posted: January 2018
Line of business: Blue Care Network

Use the e-referral system to submit BCN referrals and authorization requests

BCN's Utilization Management department (formerly called Care Management) is experiencing high call volumes.

To avoid waiting on the phone line, providers should use the e-referral system to submit or check the status of referrals or authorization requests.

We encourage providers to call 1-800-392-2512 only for urgent requests.

We apologize for the inconvenience caused by the long waiting times on our phone line.

Posted: January 2018
Line of business: Blue Care Network

Submit functional limitation G codes for BCN AdvantageSM therapy services

When billing outpatient physical, occupational and speech therapy services for BCN Advantage members, you must report the functional limitation G codes and their applicable modifiers.

It's important to report the modifiers for the nonpayable G codes as secondary to the modifiers for the primary codes. If you report these modifiers as primary, it will cause an error in our payment system and the claim will be denied.

For instructions on how to report these codes correctly, see the article Providers must submit functional limitation G codes for BCN Advantage PT, OT and ST services, in the January-February 2018 issue of BCN Provider News, on page 37.

The document Outpatient rehabilitation services: Frequently asked questions for rehab providers has been updated with this information. This document and other resources are posted on this website, on BCN's Outpatient PT, OT, ST page.

Posted: January 2018
Line of business: Blue Care Network

Reminder: New BCN authorization requirements are effective Jan. 1, 2018

As a reminder, on Jan. 1, 2018, new authorization requirements take effect for services for BCN HMOSM (commercial) and BCN AdvantageSM members. These changes apply to various types of procedures.

For the details, please review the news article Changes in authorization requirements are effective Jan. 1, 2018, in the November-December 2017 issue of BCN Provider News, on page 45.

In addition, the following documents have been updated and are now available on BCN's Authorization Requirements & Criteria page on this website:

Posted: December 2017
Line of business: Blue Care Network

Authorization required for additional BCN cardiology procedures effective Jan. 1, 2018

Services represented by procedure codes *0482T, *0501T, *0502T, *0503T and *0504T require authorization by eviCore healthcare for dates of service on or after Jan. 1, 2018. This is in addition to the cardiology services that already require authorization by eviCore.

This applies only to services for Blue Care Network HMOSM (commercial) and BCN AdvantageSM members age 18 and older.

The document Procedures that require authorization by eviCore healthcare will be updated to reflect this change.

You can find additional information about procedures managed by eviCore healthcare on this website. Click BCN. Then click eviCore-Managed Procedures.

As a reminder, eviCore healthcare manages select procedures for BCN HMO (commercial), BCN Advantage, Blue Cross PPO and Blue Cross Medicare Plus BlueSM PPO.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2016 American Medical Association. All rights reserved.

Posted: December 2017
Line of business: Blue Care Network

New BCN authorization requirements are effective Jan. 1, 2018!

On Jan. 1, 2018, new authorization requirements take effect for services for BCN HMOSM (commercial) and BCN AdvantageSM members. These changes apply to various types of procedures.

For the details, please review the news article Changes in authorization requirements are effective Jan. 1, 2018, in the November-December 2017 issue of BCN Provider News, on page 45.

Posted: October 2017
Line of business: Blue Care Network

Tell us what you think about BCN Care Management services – You could win a prize!

Your feedback is important to us. Please complete the 2017 BCN Care Management Survey and encourage your office colleagues to do so as well, including physicians, nurses and referral coordinators. Your input will help us evaluate our efforts and determine other improvements we can make to enhance our Care Management processes.

The survey will be available online through Dec. 31, 2017.

Information about a drawing for two $250 gift certificates is available in the Nov.-Dec. 2017 issue of BCN Provider News, page 44.

Posted: October 2017
Line of business: Blue Care Network

Be aware of fall-winter holiday closures when faxing acute inpatient admission requests to BCN

Providers must fax the following acute inpatient admission requests to Blue Care Network:

  • Concurrent review requests and discharge dates, but only for facilities reimbursed on the basis of DRGs
  • Authorization requests for sick or ill newborns
  • Requests for enteral and total parenteral nutrition

Faxes are not accepted on holidays when BCN is closed. The upcoming holidays during which BCN is closed are:

  • Thursday and Friday, Nov. 23 and 24, 2017 (Thanksgiving holidays)
  • Friday, Monday and Tuesday, Dec. 22, 25 and 26, 2017 (Christmas holidays)
  • Monday, Jan. 1, 2018 (New Year's Day)

Otherwise, faxes are accepted from midnight on Sunday through 4 p.m. on Friday. Faxes are not accepted on weekends.

The fax numbers to use are:

  • BCN HMOSM (commercial) members: 1-866-313-8433
  • BCN AdvantageSM members: 1-866-526-1326

Except for the admission types outlined above, all other authorization requests for acute inpatient admissions must be submitted to BCN through the e-referral system.

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

Posted: September 2017
Line of business: Blue Care Network

Revised: Use updated forms for BCN Advantage members being discharged from a hospital stay

Note: The news item originally posted on Sept. 1, 2017, is revised to show that providers may use either the updated forms that CMS provides on its website or the forms that BCN Advantage offers on its website.

Effective Aug. 28, 2017, providers must use the updated Important Message from Medicare form and Detailed Notice of Discharge form for BCN AdvantageSM members being discharged from an inpatient hospital stay.

The forms were recently revised by the Centers for Medicare & Medicaid Services and are available at these locations:

  • On the CMS website. Click here to access them.
  • On this website. Click BCN and then click Forms. Look in the BCN Advantage section of the page under the subheading "Hospitals, for inpatients." These forms have the BCN Advantage logo and contact information for KEPRO, the Quality Improvement Organization for Michigan.

You can use either the CMS forms or the forms specific to BCN Advantage.

The purpose of the forms is to inform BCN Advantage members hospitalized at an inpatient facility that they have special appeal rights if they are dissatisfied with their discharge plan or believe that coverage of their hospital stay is ending too soon.

Additional information about each form is found in the BCN Advantage chapter of the BCN Provider Manual. Look in the section titled "QIO immediate review of hospital discharges."

Posted: September 2017
Line of business: Blue Care Network

BCN Behavioral Health Physician Review Line daytime number is changing effective August 21

Effective Aug. 21, 2017, the phone number for the Blue Care Network Behavioral Health Physician Review Line is changing to 1-877-293-2788. This is the number for physician-to-physician reviews of determinations related to medical necessity.

The previous Physician Review Line number, 734-332-2567, will not be working as of that date.

Here's a summary of how to reach a BCN medical director to discuss a behavioral health determination for a BCN member as of August 21:

  • During business hours (8 a.m. to 5 p.m., Monday through Friday), call 1-877-293-2788 (the new Physician Review Line number).
  • After business hours (for emergent cases only), call 1-800-482-5982. (This is the current number and it is not changing.)

The numbers for calling BCN Behavioral Health during business hours for other purposes are not changing, either. Those are:

  • 1-800-482-5982 for BCN HMOSM (commercial) members
  • 1-800-431-1059 for BCN AdvantageSM members

Also effective August 21, the mailing address for BCN Behavioral Health is changing to:

  • Blue Care Network
  • Behavioral Health
  • Mail Code H100
  • 26899 Northwestern Highway
  • Southfield, MI 48034

Posted: August 2017
Line of business: Blue Care Network

Reminder: BCN uses InterQual criteria as guidelines in reviewing acute inpatient medical admissions

This is a reminder that Blue Care Network uses McKesson's InterQual® criteria as guidelines in reviewing acute inpatient medical admissions and that BCN's medical directors make the final determination about the most appropriate level of care based on their medical judgment.

Additional information about the InterQual criteria and about the process for reviewing these admissions is found in the Care Management chapter of the BCN Provider Manual.

Posted: July 2017
Line of business: Blue Care Network

Submit only the pertinent medical records for BCN initial inpatient admission requests

To reduce the time it takes us to respond to authorization requests for initial inpatient admissions, Blue Care Network is asking that hospitals limit the clinical information they send.

Please send only the pertinent parts of the medical record. This applies to both Blue Care Network HMOSM (commercial) and BCN AdvantageSM members.

Some hospitals send the member's entire clinical record when the request is submitted. This increases the time we spend responding to the request.

The form is optional now

The parts of the record you should send are outlined on the Request for Review of Initial Inpatient Admission form. We recommend that you use the form as a guide.

Submitting the form itself is optional now. (It was required just recently, but we're changing that.)

Hospitals that continue to submit the entire clinical record will ultimately be required to submit the form.

Accessing the form

The form is located in the BCN section of this website, on the Clinical Review & Criteria Charts page. Look under the heading "Referral/clinical review information."

Posted: June 2017
Line of business: Blue Care Network

Reminder: Effective July 1, additional medical benefit drugs for BCN HMO members are subject to a site-of-care requirement

Reminder: Effective July 1, 2017, BCN will add the injectable or infusible drugs listed below to its site-of-care optimization program. This program redirects members receiving these drugs in an outpatient hospital setting to a lower-cost, alternate site of care, such as the physician's office or member's home. This includes members who are currently receiving these drugs and members who are receiving them for the first time.

This requirement applies to Blue Care Network HMOSM (commercial) members. It does not apply to BCN AdvantageSM members.

The drugs are:

  • Benlysta® (J0490)
  • Cimzia® (J0717)
  • Cinqair® (J2786)
  • Entyvio® (J3380)
  • Ilaris® (J0638)
  • Nucala® (J2182)
  • Xolair® (J2357)

As with other drugs in the site-of-care program, if a provider feels a member is not a candidate to receive a drug on this list at a site other than the outpatient hospital, documentation supporting medical necessity must be provided to the plan for review and will be evaluated on a case-by-case basis.

All drugs listed here must meet applicable authorization criteria in addition to the site-of-care requirement.

For additional details, please review the article titled BCN expanding site of care optimization program on July 1, 2017, on page 37 of the May-June 2017 issue of BCN Provider News.

Additional information, including a complete list of drugs in the site-of-care program, is also available on the Medical Benefit Drugs - Pharmacy page in the BCN section of this website. Click Requirements for drugs covered under the medical benefit - BCN HMO under the heading "For BCN HMO (commercial) members." Look for the new July 1 site-of-care requirements in the July 2017 version of the list, which will be available at the end of June.

Posted: June 2017
Line of business: Blue Care Network

Blue Care Network changes authorization requirements for sleep management studies

Effective July 17, 2017, 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 signs and symptoms of obstructive sleep apnea. This applies to both BCN HMOSM (commercial) and BCN AdvantageSM members.

This is in addition to the requirement to submit evidence of the specific condition the member has that would exclude or contraindicate a home sleep study – a requirement that has been in place since Oct. 3, 2016.

Any documentation from the patient's medical record that is required can be attached to the request within the e-referral system, through the Case Communication field. For instructions on how to attach documentation, refer to the article "How to attach clinical information to your authorization request in the e-referral system," in the November-December 2016 BCN Provider News. These instructions are also in the e-referral User Guide, in the subsection titled "Create New (communication)."

As a reminder, home sleep studies do not require clinical review. For home sleep study requests, you must submit an authorization request to facilitate claims payment, but you are not required to complete a questionnaire for these services in the e-referral system.

Posted: May 2017
Line of business: Blue Care Network

Blue Care Network updates authorization guideline for external ECG monitoring

Blue Care Network has updated its authorization guideline for external electrocardiographic monitoring devices that are used for continuous recording and storage of data on a long-term basis (greater than 48 hours), such as Zio Patch® and LifeStar ACT.

Effective immediately, the following procedure codes no longer require clinical review for either BCN HMOSM or BCN AdvantageSM members when the services are ordered and provided by a cardiologist:

  • *0295T
  • *0296T
  • *0297T
  • *0298T

In addition, plan notification for this service is not required. However, cardiologists in the East and Southeast regions must have an active global referral on file for BCN HMO (commercial) members.

Patients are still expected to meet the criteria for coverage, which specify that external ECG monitoring is an alternative to Holter monitoring in patients.

Read more about these criteria and get additional information in the article Blue Care Network updates authorization guideline for external ECG monitoring, on page 44 in the May-June 2017 issue of BCN Provider News.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2016 American Medical Association. All rights reserved.

Posted: May 2017
Line of business: Blue Care Network

Effective July 1, additional medical benefit drugs for BCN HMO members are subject to a site-of-care requirement

Effective July 1, 2017, BCN will add the injectable or infusible drugs listed below to its site-of-care optimization program. This program redirects members receiving these drugs in an outpatient hospital setting to a lower-cost, alternate site of care, such as the physician's office or member's home. This includes members who are currently receiving these drugs and members who are receiving them for the first time.

This requirement applies to Blue Care Network HMOSM (commercial) members. It does not apply to BCN AdvantageSM members.

The drugs are:

  • Benlysta® (J0490)
  • Cimzia® (J0717)
  • Cinqair® (J2786)
  • Entyvio® (J3380)
  • Ilaris® (J0638)
  • Nucala® (J2182)
  • Xolair® (J2357)

As with other drugs in the site-of-care program, if a provider feels a member is not a candidate to receive a drug on this list at a site other than the outpatient hospital, documentation supporting medical necessity must be provided to the plan for review and will be evaluated on a case-by-case basis.

All drugs listed here must meet applicable authorization criteria in addition to the site-of-care requirement.

For additional details, please review the article titled BCN expanding site of care optimization program on July 1, 2017, on page 37 of the May-June 2017 issue of BCN Provider News.

Additional information, including a complete list of drugs in the site-of-care program, is also available on the Medical Benefit Drugs - Pharmacy page in the BCN section of this website. Click Requirements for drugs covered under the medical benefit - BCN HMO under the heading "For BCN HMO (commercial) members." Look for the new July 1 site-of-care requirements in the July 2017 version of the list, which will be available at the end of June.

Posted: May 2017
Line of business: Blue Care Network

Providers can schedule phone appointments for eviCore clinical consultations on BCN radiology reviews

Providers who want to consult with an eviCore healthcare clinical representative on Blue Care Network radiology authorization requests can now schedule phone appointments online without having to wait on hold. This applies only to radiology services reviewed by eviCore healthcare for BCN HMOSM commercial and BCN AdvantageSM members.

Here's how to schedule an appointment for a phone consultation:

  1. Visit evicore.com.
  2. Click Providers.
  3. In the line "Request Clinical Consultation Online Here," click Here.
  4. In the "Select Health Plan" field, select Blue Care Network.
  5. In the "Select Solution" field, select Radiology.
  6. In the "First name," "Last name," "Email" and "Phone" fields, enter the contact information for the office representative who will set up the appointment.
  7. In the "Select Duration Hours" field, enter the two-hour window of time during which a phone appointment can be scheduled with the eviCore physician.
  8. In the "Message" field, indicate the name of the clinician in the office who wants to talk to the eviCore physician.
  9. Click Submit.

You'll receive a phone call or an email (or both, if you requested both in the "Message" field) that indicates the 15-minute window of time within which the phone appointment is scheduled.

Sometime during that 15 minutes, the eviCore physician will call the clinician whose name you entered in the "Message" field.

Examples of clinical consultations include:

  • Questions that arise while you're submitting an authorization request, such as what clinical information must be submitted
  • Questions that arise when a request you've submitted is pended or denied

Before this scheduling option was made available, providers had to call eviCore and wait on hold until an eviCore physician was available.

For additional information about reviews performed by eviCore health for BCN commercial and BCN Advantage members, refer to the eviCore-Managed Procedures page in the BCN section at ereferrals.bcbsm.com.

Posted: April 2017
Line of business: Blue Care Network

Be aware of holiday closures when faxing acute inpatient admission requests to BCN

Providers must fax the following acute inpatient admission requests to Blue Care Network:

  • Concurrent review requests and discharge dates, but only for facilities reimbursed on the basis of DRGs
  • Authorization requests for sick or ill newborns
  • Requests for enteral and total parenteral nutrition

Faxes are not accepted on holidays when BCN is closed. The upcoming holidays in 2017 during which BCN is closed are:

  • Friday, April 14 (Good Friday)
  • Monday, May 29 (Memorial Day)
  • Monday and Tuesday, July 3 and 4 (Fourth of July)
  • Monday, September 4 (Labor Day)

Faxes are accepted from midnight on Sunday through 4 p.m. on Friday. Faxes are not accepted on weekends.

The fax numbers to use are:

  • BCN HMOSM (commercial) members: 1-866-313-8433
  • BCN AdvantageSM members: 1-866-526-1326

Except for the admission types outlined above, all other authorization requests for acute inpatient admissions must be submitted to BCN through the e-referral system.

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

Posted: April 2017
Line of business: Blue Care Network

BCN reviews inpatient readmissions within 14 days effective Jan. 19, 2017

BCN's partnership with providers is important to us. We listened to your concerns and have decided to reinstate BCN's previous inpatient readmission review guidelines.

Effective Jan. 19, 2017, BCN is reviewing inpatient readmissions as follows:

  • BCN reviews readmissions that occur within 14 days of discharge for the same or a related condition.
  • Readmission reviews are conducted according to the Guidelines for Bundling Admissions document dated November 2013. That document is now available on BCN's web-DENIS Provider Publications and Resources website.

Readmissions within 30 days of discharge that were reviewed from Oct. 1, 2016, through Jan. 18, 2017, will not be revisited, but we will conduct additional research before implementing any further changes.

We apologize for any confusion that may result from these changes.

You can access the Guidelines for Bundling Admissions document by completing the following steps:

  1. Visit bcbsm.com/providers and click Login.
  2. Log in as a provider, using your user name and password.
  3. Click BCN Provider Publications and Resources.
  4. Click Billing / Claims.
  5. Click Guidelines for Bundling Admissions.

Posted: March 2017
Line of business: Blue Care Network

Use new PT, OT codes when billing BCN for physical and occupational therapy

On Jan. 1, 2017, new procedure codes went into effect for physical and occupational therapy evaluations for BCN HMOSM (commercial) and BCN AdvantageSM members. The new codes are indicated in bold below.

  • Physical therapy (physical therapists):
    • Service 1: *97110 for treatment
    • Service 2: *97161, *97162 or *97163 for evaluation (These codes cannot be used by chiropractors.)

  • Occupational therapy:
    • Service 1: *97535 for treatment
    • Service 2: *97165, *97166 or *97167 for evaluation

The document Procedures that require clinical review by eviCore healthcare has been updated with these codes.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2016 American Medical Association. All rights reserved.

Posted: January 2017
Line of business: Blue Care Network

Hospitals must give BCN Advantage members receiving outpatient observation services the Medicare Outpatient Observation Notice

The Centers for Medicare & Medicaid Services requires hospitals to give a Medicare Outpatient Observation Notice to Medicare beneficiaries receiving outpatient observation services for more than 24 hours.

BCN AdvantageSM encourages providers to start giving these notices immediately. A copy of the Medicare Outpatient Observation Notice customized for BCN Advantage members and the instructions for using it are available on the web. These documents are available on the Care Management Forms page in the BCN section of this website, under the BCN Advantage heading.

The Medicare Outpatient Observation Notice is a standard notice that lets the member know that:

  • He or she is an outpatient receiving observation services, not an inpatient of the hospital
  • The reasons he or she is receiving observation services
  • How the observation services affect his or her cost-sharing obligations and post-hospitalization eligibility for coverage of skilled nursing facility services

The notice must be delivered no later than 36 hours after observation services begin, or sooner if the member is transferred, discharged or admitted.

The BCN Advantage chapter of the BCN Provider Manual will be updated with this information. The revised chapter will be available at the end of January on the Provider Manual Chapters page in the BCN section of this website.

Additional information about this requirement is available on the Beneficiary Notices Initiative page of the CMS website.

Posted: January 2017
Line of business: Blue Care Network

Obstetrician-gynecologists can refer BCN and BCN Advantage members to specialists

Obstetrician-gynecologists and gynecologists can refer the Blue Care Network HMOSM (commercial) and BCN AdvantageSM members in their care for OB-GYN-related specialty services without the members needing to obtain a referral from their primary care physician. OB-GYN providers in the East and Southeast regions should use the e-referral system to refer their patients.

For additional information about this, refer to the article "Obstetrician-gynecologists can refer patients to specialists" in the January-February 2017 issue of BCN Provider News.

Posted: January 2017
Line of business: Blue Care Network

BCN will not require authorization for monitored anesthesia care during GI endoscopies starting Jan. 8, 2017

Blue Care Network recently announced that authorization would be required for monitored anesthesia care during certain gastrointestinal endoscopies on or after Jan. 8, 2017. This requirement will not go into effect on that date. The need for authorization will be reassessed later in 2017.

For additional information, please refer to the document Anesthesia care for gastrointestinal endoscopy procedures.

Posted: December 2016
Line of business: Blue Care Network

BCN revises codes managed by eviCore healthcare

Blue Care Network has revised its Procedures that require clinical review by eviCore healthcare document.

What's changing?

Interventional pain management services

  • Procedure codes *62263, *62264, *64620, *64626 and *64627 were removed from the list because services associated with these codes are managed by BCN and not by eviCore. However, if you enter these procedure codes into the e-referral system, you will get a message — incorrectly — indicating that the request should be submitted to eviCore.

    IMPORTANT! Until the e-referral system is updated to accept requests involving these codes, you should call BCN Care Management 1-800-392-2512 to request review of these services.

  • The following new codes were added to the list of epidural and facet joint injections managed by eviCore as of Jan. 1, 2017: *62320, *62321, *62322, *62323, *62324, *62325, *62326 and *62327.

  • The following codes are marked as requiring review by eviCore only from Sept. 1 through Dec. 31, 2016: *62310, *62311, *62318 and *62319. These codes are being retired and will eventually be removed from the list.

Physical, occupational and speech therapy services and physical medicine service provided by chiropractors

Some codes for these services are added to the list — specifically, the codes you enter into the e-referral system.

Additional information

For more information, refer to Procedures that require clinical review by eviCore healthcare.

Posted: December 2016
Line of business: Blue Care Network

Guidelines for submitting acute inpatient admission requests to BCN

Authorization requests submitted to Blue Care Network for acute inpatient admissions are accepted only when they are submitted through the e-referral system.

Requests submitted by fax are not accepted, except for the following types of requests, which must be faxed to BCN:

  • For facilities reimbursed on the basis of DRGs, concurrent review requests and discharge dates will be accepted via fax. Facilities reimbursed on a per-diem basis must submit concurrent reviews via e-referral.
  • Authorization requests for sick or ill newborns must be faxed to BCN. They cannot be submitted through the e-referral system because the newborn is not a member covered by BCN. The BCN nurse reviewer will create a case for the newborn in the e-referral system and you will be able to see it there.
  • Requests for enteral and total parenteral nutrition requests must be faxed to BCN.

Faxes are accepted from midnight on Sunday through 4 p.m. on Friday. Faxes are not accepted on weekends. They are also not accepted on holidays when BCN is closed. The holidays observed at BCN are identified in the BCN Provider News issue published prior to the holiday occurring.

The upcoming holidays during which faxes are not accepted are:

  • Friday, Dec. 23 through Monday, Dec. 26
  • Friday, Dec. 30 through Monday, Jan. 2
  • Monday, Jan. 16

The fax numbers to use are:

  • For BCN HMOSM (commercial) members: 1-866-313-8433
  • For BCN AdvantageSM (commercial) members: 1-866-526-1326

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

Posted: December 2016
Line of business: Blue Care Network

BCN requires authorization for additional drugs starting Jan. 1, 2017

Starting Jan. 1, 2017, Blue Care Network requires authorization as shown below for the following drugs covered under the medical benefit:

Drug name Procedure code Authorization required for BCN HMOSM (commercial) members? Authorization required for BCN AdvantageSM members?
Cinqair® J2786 Yes Yes
Darzalex™ J9145 Yes No
Empliciti™ J9176 Yes No
Kanuma™ J2840 Yes Yes
Nucala® J2182 Yes Yes
Onivyde™ J9205 Yes No
Portrazza™ J9295 Yes No
Probuphine® J0570 Yes No
Yondelis® J9352 Yes No

You must submit authorization requests for these drugs using the NovoLogix web tool and must include the following clinical information to support the authorization request:

  • Diagnosis
  • Lab results
  • Names of medications previously used to treat the member's condition, including dose, regimens, dates of therapy and response

You may also be required to submit additional pertinent clinical information and documentation related to the specialty of the prescribing physician and the member's age.

These drugs currently require authorization because they were assigned not-otherwise-specified procedure codes. Starting Jan. 1, these drugs require authorization under the new codes they are assigned.

Information about using the NovoLogix web tool is available on the Medical Benefit Drugs – Pharmacy web page on this website.

Posted: November 2016
Line of business: Blue Care Network

BCN changing inpatient readmission review guidelines starting Jan. 17, 2017

Starting Jan. 17, 2017, BCN is changing the guidelines it uses to review inpatient readmissions of BCN HMOSM (commercial) and BCN AdvantageSM members for billing purposes. Under the updated guidelines, BCN will combine admissions for members readmitted within 30 days for the same or a related condition whether or not discharge criteria were met.

Currently, the admissions are typically billed separately as long as the member met the discharge criteria and had an appropriate discharge plan, even if the readmission was for a new occurrence of the same condition.

The Guidelines for Bundling Admissions document is being updated to reflect this change. The updated document will be available online prior to Jan. 17.

You can access that document by completing the following steps:

  1. Visit bcbsm.com/providers and click Login.
  2. Log in as a provider, using your user name and password.
  3. Click BCN Provider Publications and Resources.
  4. Click Billing / Claims.
  5. Click Guidelines for Bundling Admissions.

Posted: November 2016
Line of business: Blue Care Network

Reminder: eviCore healthcare to review additional outpatient pain management services for BCN effective Dec. 1

As a reminder, for dates of service on or after Dec. 1, 2016, authorization is required through eviCore healthcare for additional pediatric and adult outpatient interventional pain management services for Blue Care Network HMOSM (commercial) and BCN AdvantageSM members, for all diagnoses. Currently, eviCore reviews epidural and facet joint injections for BCN.

You can submit authorization requests for these additional procedures as early as Nov. 21 at www.evicore.com. Click Providers and log in to eviCore's provider portal.

The codes for the additional services that eviCore will review are: *0213T, *0214T, *0215T, *0216T, *0217T, *0218T, *0228T, *0229T, *0230T, *0231T, *27096, *62263, *62264, *62280, *64470, *64472, *64475, *64476, *64510, *64520, *64620, *64626, *64627, *64633, *64634, *64635 and *64636. These services include sacroiliac joint injections, epidural adhesiolysis, radio frequency ablation and regional sympathetic blocks.

The list of procedures that require review by eviCore healthcare has been updated to reflect these additional codes.

Authorization from eviCore is required for these outpatient pain management services. Services performed without authorization may be denied for payment.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2015 American Medical Association. All rights reserved.

Posted: November 2016
Line of business: Blue Care Network

REMINDER: Beginning Dec. 5, 2016, BCN requires authorization for laparoscopic cholecystectomies

Beginning Dec. 5, 2016, BCN requires authorization for laparoscopic cholecystectomies.

What's changing? For dates of service on or after Dec. 5, 2016, BCN requires authorization for laparoscopic cholecystectomies.

Who's affected? This applies to BCN HMOSM (commercial) and BCN AdvantageSM members and to services related to procedure codes *47562-*47564.

Where to find more information: The authorization criteria for laparoscopic cholecystectomies is available on the Clinical Review & Criteria Charts page in the BCN section of ereferrals.bcbsm.com. You can also find a preview questionnaire, which shows the questions contained in the questionnaire displayed in the e-referral system. For both these documents, look in the table with the heading "Other procedures."

Also see the article "Update and reminder about clinical review requirements for certain surgeries," published in the September-October 2016 issue of BCN Provider News.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2015 American Medical Association. All rights reserved.

Posted: November 2016
Line of business: Blue Care Network

Dec. 1 changeover to Novologix web tool scheduled for drugs covered under the BCN medical benefit

BCN providers requesting authorizations for drugs covered under the medical benefit must use the NovoLogix web tool for these requests beginning Dec. 1.

Dec. 1 is the new changeover date. (This is a change from the earlier date of Oct. 1, which was delayed.)

If you are new to the NovoLogix web tool, there are many resources on the Medical Benefit Drugs (Pharmacy) page in the BCN section of ereferrals.bcbsm.com to help you. These include:

  • NovoLogix training video
  • NovoLogix user guide for BCN providers
  • NovoLogix web-based training

How to log in to the Novologix system. Starting Dec. 1, to log in to the NovoLogix system:

  1. Log in as a provider at bcbsm.com.
  2. Click BCN Medical Benefit – Prior Authorization on the Provider Secured Services welcome page.
  3. Enter your NPI.

This will bring you to the NovoLogix welcome page.

BCN's Pharmacy Help Desk. BCN's Pharmacy Help Desk can also input the request on your behalf. You can call the Help Desk at 1-800-437-3803.

Training webinar on Wednesday, Dec. 7. Sign up for a one-hour training webinar on the NovoLogix web tool. There are two times available on Wednesday, Dec. 7. Select either 10 a.m. or 1 p.m. when you register.

Additional information. BCN will move the current active authorizations from the e-referral system to the NovoLogix system before Dec. 1. These authorizations will not be interrupted when the change in the system occurs.

Posted: November 2016
Line of business: Blue Care Network

Tell us what you think about BCN Care Management Services

Your feedback is important to us. Please complete the 2016 BCN Care Management Survey and encourage your office colleagues to do so as well, including physicians, nurses and referral coordinators. Your input will help us evaluate our efforts and determine other improvements we can make to enhance our Care Management processes.

The survey will be available online through Dec. 31, 2016.

Information about a drawing for two $250 gift certificates is available in the Sept.-Oct. issue of BCN Provider News, Page 22.

Posted: November 2016
Line of business: Blue Care Network

REMINDER AND CHANGE: Starting Nov. 1, submit authorization requests for outpatient ECT and TMS services via e-referral but no forms are required

As a reminder, effective Nov. 1, 2016, BCN behavioral health providers must submit authorization requests for outpatient electroconvulsive therapy and transcranial magnetic stimulation services via the e-referral system. You'll also need to complete a questionnaire that displays while you're in the authorization request. The questionnaire will be pertinent to the service you're requesting.

We previously reported that you would also be required to complete a form and attach it to the case in the e-referral system, but the form will actually not be required. Please disregard any instructions to complete a form for these services that we included in our earlier messages and in the article in the November-December 2016 issue of BCN Provider News that was just recently published online. The only requirement is that you complete the questionnaire that displays in the e-referral system.

Posted: OCtober 2016
Line of business: Blue Care Network

ALERT: Phone issues on eviCore's BCN provider line

ALERT: Due to the Hurricane Matthew evacuation that's now in progress, eviCore healthcare is experiencing longer-than-normal call times on its BCN provider phone line (1-855-774-1317). There are also periodic phone issues such as messages and phone prompts that cut off early. If you encounter phone issues when trying to reach eviCore, please stay on the line and you will be connected to an eviCore representative.

If you need to submit an authorization request for a BCN member to eviCore, here's what we suggest:

  • Submit the request through the evicore.com web portal. This is the most efficient way to initiate a request.
  • Call the 1-855-774-1317 number only if absolutely necessary. If you call, stay on the line and you will be connected to an eviCore representative.

eviCore is working to address the phone issues. Also, we're aware that some eviCore call centers have been ordered to evacuate in preparation for Hurricane Matthew. We've been advised by eviCore that calls are being answered in centers not affected by the hurricane evacuation.

Posted: October 2016
Line of business: Blue Care Network

Updated BCN authorization criteria and preview questionnaires now available

Blue Care Network has made updated authorization criteria and preview questionnaires available on this website, on the Clinical Review & Criteria Charts page. These resources are available for the following service types:

  • Knee arthroscopy
  • Cervical spine surgery
  • Joint replacement surgery (knee, hip and shoulder)
  • Lumbar spine surgery

We encourage you to review the criteria and preview questionnaires prior to submitting an authorization request for these services in the e-referral system. You can use the questionnaires, in particular, as guides in gathering the clinical information you'll need when you encounter the actual questionnaires that display in the e-referral system.

Posted: September 2016
Line of business: Blue Care Network

BCN's Behavioral Health e-referral User Guide updated

BCN's Behavioral Health e-referral User Guide (PDF) has been updated and is now available on the Training Tools page of this website. The updated guide includes instructions for the following:

  • Submitting authorization requests for higher levels of care
  • Completing the questionnaire for concurrent review of patients in the higher levels of care
  • Attaching the BCN Behavioral Health Discharge Summary form to your case in the e-referral system
  • Submitting authorization requests for outpatient electroconvulsive therapy and transcranial magnetic stimulation services

Posted: September 2016
Line of business: Blue Care Network

eviCore healthcare to review additional outpatient pain management services for BCN effective Dec. 1

For dates of service on or after Dec. 1, 2016, authorization is required through eviCore healthcare for additional outpatient pain management services for adult and pediatric Blue Care Network HMOSM (commercial) and BCN AdvantageSM members, for all diagnoses. Currently, eviCore reviews epidural and facet joint injections for BCN.

The codes for the additional services that eviCore will review are: *0213T, *0214T, *0215T, *0216T, *0217T, *0218T, *0228T, *0229T, *0230T, *0231T, *27096, *62263, *62264, *62280, *64470, *64472, *64475, *64476, *64510, *64520, *64620, *64626, *64627, *64633, *64634, *64635 and *64636. These services include sacroiliac joint injections, epidural adhesiolysis, radiofrequency ablation and regional sympathetic blocks.

The list of procedures that require review by eviCore healthcare is being updated to reflect these additional codes.

Authorization from eviCore is required for these outpatient pain management services. Services performed without authorization may be denied for payment.

Look for additional information on this topic in the November-December 2016 issue of BCN Provider News, which will be available online in late October.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2015 American Medical Association. All rights reserved.

Posted: September 2016
Line of business: Blue Care Network

REMINDER: BCN will review inpatient readmissions occurring within 30 days of discharge effective Oct. 1, 2016

As a reminder, effective Oct. 1, 2016, BCN will review readmissions that occur within 30 days of discharge. Currently, readmissions that occur within 14 days of discharge are reviewed.

A determination is made as to whether the readmission should be billed separately or bundled with the previous admission. In some instances, the two admissions are combined into one for purposes of DRG reimbursement.

Questionnaires in the e-referral system. The questionnaires you'll encounter in the e-referral system will reflect the 14-day time frame for awhile. Updated questionnaires that reflect the new 30-day time frame will be available in the e-referral system in the near future. We suggest you answer the existing questionnaires with the 30-day time frame in mind, even though they refer to a 14-day time frame.

Documents are being updated. The documents listed below are being updated to reflect the change to 30 from 14 days. All of the revised documents will be available online by Sept. 30.

  • Guidelines for bundling admissions
  • The Care Management and Claims chapters of the BCN Provider Manual
  • The readmission checklist, which facilities should use to ensure that all necessary documentation is available for the review of a readmission that has occurred within 30 days

You can access all these documents by completing the following steps:

  1. Visit bcbsm.com/providers and click Login.
  2. Log in to Provider Secured Services using your user ID and password.
  3. Click BCN Provider Publications and Resources.
  4. Click either Billing/Claims, Provider Manual or Forms, to open the appropriate Web page.

Posted: September 2016
Line of business: Blue Care Network

Changeover to using Novologix web tool is delayed for BCN providers

The effective date for BCN providers to start using the NovoLogix web tool to submit authorization requests for drugs covered under the medical benefit is changing. The date previously announced was Oct. 7, 2016. The new date has not yet been determined.

Providers should continue to submit authorization requests for these services through the e-referral system. Watch for updated information in the news alerts on this website and in web-DENIS messages.

The webinars scheduled for September and October are cancelled. New webinar dates will be announced on this website and in web-DENIS messages once the new changeover date is known.

Additional information about drugs covered under the medical benefit is available on the Medical Benefit Drugs–Pharmacy page on this website.

Posted: September 2016
Line of business: Blue Care Network

ALERT: e-referral system is displaying updated BCN knee arthroscopy questionnaires earlier than expected

The e-referral system is displaying updated BCN knee arthroscopy questionnaires for earlier dates of service than expected. The updated questionnaires were intended to display only for dates of service on or after Oct. 3, 2016, but are instead displaying for all dates of service, including those earlier than Oct. 3. This is occurring for providers who request authorization for knee arthroscopy procedures for adult BCN HMOSM (commercial) and BCN AdvantageSM members 18 years of age and older.

We advise that providers simply complete the updated questionnaire. The e-referral system will either approve or pend the request. If the request pends and BCN cannot authorize it, BCN will contact the provider for additional clinical information.

We apologize for any confusion caused by the updated questionnaires displaying for dates of service prior to Oct. 3.

Updated preview questionnaires and medical necessity criteria are being prepared and will be available on the Clinical Review & Criteria Charts page of this website by the end of September.

Posted: September 2016
Line of business: Blue Care Network

Authorization requests for outpatient ECT and TMS services must be submitted via e-referral starting Nov. 1, 2016

Effective Nov. 1, 2016, BCN behavioral providers must submit authorization requests for outpatient electroconvulsive therapy and transcranial magnetic stimulation services via the e-referral system.

While submitting the authorization request through e-referral, you'll be presented with a questionnaire pertinent to the service you're requesting. You'll need to answer the questions on the questionnaire.

You'll also need to complete a form and attach it to the authorization request in the e-referral system. You'll complete a form for one of the following:

  • ECT – initial outpatient treatment
  • ECT – continuation of outpatient care
  • TMS – outpatient

All of these forms will be available on the Behavioral Health page of this website prior to Nov. 1.

Instructions for attaching information to an authorization request in the e-referral system are found in the BCN Behavioral Health e-referral User Guide.

Posted: September 2016
Line of business: Blue Care Network

eviCore to review additional radiation therapy codes for BCN effective Nov. 1, 2016

Effective for dates of service on or after Nov. 1, 2016, eviCore healthcare will review authorization requests for additional radiation therapy services, for BCN HMOSM (commercial) and BCN AdvantageSM members.

These additional services are associated with the following procedure codes: *79101, *79403, A9543, C2616 and Q3001

Here's what you need to know:

  • Authorization is required prior to services being given.
  • You'll need to submit pertinent clinical information with the authorization request

An updated list of codes reviewed by eviCore, including these additional codes, is available on the eviCore Managed Procedures page on this website.

As a reminder, BCN contracts with eviCore healthcare to review select non-emergent cardiology, interventional pain management, radiation therapy and radiologyprocedures when performed in freestanding diagnostic facilities, outpatient hospital settings, ambulatory surgery centers and physician offices for BCN HMO and BCN Advantage members.

* CPT codes, descriptions and two-digit numeric modifiers only are copyright 2015 American Medical Association. All rights reserved.

Posted: September 2016
Line of business: Blue Care Network

ALERT: e-referral system is displaying updated BCN sleep study questionnaire earlier than expected

The e-referral system is displaying an updated BCN sleep study questionnaire earlier than the intended effective date of Oct. 3, for providers who request authorization for outpatient facility and clinic-based sleep management studies for adult members 18 years of age and older.

Here is what's happening: The updated questionnaire instructs providers to attach evidence from the member's medical record that confirms the specific condition the member has that excludes or contraindicates a home sleep study. This is requested for dates of service prior to Oct. 3, 2016, even though it is required only for dates of service on or after Oct. 3, 2016.

The result is that all cases pend, even for dates of service prior to Oct. 3.

Here's what to do: For requests to authorize these procedures for dates of service prior to Oct. 3, do the following:

  1. Complete the questionnaire in the e-referral system. This includes commenting on:
    • Symptoms of sleepiness
    • Daytime sleepiness determined by an assessment tool (Epworth Sleepiness Scale or the Stanford Sleepiness Scale)
    • Level of alertness different times of the day
    • Diabetes
    • Presence of other health conditions
    • Neck circumference

  2. For repeat sleep studies, submit the results of the initial sleep study. Attach these results to the authorization request in the e-referral system.

For dates of service prior to Oct. 3, BCN's Care Management staff will review the answers on the questionnaire without requiring evidence from the member's medical record showing that a home sleep study is excluded or contraindicated.

We apologize for any confusion caused by the updated questionnaire appearing for dates of service prior to Oct. 3.

Posted: September 2016
Line of business: Blue Care Network

BCN launches new Medical Benefit Drugs-Pharmacy web page

BCN has launched a new Medical Benefit Drugs-Pharmacy web page on this website. You can go to that page and get all the information you need about drugs covered under the medical benefit.

To open this new page, click the Medical Benefit Drugs-Pharmacy link on the left navigation bar, on the BCN part of this website.

The new page offers the following resources for providers offering drugs covered under the medical benefit:

  • Authorization requirements (We've added a link that currently opens the pertinent pages in the BCN Referral and Clinical Review Program document but that will later open an all-in-one document outlining authorization requirements and medical necessity criteria and more.)

  • Medical necessity criteria (commercial)

  • National Drug Code pricing guidelines (unit of measure guidelines for submitting commercial claims)

  • Newsletter articles

  • Instructions for accessing information in the Pharmacy chapter of the BCN Provider Manual

Over time, you'll be able to open more documents from this new web page, as they become available.

Also, we've removed medical benefit drug information from the Clinical Review and Criteria Resources web page and moved it to the new page.

Posted: August 2016
Line of business: Blue Care Network

MSU Student and Graduate Assistants Health Plans information

Referrals for the new BCN health plans for Michigan State University students and graduate assistants work differently from what you're used to. If you were unable to attend one of the August webinars, you can view the plan flier (PDF) for more information.

Posted: August 2016 / Updated: September 2016
Line of business: Blue Care Network

Sign up for online webinar on how to submit pain management authorization requests in eviCore's electronic system

As a reminder, starting with dates of service on or after Sept. 1, 2016, for BCN HMOSM (commercial) and BCN AdvantageSM members, eviCore healthcare will manage authorizations for interventional pain management services (epidural and facet joint injections). The details about this change are in the news item titled "eviCore healthcare to review epidural and facet joint procedures for BCN effective September 1," which you'll find among the July 2016 news items on this website.

Sign up for an online orientation. eviCore has scheduled online orientation sessions to assist you and your staff with submitting pain management authorization requests through their electronic system.

You can attend the webinar orientation session that best fits into your schedule. This training is for utilization management and for any other appropriate staff.

To attend one of the sessions, please register in advance. Each session is free and will last approximately one hour.

All session times listed below are Eastern time. Note: The webex schedule displays Central time (Chicago), which is one hour before Eastern time (Michigan).

Day Date Time
Tuesday Aug. 23, 2016 11 a.m. Eastern time (listed as 10 a.m. Central time)
Wednesday Aug. 24, 2016 3 p.m. Eastern time (listed as 2 p.m. Central time)
Tuesday Aug. 30, 2016 9 a.m. Eastern time (listed as 8 a.m. Central time)
Wednesday Aug. 31, 2016 9 a.m. Eastern time (listed as 8 a.m. Central time)
Thursday Sept. 8, 2016 2 p.m. Eastern time (listed as 1 p.m. Central time)
Friday Sept. 9, 2016 9 a.m. Eastern time (listed as 8 a.m. Central time)

Click for instructions on how to register. Click the webinar orientation announcement for the instructions on how to register.

eviCore healthcare is an independent company that provides clinical review services for Blue Care Network.

Posted: August 2016
Line of business: Blue Care Network

UPDATED: Effective Aug. 18, in some instances, only eviCore's electronic system and letters will display the correct number of units authorized for cardiology, radiology and radiation therapy services for BCN members

For Blue Care Network providers submitting authorization requests to eviCore healthcare for the cardiology, radiology and radiation therapy services eviCore manages for BCN, a change will take place in mid-August.

Currently, both eviCore's electronic system and BCN's e-referral system show the same number of units authorized by eviCore.

Beginning Aug. 18, 2016, in some instances, you may see 250 units authorized in BCN's e-referral system for each service approved by eviCore. This will be more than the actual number of units authorized by eviCore. It is necessary for the 250 units to be downloaded to BCN's e-referral system to facilitate the payment of claims.

In these instances, the actual number of units authorized by eviCore will be visible in eviCore's electronic system and will be included in the letters eviCore sends.

So, starting Aug. 18, if the e-referral system shows 250 units authorized for your request, you should visit eviCore's electronic system and read the letters eviCore sends, to see the correct number of units authorized. When the e-referral system shows 250 units authorized, these will not be the correct number of units authorized.

As a reminder, eviCore healthcare reviews certain outpatient radiology, cardiology and radiation therapy services for BCN. Separately, eviCore also reviews physical, occupational, and speech therapy, and physical medicine services provided by chiropractors. Starting Sept. 1, eviCore will also review non-emergent pain management services for facet joint and epidural injections.

Additional information is available at ereferrals.bcbsm.com. Click BCN. Finally, click eviCore-Managed Procedures.

Posted: August 2016
Line of business: Blue Care Network

Coming October 1 for BCN behavioral health higher levels of care: Changes in submitting initial authorization requests, concurrent reviews and discharge summaries

Starting Oct. 1, 2016, the requirements for how BCN's behavioral health facilities submit initial authorization requests, concurrent reviews and discharge summaries for inpatient, partial hospital and intensive outpatient services will change. The changes will affect both substance use and mental health cases.

Here's a summary of the changes:

Type of request Current practice Changes effective Oct. 1, 2016
Initial authorization All initial authorization requests are currently submitted by phone. When the member is in the emergency department and not yet admitted to a bed, and you need an immediate response to your request, continue to call in your request to BCN at 1-800-482-5982.

When the member has already been admitted to a bed, you must submit the initial authorization request through the e-referral system.
Concurrent review Currently, concurrent reviews are submitted using the Behavioral Health IP/PHP/IOP Concurrent Review Form. You must submit requests for concurrent reviews through the e-referral system. You'll need to complete a questionnaire within the e-referral system.

BCN will no longer accept concurrent review requests submitted by fax. The Behavioral Health IP/PHP/IOP Concurrent Review Form will no longer be available. The questionnaire in the e-referral system will take the place of the form.
Discharge summary Currently, discharge summaries are submitted via fax, using a Microsoft® Word® version the BCN Behavioral Health Discharge Summary form. You must complete an Adobe® PDF version of the BCN Behavioral Health Discharge Summary form and attach it to the case in the e-referral system.

The PDF form will be available on the BCN Behavioral Health page on this website in late September.

e-referral User Guide will be updated. Prior to October 1, BCN's Behavioral Health e-referral User Guide will be updated to include instructions for the higher levels of care. Watch for the announcement!

You can refer to the updated User Guide for instructions on how to attach the BCN Behavioral Health Discharge Summary form to the case in the e-referral system. The User Guide will also show you how to complete the questionnaire for a concurrent review.

You can access the User Guide on the Training Tools page of this website.

Sign up to use the e-referral system. BCN-contracted facilities that have not already signed up for access to the e-referral system should apply immediately. Each utilization review user at each facility will need his or her own individual access.

To get access to e-referral, you must register to use the Blue Cross/BCN Provider Secured Services portal. To do that, click to open the Sign Up or Change a User page on this website. Follow the instructions under the heading "To sign up as a new e-referral user."

This applies whether your facility is new to Provider Secured Services or you're already signed up for Provider Secured Services and just need access to the e-referral system.

It is critical that you sign up as soon as possible since granting access takes some time and you'll need access prior to October 1.

Posted: August 2016
Line of business: Blue Care Network

e-referral User Guide updated and available

The e-referral User Guide (PDF) has been updated on the Training Tools page. The updated guide now includes:

  • How to check a Blue Cross member's eligibility and benefits in web-DENIS
  • How to submit authorizations and referrals to the University of Michigan Health System and the Henry Ford Health System
  • An example of the Potential Duplicate Referral or Authorization screen
  • Instructions on attaching medical record documentation to a request in the Case Communication field
  • A section outlining how to submit an emergency/urgent inpatient authorization
  • A section discussing how to submit for a sick/ill newborn
  • An expansion of how the outpatient authorization questionnaire works

Posted: July 2016
Line of business: Blue Care Network

eviCore healthcare to review epidural and facet joint procedures for BCN effective September 1

What's changing. Effective with dates of service on or after Sept. 1, 2016, eviCore healthcare will complete clinical reviews for non-emergent pain management services for facet joint and epidural injections. BCN Care Management has reviewed these procedures since April 2011 but with this change, eviCore will manage those services for BCN.

Currently, eviCore reviews certain outpatient radiology, cardiology and radiation therapy services for BCN. Separately, eviCore also reviews physical, occupational, and speech therapy, and physical medicine services provided by chiropractors.

For epidural and facet joint procedures, clinical review will be required for all diagnoses, for both BCN HMOSM (commercial) and BCN AdvantageSM members. This applies to services associated with the following procedure codes: *62281, *62282, *62310, *62311, *62318, *62319, *64479, *64480, *64483, *64484, *64490, *64491, *64492, *64493, *64494, *64495.

How to submit review requests. Starting September 1, providers will be able to submit requests for clinical review for these procedures in one of two ways:

  • Preferred method: online at evicore.com
  • By phone at 1-855-774-1317

Starting August 25, providers can call eviCore at 1-855-774-1317 to review requests for services that will begin on or after September 1.

All 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.

Other information. eviCore's interventional pain guidelines will be made available to providers at evicore.com.

In addition, by the end of August, the document Procedures that require clinical review by eviCore healthcare will be updated to include the pain management procedure codes. This document is available on the eviCore-Managed Procedures page on this website.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2015 American Medical Association. All rights reserved.

Posted: July 2016
Line of business: Blue Care Network

Group practice staff should select correct provider ID in BCN and eviCore electronic systems

Physical therapists, occupational therapists, speech therapists and chiropractors performing physical medicine services for Blue Care Network members should select the correct provider ID in each provider category in BCN's e-referral system and in eviCore healthcare's electronic system. Selecting the correct provider ID helps ensure that authorizations are assigned correctly and that claims pay correctly.

Refer to the article "Therapists and physical medicine providers in a group practice should select correct providers in electronic systems" in the July-August 2016 issue of BCN Provider News, for instructions on how to select the correct provider ID.

Posted: July 2016
Line of business: Blue Care Network

eviCore changes reconsideration process for PTs' utilization categories

Effective immediately, eviCore healthcare has changed the process by which physical therapists request reconsideration of an assigned utilization category. The changes apply to category assignments that are effective Aug. 1, 2016, and affect reconsideration requests that are currently in progress.

If you are a physical therapist who provides services to BCN HMO (commercial) and BCN AdvantageSM members, you'll want to familiarize yourself with the revised process.

For the additional details you'll need to know, read the article "Changes in eviCore's reconsideration process for physical therapists' utilization categories" in the July-August 2016 issue of BCN Provider News.

Posted: July 2016
Line of business: Blue Care Network

UPDATED: BCN will review inpatient readmissions occurring within 30 days of discharge effective October 1

This story is updated to show that the effective date for this change is Oct. 1, 2016, not Sept. 1, 2016, as reported earlier.

BCN reviews inpatient readmissions from facilities reimbursed by diagnosis-related groups when the member is readmitted with the same or a similar diagnosis.

What's changing? Effective Oct. 1, 2016, BCN will review readmissions that occur within 30 days of discharge. Currently, readmissions that occur within 14 days of discharge are reviewed.

A determination is made as to whether the readmission should be billed separately or bundled with the previous admission. In some instances, the two admissions are combined into one for purposes of DRG reimbursement.

Documents will be updated. The documents listed below will be updated to reflect the change to 30 from 14 days. All of the revised documents will be available online by the end of September:

  • Guidelines for bundling admissions
  • The Care Management and Claims chapters of the BCN Provider Manual
  • The readmission checklist, which facilities should use to ensure that all necessary documentation is available for the review of a readmission that has occurred within 30 days

For additional information, you can access all these documents by completing the following steps:

  1. Visit bcbsm.com/providers and click Login.
  2. Log in to Provider Secured Services using your user ID and password.
  3. Click BCN Provider Publications and Resources.
  4. Click either Billing/Claims, Provider Manual or Forms, to open the appropriate Web page.

Posted: August 2016
Line of business: Blue Care Network

Radiology procedure code 75635 requires authorization in the e-referral system

Services associated with radiology procedure code *75635 need to be authorized by BCN through the e-referral system to allow claims to pay.

Claims involving radiology procedure code *75635 will pay if there's an authorization in the e-referral system that matches the claim submitted. If no authorization is in the system, the claims will be denied.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2015 American Medical Association. All rights reserved.

Posted: June 2016
Line of business: Blue Care Network

UPDATED: Changes in BCN's sleep study requirements

The following changes in Blue Care Network's sleep study requirements are occurring:

Home sleep studies. Effective immediately, home sleep studies do not require clinical review, but an authorization is still needed in the e-referral system so that claims can be paid. This means that there is no longer a need to complete a questionnaire in the e-referral system for home sleep studies.

As a reminder, only providers who have signed a specific sleep testing agreement may provide home sleep studies to BCN members. Hospitals billing for services related to home sleep studies must also execute a specific sleep testing agreement and bill in accordance with BCN requirements.

Sleep studies in outpatient and clinic-based settings. Effective Oct. 3, 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 for outpatient facilities or clinic-based settings 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 Case Communication field.

Additional information. Look for more information on this in the July-August 2016 issue of BCN Provider News, which will be available online at the end of June.

Posted: June 2016
Line of business: Blue Care Network

Submit obstetrical admissions one day after discharge – not sooner

The process for submitting information on obstetrical admissions to BCN has not changed.

Please continue to submit obstetrical admissions one day after discharge. Do not submit these admissions sooner than that.

For all deliveries, submit the following information via the e-referral system:

  • Admission date, delivery date and discharge date
  • Type of delivery
  • Whether the baby was born alive
  • Whether both mother and baby were discharged alive

The news item published in April about changes in submitting acute inpatient medical / surgical admissions does not apply to obstetrical admissions.

Posted: June 2016
Line of business: Blue Care Network

Some medical drugs no longer require authorization for BCN AdvantageSM members

Authorization is no longer required for BCN Advantage members for the following drugs covered under the medical benefit:

  • J0881: Aranesp®
  • J0885: Epogen® and Procrit®
  • J0178: Eylea®
  • J2778: Lucentis®
  • J2505: Neulasta®

For a full list of all drugs covered under the medical benefit that require authorization, along with their procedure codes, refer to the BCN Referral and Clinical Review Program, available on this website.

Details on medical necessity criteria are also available on this website. Click Clinical Information for Drugs Covered under the Medical Benefit That Require Medical Necessity Review.

Both of these documents will be updated with the changes outlined in this news item. The revised documents will be available on this website, on the Clinical Review & Criteria Charts page, at the end of June.

Posted: May 2016
Line of business: Blue Care Network

InterQual® criteria used as guidelines in reviewing BCN acute inpatient medical admissions

While Blue Care Network uses McKesson's InterQual criteria as guidelines in reviewing acute inpatient medical admissions, BCN's medical directors will make the final determination about the most appropriate level of care based on their medical judgment. This will be effective starting May 30, 2016.

Additional information about the InterQual criteria and about the process for reviewing these admissions is found in the Care Management chapter of the BCN Provider Manual.

Posted: May 2016
Line of business: Blue Care Network

2016 InterQual® criteria and BCN Local Rules take effect August 1

As announced earlier, 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. This change is effective on Aug. 1, 2016.

On that date, updated versions of BCN's Local Rules will also go into effect.

Additional information about these criteria updates and BCN's Local Rules will be included in the July-August 2016 issue of BCN Provider News, which will be available in late June.

Posted: May 2016
Line of business: Blue Care Network

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.

Posted: April 2016
Line of business: Blue Care Network

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 "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" posted in March.

The new guide includes step-by-step instructions on how to use the e-referral system for submitting and managing authorization requests electronically.

Posted: April 2016
Line of business: Blue Care Network

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 "Changes start May 1 for authorization requests submitted for inpatient acute medical / surgical admissions" posted in March 2016.

Posted: April 2016
Line of business: Blue Care Network

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.

Posted: April 2016
Line of business: Blue Care Network

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.

Posted: March 2016
Line of business: Blue Care Network

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:

  • For all BCN care management requests that eviCore manages: Continue to use the existing eviCore portal. There's no need to register for eviCore 2.0 for the BCN requests.
  • For non-BCN requests: Submit non-BCN requests through eviCore 2.0. Follow the instructions in the email you received from eviCore to register for eviCore 2.0.

If you have questions about eviCore's provider portals, email eviCore at providernewsletter@medsolutions.com.

Posted: March 2016
Line of business: Blue Care Network

CLARIFIED: Effective May 1, BCN behavioral health providers must use e-referral to submit initial outpatient requests for authorization

Starting May 1, 2016, BCN's behavioral health providers will be required to submit initial outpatientrequests for authorization using the e-referral system. This applies only to non-urgent outpatient (clinic or 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.

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!

Posted: March 2016
Line of business: Blue Care Network

Changes start May 1 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:

  • From May 1 through June 30, 2016, providers are strongly encouraged to submit these authorization requests via the e-referral system. Faxes will be accepted during certain times, however. The details about faxing are outlined later in this news item.
  • Beginning July 1, 2016, these authorization requests will be accepted only when they are submitted through the e-referral system. Requests submitted by fax will no longer be accepted.

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:

  • From noon on Friday through midnight on the following Sunday
  • Anytime on the day prior to a holiday on which BCN offices are closed. (The holidays observed at BCN are identified in the BCN Provider News issue published prior to the holiday occurring.)

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:

  • For BCN HMO (commercial) members: 1-866-313-8433
  • For BCN Advantage members: 1-866-526-1326

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.

Posted: March 2016
Line of business: Blue Care Network

Additional BCN Local Rules for acute care and skilled nursing facility services go into effect May 2

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:

  • Infection GI/GU/GYN: Diverticulitis
  • Gastrointestinal or biliary: Dehydration or gastroenteritis
  • Gastrointestinal or biliary: Jaundice or bilirubin
  • Gastrointestinal or biliary: Pancreatitis, chronic
  • Genitourinary: Acute kidney injury
  • Deep vein thrombosis
  • Diabetes
  • Syncope
  • Infection: General
  • Major joint arthroplasty for rehabilitation and skilled nursing facility
  • Pain management for skilled nursing facility

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.

Posted: March 2016
Line of business: Blue Care Network

AMC Health to manage members with CHF and COPD effective April 1

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:

  • These members will receive letters in March 2016 letting them know about the transfer.
  • AMC Health will contact members who require monitoring to introduce themselves and set up monitoring in early April.
  • The primary care physicians for these members will continue to receive reports about these patients.

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.

Posted: March 2016
Line of business: Blue Care Network

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.

Posted: March 2016
Line of business: Blue Care Network

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:

  • Has fields into which you can type the information about your agency and the patient. Open the form and save it to your hard drive. Then type the data into the fields.
  • Includes information for patients getting total parenteral nutrition feedings as well as enteral feedings
  • Shows two different fax numbers – one for BCN HMOSM (commercial) members and one for BCN AdvantageSM members. Faxing the form to BCN using the appropriate fax number will help facilitate your request.

What's important to know. Be aware that:

  • The home infusion agency's name, contact person and contact number must be entered into the form. Without that information, BCN cannot complete the authorization process and get the authorization decision back to you in timely fashion.
  • You must provide the start-of-care date. That date may be different from the assessment date and the date the form is submitted.
  • Enteral and TPN feeding services must be provided by an infusion provider contracted with BCN. You can search for an infusion provider by visiting bcbsm.com/find-a-doctor.
  • It is BCN, not Northwood, Inc., that receives and processes requests to authorize home infusion services. The fax numbers you'll use to return the completed form go to BCN, not to Northwood.

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.

Posted: March 2016
Line of business: Blue Care Network

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.

Posted: February 2016
Line of business: Blue Care Network

Additional Local Rules for acute care and skilled nursing facility requests go into effect May 1

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.

Posted: February 2016
Line of business: Blue Care Network

Care management requirements change for members with low back pain effective March 1

Effective March 1, 2016, the following two changes go into effect for members with low back pain:

  • These members are no longer required to see a physical medicine and rehabilitation provider for evaluation prior to referral to a neurosurgeon or orthopedic surgeon. The requirement for a referral to a physical medicine and rehabilitation provider had been part of BCN's Spine Care Referral Program.

  • Clinical review is no longer required for the initial visit to a neurosurgeon or orthopedic surgeon and for office visits and procedures. These visits may require a referral from the member's primary care physician, depending on the region.

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.

Posted: February 2016
Line of business: Blue Care Network

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:

  • Authorization is required only for BCN commercial (non-Medicare) members with coverage through Fiat Chrysler Automobiles (employer group 100181) and General Motors (employer group 100355) when the drugs listed below are administered at an infusion center with a location code of 19 or 22.

  • No authorization is required for these members when the therapy is administered at other locations (at the physician's office, at the member's home or at an infusion center that's not affiliated with a hospital (that is, an infusion center with a location code other than 19 or 22).

The drugs are:

  • Orencia® (procedure code J0129)
  • Remicade® (procedure code J1745)
  • Tysabri® (procedure code J2323)

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.

Posted: January 2016
Line of business: Blue Care Network

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:

  • Radiology: CPT codes *74712, *78265 and *78266
  • Radiation therapy: CPT codes *0394T, *0395T, *77767, *77768, *77770, *77771 and *77772

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:

  • Radiology: CPT codes *75635 and 77022
  • Radiation therapy: CPT code *77014

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.

Posted: January 2016
Line of business: Blue Care Network

BCN Behavioral Health utilization management criteria is changing on January 1

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:

  • Transcranial magnetic stimulation criteria
  • Neurofeedback training criteria for attention deficit disorder / attention deficit hyperactivity disorder criteria
  • Autism spectrum disorder / applied behavior analysis criteria
  • Residential mental health services / adult, adolescent and child criteria

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:

  • Diagnostic and Statistical Manual of Mental Disorders
  • Peer-reviewed scientific literature
  • Available nationally recognized clinical guidelines

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:

  • "Add-on" codes do not require prior authorization. Prior authorization is required only for the primary code. A separate authorization is not needed to bill BCN for add-on codes if there is a valid authorization on file for the primary code. Claims submitted to BCN for add-on codes without authorization for the associated primary code will not be reimbursed. The affected add-on procedure codes are *0159T, *0190T, *19297, *33225, *49412, *75565, *77293, *78020, *78730, *93320, *93321, *93325, *93352, and *93462.

  • Select radiation therapy codes also do not require prior authorization. Click here to see a list of the affected radiation therapy codes.

  • The unlisted radiation therapy procedure code *77799 is no longer managed by eviCore. Requests to authorize this procedure should be submitted to BCN Care Management.

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:

  • Streamlined registration — Users can now register by email address
  • Pause/Start feature — Users can return to a case in progress
  • Upload PDF/Word files — no more faxing required
  • Duplication — Users can duplicate information into a new case

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):

  • Monday, Nov. 2, 2015 at 1 p.m.
  • Tuesday, Nov. 3, 2015 at 2 p.m.
  • Thursday, Nov. 5, 2015 at 11 a.m.
  • Monday, Nov. 9, 2015 at 2:30 p.m.
  • Tuesday, Nov. 10, 2015 at 1:30 p.m.
  • Wednesday, Nov. 11, 2015 at 11 a.m.
  • Tuesday, Nov. 17, 2015 at 1:30 p.m.
  • Wednesday, Nov. 18, 2015 at 11 a.m.
  • Friday, Nov. 20, 2015 at 1 p.m.
  • Monday, Nov. 23, 2015 at 2:30 p.m.
  • Tuesday, Nov. 24, 2015 at 1:30 p.m.
  • Wednesday, Nov. 25, 2015 at 11 a.m.

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 diag