Archives 2016




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


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
  • Cellular immunotherapy (CAR-T)
  • Fertility care
  • Gene therapy – ocular disorders
  • Knee and hip replacements
  • Maternity care
  • Spine surgery
  • Substance use treatment and recovery
  • Transplants

For more information, refer to:

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

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

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

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

The Blue Cross® Personal Choice PPO page on this website now has expanded information including upcoming webinars, an FAQ document, an e-referral user guide and more.

You can navigate to the Blue Cross Personal Choice PPO page on this site by clicking Blue Cross and then Blue Cross Personal Choice PPO in the Blue Cross Authorizations / Referrals section of the left navigation.

Posted: August 2016
Line of business: Blue Care Network