Archives 2017




December 2017

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

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

eviCore accepting Blue Cross PPO authorization requests starting Dec. 22

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

November 2017

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

October 2017

New BCN authorization requirements are effective Jan. 1, 2018

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

e-referral site wins communications awards

Do not refer new patients to MedEQUIP in Ann Arbor

Clarification on Blue Cross inpatient authorization requirements for newborns

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

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

September 2017

2017 InterQual criteria to be implemented starting October 2

New name for Blue Cross® Physician Choice PPO

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

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

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

Blue Cross inpatient authorization requirements clarified

August 2017

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

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

Reminder: 2017 InterQual criteria delayed until October 2017

July 2017

Clarifying authorization requirements for Blue Cross members

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

June 2017

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

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

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

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

May 2017

2017 InterQual criteria delayed until October 2017

Blue Care Network changes authorization requirements for sleep management studies

Blue Care Network updates authorization guideline for external ECG monitoring

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

April 2017

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

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

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

March 2017

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

RC Claim Assist tool is now available

January 2017

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

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

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


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.

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

Behavioral health medical record documentation requirements are now available online. These requirements apply across all lines of business (Blue Cross PPO, Blue Cross Medicare Plus BlueSM PPO, BCN HMOSM and BCN AdvantageSM).

The requirements are available on this website, on both the Blue Cross Behavioral Health page and the BCN Behavioral Health page.

Professional, hospital and facility behavioral health providers contracted with Blue Cross or BCN must follow these requirements when documenting behavioral health services provided to our members.

One set of guidelines is for applied behavior analysis services. The other set applies to non-ABA services.

For additional information on these requirements, including why they were put in place, please review the following news articles:

Posted: November 2017
Line of business: Blue Cross and Blue Care Network

e-referral site wins communications awards

The e-referral site was honored recently with two awards from the International Association of Business Communicators.

Locally, the site received a Detroit Renaissance Award of Merit in Digital Communications. The Detroit chapter includes professional communicators from southeast Michigan.

At a regional level, the site received a Silver Quill Award of Merit from the IABC Heritage Region, which includes 17 states and the District of Columbia. The e-referral redesign was the only project from Michigan to receive this prestigious award.

Congratulations to the team behind the award-winning e-referral site.

Posted: October 2017
Line of business: Blue Cross and Blue Care Network

Do not refer new patients to MedEQUIP in Ann Arbor

Michigan Medicine's MedEQUIP provider of durable medical equipment is not accepting new patients as of Oct. 20, 2017. This is a temporary situation. Please see the MedEQUIP website for any exceptions and the latest information.

Posted: October 2017
Line of business: Blue Cross and Blue Care Network

2017 InterQual criteria to be implemented starting October 2

Blue Cross Blue Shield of Michigan and Blue Care Network will implement the 2017 InterQual® criteria starting Oct. 2, 2017, for all levels of care. These criteria are used to make utilization management and care management determinations for the services subject to review.

Until that date, the 2016 InterQual criteria will be used.

In addition, starting October 2, Blue Cross and BCN will implement their local rules. Until that date, the 2016 local rules will be used.

To access the 2017 Blue Cross Local Rules, do the following:

  1. Log in to Provider Secured Services.
  2. Click BCBSM Provider Publications and Resources.
  3. Click Newsletters & Resources.
  4. Click Clinical Criteria & Resources.
  5. Scroll down to the heading "BCBSM modifications to InterQual criteria."
  6. Click 2017 BCBSM modifications to InterQual criteria.

To access the 2017 BCN Local Rules, visit BCN's Clinical Review & Criteria Charts page on this website and click BCN's current Local Rules.

As a reminder, implementation of the 2017 criteria and local rules was delayed due to upgrades being made to the e-referral system.

Posted: September 2017
Line of business: Blue Cross and Blue Care Network

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

While the eviCore call centers, located in Florida and South Carolina, may be affected by Hurricane Irma, the online portal will remain fully operational.

You are encouraged to use the online portal at evicore.com to initiate authorization requests and check case status until the area has recovered. Calls will continue to be answered, but you may experience longer phone hold times or other issues.

Thank you for your patience.

Posted: September 2017
Line of business: Blue Cross and Blue Care Network

Reminder: 2017 InterQual criteria delayed until October 2017

As a reminder, Blue Cross Blue Shield of Michigan and Blue Care Network will delay implementing the 2017 InterQual® criteria until October 2017. This delay is due to upgrades being made to the e-referral system.

Until these upgrades are complete, we will continue to follow the 2016 InterQual criteria for all levels of care.

When we have a new date for implementing the 2017 criteria, we'll let you know through our standard channels of communication.

Posted: August 2017
Line of business: Blue Cross and Blue Care Network

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

Providers who need to contact the Pharmacy Clinical Help Desk about drugs covered under the medical benefit should call 1-800-437-3803, effective July 5, 2017. This applies to members covered through BCN HMOSM (commercial), BCN AdvantageSM and Blue Cross Medicare Plus BlueSM PPO products.

Providers who have been using other numbers to contact the Pharmacy Clinical Help Desk for drugs covered under the medical benefit should begin using the 1-800-437-3803 number effective July 5, 2017. All other numbers to the Pharmacy Clinical Help Desk will be discontinued as of July 5, 2017.

Posted: June 2017
Line of business: Blue Cross and Blue Care Network

2017 InterQual criteria delayed until October 2017

Blue Cross Blue Shield of Michigan and Blue Care Network will delay implementing the 2017 InterQual® criteria until October 2017. This delay is due to upgrades being made to the e-referral system.

Until these upgrades are complete, we will continue to follow the 2016 InterQual criteria for all levels of care.

When we have a new date for implementing the 2017 criteria, we'll let you know through our standard channels of communication.

Posted: May 2017
Line of business: Blue Cross and Blue Care Network

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

Providers who bill for drugs covered under the medical benefit for their Blue Cross and Blue Care Network commercial members are encouraged to review the additional information now available on the RC Claim Assist tool.

On this website, select BCN or Blue Cross and click to open:

The resources available include:

About RC Claim Assist

RC Claim Assist, created by RJ Health Systems, is a free resource now available to Blue Cross Blue Shield of Michigan and Blue Care Network contracted providers who bill for drugs covered under the medical benefit. The tool can help ensure that you are billing:

  • The correct National Drug Code with the billable HCPCS/CPT code
  • The correct NDC quantity
  • The correct unit of measure

Additional webinars to be scheduled later in the year

Additional provider webinars on the RC Claim Assist tool will be scheduled later in 2017. In the meantime, you should review the information currently available, register for the tool and begin using it. Click here to register for RC Claim Assist or to log in, if you are already registered.

Posted: April 2017
Line of business: Blue Cross and Blue Care Network

RC Claim Assist tool is now available

RC Claim Assist, created by RJ Health Systems, is a free resource now available to Blue Cross Blue Shield and Blue Care Network contracted providers who bill for drugs covered under the medical benefit. The tool can help ensure that you are billing:

  • The correct National Drug Code with the billable HCPCS/CPT®* code
  • The correct NDC quantity
  • The correct unit of measure

Training webinar

Click to open our webinar invitation and sign up to attend one of the RC Claim Assist training webinars we're hosting on March 14, 2017.

How do I access RC Claim Assist?

Visit the RC Claim Assist log-in page. Register to use RC Claim Assist by completing the following steps:

  1. Enter your NPI. (Very important!)
  2. Enter your first name and last name.
  3. Create your unique password when you are prompted to do so.

RC Claim Assist should be used only for claims submitted for Blue Cross Blue Shield of Michigan and Blue Care Network commercial members.

Questions?

Here's how to get your questions answered:

  • For questions concerning the data you see on RC Claim Assist, please email info@rjhealthsystems.com
  • For questions about billing or claims, contact Provider Inquiry.
  • For questions about a claim that are contractual or complex in nature, contact your provider consultant.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2016 American Medical Association. All rights reserved.

Posted: March 2017
Line of business: Blue Cross and Blue Care Network

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

As a reminder, on Jan. 1, 2018, new authorization requirements take effect for services for BCN HMOSM (commercial) and BCN AdvantageSM members. These changes apply to various types of procedures.

For the details, please review the news article Changes in authorization requirements are effective Jan. 1, 2018, in the November-December 2017 issue of BCN Provider News, on page 45.

In addition, the following documents have been updated and are now available on BCN's Authorization Requirements & Criteria page on this website:

Posted: December 2017
Line of business: Blue Care Network

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

Services represented by procedure codes *0482T, *0501T, *0502T, *0503T and *0504T require authorization by eviCore healthcare for dates of service on or after Jan. 1, 2018. This is in addition to the cardiology services that already require authorization by eviCore.

This applies only to services for Blue Care Network HMOSM (commercial) and BCN AdvantageSM members age 18 and older.

The document Procedures that require authorization by eviCore healthcare will be updated to reflect this change.

You can find additional information about procedures managed by eviCore healthcare on this website. Click BCN. Then click eviCore-Managed Procedures.

As a reminder, eviCore healthcare manages select procedures for BCN HMO (commercial), BCN Advantage, Blue Cross PPO and Blue Cross Medicare Plus BlueSM PPO.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2016 American Medical Association. All rights reserved.

Posted: December 2017
Line of business: Blue Care Network

New BCN authorization requirements are effective Jan. 1, 2018!

On Jan. 1, 2018, new authorization requirements take effect for services for BCN HMOSM (commercial) and BCN AdvantageSM members. These changes apply to various types of procedures.

For the details, please review the news article Changes in authorization requirements are effective Jan. 1, 2018, in the November-December 2017 issue of BCN Provider News, on page 45.

Posted: October 2017
Line of business: Blue Care Network

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

Your feedback is important to us. Please complete the 2017 BCN Care Management Survey and encourage your office colleagues to do so as well, including physicians, nurses and referral coordinators. Your input will help us evaluate our efforts and determine other improvements we can make to enhance our Care Management processes.

The survey will be available online through Dec. 31, 2017.

Information about a drawing for two $250 gift certificates is available in the Nov.-Dec. 2017 issue of BCN Provider News, page 44.

Posted: October 2017
Line of business: Blue Care Network

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

Providers must fax the following acute inpatient admission requests to Blue Care Network:

  • Concurrent review requests and discharge dates, but only for facilities reimbursed on the basis of DRGs
  • Authorization requests for sick or ill newborns
  • Requests for enteral and total parenteral nutrition

Faxes are not accepted on holidays when BCN is closed. The upcoming holidays during which BCN is closed are:

  • Thursday and Friday, Nov. 23 and 24, 2017 (Thanksgiving holidays)
  • Friday, Monday and Tuesday, Dec. 22, 25 and 26, 2017 (Christmas holidays)
  • Monday, Jan. 1, 2018 (New Year's Day)

Otherwise, faxes are accepted from midnight on Sunday through 4 p.m. on Friday. Faxes are not accepted on weekends.

The fax numbers to use are:

  • BCN HMOSM (commercial) members: 1-866-313-8433
  • BCN AdvantageSM members: 1-866-526-1326

Except for the admission types outlined above, all other authorization requests for acute inpatient admissions must be submitted to BCN through the e-referral system.

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

Posted: September 2017
Line of business: Blue Care Network

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

Note: The news item originally posted on Sept. 1, 2017, is revised to show that providers may use either the updated forms that CMS provides on its website or the forms that BCN Advantage offers on its website.

Effective Aug. 28, 2017, providers must use the updated Important Message from Medicare form and Detailed Notice of Discharge form for BCN AdvantageSM members being discharged from an inpatient hospital stay.

The forms were recently revised by the Centers for Medicare & Medicaid Services and are available at these locations:

  • On the CMS website. Click here to access them.
  • On this website. Click BCN and then click Forms. Look in the BCN Advantage section of the page under the subheading "Hospitals, for inpatients." These forms have the BCN Advantage logo and contact information for KEPRO, the Quality Improvement Organization for Michigan.

You can use either the CMS forms or the forms specific to BCN Advantage.

The purpose of the forms is to inform BCN Advantage members hospitalized at an inpatient facility that they have special appeal rights if they are dissatisfied with their discharge plan or believe that coverage of their hospital stay is ending too soon.

Additional information about each form is found in the BCN Advantage chapter of the BCN Provider Manual. Look in the section titled "QIO immediate review of hospital discharges."

Posted: September 2017
Line of business: Blue Care Network

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

Effective Aug. 21, 2017, the phone number for the Blue Care Network Behavioral Health Physician Review Line is changing to 1-877-293-2788. This is the number for physician-to-physician reviews of determinations related to medical necessity.

The previous Physician Review Line number, 734-332-2567, will not be working as of that date.

Here's a summary of how to reach a BCN medical director to discuss a behavioral health determination for a BCN member as of August 21:

  • During business hours (8 a.m. to 5 p.m., Monday through Friday), call 1-877-293-2788 (the new Physician Review Line number).
  • After business hours (for emergent cases only), call 1-800-482-5982. (This is the current number and it is not changing.)

The numbers for calling BCN Behavioral Health during business hours for other purposes are not changing, either. Those are:

  • 1-800-482-5982 for BCN HMOSM (commercial) members
  • 1-800-431-1059 for BCN AdvantageSM members

Also effective August 21, the mailing address for BCN Behavioral Health is changing to:

  • Blue Care Network
  • Behavioral Health
  • Mail Code H100
  • 26899 Northwestern Highway
  • Southfield, MI 48034

Posted: August 2017
Line of business: Blue Care Network

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

This is a reminder that Blue Care Network uses McKesson's InterQual® criteria as guidelines in reviewing acute inpatient medical admissions and that BCN's medical directors make the final determination about the most appropriate level of care based on their medical judgment.

Additional information about the InterQual criteria and about the process for reviewing these admissions is found in the Care Management chapter of the BCN Provider Manual.

Posted: July 2017
Line of business: Blue Care Network

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

To reduce the time it takes us to respond to authorization requests for initial inpatient admissions, Blue Care Network is asking that hospitals limit the clinical information they send.

Please send only the pertinent parts of the medical record. This applies to both Blue Care Network HMOSM (commercial) and BCN AdvantageSM members.

Some hospitals send the member's entire clinical record when the request is submitted. This increases the time we spend responding to the request.

The form is optional now

The parts of the record you should send are outlined on the Request for Review of Initial Inpatient Admission form. We recommend that you use the form as a guide.

Submitting the form itself is optional now. (It was required just recently, but we're changing that.)

Hospitals that continue to submit the entire clinical record will ultimately be required to submit the form.

Accessing the form

The form is located in the BCN section of this website, on the Clinical Review & Criteria Charts page. Look under the heading "Referral/clinical review information."

Posted: June 2017
Line of business: Blue Care Network

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

Reminder: Effective July 1, 2017, BCN will add the injectable or infusible drugs listed below to its site-of-care optimization program. This program redirects members receiving these drugs in an outpatient hospital setting to a lower-cost, alternate site of care, such as the physician's office or member's home. This includes members who are currently receiving these drugs and members who are receiving them for the first time.

This requirement applies to Blue Care Network HMOSM (commercial) members. It does not apply to BCN AdvantageSM members.

The drugs are:

  • Benlysta® (J0490)
  • Cimzia® (J0717)
  • Cinqair® (J2786)
  • Entyvio® (J3380)
  • Ilaris® (J0638)
  • Nucala® (J2182)
  • Xolair® (J2357)

As with other drugs in the site-of-care program, if a provider feels a member is not a candidate to receive a drug on this list at a site other than the outpatient hospital, documentation supporting medical necessity must be provided to the plan for review and will be evaluated on a case-by-case basis.

All drugs listed here must meet applicable authorization criteria in addition to the site-of-care requirement.

For additional details, please review the article titled BCN expanding site of care optimization program on July 1, 2017, on page 37 of the May-June 2017 issue of BCN Provider News.

Additional information, including a complete list of drugs in the site-of-care program, is also available on the Medical Benefit Drugs - Pharmacy page in the BCN section of this website. Click Requirements for drugs covered under the medical benefit - BCN HMO under the heading "For BCN HMO (commercial) members." Look for the new July 1 site-of-care requirements in the July 2017 version of the list, which will be available at the end of June.

Posted: June 2017
Line of business: Blue Care Network

Blue Care Network changes authorization requirements for sleep management studies

Effective July 17, 2017, all requests to authorize outpatient facility and clinic-based sleep management studies for adult members 18 years of age and older will require the submission of evidence from the member's medical record. This evidence must confirm signs and symptoms of obstructive sleep apnea. This applies to both BCN HMOSM (commercial) and BCN AdvantageSM members.

This is in addition to the requirement to submit evidence of the specific condition the member has that would exclude or contraindicate a home sleep study – a requirement that has been in place since Oct. 3, 2016.

Any documentation from the patient's medical record that is required can be attached to the request within the e-referral system, through the Case Communication field. For instructions on how to attach documentation, refer to the article "How to attach clinical information to your authorization request in the e-referral system," in the November-December 2016 BCN Provider News. These instructions are also in the e-referral User Guide, in the subsection titled "Create New (communication)."

As a reminder, home sleep studies do not require clinical review. For home sleep study requests, you must submit an authorization request to facilitate claims payment, but you are not required to complete a questionnaire for these services in the e-referral system.

Posted: May 2017
Line of business: Blue Care Network

Blue Care Network updates authorization guideline for external ECG monitoring

Blue Care Network has updated its authorization guideline for external electrocardiographic monitoring devices that are used for continuous recording and storage of data on a long-term basis (greater than 48 hours), such as Zio Patch® and LifeStar ACT.

Effective immediately, the following procedure codes no longer require clinical review for either BCN HMOSM or BCN AdvantageSM members when the services are ordered and provided by a cardiologist:

  • *0295T
  • *0296T
  • *0297T
  • *0298T

In addition, plan notification for this service is not required. However, cardiologists in the East and Southeast regions must have an active global referral on file for BCN HMO (commercial) members.

Patients are still expected to meet the criteria for coverage, which specify that external ECG monitoring is an alternative to Holter monitoring in patients.

Read more about these criteria and get additional information in the article Blue Care Network updates authorization guideline for external ECG monitoring, on page 44 in the May-June 2017 issue of BCN Provider News.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2016 American Medical Association. All rights reserved.

Posted: May 2017
Line of business: Blue Care Network

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

Effective July 1, 2017, BCN will add the injectable or infusible drugs listed below to its site-of-care optimization program. This program redirects members receiving these drugs in an outpatient hospital setting to a lower-cost, alternate site of care, such as the physician's office or member's home. This includes members who are currently receiving these drugs and members who are receiving them for the first time.

This requirement applies to Blue Care Network HMOSM (commercial) members. It does not apply to BCN AdvantageSM members.

The drugs are:

  • Benlysta® (J0490)
  • Cimzia® (J0717)
  • Cinqair® (J2786)
  • Entyvio® (J3380)
  • Ilaris® (J0638)
  • Nucala® (J2182)
  • Xolair® (J2357)

As with other drugs in the site-of-care program, if a provider feels a member is not a candidate to receive a drug on this list at a site other than the outpatient hospital, documentation supporting medical necessity must be provided to the plan for review and will be evaluated on a case-by-case basis.

All drugs listed here must meet applicable authorization criteria in addition to the site-of-care requirement.

For additional details, please review the article titled BCN expanding site of care optimization program on July 1, 2017, on page 37 of the May-June 2017 issue of BCN Provider News.

Additional information, including a complete list of drugs in the site-of-care program, is also available on the Medical Benefit Drugs - Pharmacy page in the BCN section of this website. Click Requirements for drugs covered under the medical benefit - BCN HMO under the heading "For BCN HMO (commercial) members." Look for the new July 1 site-of-care requirements in the July 2017 version of the list, which will be available at the end of June.

Posted: May 2017
Line of business: Blue Care Network

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

Providers who want to consult with an eviCore healthcare clinical representative on Blue Care Network radiology authorization requests can now schedule phone appointments online without having to wait on hold. This applies only to radiology services reviewed by eviCore healthcare for BCN HMOSM commercial and BCN AdvantageSM members.

Here's how to schedule an appointment for a phone consultation:

  1. Visit evicore.com.
  2. Click Providers.
  3. In the line "Request Clinical Consultation Online Here," click Here.
  4. In the "Select Health Plan" field, select Blue Care Network.
  5. In the "Select Solution" field, select Radiology.
  6. In the "First name," "Last name," "Email" and "Phone" fields, enter the contact information for the office representative who will set up the appointment.
  7. In the "Select Duration Hours" field, enter the two-hour window of time during which a phone appointment can be scheduled with the eviCore physician.
  8. In the "Message" field, indicate the name of the clinician in the office who wants to talk to the eviCore physician.
  9. Click Submit.

You'll receive a phone call or an email (or both, if you requested both in the "Message" field) that indicates the 15-minute window of time within which the phone appointment is scheduled.

Sometime during that 15 minutes, the eviCore physician will call the clinician whose name you entered in the "Message" field.

Examples of clinical consultations include:

  • Questions that arise while you're submitting an authorization request, such as what clinical information must be submitted
  • Questions that arise when a request you've submitted is pended or denied

Before this scheduling option was made available, providers had to call eviCore and wait on hold until an eviCore physician was available.

For additional information about reviews performed by eviCore health for BCN commercial and BCN Advantage members, refer to the eviCore-Managed Procedures page in the BCN section at ereferrals.bcbsm.com.

Posted: April 2017
Line of business: Blue Care Network

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

Providers must fax the following acute inpatient admission requests to Blue Care Network:

  • Concurrent review requests and discharge dates, but only for facilities reimbursed on the basis of DRGs
  • Authorization requests for sick or ill newborns
  • Requests for enteral and total parenteral nutrition

Faxes are not accepted on holidays when BCN is closed. The upcoming holidays in 2017 during which BCN is closed are:

  • Friday, April 14 (Good Friday)
  • Monday, May 29 (Memorial Day)
  • Monday and Tuesday, July 3 and 4 (Fourth of July)
  • Monday, September 4 (Labor Day)

Faxes are accepted from midnight on Sunday through 4 p.m. on Friday. Faxes are not accepted on weekends.

The fax numbers to use are:

  • BCN HMOSM (commercial) members: 1-866-313-8433
  • BCN AdvantageSM members: 1-866-526-1326

Except for the admission types outlined above, all other authorization requests for acute inpatient admissions must be submitted to BCN through the e-referral system.

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

Posted: April 2017
Line of business: Blue Care Network

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

BCN's partnership with providers is important to us. We listened to your concerns and have decided to reinstate BCN's previous inpatient readmission review guidelines.

Effective Jan. 19, 2017, BCN is reviewing inpatient readmissions as follows:

  • BCN reviews readmissions that occur within 14 days of discharge for the same or a related condition.
  • Readmission reviews are conducted according to the Guidelines for Bundling Admissions document dated November 2013. That document is now available on BCN's web-DENIS Provider Publications and Resources website.

Readmissions within 30 days of discharge that were reviewed from Oct. 1, 2016, through Jan. 18, 2017, will not be revisited, but we will conduct additional research before implementing any further changes.

We apologize for any confusion that may result from these changes.

You can access the Guidelines for Bundling Admissions document by completing the following steps:

  1. Visit bcbsm.com/providers and click Login.
  2. Log in as a provider, using your user name and password.
  3. Click BCN Provider Publications and Resources.
  4. Click Billing / Claims.
  5. Click Guidelines for Bundling Admissions.

Posted: March 2017
Line of business: Blue Care Network

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

On Jan. 1, 2017, new procedure codes went into effect for physical and occupational therapy evaluations for BCN HMOSM (commercial) and BCN AdvantageSM members. The new codes are indicated in bold below.

  • Physical therapy (physical therapists):
    • Service 1: *97110 for treatment
    • Service 2: *97161, *97162 or *97163 for evaluation (These codes cannot be used by chiropractors.)

  • Occupational therapy:
    • Service 1: *97535 for treatment
    • Service 2: *97165, *97166 or *97167 for evaluation

The document Procedures that require clinical review by eviCore healthcare has been updated with these codes.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2016 American Medical Association. All rights reserved.

Posted: January 2017
Line of business: Blue Care Network

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

The Centers for Medicare & Medicaid Services requires hospitals to give a Medicare Outpatient Observation Notice to Medicare beneficiaries receiving outpatient observation services for more than 24 hours.

BCN AdvantageSM encourages providers to start giving these notices immediately. A copy of the Medicare Outpatient Observation Notice customized for BCN Advantage members and the instructions for using it are available on the web. These documents are available on the Care Management Forms page in the BCN section of this website, under the BCN Advantage heading.

The Medicare Outpatient Observation Notice is a standard notice that lets the member know that:

  • He or she is an outpatient receiving observation services, not an inpatient of the hospital
  • The reasons he or she is receiving observation services
  • How the observation services affect his or her cost-sharing obligations and post-hospitalization eligibility for coverage of skilled nursing facility services

The notice must be delivered no later than 36 hours after observation services begin, or sooner if the member is transferred, discharged or admitted.

The BCN Advantage chapter of the BCN Provider Manual will be updated with this information. The revised chapter will be available at the end of January on the Provider Manual Chapters page in the BCN section of this website.

Additional information about this requirement is available on the Beneficiary Notices Initiative page of the CMS website.

Posted: January 2017
Line of business: Blue Care Network

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

Obstetrician-gynecologists and gynecologists can refer the Blue Care Network HMOSM (commercial) and BCN AdvantageSM members in their care for OB-GYN-related specialty services without the members needing to obtain a referral from their primary care physician. OB-GYN providers in the East and Southeast regions should use the e-referral system to refer their patients.

For additional information about this, refer to the article "Obstetrician-gynecologists can refer patients to specialists" in the January-February 2017 issue of BCN Provider News.

Posted: January 2017
Line of business: Blue Care Network

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

Blue Care Network recently announced that authorization would be required for monitored anesthesia care during certain gastrointestinal endoscopies on or after Jan. 8, 2017. This requirement will not go into effect on that date. The need for authorization will be reassessed later in 2017.

For additional information, please refer to the document Anesthesia care for gastrointestinal endoscopy procedures.

Posted: December 2016
Line of business: Blue Care Network

BCN revises codes managed by eviCore healthcare

Blue Care Network has revised its Procedures that require clinical review by eviCore healthcare document.

What's changing?

Interventional pain management services

  • Procedure codes *62263, *62264, *64620, *64626 and *64627 were removed from the list because services associated with these codes are managed by BCN and not by eviCore. However, if you enter these procedure codes into the e-referral system, you will get a message — incorrectly — indicating that the request should be submitted to eviCore.

    IMPORTANT! Until the e-referral system is updated to accept requests involving these codes, you should call BCN Care Management 1-800-392-2512 to request review of these services.

  • The following new codes were added to the list of epidural and facet joint injections managed by eviCore as of Jan. 1, 2017: *62320, *62321, *62322, *62323, *62324, *62325, *62326 and *62327.

  • The following codes are marked as requiring review by eviCore only from Sept. 1 through Dec. 31, 2016: *62310, *62311, *62318 and *62319. These codes are being retired and will eventually be removed from the list.

Physical, occupational and speech therapy services and physical medicine service provided by chiropractors

Some codes for these services are added to the list — specifically, the codes you enter into the e-referral system.

Additional information

For more information, refer to Procedures that require clinical review by eviCore healthcare.

Posted: December 2016
Line of business: Blue Care Network

Guidelines for submitting acute inpatient admission requests to BCN

Authorization requests submitted to Blue Care Network for acute inpatient admissions are accepted only when they are submitted through the e-referral system.

Requests submitted by fax are not accepted, except for the following types of requests, which must be faxed to BCN:

  • For facilities reimbursed on the basis of DRGs, concurrent review requests and discharge dates will be accepted via fax. Facilities reimbursed on a per-diem basis must submit concurrent reviews via e-referral.
  • Authorization requests for sick or ill newborns must be faxed to BCN. They cannot be submitted through the e-referral system because the newborn is not a member covered by BCN. The BCN nurse reviewer will create a case for the newborn in the e-referral system and you will be able to see it there.
  • Requests for enteral and total parenteral nutrition requests must be faxed to BCN.

Faxes are accepted from midnight on Sunday through 4 p.m. on Friday. Faxes are not accepted on weekends. They are also not accepted on holidays when BCN is closed. The holidays observed at BCN are identified in the BCN Provider News issue published prior to the holiday occurring.

The upcoming holidays during which faxes are not accepted are:

  • Friday, Dec. 23 through Monday, Dec. 26
  • Friday, Dec. 30 through Monday, Jan. 2
  • Monday, Jan. 16

The fax numbers to use are:

  • For BCN HMOSM (commercial) members: 1-866-313-8433
  • For BCN AdvantageSM (commercial) members: 1-866-526-1326

Refer to the document Submitting acute inpatient admission requests to BCN for additional information.

Posted: December 2016
Line of business: Blue Care Network

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

Effective Dec. 18, 2017, inpatient authorization requests submitted through the e-referral system for Blue Cross PPO members from group 71575 are resulting in an inaccurate response. The response says, "You are not able to submit this request. Requests for Ascension members are managed by ABS. Submit authorization request to ABS PreCert...".

If you see this message, please check the member's group number on the ID card. If the group number is 71575, then that member is not an Ascension member and the request should not be submitted to ABS PreCert.

We are working to fix this systems error and estimate it will be corrected by Jan. 15, 2018. Until then, we ask that you fax inpatient authorization requests for members from group 71575 to 1-866-411-2585. Remember to include member demographic and clinical information and a contact number in case we have questions.

We apologize for the inconvenience caused by this systems error.

Posted: December 2017
Line of business: Blue Cross

eviCore accepting Blue Cross PPO authorization requests starting Dec. 22

For services that require authorization by eviCore healthcare for Blue Cross PPO members for dates of service on or after Jan. 1, 2018, don't submit authorization requests until Friday, Dec. 22, 2017.

An article in the November 2017 issue of The Record had indicated that requests could be submitted as early as Dec. 18, but eviCore's system won't be ready to accept those requests until Dec. 22.

For more information on these authorization requirements, refer to:

Posted: December 2017
Line of business: Blue Cross

Clarification on Blue Cross inpatient authorization requirements for newborns

Only sick newborns—not well babies—require inpatient admission authorization from Blue Cross Blue Shield of Michigan. Since newborns take a few days to get added to their parent's health care coverage, and since the e-referral application doesn't allow for temporary requests until the sick baby has coverage, sick newborn inpatient admission authorization requests should be submitted by fax. Use the Acute Inpatient Fax Assessment Form to submit the request for patients with Blue Cross commercial PPO coverage. If the baby is not yet named, you can use "Baby Boy" or "Baby Girl" or, in the case of multiple births, "Baby Boy 1", "Baby Boy 2" as the baby's first name.

Our October Record article, Here's what you need to know about Blue Cross inpatient authorization requirements, initially caused some confusion. It listed newborn and gender assignment authorization requests as the only exceptions to using e-referral for submitting Blue Cross inpatient admission authorization requests. We should have said that only sick newborns and gender assignment require inpatient authorization via fax. We updated our October article to clarify this. We apologize for the confusion.

Posted: October 2017
Line of business: Blue Cross

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

On Jan. 1, 2017, we launched our eviCore physical therapy program with the intent of partnering with our provider community to foster better health outcomes for our members. We introduced this initiative by implementing an evidence-based tool delivered by eviCore that we felt would allow providers to offer their patients appropriate care at the right time.

We expected the program transition to be a seamless and positive experience for our providers. Unfortunately, the affects of this implementation didn't align with our intent. We apologize for any unnecessary confusion, frustration or inconvenience that you may have experienced during this transition. We truly value your partnership and want to assure you that we've heard your concerns and taken them seriously. As such, we've been working with eviCore to identify solutions to address these concerns.

Effective Oct. 1, 2017, we're implementing an interim solution that we hope you'll find satisfactory. When a member has had recent surgery and requires physical therapy as a part of their treatment plan, he or she will be entitled to receive a minimum of 12 visits within 45 days. This approach will allow these members to have two visits per week over the course of six weeks, and gives our providers more time to request approvals for any additional visits they want to have added to a member's treatment plan without creating a lapse in care.

While our interim solution is just a start, we want you to know there are long-term changes on the horizon. We've posted two documents on the e-referral site that detail the changes eviCore is making through the implementation of its new authorization model called corePathSM, effective Jan. 1, 2018:

If you have any questions regarding the information in this message, please reach out to your provider consultant. Thank you for your continued partnership.

Posted: October 2017
Line of business: Blue Cross

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

Starting Oct. 16, 2017, the way behavioral health facilities submit initial authorization requests, concurrent reviews and discharge summaries for Blue Cross Blue Shield of Michigan Medicare Plus BlueSM PPO members will change.

This applies to inpatient, partial hospital and intensive outpatient services. It applies to both substance use and mental health disorders.

The changes are summarized in an article in the October 2017 issue of The Record. Addition information is available on the Behavioral Health page in the Blue Cross section of this website.

Posted: October 2017
Line of business: Blue Cross

New name for Blue Cross® Physician Choice PPO

Blue Cross® Personal Choice PPO is now called Blue Cross Physician Choice PPO. See the Blue Cross Physician Choice PPO page for more information, including:

  • Online learning
  • Provider flyer
  • Frequently asked questions
  • User Guide

Posted: September 2017
Line of business: Blue Cross

Blue Cross inpatient authorization requirements clarified

As of July 31, 2017, inpatient admission authorization requests for Blue Cross Blue Shield of Michigan commercial PPO and Blue Cross Medicare Plus Blue® PPO must be submitted through e-referral except for newborn and gender reassignment which must be faxed. See the Blue Cross commercial and Medicare Advantage inpatient authorization requirements table on the Blue Cross Authorization Requirements & Criteria webpage for more information.

The application of clinical criteria is required in some cases to receive authorization. Concurrent review will occur for all inpatient admissions for members with Blue Cross Medicare Plus Blue PPO coverage and members with Blue Cross commercial PPO coverage through the UAW Retiree Medical Benefits Trust.

Facilities and providers should request an appropriate number of days when submitting their authorization request based on the member's diagnosis and clinical presentation. Requests for additional days must be submitted through e-referral and must include clinical updates.

If the member is discharged prior to the last covered day, a discharge date should be entered in e-referral. The discharge date and the total number of days the member was inpatient can be added to e-referral as a note. For instructions on how to do this, see the e-referral User Guide (PDF). Go to the Submitting an Inpatient Authorization section, and review the Create New (communication) instructions.

Posted: September 2017
Line of business: Blue Cross

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

A document titled Frequently asked questions about using the e-referral system has been posted to this website that gives providers important details about submitting authorization requests for services for Blue Cross PPO (commercial) and Blue Cross Medicare Plus BlueSM PPO members. It includes questions and answers emanating from an August 2017 webinar that showed providers how to use the system.

We hope this document will prove especially helpful to providers who started making the transition to the e-referral system on July 31, 2017. This was the effective date for submitting Blue Cross authorization requests through the e-referral system instead of through the prenotification system.

Additional information on using the e-referral system, including the e-referral User Guide, is available on the Blue Cross Training Tools page on this website.

Posted: August 2017
Line of business: Blue Cross

Clarifying authorization requirements for Blue Cross members

We are receiving authorization requests through the e-referral system for Blue Cross PPO (commercial) members that do not need to be submitted.

If you are submitting requests for Blue Cross PPO (commercial) members for procedures identified in the list of Services That Require Authorization as requiring authorization as of July 31, 2017, here's what you need to know: This document applies only to Blue Cross Medicare Plus BlueSM members.

Here's a summary of what's required for both sets of members.

For procedures

  • For Blue Cross Medicare Plus Blue members, professional providers must submit authorization requests through the e-referral system for the procedures listed on the Services That Require Authorization document. Authorization criteria related to these procedures are now available on the Blue Cross Authorization Requirements & Criteria page on this website.

  • For Blue Cross PPO (commercial) members, professional providers should continue to request authorization only for procedures that currently require it, such as the radiology procedures submitted through AIM and a few others. Joint replacements and similar procedures, which require authorization for Blue Cross Medicare Plus Blue members starting July 31, do not require authorization for Blue Cross commercial members.

For inpatient admissions

Facility providers should submit authorization requests for inpatient admissions through the e-referral system for dates of service on or after July 31, 2017, instead of using the prenotification system that's been used for these requests in the past.

For issues related to Blue Cross commercial member authorizations, please call 1-800-572-3413.

For Issues related to Blue Cross Medicare Plus Blue member authorizations, please call 1-866-309-1719.

To add a temporary member to Blue Cross commercial, such as a newborn admitted to a NICU, please fax requests to 1-866-411-2585.

Posted: July 2017
Line of business: Blue Cross

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

Beginning July 31, 2017, providers will use the e-referral system instead of the prenotification system for their Blue Cross PPO (commercial) and Blue Cross Medicare Plus BlueSM PPO members.

If you've been using the prenote system for services requiring prior authorization (also called authorization or preauthorization), you'll be switching to e-referral.

Interested providers are invited to attend an upcoming webinar on July 27 or August 31 for e-referral training. Fill out and submit the webinar invitation. Instructions for signing in to the webinar will be emailed to you prior to the event you sign up for.

Posted: June 2017
Line of business: Blue Cross