Archives 2018




December 2018

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

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

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

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

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

Additional updated authorization criteria and e-referral questionnaires

e-referral User Guides, online eLearning updated

Xgeva® to require authorization for BCN AdvantageSM members

November 2018

eviCore to manage two radiopharmaceutical drugs, starting Feb. 1

Complete the provider specialty questionnaire in the e-referral system

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

Updated authorization criteria and e-referral questionnaires

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

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

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

October 2018

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

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

Additional updated authorization criteria and e-referral questionnaires

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

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

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

Register now for an AIM Specialty Health® ProviderPortalSM webinar

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

Treat Medicare Advantage members with Avastin® before other specialty drugs

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

September 2018

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

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

BCN updates sleep study questionnaire in the e-referral system

Additional updated authorization criteria and e-referral questionnaires

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

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

August 2018

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

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

Renflexis® requires authorization for BCN AdvantageSM starting Oct. 1

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

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

How to submit BCN inpatient authorization requests during upcoming holiday closures

FAQ available about LLPs and LMFTs

Additional updated authorization criteria and e-referral questionnaires in effect

Phone numbers change for BCN Case Management and Care Transition programs

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

Updated authorization criteria and e-referral questionnaires in effect

Error issue resolved in e-referral system

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

July 2018

2018 InterQual® criteria implementation delayed until Aug. 6

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

2018 InterQual® criteria to be implemented starting Aug. 6

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

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

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

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

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

We're updating you on Blue Distinction® Specialty Care

Deleting your browsing history after an e-referral system outage

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

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

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

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

How to submit BCN inpatient authorization requests during upcoming holiday closures

June 2018

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

Updated authorization criteria and e-referral questionnaires are in effect

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

Where to get help in using the e-referral system

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

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

May 2018

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

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

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

How to submit BCN inpatient authorization requests during upcoming holiday closures

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

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

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

April 2018

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

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

Medicare Outpatient Observation Notice requirements clarified

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

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

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

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

March 2018

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

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

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

How to submit BCN inpatient authorization requests during upcoming holiday closures

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

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

Provider forums are coming to a town near you

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

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

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

February 2018

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

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

January 2018

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

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

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

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

How to submit BCN inpatient authorization requests during upcoming holiday closures

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

Submit functional limitation G codes for BCN AdvantageSM therapy services


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.

e-referral User Guides, online eLearning updated

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

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

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

The updated User Guides also include:

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

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

eviCore to manage two radiopharmaceutical drugs, starting Feb. 1

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

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

This applies to members covered by:

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

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

  • BCN HMOSM (commercial) and BCN AdvantageSM

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

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

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

Note: These changes do not apply to MESSA members.

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

Updated authorization criteria and e-referral questionnaires

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

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

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

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

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

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

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

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

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

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

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

Medicare Plus Blue PPO

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

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

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

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

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

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

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

BCN Advantage

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

    • J9032 Beleodaq®
    • J9310 Rituxan®

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

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

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

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

Important reminder

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

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

Additional updated authorization criteria and e-referral questionnaires

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

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

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

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

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

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

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

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

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

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

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

Register for one of the following webinars now:

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

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

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

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

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

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

How to submit authorization requests

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

Always verify benefits

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

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

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

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

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

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

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

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

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

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

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

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

Treat Medicare Advantage members with Avastin® before other specialty drugs

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

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

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

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

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

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

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

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

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

What's changing?

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

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

Use NovoLogix® to submit authorization requests

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

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

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

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

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

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

Register for a webinar now:

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

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

Additional updated authorization criteria and e-referral questionnaires

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

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

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

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

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

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

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

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

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

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

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

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

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

Our goal is to:

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

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

    Blue Cross PPO

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

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

    Blue Cross Medicare Plus Blue PPO

    Call either of the following resources:

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

    BCN HMO and BCN Advantage

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

Need more help?

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

    Blue Cross PPO, BCN HMO or BCN Advantage

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

    Blue Cross Medicare Plus Blue PPO

    Call 1-866-309-1719.

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

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

FAQ available about LLPs and LMFTs

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

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

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

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

Additional updated authorization criteria and e-referral questionnaires in effect

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

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

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

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

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

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

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

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

Updated authorization criteria and e-referral questionnaires in effect

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

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

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

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

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

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

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

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

Error issue resolved in e-referral system

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

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

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

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

2018 InterQual® criteria implementation delayed until Aug. 6

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

2018 InterQual® criteria to be implemented starting Aug. 6

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

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

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

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

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

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

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

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

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

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



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

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

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

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

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

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

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

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

We're updating you on Blue Distinction Specialty Care

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

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

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

Deleting your browsing history after an e-referral system outage

The e-referral system is available again.

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

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

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

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

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

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

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

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

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

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

Non-behavioral health inpatient admissions

For BCN HMO (commercial) and BCN Advantage members:

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

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

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

Behavioral health inpatient admissions

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

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

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

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

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

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

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

See the table below for a summary of the requirements.

Drug name HCPCS code Prior authorization requirement Site-of-care requirement
Trogarzo (ibalizumab-uiyk) J3590 Blue Cross PPO (commercial) and BCN HMO (commercial) BCN HMO (commercial) only
Zilretta (triamcinolone acetonide extended release) Q9993 Blue Cross PPO (commercial) and BCN HMO (commercial) No

Note:

  • For members currently on Trogarzo, no action is required.

  • For members currently on Zilretta, authorization will be required for dates of service on or after Oct. 1, 2018.

You can refer to the opt-out list to see which groups don't require members to participate in these programs. This applies to Blue Cross PPO (commercial) groups only. To access the list, complete these steps:

  1. Visit bcbsm.com/providers.
  2. Log in to Provider Secured Services.
  3. Click BCBSM Provider Publications and Resources.
  4. Click Newsletters & Resources.
  5. Click Forms.
  6. Click Physician administered medications.
  7. Click BCBSM Medical Drug Prior Authorization Program list of groups that have opted out.

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

Additional information on medical benefit drugs is available at ereferrals.bcbsm.com, on the Blue Cross Medical Benefit Drugs — Pharmacy page and the BCN Medical Benefit Drugs — Pharmacy page.

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

Starting Aug. 1, updated utilization management criteria used for behavioral health

Starting Aug. 1, 2018, Blue Care Network and Blue Cross Medicare Plus BlueSM PPO will use the 2018 InterQual® criteria for behavioral health utilization management determinations. The 2017 InterQual criteria will be used through the end of July.

For certain services, we will base utilization management decisions on modified 2018 InterQual criteria, local rules or medical policies, instead. These changes will also begin Aug. 1. The services affected by these changes are outlined in this table.

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

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

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

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

Updated authorization criteria and e-referral questionnaires are in effect

For certain services, the authorization criteria and the questionnaires in the e-referral system have been updated. These are used in making utilization management determinations for the following members:

  • BCN HMOSM (commercial)
  • BCN AdvantageSM
  • Blue Cross Medicare Plus BlueSMPPO

Click here for a list of the authorization criteria and questionnaires that were updated in May and June 2018.

The updated authorization criteria and preview questionnaires are available on this website, on these pages:

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

As a reminder, new questionnaires will open in the e-referral system for blepharoplasty and repair of brow ptosis (starting June 25, for any date of service) and hyperbaric oxygen therapy (for dates of service on or after July 1). We first communicated about this in May, in a web-DENIS message and a news item on this website. You'll see these questionnaires included in the list of updated authorization criteria and questionnaires.

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

2018 InterQual® criteria to be implemented starting Aug. 1

Blue Cross Blue Shield of Michigan and Blue Care Network will implement the 2018 InterQual criteria starting Aug. 1, 2018, for all levels of care. Until that date, the 2017 InterQual criteria will be used.

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

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

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

  • For behavioral health determinations, the 2018 local rules will be used starting Aug. 1. The updated rules will be available at the end of July on the Blue Cross Behavioral Health page and the BCN Behavioral Health page on this website. This applies to BCN HMO (commercial), BCN Advantage and Medicare Plus Blue PPO requests.

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

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

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

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

Where to get help in using the e-referral system

Recently, the Web Support Help Desk has been experiencing an increase in calls for e-referral assistance. As a reminder, the Web Support Help Desk is only available to assist with password reset, navigation and technical help.

Please follow these guidelines for other e-referral issues:

  • For Blue Cross PPO (commercial) members, you can find the appropriate Provider Inquiry phone number in the Blue Cross provider resource guide at a glance document, on the Quick Guides page of this website.

  • For Blue Cross Medicare Plus BlueSM PPO members, you can find the appropriate Provider Inquiry phone number in the Services That Require Authorization – Medicare Plus Blue PPO document, on the Authorization Requirements & Criteria page in the Blue Cross section of this website.

  • For BCN HMOSM (commercial) or BCN AdvantageSM members, please call 1-800-392-2512.

For additional help using e-referral, contact your provider consultant or consult the user guides and online training available on the Training Tools page on this website.

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

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

For dates of service on or after Aug. 7, 2018, authorization is required for the following Part B specialty drugs covered under the medical benefit:

  • Fasenra (benralizumab)
  • Luxturna (voretigene neparvovec-rzyl)

This authorization requirement applies to Blue Cross Medicare Plus BlueSM PPO and BCN AdvantageSM members.

Note: Authorization is already required for Blue Cross PPO and BCN HMOSM (commercial) members.

For Medicare Plus Blue and BCN Advantage members, authorization is required for these medications when they are billed on a professional HCFA 1500 claim form or by electronic submission via ANSI 837P, for the following sites of care:

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

Authorization is not required for these medications when they are billed on a facility claim form (such as the UB-92, UB-04 or UCB).

Both medications are billed with HCPCS procedure code J3590.

You must submit authorization requests for these medications through the NovoLogix online tool. Authorization must be obtained prior to the medications being administered.

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

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

Several new upgrades and changes are coming to the e-referral system. The biggest change is the combining of BCN and BCBSM e-referral systems into one portal.

In order to upgrade the system, e-referral will not be available starting 6 p.m. on Friday, April 27, 2018. At 6 a.m. on Monday, April 30, 2018, users will see only one e-referral link to be used for both Blue Cross and BCN submissions. Please see the article on page 42 of the May-June 2018 BCN Provider News for full details.

Here's some information on how to process certain requests while the e-referral system is down.

For urgent acute inpatient requests that need to be processed within 24 hours, call the appropriate number below:

  • For Blue Cross requests, call the critical phone line at (313) 448-3619.
  • For BCN requests, call the BCN After-Hours Care Manager Hotline at 1-800-851-3904.

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

To reach BCN Behavioral Health, call 1-800-482-5982.

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

Medicare Outpatient Observation Notice requirements clarified

We're clarifying the requirements for notifying Medicare Advantage members using the Medicare Outpatient Observation Notice form.

Here's when hospitals need to notify members

Hospitals must use the Medicare Outpatient Observation Notice form, available on the CMS website* under Downloads, to notify Blue Cross Medicare Plus BlueSM PPO and BCN AdvantageSM members that they're receiving outpatient, rather than inpatient, services when a member is:

  • In the emergency department and is being considered for inpatient admission but has not yet been approved for admission by Blue Cross or BCN
  • Being moved to observation status within the hospital from any other status or source
  • In observation status for 24 hours or more, if the member has not already received the form before being admitted for observation

For Medicare Advantage members in these circumstances, hospitals must present the member with a completed Medicare Outpatient Observation Notice. This is a Centers for Medicare & Medicaid Services requirement.

Hospitals should also review the instructions for notifying members using the Medicare Outpatient Observation Notice.

Here's when hospitals do not need to notify members

When Blue Cross or BCN has approved an inpatient admission, there's no need to notify the member using the form. When the member is not being considered for inpatient care, there's no need to notify either the member or the plan.

*Blue Cross Blue Shield of Michigan doesn't own or control this website.

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

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

For dates of service on or after June 1, 2018, diabetic shoes and inserts will be managed by Northwood, Inc., for Blue Care Network HMOSM (commercial), BCN AdvantageSM and Blue Cross Medicare Plus Blue PPO members. This applies to HCPCS codes A5500 through A5513 and code K0903.

J&B Medical Supply currently manages these items and will manage them for dates of service on or before May 31, 2018.

Here's how to contact these vendors:

  • Northwood: Call Northwood at 1-800-393-6432 to identify a contracted supplier near you. The supplier submits the request to Northwood for review. Northwood representatives are available weekdays from 8:30 a.m. to 5 p.m. Northwood on-call associates are available after normal business hours at the same number.

  • J&B Medical Supply: Call J&B at 1-888-896-6233. J&B representatives are available weekdays from 8 a.m. to 5 p.m. J&B on-call associates are available after normal business hours at the same number.

We'll be updating the BCN and Blue Cross Medicare Plus Blue PPO provider manuals to reflect the changes related to diabetic shoes and inserts.

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

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

Time is running out to give us your opinion on our provider manuals. Please complete our online survey by April 30. You could win a $25 gift certificate. For more information see recent articles in The Record and page 13 of BCN Provider News.

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

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

Earlier this year, we notified you and members that Blue Cross and Blue Care Network will no longer cover hyaluronic acids beginning April 1.

After further review, we've decided to continue covering hyaluronic acids while we conduct additional research. We hope to have a final decision in the next few months and will continue to update you on this critical initiative.

Members will receive a letter soon with the updated information.

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

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

As a reminder, effective for dates of service on or after April 2, 2018, all non-emergency air ambulance transports for Blue Cross Blue Shield of Michigan PPO (commercial) and Blue Care Network HMOSM (commercial) members require authorization.

Requests to authorize non-emergency flights must be submitted to and approved by Alacura Medical Transportation Management, LLC, prior to the flight. This requirement applies to both in-state and out-of-state air ambulance transports.

Emergency flights – when the patient cannot safely wait six hours to take off – do not require authorization. This includes situations that involve delays due to weather or stabilizing the patient. When it's an emergency, just transport the patient.

How to request an authorization for non-emergency flights

To contact Alacura about authorizing a non-emergency flight request, do the following:

  1. Complete the Air ambulance flight information (non-emergency) form and fax it, along with clinical documentation in support of the request, to Alacura at 1-844-608-3572.
  2. Call Alacura at 1-844-608-3676 to obtain an authorization number.

Additional information

You'll find additional information about air ambulance requirements on page 2 of the Air ambulance flight information (non-emergency) form and in upcoming issues of The Record and BCN Provider News. The Blue Cross and BCN provider manuals are also being updated.

The following articles were published in past newsletter issues:

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

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

We're working to improve our service to you and would like your opinion on our provider manuals. Please complete our online survey by April 30. You could win a $25 gift certificate. For more information, see recent articles in The Record and BCN Provider News.

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

Provider forums are coming to a town near you

Blue Cross Blue Shield of Michigan and Blue Care Network's 2018 provider forums begin in May. You can register for the full day or choose to attend just the morning or afternoon session. Dates, times, locations and registration information can be found on our provider forum flyer (PDF).

The morning sessions will have content specifically geared to physician office staff who are responsible for closing gaps related to quality measures and coding and will include:

  • The patient experience - why it's important to your practice and how you can improve it
  • 2018 CPT updates and coding scenarios for primary care physicians and specialists
  • HEDIS® measures

The afternoon sessions will be geared toward all office personnel and will include:

  • New provider service model
  • eviCore and prior authorizations
  • e-referral
  • The opioid epidemic
  • Behavioral health
  • Provider enrollment and provider inquiry updates

We hope you can join us.

HEDIS® is a registered trademark of the National Committee for Quality Assurance, or NCQA.

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

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

Effective immediately, the following CAR (chimeric antigen receptor) T-cell therapies require authorization for Blue Cross Medicare Plus BlueSM PPO and BCN AdvantageSM members:

HCPCS code Brand name Generic name
Q2041 YescartaTM axicabtagene ciloleucel
Q2040 KymriahTM tisagenlecleucel

To request authorization for these therapies:

  1. Complete the Medication Authorization Request Form on this page for the medication you're requesting.
  2. Gather the following supporting clinical documentation:
    • The member's eligibility for autologous hematopoietic stem cell transplant
    • Testing for CD19 tumor expression
    • Previous gene therapy
    • Detailed information about the therapies the member has already received
  3. Fax the completed form and the clinical documentation to 1-866-392-6465.

Since these requests require thorough review, we ask that you request an expedited review only if the standard review time frame could place the member's health in serious jeopardy.

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

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

When submitting authorization requests for knee arthroplasty procedures in an outpatient setting, you may see a message in the e-referral system indicating "Procedure is not appropriate for treatment setting."

Here's what to do: Please ignore the message and proceed with the outpatient authorization request.

This applies to procedure codes *27446 and *27447, for BCN HMOSM (commercial), BCN AdvantageSM and Blue Cross Medicare Plus BlueSM members.

This year, the Centers for Medicare & Medicaid Services began allowing knee arthroplasty procedures to be done in an outpatient setting. The e-referral system will accept those authorization requests but it's displaying the message that makes it seem like it won't. We're getting many calls from providers asking what they should do.

The e-referral system is being adjusted to stop displaying the message, but the update won't be completed until sometime in April. At that time, you'll no longer see the "Procedure is not appropriate for treatment setting" message when submitting outpatient knee arthroplasty authorization requests.

Meanwhile, ignore the message and proceed with the outpatient request.

We appreciate your patience as we update the e-referral system.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2017 American Medical Association. All rights reserved.

Posted: February 2018
Line of business: Blue Cross and Blue Care Network

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

Effective for dates of service on or after April 2, 2018, all non-emergency air ambulance transports for Blue Cross PPO (commercial) and Blue Care Network HMOSM (commercial) members require authorization. Requests for authorization must be submitted to Alacura Medical Transportation Management, LLC, prior to the flight. Information about the process to use in submitting these requests will be made available closer to the April effective date.

This requirement applies to both in-state and out-of-state air ambulance transports.

Blue Cross and BCN are partnering with Alacura to provide review of non-emergency air ambulance flights. Alacura will use the Blue Cross and BCN medical policy titled Air Ambulance Services to determine the appropriateness of non-emergency flights.

There are no changes to member benefits related to air ambulance services. Non-emergency air ambulance services are eligible for reimbursement if the member has the benefit and if Alacura authorizes the flight.

Reason for this change: Air ambulance transports that are not medically necessary or that are flown by noncontracted providers expose Blue Cross and BCN members to significantly greater out-of-pocket costs and are much costlier for the plan. The requirement for authorization prior to non-emergency flights is expected to lower costs for Blue Cross and BCN members and customers.

Billing air ambulance claims: As a reminder, instructions for billing emergency and non-emergency air ambulance services for dates of service on or after Jan. 1, 2017, are now available. For the details, see the web-DENIS message posted Jan. 12, 2018, titled "Air ambulance billing instructions are now available."

Posted: January 2018
Line of business: Blue Cross and Blue Care Network

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

Blue Cross Blue Shield of Michigan PPO (commercial) and Blue Care Network HMOSM (commercial) plans won't cover hyaluronic acids, beginning April 1, 2018.

Hyaluronic acids, also known as viscosupplements, are used to treat osteoarthritis of the knee.

Randomized controlled trials and national guidelines have examined the effect of hyaluronic acids on pain and function. The combined data show:

  • A lack of defined meaningful clinical improvements over placebo
  • Well-characterized biases among trials
  • Publication bias
  • Missing study results

Effective April 1, 2018, the following hyaluronic acids will be considered investigational and won't be covered for Blue Cross and BCN commercial (non-Medicare) members.

J code Drug description
J7320 Hyaluronan or derivative, GenVisc® 850 for intra-articular injection, 1 mg
J7321 Hyaluronan or derivative, Hyalgan® for SupartzTM for intra-articular injection, per dose
J7322 Hyaluronan or derivative, Hymovis® for intra-articular injection, 1 mg
J7323 Hyaluronan or derivative, Euflexxa® for intra-articular injection, per dose
J7324 Hyaluronan or derivative, Orthovisc® for intra-articular injection, per dose
J7325 Hyaluronan or derivative, Synvisc® or Synvisc-One® for intra-articular injection, 1 mg
J7326 Hyaluronan or derivative, Gel-One® for intra-articular injection, per dose
J7327 Hyaluronan or derivative, Monovisc® for intra-articular Injection, per dose
J7328 Hyaluronan or derivative, Gel-SynTM for intra-articular injection, 0.1 mg
Future J codes Future hyaluronan or derivative products, not yet approved by the FDA

Posted: January 2018
Line of business: Blue Cross and Blue Care Network

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

Effective April 1, 2019, BCN is adding the following medications to its site-of-care optimization program, for BCN HMO (commercial) members only:

  • Fasenra (benralizumab, HCPCS code J0517)

  • Radicava (edaravone, HCPCS code J1301)

Note: This requirement does not apply to BCN AdvantageSM members.

The site-of-care program redirects members receiving select drugs in an outpatient hospital setting to a lower-cost, alternate site of care, such as the physician's office or the member's home.

If a provider feels a member is not a candidate to receive these drugs at a site other than the outpatient hospital, documentation supporting medical necessity must be provided to the plan for review. Those requests will be evaluated on a case-by-case basis.

Requests for Fasenra and Radicava must meet applicable authorization criteria in addition to the site-of-care requirement.

For a list of requirements related to drugs covered under the medical benefit, including all drugs identified as subject to a site-of-care requirement, do the following:

  1. Visit the Medical Benefit Drugs – Pharmacy page in the BCN section of this website.

  2. Click Requirements for drugs covered under the medical benefit - BCN HMO and Blue Cross PPO under the heading "For BCN HMO (commercial) members."

The new site-of-care requirement for Fasenra and Radicava will be reflected in the requirements list before the April 1 effective date.

Posted: December 2018
Line of business: Blue Care Network

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

Effective Jan. 7, 2019, BCN is changing the process for requesting a peer-to-peer review discussion with a BCN medical director related to a non-behavioral health authorization request that was denied. This applies to both BCN HMOSM (commercial) or BCN AdvantageSM members.

To get the details, please review the document How to request a peer-to-peer review with a BCN medical director, as follows:

  • See Section 1 for how to request a peer-to-peer review for non-behavioral health cases. Instead of calling in the request, you'll now fax it in using the Physician peer-to-peer request form (for non-behavioral health cases).

  • See Section 2 for how to request a peer-to-peer review on behavioral health cases. For these cases, the process is not changing. No form is used.

You can access both these documents — the process description and the form for non-behavioral health cases — on this website. Click BCN, then click Authorization Requirements & Criteria. Look under the "Referral and authorization information" heading.

The BCN Provider Manual will be updated to reflect this new information by the end of December.

Posted: December 2018
Line of business: Blue Care Network

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

BCN Advantage members don't need a referral to see a specialist within their health plan's network. However, authorizations and plan notifications are still required for certain services. Also, all services with a provider who's not in the member's health plan network require an authorization. More information is available in the Jan-Feb 2019 BCN Provider News.

Posted: December 2018
Line of business: Blue Care Network

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

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will close on the following holidays:

  • Monday, Dec. 24 and Tuesday, Dec. 25 for the Christmas holidays
  • Monday, Dec. 31 and Tuesday, Jan. 1 for the New Year

During these office closures, BCN's inpatient utilization management area will still accept inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

Here's what you need to know about submitting inpatient authorization requests to BCN when our corporate offices are closed.

Acute initial inpatient admissions. Submit these authorization requests as well as concurrent reviews and discharge dates through the e-referral system, which is available 24 hours a day, seven days a week.

Note: These requests may also be submitted through the X12N 278 Health Care Services Review – Request for Review and Response electronic standard transaction.

Post-acute initial and concurrent admission reviews. Follow the current process you use to submit these requests by fax at 1-866-534-9994. Refer to the document Post-acute care admissions: Submitting authorization requests to BCN for additional information.

Other authorization requests. The types of requests listed below must be submitted by fax. For these requests, faxes are processed only Monday through Friday. They are not processed on weekends or on the holidays on which BCN is closed. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

  • Authorization requests for sick or ill newborns
  • Authorization requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN after-hours care manager hotline at 1-800-851-3904 and listen to the prompts for help with the following:

  • Determining alternatives to inpatient admissions and triage to alternative care settings
  • Arranging for emergency home health care, home infusion services and in-home pain control
  • Arranging for durable medical equipment
  • Handling emergency discharge planning coordination and authorization
  • Handing expedited appeals of utilization management decisions

Note: Do not use the after-hours care manager phone number to request authorization for routine inpatient admissions.

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

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member's medical condition and coordinate care prior to admitting the member.

Posted: December 2018
Line of business: Blue Care Network

Additional updated authorization criteria and e-referral questionnaires

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

  • Cholecystectomy (laparoscopic) for adults
  • Endoscopy, upper gastrointestinal, for gastroesophageal reflux disease
  • Hyperbaric oxygen therapy
  • Varicose vein treatment

For these services, you'll see the updated questionnaires in the e-referral system starting Dec. 16, 2018.

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

  • BCN HMOSM (commercial)
  • BCN AdvantageSM

The updated authorization criteria and preview questionnaires are available at ereferrals.bcbsm.com. To find them, click BCN, then click Authorization Requirements & Criteria. Next, look in the "Authorization criteria and preview questionnaires" section.

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

Posted: December 2018
Line of business: Blue Care Network

Xgeva® to require authorization for BCN AdvantageSM members

Xgeva (J0897) will continue to require authorization for BCN Advantage members in 2019.

On Nov. 1, 2018, a web-DENIS message and a news item at ereferrals.bcbsm.com were posted indicating that Xgeva would not require authorization starting Jan. 1, 2019, for BCN Advantage members.

However, you'll need to continue to submit authorization requests for this drug. We apologize for any inconvenience this may cause.

We've updated the earlier communications, titled "Medicare Part B medical specialty drug prior authorization lists changing in 2019," to reflect the change. You may want to review the earlier communications to refresh your memory on the other changes that will take place.

Additional information

For BCN Advantage, we require prior authorization for Xgeva when you bill it as a professional service or an outpatient facility service based on the following:

Professional CMS-1500 claim form (or electronically via an 837P transaction) for the following sites of care:

  • Physician office (Place of Service Code 11)
  • Home (Place of Service Code 12)

Facility UB04 claim form (or electronically via an 837I transaction):

  • Outpatient facility (Type of Bill 013x)

Important reminder

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

Posted: December 2018
Line of business: Blue Care Network

Complete the provider specialty questionnaire in the e-referral system

We'e added a questionnaire to the e-referral system that asks you to select the specialty of the provider you're referring a member to. That's the only question you'll need to answer.

You'll see this provider specialty questionnaire only when you're submitting a global referral to a multispecialty group. As a reminder, only BCN HMOSM (commercial) members require a global referral.

If you're making a global referral to a multispecialty group, you'll see a prompt asking you to complete the provider specialty questionnaire. Here's what to do:

  1. Click the link to open the questionnaire.
  2. Select the specialty of the provider you're referring to from the drop-down menu.
  3. Click Next to continue submitting your global referral.

Completing the questionnaire will help your referral get to the right provider in the multispecialty group.

The provider specialty questionnaire began opening in the e-referral system on Oct. 28, 2018.

We're updating the e-referral User Guide with information on the provider specialty questionnaire.

Posted: November 2018
Line of business: Blue Care Network

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

A new provider training tool is available to give providers a summary of our authorization programs through AIM Specialty Health®. The presentation also explains when a new AIM authorization is required.

The AIM presentation is posted in three areas:

  • On this website, on BCN's AIM-Managed Procedures page
  • On the BCN Provider Publications and Resources website, on the Learning Opportunities page
  • On the BCBSM Provider Publications and Resources website, on the Provider Training page

As a reminder, for dates of service on or after Oct. 1, 2018, you must submit authorization requests for cardiology and high-tech radiology procedures for BCN members to AIM Specialty Health.

Some providers are still submitting these requests to eviCore in error.

Here are some important things to know:

  • AIM started accepting authorization requests on Sept. 17, 2018, for dates of service on or after Oct. 1. You can submit these requests either through the AIM provider portal or by calling AIM at 1-844-377-1278.

  • For dates of service prior to Oct. 1, continue to submit your authorization requests to eviCore healthcare. eviCore will handle all requests for dates of service prior to Oct. 1, including postservice requests.

This applies to BCN HMOSM (commercial) and BCN AdvantageSM members.

Information about what AIM manages for BCN

Look on the new AIM-Managed Procedures page in the BCN section of this website to find:

Posted: November 2018
Line of business: Blue Care Network

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

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will close on the following holidays:

  • Tuesday, Nov. 6, 2018 (Election Day)
  • Thursday, Nov. 22, 2018 (Thanksgiving)
  • Friday, Nov. 23, 2018 (day after Thanksgiving)

During these office closures, BCN's inpatient utilization management area will still accept inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

Here's what you need to know about submitting inpatient authorization requests to BCN when our corporate offices are closed.

Acute initial inpatient admissions. Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week.

Note: These requests may also be submitted through the X12N 278 Health Care Services Review – Request for Review and Response electronic standard transaction.

Post-acute initial and concurrent admission reviews. Follow the current process you use to submit these requests by fax at 1-866-534-9994. Refer to the document Post-acute care admissions: Submitting authorization requests to BCN for additional information.

Other authorization requests. The types of requests listed below must be submitted by fax. For these requests, faxes are processed only Monday through Friday. They are not processed on weekends or on the holidays on which BCN is closed. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

  • Authorization requests for sick or ill newborns
  • Authorization requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN after-hours care manager hotline at 1-800-851-3904 and listen to the prompts for help with the following:

  • Determining alternatives to inpatient admissions and triage to alternative care settings
  • Arranging for emergency home health care, home infusion services and in-home pain control
  • Arranging for durable medical equipment
  • Handling emergency discharge planning coordination and authorization
  • Handing expedited appeals of utilization management decisions

Note: Do not use the after-hours care manager phone number to request authorization for routine inpatient admissions.

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

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member's medical condition and coordinate care prior to admitting the member.

Posted: November 2018
Line of business: Blue Care Network

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

We're letting BCN Advantage members know they don't need a referral from their primary care physician for covered services with a specialist who's in the provider network for the member's health plan. Authorizations are still required for certain services.

For details, see the article in the November-December 2018 BCN Provider News, on page 10.

Posted: October 2018
Line of business: Blue Care Network

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

As a reminder, for dates of service on or after Oct. 1, 2018, you must submit authorization requests for cardiology and high-tech radiology procedures for BCN members to AIM Specialty Health®.

Some providers are still submitting these requests to eviCore in error.

Here are some important things to know:

  • AIM started accepting authorization requests on Sept. 17, 2018, for dates of service on or after Oct. 1. You can submit these requests either through the AIM provider portal or by calling AIM at 1-844-377-1278.

  • For dates of service prior to Oct. 1, continue to submit your authorization requests to eviCore healthcare. eviCore will handle all requests for dates of service prior to Oct. 1, including postservice requests.

This applies to BCN HMOSM (commercial) and BCN AdvantageSM members.

Information about what AIM manages for BCN

Look on the new AIM-Managed Procedures page in the BCN section of this website to find:

Posted: October 2018
Line of business: Blue Care Network

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

As a reminder, for dates of service on or after Oct. 1, 2018, AIM Specialty Health manages the authorization process for cardiology and high-tech radiology procedures for BCN HMOSM (commercial) and BCN AdvantageSM members. We first communicated about this in the article AIM Specialty Health to manage cardiology and high-tech radiology procedures for BCN starting October 1 in the July-August 2018 issue of BCN Provider News, on page 33.

Here are some important things to know:

  • AIM started accepting authorization requests on Sept. 17, 2018, for dates of service on or after Oct. 1. You can submit these requests either through the AIM provider portal or by calling AIM at 1-844-377-1278.
  • For dates of service prior to Oct. 1, continue to submit your authorization requests to eviCore healthcare. eviCore will handle all requests for dates of service prior to Oct. 1, including postservice requests.

Information about what AIM manages for BCN

Look on the new AIM-Managed Procedures page in the BCN section of this website to find:

Webinars offered in October

There's still time to sign up for training webinars to learn how to register for and use the AIM ProviderPortalSM, an online tool used to request authorization from AIM. Here are the days and times for the remaining webinars:

  • Wednesday, Oct. 3, 10-11 a.m.
  • Thursday, Oct. 4, 2-3 p.m.

For the instructions on how to register, see the webinar invitation.

Posted: September 2018
Line of business: Blue Care Network

BCN updates sleep study questionnaire in the e-referral system

BCN has updated the sleep study questionnaire in the e-referral system. We've condensed the questionnaire, so you'll have fewer questions to answer. The questionnaire pertains to sleep studies in an outpatient facility or clinic-based setting. It became available in the e-referral system starting Sept. 23, 2018.

We use the updated questionnaire in making utilization management determinations for BCN HMOSM and BCN AdvantageSM members.

You'll find a link to the updated preview questionnaire and the medical policy titled "Sleep Disorders, Diagnosis and Medical Management" on this website. Click BCN, then click Authorization Requirements & Criteria. Next, look in the "Authorization criteria and preview questionnaires" section.

You'll also find links to these documents on the Sleep Management Program page in the BCN section of this website.

You can look over the preview questionnaire to see what questions you'll need to answer so you can prepare your answers ahead of time. This can cut down on the time it takes to submit the authorization request.

Posted: September 2018
Line of business: Blue Care Network

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

As a reminder, effective Oct. 1, 2018, BCN is adding the following two drugs to its site-of-care optimization program:

  • Prolia
  • Xgeva

For both medications, the generic name is denosumab and the HCPCS code is J0897.

The site-of-care requirement applies only to BCN HMO (commercial) members. It does not apply to BCN AdvantageSM members.

The site-of-care program redirects members receiving select drugs in an outpatient hospital setting to a lower-cost, alternate site of care, such as the physician's office or the member's home.

If a provider feels a member is not a candidate to receive these drugs at a site other than the outpatient hospital, documentation supporting medical necessity must be provided to the plan for review. Those requests will be evaluated on a case-by-case basis.

Requests for Prolia and Xgeva must meet applicable authorization criteria in addition to the site-of-care requirement. This applies to first-time and current users of these medications.

For additional requirements related to drugs covered under the medical benefit, including all drugs identified as subject to site-of-care requirements, refer to the Medical Benefit Drugs – Pharmacy page in the BCN section of this website. Click Requirements for drugs covered under the medical benefit – BCN HMO under the heading "For BCN HMO (commercial) members."

The new site-of-care requirement for Prolia and has been added to the list.

Posted: September 2018
Line of business: Blue Care Network

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

For dates of service on or after Oct. 1, 2018, additional specialty medications covered under the Medicare Part B medical benefit require authorization for BCN Advantage members.

We first communicated about this in the article Starting Oct. 1, additional specialty medications require authorization for BCN Advantage members, on page 28 of the July-August 2018 BCN Provider News. Please review the article to see which drugs require authorization starting October 1.

These medications are not self administered. They must be given by injection or infusion by a physician or health care professional in the office or outpatient facility setting.

These medications require authorization when billed as a professional service (via the paper HCFA 1500 claim form or electronically as an 837P transaction) or as an outpatient facility service (via the UB-04 or electronically as an 837I transaction) and one of the following place of service codes is used:

  • Physician office (Place of Service code 11)
  • Outpatient facility (Place of Service codes 19, 22 and 24)

We also published an update in the article Clarification: Vivaglobin does not require authorization, on page 8 of the September-October 2018 BCN Provider News.

In addition, an updated list of drugs requiring authorization for BCN Advantage members will be available on this website by the end of September. To see the list, click BCN and then click Medical Benefit Drugs – Pharmacy. Finally, click Requirements for drugs covered under the medical benefit – BCN Advantage.

Note: This communication updates earlier ones, including the newsletter articles, which incorrectly stated that authorization is not required for these medications when they are billed on a facility claim form (such as the UB 04) or electronically via an 837I transaction. We apologize for this error.

Posted: September 2018
Line of business: Blue Care Network

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

Please fax all authorization requests to BCN for post-acute care services for BCN HMOSM (commercial) and BCN AdvantageSM members. This applies to members transitioning to a skilled nursing facility, a rehabilitation facility or a long-term acute care hospital.

Here's what you need to know

  • Fax authorization requests to 1-866-534-9994. We accept faxed requests 24 hours a day, seven days a week.

  • Normal business hours for BCN post-acute care staff are Monday through Saturday, 8 a.m. to 5 p.m.

  • The on-call nurse is available to assist with admissions on Sundays and holidays and at other times outside of normal business hours. During those times, call the on-call nurse at 1- 800-851-3904 and fax the documentation to 1-866-534-9994.

Here's what to fax

For SNF and rehabilitation admissions, fax these documents:

  • A completed Rehabilitation Assessment Form
  • History and physical from the hospital admission
  • Physical medicine and rehabilitation consultation notes, as appropriate

For LTACH admissions, fax these documents:

  • A completed LTACH Assessment Form
  • History and physical from the hospital admission
  • Physical medicine and rehabilitation consultation notes, as appropriate
  • Last two days of practitioner progress notes (admission and concurrent)
  • Current intravenous and subcutaneous medication lists

The forms are available on this website, on the BCN Forms page.

A summary of these instructions is available on this website. Click BCN and then click Authorization Requirements & Criteria. Finally, click Post-acute care admissions: Submitting authorization requests to BCN.

The Care Management chapter of the BCN Provider Manual is being updated to reflect this information.

Posted: September 2018
Line of business: Blue Care Network

Renflexis® requires authorization for BCN AdvantageSM starting Oct. 1

For dates of service on or after Oct. 1, 2018, Renflexis requires authorization for BCN Advantage members.

This medication is not self-administered. It must be given by injection or infusion by a physician or health care professional in the office, home or outpatient facility setting.

This medication requires authorization when it is billed on either a professional HCFA 1500 claim form (or submitted electronically using an 837P transaction) or on a facility claim form such as the UB-04 (or submitted electronically using an 837I transaction), for the following places of service:

  • Physician office (Place of Service code 11)
  • Home (Place of Service code 12)
  • Outpatient facility (Place of Service codes 19 and 22)

Submit authorization requests for this medication through the Novologix online tool. Authorization must be obtained prior to the medication being administered.

Posted: September 2018
Line of business: Blue Care Network

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

Starting Sept. 4, 2018, you can submit inpatient continued stay reviews and discharge notifications for BCN HMOSM (commercial) and BCN AdvantageSM members through the e-referral system. This applies to members admitted for non-behavioral health services.

Currently, these requests are faxed in to BCN. However, starting Nov. 1, 2018, we will no longer accept faxed requests.

This change means that BCN HMO (commercial) and BCN Advantage inpatient discharge notifications and continued stay reviews will be processed through the e-referral system, just like they are for Blue Cross PPO (commercial) and Blue Cross Medicare Plus BlueSM PPO members.

To request additional days on an inpatient admission

To request additional days, follow the instructions in the e-referral User Guide for extending an inpatient authorization. Here's what it says: To extend service on an existing Inpatient Authorization, begin by locating your authorization. Click the Edit button on the right side of the details page. Scroll down to the Confinement Extension(s) section, click the Create New button and enter your new dates and the number of days.

You must also submit clinical information related to the continued stay. To do that, follow the instructions in the article How to attach clinical information to your authorization request in the e-referral system, on page 44 in the November-December 2016 issue of BCN Provider News.

To submit a discharge notification

To notify us of a member's discharge, enter the discharge date in the e-referral Case Communication field. As an alternative, you can record the discharge date on a discharge summary form and attach it to the case in e-referral.

Sign up for e-referral

If you don't currently have access to the e-referral system, we encourage you to sign up for it now so you'll be ready to use it before November 1, when faxes are no longer accepted. Follow the instructions on the Sign Up or Change a User page on this website.

Posted: August 2018
Line of business: Blue Care Network

How to submit BCN inpatient authorization requests during upcoming holiday closures

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices are closed on the following days:

  • Monday, Sept. 3, 2018 (Labor Day holiday)
  • Tuesday, Nov. 6, 2018 (Election Day holiday)

During these holiday closures, BCN's inpatient utilization management area remains available to accept inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

Here's what you need to know about submitting inpatient authorization requests to BCN when our corporate offices are closed.

Acute initial inpatient admissions. Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week.

Note: These requests may also be submitted through the X12N 278 Health Care Services Review – Request for Review and Response electronic standard transaction.

Post-acute initial and concurrent admission reviews. Follow the current process you use to submit these requests by fax at 1-866-534-9994.

Other authorization requests. The types of requests listed below must be submitted by fax. For these requests, faxes are processed only Mondays through Friday. They are not processed on weekends or on the holidays on which BCN is closed. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

  • Acute inpatient concurrent reviews and discharge dates, but only for facilities reimbursed on the basis of DRGs
  • Authorization requests for sick or ill newborns
  • Authorization requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN After-Hours Care Manager hotline at 1-800-851-3904 and listen to the prompts for help with the following:

  • Determining alternatives to inpatient admissions and triage to alternative care settings
  • Arranging for emergency home health care, home infusion services and in-home pain control
  • Arranging for durable medical equipment
  • Handling emergency discharge planning coordination and authorization
  • Handing expedited appeals of utilization management decisions

Note: Do not use the after-hours care manager phone number to request authorization for routine inpatient admissions.

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

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member's medical condition and coordinate care prior to admitting the member.

Posted: August 2018
Line of business: Blue Care Network

Phone numbers change for BCN Case Management and Care Transition programs

The phone numbers for BCN's Case Management and Care Transition to Home programs have changed.

To reach staff in these programs, call 1-800-775-2583. Wait to hear the prompts and press the number for the prompt that matches your request.

Please update your files to show the following:

  • Instead of the 1-800-943-9744 number for BCN Case Management, call 1-800-775-2583.

  • Instead of the 1-800-728-3010 number for the BCN Care Transition to Home program, call 1- 800-775-2583.

The Care Management and BCN Advantage chapters of the BCN Provider Manual are being updated to reflect the new 1-800-775-2583 phone number.

Posted: August 2018
Line of business: Blue Care Network

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

As a reminder, for dates of service on or after Oct. 1, 2018, AIM Specialty Health will manage the authorization process for cardiology and high-tech radiology procedures for BCN HMOSM (commercial) and BCN AdvantageSM members. We first communicated about this in the article AIM Specialty Health to manage cardiology and high-tech radiology procedures for BCN starting October 1 in the July-August 2018 issue of BCN Provider News, on page 33.

Here are some important things to know:

  • AIM will accept authorization requests starting Sept. 17, 2018, for dates of service on or after Oct. 1. You can submit these requests either through the AIM provider portal or by calling AIM at 1-844-377-1278.

  • For dates of service prior to Oct. 1, continue to submit your authorization requests to eviCore healthcare. eviCore will handle all requests for dates of service prior to Oct. 1, including postservice requests.

Codes for procedures AIM will manage

Click here for a list of the procedure codes AIM will manage. You'll be able to find the list of codes on this website by the end of September.

Webinars offered in August, September and October

There's still time to sign up for training webinars to learn how to register for and use the AIM ProviderPortalSM, an online tool used to request authorization from AIM.

Here are the webinar days and times:

  • Wednesday, Aug. 22, 10-11 a.m.
  • Thursday, Aug. 23, 2-3 p.m.
  • Wednesday, Aug. 29, 10-11 a.m.
  • Thursday, Aug. 30, 2-3 p.m.
  • Wednesday, Sept. 5, 10-11 a.m.
  • Thursday, Sept. 6, 2-3 p.m.
  • Wednesday, Oct. 3, 10-11 a.m.

For the instructions on how to register, refer to the article in BCN Provider News.

Posted: August 2018
Line of business: Blue Care Network

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

For dates of service on or after Oct. 1, 2018, AIM Specialty Health will manage the authorization process for cardiology and high-tech radiology procedures for BCN HMOSM (commercial) and BCN AdvantageSM members. We first communicated about this in the article AIM Specialty Health to manage cardiology and high-tech radiology procedures for BCN starting October 1 in the July-August 2018 issue of BCN Provider News, on page 33.

AIM will accept authorization requests starting Sept. 17, 2018. You can submit these requests either through the AIM provider portal or by calling AIM at 1-844-377-1278.

For dates of service prior to Oct. 1, continue to submit your authorization requests to eviCore healthcare.

Webinars offered in August, September and October

We've scheduled training webinars so you can learn how to register for and use the AIM ProviderPortalSM, an online tool used to request authorization from AIM.

For the training dates and the instructions on how to register, refer to the article in BCN Provider News.

Codes for procedures AIM will manage

Click here for a list of the procedure codes AIM will manage. The list shows the following categories of procedures:

  • Category 1: Procedures that require authorization by eviCore healthcare for dates of service through Sept. 30, 2018, and will continue to require authorization by AIM for dates of service on or after Oct. 1, 2018

  • Category 2: Procedures that require authorization by eviCore healthcare for dates of service through Sept. 30, 2018, but will not require authorization by AIM for dates of service on or after Oct. 1, 2018

  • Category 3: A few procedures that require authorization by eviCore healthcare for dates of service through Sept. 30, 2018, will require authorization by BCN for dates of service on or after Oct. 1, 2018. Submit authorization requests for these procedures directly to BCN through the e-referral system. Don't submit them to AIM.

  • Category 4: Procedures that do not require authorization by eviCore healthcare for dates of service through Sept. 30, 2018, but will require authorization by AIM for dates of service on or after Oct. 1, 2018

You'll be able to find the list of codes on our ereferrals.bcbsm.com website by the end of September.

Posted: July 2018
Line of business: Blue Care Network

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

For dates of service on or after Oct. 1, 2018, additional specialty medications covered under the Medicare Part B medical benefit require authorization for BCN Advantage members.

We first communicated about this in the article Starting Oct. 1, additional specialty medications require authorization for BCN Advantage members, on page 28 of the July-August 2018 BCN Provider News.

Please review the article to see which drugs require authorization starting October 1.

Exception: Vivaglobin® (HCPCS code J1562) will not require authorization because it is being discontinued. This is a change from what we communicated in the newsletter article.

These medications are not self administered. They must be given by injection or infusion by a physician or health care professional in the office or outpatient facility setting.

These medications require authorization when billed as a professional service (via the paper HCFA 1500 claim form or electronically as an 837P transaction) or as an outpatient facility service (via the UB-04 or electronically as an 837I transaction) and one of the following place of service codes is used:

  • Physician office (Place of Service code 11)
  • Outpatient facility (Place of Service codes 19, 22 and 24)
  • Note: In the July-August 2018 newsletter article, we mentioned only Place of Service codes 19 and 22 for outpatient facilities, but authorization is also required for Place of Service code 24.

Please review the July-August newsletter article for additional information.

In addition, look for an article in the September-October 2018 BCN Provider News that will clarify these changes.

Posted: July 2018
Line of business: Blue Care Network

How to submit BCN inpatient authorization requests during upcoming holiday closures

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices are closed on the following days:

  • Wednesday, July 4, 2018 (Fourth of July holiday)
  • Monday, Sept. 3, 2018 (Labor Day holiday)

During these holiday closures, BCN's inpatient utilization management area remains available to accept inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

Here's what you need to know about submitting inpatient authorization requests to BCN when our corporate offices are closed.

Acute initial inpatient admissions. Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week.

Note: These requests may also be submitted through the X12N 278 Health Care Services Review – Request for Review and Response electronic standard transaction.

Post-acute initial and concurrent admission reviews. Follow the current process you use to submit these requests by fax at 1-866-534-9994.

Other authorization requests. The types of requests listed below must be submitted by fax. For these requests, faxes are processed only Mondays through Friday. They are not processed on weekends or on the holidays on which BCN is closed. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

  • Acute inpatient concurrent reviews and discharge dates, but only for facilities reimbursed on the basis of DRGs
  • Authorization requests for sick or ill newborns
  • Authorization requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN After-Hours Care Manager hotline at 1-800-851-3904 and listen to the prompts for help with the following:

  • Determining alternatives to inpatient admissions and triage to alternative care settings
  • Arranging for emergency home health care, home infusion services and in-home pain control
  • Arranging for durable medical equipment
  • Handling emergency discharge planning coordination and authorization
  • Handing expedited appeals of utilization management decisions

Note: Do not use the after-hours care manager phone number to request authorization for routine inpatient admissions.

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

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member's medical condition and coordinate care prior to admitting the member.

Posted: July 2018
Line of business: Blue Care Network

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

Effective Oct. 1, 2018, BCN is adding the following two drugs to its site-of-care optimization program:

  • Prolia
  • Xgeva

For both medications, the generic name is denosumab and the HCPCS code is J0897.

The site-of-care requirement applies only to BCN HMO (commercial) members. It does not apply to BCN AdvantageSM members.

The site-of-care program redirects members receiving select drugs in an outpatient hospital setting to a lower-cost, alternate site of care, such as the physician's office or the member's home.

If a provider feels a member is not a candidate to receive these drugs at a site other than the outpatient hospital, documentation supporting medical necessity must be provided to the plan for review. Those requests will be evaluated on a case-by-case basis.

Requests for Prolia and Xgeva must meet applicable authorization criteria in addition to the site-of-care requirement. This applies to first-time and current users of these medications.

For additional requirements related to drugs covered under the medical benefit, including all drugs identified as subject to site-of-care requirements, refer to the Medical Benefit Drugs – Pharmacy page in the BCN section of this website. Click Requirements for drugs covered under the medical benefit – BCN HMO under the heading "For BCN HMO (commercial) members."

The new site-of-care requirement for Prolia and Xgeva will be added to the list in late September.

Posted: June 2018
Line of business: Blue Care Network

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

Effective June 22, 2018, providers must submit appeals of eviCore healthcare's decisions on BCN Advantage authorization requests to the BCN Advantage Grievances and Appeals Unit and not to eviCore. Here's where to submit:

By mail:

Blue Care Network
ATTN: BCN Advantage Grievances and Appeals Unit
P.O. Box 284
Southfield MI 48076-5043

By fax: 1-866-522-7345

BCN will process these appeals using the normal BCN Advantage appeal process for standard and expedited appeals. For information on that process, refer to the BCN Advantage chapter of the BCN Provider Manual. Look in the section titled "BCN Advantage provider appeals."

Appeals of eviCore decisions on BCN HMOSM (commercial) authorization requests should continue to be submitted to eviCore.

Posted: June 2018
Line of business: Blue Care Network

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

As a reminder, effective July 1, 2018, BCN is adding the following two drugs to its site-of-care optimization program:

Brand name HCPCS code Generic name
Krystexxa J2507 pegloticase
Stelara (SQ/IV) J3357, J3358 ustekinumab

This requirement applies only to BCN HMO (commercial) members, for first-time and current users of these medications. It does not apply to BCN AdvantageSM members.

The site-of-care program redirects members receiving select medical benefit drugs in an outpatient hospital setting to a lower-cost, alternate site of care, such as the physician's office or the member's home.

If a provider feels a member is not a candidate to receive these drugs at a site other than the outpatient hospital, documentation supporting medical necessity must be provided to the plan for review. Those requests will be evaluated on a case-by-case basis.

Requests for Krystexxa and Stelara (SQ/IV) must meet applicable authorization criteria in addition to the site-of-care requirement.

For additional requirements related to drugs covered under the medical benefit, including all drugs identified as subject to site-of-care requirements, refer to the Medical Benefit Drugs – Pharmacy page in the BCN section of this website. Click Requirements for drugs covered under the medical benefit – BCN HMO under the heading "For BCN HMO (commercial) members."

The new site-of-care requirement for Krystexxa and Stelara is included in the list that is now available online.

Posted: June 2018
Line of business: Blue Care Network

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

Providers must complete questionnaires in the e-referral system for the following procedures:

  • Blepharoplasty and repair of brow ptosis – beginning June 25, 2018, for any date of service
  • Hyperbaric oxygen therapy – for dates of service on or after July 1, 2018

The questionnaires will open in the e-referral system when you're submitting authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

These procedures already require authorization. It's just the questionnaires that are new.

How the questionnaires work

If your responses to the questionnaire in the e-referral system indicate that the procedure meets criteria, the authorization request will automatically be approved. If the criteria are not met, the request will be pended for clinical review by BCN's Utilization Management staff.

For cases that are not automatically approved via e-referral after you complete the questionnaire, you must include additional clinical information. You can type the information directly into the Case Communication section in the e-referral system or you can attach it to the case. The instructions for attaching clinical information to the case are outlined in the article How to attach clinical information to your authorization request in the e-referral system, on page 44 in the November-December 2016 BCN Provider News.

Where to find medical policies and preview questionnaires

The medical policies for these procedures will guide the decisions on these authorization requests. Click to open the policies:

The medical policies for these procedures will be posted online before the end of June in the BCN section of this website, on the Authorization Requirements & Criteria page.

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

Posted: May 2018
Line of business: Blue Care Network

How to submit BCN inpatient authorization requests during upcoming holiday closures

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices are closed on the following days:

  • Monday, May 28, 2018 (Memorial Day)
  • Wednesday, July 4, 2018 (Fourth of July holiday)

During these holiday closures, BCN's inpatient utilization management area remains available to accept inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

Here's what you need to know about submitting inpatient authorization requests to BCN when our corporate offices are closed.

Acute initial inpatient admissions. Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week.

Post-acute initial and concurrent admission reviews. Follow the current process you use to submit these requests by fax at 1-866-534-9994.

Other authorization requests. The types of requests listed below must be submitted by fax. For these requests, faxes are processed only Mondays through Friday. They are not processed on weekends or on the holidays on which BCN is closed. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

  • Acute inpatient concurrent reviews and discharge dates, but only for facilities reimbursed on the basis of DRGs
  • Authorization requests for sick or ill newborns
  • Authorization requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN After-Hours Care Manager hotline at 1-800-851-3904 and listen to the prompts for help with the following:

  • Determining alternatives to inpatient admissions and triage to alternative care settings
  • Arranging for emergency home health care, home infusion services and in-home pain control
  • Arranging for durable medical equipment
  • Handling emergency discharge planning coordination and authorization
  • Handing expedited appeals of utilization management decisions

Note: Do not use the after-hours care manager phone number to request authorization for routine inpatient admissions.

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

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member's medical condition and coordinate care prior to admitting the member.

Posted: May 2018
Line of business: Blue Care Network

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

Later this year, providers who currently submit their initial authorization requests for physical, occupational and speech therapy, or for physical medicine services by chiropractors, through the e-referral system or by calling BCN will submit these requests through eviCore healthcare's provider portal instead.

At the same time, requests to authorize follow-up services will also be submitted through the eviCore provider portal instead of through the Landmark Healthcare portal.

This change will apply to requests for BCN HMOSM (commercial) and BCN AdvantageSM members and to the following providers:

  • Facilities
  • Therapists performing physical, occupational and speech therapy
  • Chiropractors performing physical medicine services
  • Referring physicians
  • Podiatrists

In addition, BCN is working with eviCore to implement the corePathSM authorization model for these requests for BCN HMO (commercial) and BCN Advantage members. corePath will streamline the authorization process and make it easier for providers to submit authorization requests. It's the same model that was implemented for Blue Cross Medicare Plus BlueSM PPO authorization requests starting Jan. 1, 2018.

We first communicated about this change in the article titled eviCore to handle BCN initial and follow-up authorization requests for PT, OT and ST starting later in 2018, on page 42 of the May-June 2018 BCN Provider News.

More details about these changes will be provided in the coming months.

Posted:
Line of business: Blue Care Network

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

Brineura (cerliponase alfa), a medication covered under the medical benefit, will not be subject to a site-of-care requirement starting July 1, 2018, for BCN HMO (commercial) members, as we had previously announced.

In April, we communicated that we were adding Brineura to the site-of-care optimization program starting July 1. However, we have decided after additional review that we will not add Brineura to that program.

The document Requirements for drugs covered under the medical benefit – BCN HMO has been updated to reflect this change. However, please check that document for the authorization requirements that do pertain to Brineura and for the requirements that pertain to other drugs covered under the medical benefit for BCN HMO (commercial) members.

Posted: May 2018
Line of business: Blue Care Network

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

For dates of service on or after June 1, 2018, authorization is not required for routine outpatient therapy for mental health and substance use disorders, for contracted behavioral health providers in Michigan. This applies to both BCN HMOSM (commercial) and BCN AdvantageSM members.

Currently, these services require authorization for all providers and authorization requests are submitted through the e-referral system.

Authorization will continue to be required for:

  • Providers who do not belong to the network assigned to a member's plan
  • Noncontracted providers, including providers outside of Michigan

In addition, the outpatient services listed here will continue to require authorization through the e-referral system for all providers:

  • Autism evaluation and treatment
  • Electroconvulsive therapy
  • Neurofeedback
  • Transcranial magnetic stimulation

We'll be updating the Behavioral Health chapter of the BCN Provider Manual and other documents to reflect the change in authorization requirements.

Posted: April 2018
Line of business: Blue Care Network

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

Effective for dates of service on or after July 1, 2018, multiple sclerosis medications covered under the medical benefit will not require authorization, for Blue Cross PPO (commercial) and BCN HMOSM (commercial) members. This change applies to the following medications:

Brand name Generic name HCPCS code
LemtradaTM alemtuzumab J0202
OcrevusTM ocrelizumab J2350
Tysabri® natalizumab J2323

For Blue Cross and BCN commercial members with an active authorization for one of these medications, no additional action is required by the member or the provider.

This change does not apply to BCN AdvantageSM, Blue Cross Medicare Plus BlueSM PPO or Federal Employee Program® members. The requirements for these products are as follows:

  • For BCN Advantage and Federal Employee Program members, no authorization is currently required.
  • For Medicare Plus Blue members, authorization is currently required and will continue to be required.

For additional information on the change related to commercial members, look for articles in the following upcoming newsletters:

  • May 2018 issue of The Record
  • May-June 2018 issue of BCN Provider News

Posted: April 2018
Line of business: Blue Care Network

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

Blue Care Network is helping BCN HMOSM (commercial) and BCN AdvantageSM members get access to long-acting injectable medications for the treatment of certain psychiatric and substance use disorders.

We've contracted with home health care agencies that can visit the member's home to administer the injections and complete a nursing assessment of the member. The agencies can be used when the primary care physician, psychiatrist or facility is unable to administer these medications.

The newer long-acting injectable medications may be used for the medically assisted treatment of psychiatric and substance use disorders. These medications have fewer side effects and are better tolerated than some of the older formulations. They are also now usually preferred early in treatment and should often be the first line of treatment for certain psychiatric and substance use disorders.

The member just needs a doctor's order to be sent to the home health agency. The doctor also needs to order the medication through AllianceRx Walgreens Prime Specialty Pharmacy on behalf of the member.

By providing this service, we're removing a barrier for members. We're providing a place to get the injection.

For information on how to use this service, refer to the document Administering long-acting injectable medications at home (behavioral health). This document is on the Behavioral Health page in the BCN section of this website, under the "Other resources" heading.

This document shows:

  • The steps for initiating and continuing the administration of the medications in the member's home
  • A list of some long-acting injectable medications that can be obtained through AllianceRx Walgreens Prime Specialty Pharmacy
  • A list of the BCN-contracted home health agencies that provide in-home long-acting injectables

We're also updating the Behavioral Health chapter of the BCN Provider Manual with a link to this document.

Posted: April 2018
Line of business: Blue Care Network

How to submit BCN inpatient authorization requests during upcoming holiday closures

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices are closed on the following days:

  • Friday, March 30, 2018 (Good Friday)
  • Monday, May 28, 2018 (Memorial Day)

During these holiday closures, BCN's inpatient utilization management area remains available to accept inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

Here's what you need to know about submitting inpatient authorization requests to BCN when our corporate offices are closed.

Acute initial inpatient admissions. Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week.

Post-acute initial and concurrent admission reviews. Follow the current process you use to submit these requests by fax at 1-866-534-9994.

Other authorization requests. The types of requests listed below must be submitted by fax. For these requests, faxes are processed only Mondays through Friday. They are not processed on weekends or on the holidays on which BCN is closed. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

  • Acute inpatient concurrent reviews and discharge dates, but only for facilities reimbursed on the basis of DRGs
  • Authorization requests for sick or ill newborns
  • Authorization requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN After-Hours Care Manager hotline at 1-800-851-3904 and listen to the prompts for help with the following:

  • Determining alternatives to inpatient admissions and triage to alternative care settings
  • Arranging for emergency home health care, home infusion services and in-home pain control
  • Arranging for durable medical equipment
  • Handling emergency discharge planning coordination and authorization
  • Handing expedited appeals of utilization management decisions

Note: Do not use the after-hours care manager phone number to request authorization for routine inpatient admissions.

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

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member's medical condition and coordinate care prior to admitting the member.

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Posted: March 2018
Line of business: Blue Care Network

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

Effective July 1, 2018, BCN is adding the following two drugs to its site-of-care optimization program:

Brand name HCPCS code Generic name
Krystexxa J2507 pegloticase
Stelara (SQ/IV) J3357, J3358 ustekinumab

This requirement applies only to BCN HMO (commercial) members, for first-time and current users of these medications. It does not apply to BCN AdvantageSM members.

The site-of-care program redirects members receiving select medical benefit drugs in an outpatient hospital setting to a lower-cost, alternate site of care, such as the physician's office or the member's home.

If a provider feels a member is not a candidate to receive these drugs at a site other than the outpatient hospital, documentation supporting medical necessity must be provided to the plan for review. Those requests will be evaluated on a case-by-case basis.

Requests for Krystexxa and Stelara (SQ/IV) must meet applicable authorization criteria in addition to the site-of-care requirement.

For additional requirements related to drugs covered under the medical benefit, including all drugs identified as subject to site-of-care requirements, refer to the Medical Benefit Drugs – Pharmacy page in the BCN section of this website. Click Requirements for drugs covered under the medical benefit – BCN HMO under the heading "For BCN HMO (commercial) members."

The new site-of-care requirement for Krystexxa and Stelara will be included in the April 2018 version of the list, which will be available online in late March.

Posted: March 2018
Line of business: Blue Care Network

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

Effective March 19, 2018, two fax numbers will change:

  • Use the fax number 1-866-392-6465 for BCN AdvantageSM Medicare Part B authorization requests. It's the same fax number you're currently using for Blue Cross Medicare Plus BlueSM PPO requests.
  • Use the fax number 1-877-325-5979 for BCN HMOSM (commercial) requests. It's the same fax number you're currently using for Blue Cross PPO (commercial) requests.

We encourage you to submit all authorization requests for drugs covered under the medical benefit using the Novologix® electronic system. It's the most efficient way to submit a request and get a determination.

When you need assistance, however, you can call the Pharmacy Help Desk at 1-800-437-3803 or fax your request using the appropriate fax number.

The BCN Provider Manual will be updated with these changes. The Medical Benefit Drugs – Pharmacy page in the BCN section of this website will also be updated. You can find additional information about drugs covered under the medical benefit on that page.

Posted: March 2018
Line of business: Blue Care Network

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

Effective immediately, BCN is adding Mepsevii (vestronidase alfa-vjbk) to its site-of-care optimization program. This program redirects members receiving select drugs in an outpatient hospital setting to a lower-cost, alternate site of care, such as the physician's office or the member's home.

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

If a provider feels a member is not a candidate to receive this drug at a site other than the outpatient hospital, documentation supporting medical necessity must be provided to the plan for review. Those requests will be evaluated on a case-by-case basis. Requests for Mepsevii must meet applicable authorization criteria in addition to the site-of-care requirement.

For additional requirements related to drugs covered under the medical benefit, including all drugs identified as subject to site-of-care requirements, visit the Medical Benefit Drugs – Pharmacy page in the BCN section of this website. Click Requirements for drugs covered under the medical benefit – BCN HMO (PDF) under the heading "For BCN HMO (commercial) members."

The new Mepsevii site-of-care requirement is included in the March 2018 version of the list, which is available now.

Posted: March 2018
Line of business: Blue Care Network

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

For dates of service on or after April 1, 2018, authorization is required for the two medical benefit drugs shown in the table below, for BCN HMOSM (commercial) members only.

Drug name Procedure code Additional information
MakenaTM J1726 Applies only to BCN HMO (commercial) members who start this drug on or after April 1, 2018
Tysabri® J2323 Applies to BCN HMO (commercial) members who start this drug on or after April 1, 2018, and those who currently take this drug

Providers must submit an authorization request through the NovoLogix electronic system to demonstrate medical necessity. Authorization requests for these drugs should be submitted prior to the start of services.

Medical necessity criteria for these drugs include but are not limited to diagnosis, lab results, dose and frequency of administration. Documentation may also be required that shows the medications previously used to treat the member's condition, including the dose, regimens, dates of therapy and response. Additional pertinent clinical information may also be required.

These new authorization requirements do not apply to BCN AdvantageSM members.

For a full list of drugs that require authorization and for information on how to request authorization, visit the Medical Benefit Drugs–Pharmacy page in the BCN section of this website.

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Posted: February 2018
Line of business: Blue Care Network

How to submit BCN inpatient authorization requests during upcoming holiday closures

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices are closed on the following days:

  • Monday, Jan. 15, 2018 (Martin Luther King, Jr., Day)
  • Friday, March 30, 2018 (Good Friday)

During these holiday closures, BCN's inpatient utilization management area remains available to accept inpatient authorization requests for BCN HMOSM (commercial) and BCN AdvantageSM members.

Here's what you need to know about submitting inpatient authorization requests to BCN when our corporate offices are closed.

Acute initial inpatient admissions. Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week.

Post-acute initial and concurrent admission reviews. Follow the current process you use to submit these requests by fax at 1-866-534-9994.

Other authorization requests. The types of requests listed below must be submitted by fax. For these requests, faxes are processed only Mondays through Friday. They are not processed on weekends or on the holidays on which BCN is closed. Fax BCN HMO (commercial) requests to 1-866-313-8433. Fax BCN Advantage requests to 1-866-526-1326.

  • Acute inpatient concurrent reviews and discharge dates, but only for facilities reimbursed on the basis of DRGs
  • Authorization requests for sick or ill newborns
  • Authorization requests for enteral and total parenteral nutrition

Additional information. You can also call the BCN After-Hours Care Manager hotline at 1-800-851-3904 and listen to the prompts for help with the following:

  • Determining alternatives to inpatient admissions and triage to alternative care settings
  • Arranging for emergency home health care, home infusion services and in-home pain control
  • Arranging for durable medical equipment
  • Handling emergency discharge planning coordination and authorization
  • Handing expedited appeals of utilization management decisions

Note: Do not use the after-hours care manager phone number to request authorization for routine inpatient admissions.

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

As a reminder, when an admission occurs through the emergency room, we ask that you contact the primary care physician to discuss the member's medical condition and coordinate care prior to admitting the member.

__

Posted: January 2018
Line of business: Blue Care Network

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

BCN's Utilization Management department (formerly called Care Management) is experiencing high call volumes.

To avoid waiting on the phone line, providers should use the e-referral system to submit or check the status of referrals or authorization requests.

We encourage providers to call 1-800-392-2512 only for urgent requests.

We apologize for the inconvenience caused by the long waiting times on our phone line.

Posted: January 2018
Line of business: Blue Care Network

Submit functional limitation G codes for BCN AdvantageSM therapy services

When billing outpatient physical, occupational and speech therapy services for BCN Advantage members, you must report the functional limitation G codes and their applicable modifiers.

It's important to report the modifiers for the nonpayable G codes as secondary to the modifiers for the primary codes. If you report these modifiers as primary, it will cause an error in our payment system and the claim will be denied.

For instructions on how to report these codes correctly, see the article Providers must submit functional limitation G codes for BCN Advantage PT, OT and ST services, in the January-February 2018 issue of BCN Provider News, on page 37.

The document Outpatient rehabilitation services: Frequently asked questions for rehab providers has been updated with this information. This document and other resources are posted on this website, on BCN's Outpatient PT, OT, ST page.

Posted: January 2018
Line of business: Blue Care Network

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

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will close on the following holidays:

  • Monday, Dec. 24 and Tuesday, Dec. 25 for the Christmas holidays
  • Monday, Dec. 31 and Tuesday, Jan. 1 for the New Year

During these office closures, the Blue Cross inpatient utilization management area will still accept inpatient authorization requests for Blue Cross PPO (commercial) and Blue Cross Medicare Plus BlueSM PPO members. Follow this advice for submitting inpatient authorization requests during corporate office closures:

Type of request Blue Cross PPO (commercial) Blue Cross Medicare Plus Blue PPO
Acute initial inpatient admissions Submit requests 24/7 through the e-referral system.
Or, you can submit them through the X12N 278 Health Care Services Review – Request for Review and Response electronic standard transaction.
Post-acute initial and concurrent admission reviews
  • Follow the current process.
  • Fax requests to 1-866-411-2573.
  • Follow the current process.
  • Fax requests to eviCore healthcare at 1-844-407-5293.
Other inpatient services Fax the following requests to 1-800-482-1713:

  • Authorization requests for sick or ill newborns
  • Federal Employee Program members with contract eligibility issues
  • Ineligible members or members with no contract
Not applicable
Urgent inpatient requests only Call the Blue Cross after-hours urgent hotline at 313-448-3619 for any immediate or urgent need.

Find additional e-referral system resources elsewhere on this website.

Posted: December 2018
Line of business: Blue Cross Blue Shield of Michigan

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

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will close on the following holidays:

  • Tuesday, Nov. 6, 2018 (Election Day)
  • Thursday, Nov. 22, 2018 (Thanksgiving)
  • Friday, Nov. 23, 2018 (day after Thanksgiving)

During these office closures, the Blue Cross inpatient utilization management area will still accept inpatient authorization requests for Blue Cross PPO (commercial) and Blue Cross Medicare Plus BlueSM PPO members. Follow this advice for submitting inpatient authorization requests during corporate office closures:

Type of request Blue Cross PPO (commercial) Blue Cross Medicare Plus Blue PPO
Acute initial inpatient admissions Submit requests 24/7 through the e-referral system.
Or, you can submit them through the X12N 278 Health Care Services Review – Request for Review and Response electronic standard transaction.
Post-acute initial and concurrent admission reviews
  • Follow the current process.
  • Fax requests to 1-866-411-2573.
  • Follow the current process.
  • Fax requests to eviCore healthcare at 1-844-407-5293.
Other inpatient services Fax the following requests to 1-800-482-1713:

  • Authorization requests for sick or ill newborns
  • Federal Employee Program members with contract eligibility issues
  • Ineligible members or members with no contract
Not applicable
Urgent inpatient requests only Call the Blue Cross after-hours urgent hotline at 313-448-3619 for any immediate or urgent need.

Find additional e-referral system resources elsewhere on this website.

Posted: November 2018
Line of business: Blue Cross Blue Shield of Michigan

Register now for an AIM Specialty Health® ProviderPortalSM webinar.

Beginning Jan. 1, 2019, Blue Cross Blue Shield of Michigan will implement two new utilization management programs for oncology services for UAW Retiree Medical Benefits Trust (URMBT), non-Medicare members. With these programs, prior authorization must be obtained through AIM Specialty Health for some outpatient medical and radiation oncology treatments. The programs require prior authorization for radiation oncology and medical oncology services in outpatient settings.

Sign up for a webinar to hear an overview of the program and learn how to access the AIM system and how the submission process works. The webinars listed are split between medical oncology and radiation oncology for clinical and non-clinical staff.

To register, click here. Once the host approves your registration, you'll receive a confirmation email with instructions for joining the session. For more information, see the article in the October 2018 issue of The Record.

Posted: October 2018
Line of business: Blue Cross Blue Shield of Michigan

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

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices are closed on the following days:

  • Monday, Sept. 3, 2018 (Labor Day holiday)
  • Tuesday, Nov. 6, 2018 (Election Day holiday)

During these holiday closures, the Blue Cross inpatient utilization management area remains available to accept inpatient authorization requests for Blue Cross PPO (commercial) and Blue Cross Medicare Plus BlueSM PPO members.

See the table below for instructions on submitting inpatient authorization requests when our corporate offices are closed.

Type of request Blue Cross PPO (commercial) Blue Cross Medicare Plus Blue PPO
Acute initial inpatient admissions Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week. These requests may also be submitted through the X12N 278 Health Care Services Review – Request for Review and Response electronic standard transaction Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week. These requests may also be submitted through the X12N 278 Health Care Services Review – Request for Review and Response electronic standard transaction
Post-acute initial and concurrent admission reviews Follow the current process and fax to 1-866-411-2573. Follow the current process and fax to eviCore healthcare 1-844-407-5293.
Other inpatient services The requests listed below must be faxed to 1-800-482-1713:

  • Authorization requests for sick or ill newborns
  • Federal Employee Program members with contract eligibility issues
  • Ineligible members or members with no contract
Not applicable
Urgent inpatient requests only Call the Blue Cross after-hours urgent hotline at 313-448-3619 for any immediate or urgent need. Call the Blue Cross after-hours urgent hotline at 313-448-3619 for any immediate or urgent need.

Additional resources related to the e-referral system are found elsewhere on this website.

Posted: July 2018
Line of business: Blue Cross Blue Shield of Michigan

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

In this course, you'll refresh your skills with the NovoLogix® web tool, and learn how to create prior-authorization requests for provider-administered specialty medical drugs.

Register for one of the following Blue Cross Medicare Plus BlueSM PPO webinars:

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

*In July 2017, Blue Cross Medicare Plus Blue PPO launched a prior-authorization program for select provider-administered specialty medical drugs.

Posted: August 2018
Line of business: Blue Cross Blue Shield of Michigan

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

In this course, you'll refresh your skills with the NovoLogix® web tool, and learn how to create prior-authorization requests for provider-administered specialty medical drugs.

Register for one of the following Blue Cross Medicare Plus BlueSM PPO webinars:

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

*In July 2017, Blue Cross Medicare Plus Blue PPO launched a prior-authorization program for select provider-administered specialty medical drugs.

Posted: July 2018
Line of business: Blue Cross Blue Shield of Michigan

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

All providers have the right to appeal an adverse decision made by the Blue Cross Medicare Plus Blue PPO utilization management staff on an inpatient admission authorization request.

The instructions for submitting an appeal are within the Blue Cross Medicare Plus Blue PPO Provider Manual (in the Utilization management chapter, and the "Contracted MI Provider Acute Inpatient Admission Appeals" section).

Expedited appeals: You may ask for an expedited appeal when circumstances require that we make a decision in a short period of time. To request an expedited appeal, call 1-866-807-4811.

First-level appeals: Send these to Medicare Plus Blue by fax, email or mail within 45 calendar days of the date noted on the written denial notification. You can submit additional clarifying clinical information to support your request, as follows:

  • Fax: 1-877-495-3755

  • Email: MedicarePlusBlueInpatientAppeals@bcbsm.com

  • Mail:
  • Medicare Plus Blue Inpatient Provider Appeals
    Blue Cross Blue Shield of Michigan
    Mail Code 1516
    600 E. Lafayette Blvd.
    Detroit, MI 48231-26271

Second-level appeals: Send these to us within 21 calendar days of the date noted on the first-level appeal decision.

Look for upcoming articles on this topic in The Record.

Posted: July 2018
Line of business: Blue Cross Blue Shield of Michigan

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

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices are closed on the following days:

  • Wednesday, July 4, 2018 (Fourth of July holiday)
  • Monday, Sept. 3, 2018 (Labor Day holiday)

During these holiday closures, the Blue Cross inpatient utilization management area remains available to accept inpatient authorization requests for Blue Cross PPO (commercial) and Blue Cross Medicare Plus BlueSM PPO members.

See the table below for instructions on submitting inpatient authorization requests when our corporate offices are closed.

Type of request Blue Cross PPO (commercial) Blue Cross Medicare Plus Blue PPO
Acute initial inpatient admissions Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week. Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week.
Post-acute initial and concurrent admission reviews Follow the current process and fax to 1-866-411-2573. Follow the current process and fax to 1-866-464-8223.
Other inpatient services The requests listed below must be faxed to 1-800-482-1713:

  • Authorization requests for sick or ill newborns
  • Federal Employee Program members with contract eligibility issues
  • Ineligible members or members with no contract
Not applicable
Urgent inpatient requests only Call the Blue Cross after-hours urgent hotline at 313-448-3619 for any immediate or urgent need. Call the Blue Cross after-hours urgent hotline at 313-448-3619 for any immediate or urgent need.

Note: Acute initial inpatient admissions may also be submitted through the X12N 278 Health Care Services Review – Request for Review and Response electronic standard transaction.

Additional resources related to the e-referral system are found elsewhere on this website.

Posted: July 2018
Line of business: Blue Cross Blue Shield of Michigan

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

Recently, an error in the e-referral system has been causing Blue Cross outpatient authorization requests that should not have been entered into the system to pend. Upon submission, providers submitting these authorizations in error receive a case ID and a pending message.

As a reminder, please check requirements before submitting outpatient cases to e-referral:

While this issue is being resolved, we are voiding these cases manually and sending a message to providers why the case has been voided.

Posted: June 2018
Line of business: Blue Cross Blue Shield of Michigan

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

We invite you to register for one of the educational webinars we're hosting about the upcoming changes to the Medicare Plus Blue specialty medication prior authorization program.

What you'll learn at the webinar

You'll learn about how Medicare Plus Blue is expanding its specialty medication authorization requirements to include outpatient facilities that bill with Place of Service 19, 22 or 24. Currently, only providers that bill with Place of Service 11 are subject to these requirements.

We first communicated about this change in a web-DENIS message posted on May 1, 2018.

How to register for the webinar

To sign up for a webinar, decide which webinar day and time is best for you:

  • Tuesday, June 19, 2018, from 9 to 9:30 a.m. (RSVP by Monday, June 18.)
  • Wednesday, June 20, 2018, from 1 to 1:30 p.m. (RSVP by Monday, June 18.)

Then complete the registration form and fax it to 1-866-652-8983 or email it as an attachment to ProviderInvitations@bcbsm.com. Instructions will be emailed to you a day or two prior to the webinar.

Posted: May 2018
Line of business: Blue Cross Blue Shield of Michigan

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

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices are closed on the following days:

  • Monday, May 28, 2018 (Memorial Day)
  • Wednesday, July 4, 2018 (Fourth of July holiday)

During these holiday closures, the Blue Cross inpatient utilization management area remains available to accept inpatient authorization requests for Blue Cross PPO (commercial) and Blue Cross Medicare Plus BlueSM PPO members.

Here's what you need to know about submitting inpatient authorization requests to Blue Cross when our corporate offices are closed.

Acute initial inpatient admissions. Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week.

Post-acute initial and concurrent admission reviews. Follow the current process and fax to 1-866-464-8223.

Other authorization requests. The types of requests listed below must be submitted by fax to 1-866-411-2585:

  • Authorization requests for sick or ill newborns
  • Authorization requests for gender reassignment
  • Contract eligibility issues for Federal Employee Program members

Additional information. You can also call the Blue Cross after-hours urgent hotline at 313-448-3619 for any immediate or urgent need.

Additional resources related to the e-referral system are found elsewhere on this website.

Posted: May 2018
Line of business: Blue Cross Blue Shield of Michigan

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

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices are closed on the following days:

  • Friday, March 30, 2018 (Good Friday)
  • Monday, May 28, 2018 (Memorial Day)

During these holiday closures, the Blue Cross inpatient utilization management area remains available to accept inpatient authorization requests for Blue Cross PPO (commercial) and Blue Cross Medicare Plus Blue SM PPO members.

Here's what you need to know about submitting inpatient authorization requests to Blue Cross when our corporate offices are closed.

Acute initial inpatient admissions. Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week.

Post-acute initial and concurrent admission reviews. Follow the current process and fax to 1-866-464-8223.

Other authorization requests. The types of requests listed below must be submitted by fax to 1-866-411-2585:

  • Authorization requests for sick or ill newborns
  • Authorization requests for gender reassignment
  • Contract eligibility issues for Federal Employee Program members

Additional information. You can also call the Blue Cross after-hours urgent hotline at 313-448-3619 for any immediate or urgent need.

Additional resources related to the e-referral system are found elsewhere on this website.

Posted: March 2018
Line of business: Blue Cross

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

In December, we told you about an inaccurate response you could receive when submitting an inpatient authorization request through the e-referral system for Blue Cross PPO members from group 71575. This system error has been fixed.

Now only Ascension members will generate an (appropriate) e-referral message instructing you to submit their authorization requests through ABS.

We apologize for the inconvenience caused by the prior systems error.

Posted: January 2018
Line of business: Blue Cross

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

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices are closed on the following days:

  • Monday, Jan. 15, 2018 (Martin Luther King, Jr., Day)
  • Friday, March 30, 2018 (Good Friday)

During these holiday closures, the Blue Cross inpatient utilization management area remains available to accept inpatient authorization requests for Blue Cross PPO (commercial) and BLue Cross Medicare Plus Blue SM PPO members.

Here's what you need to know about submitting inpatient authorization requests to Blue Cross when our corporate offices are closed.

Acute initial inpatient admissions. Submit these authorization requests through the e-referral system, which is available 24 hours a day, seven days a week.

Post-acute initial and concurrent admission reviews. Follow the current process and fax to 1-866-464-8223.

Other authorization requests. The types of requests listed below must be submitted by fax to 1-866-411-2585:

  • Authorization requests for sick or ill newborns
  • Authorization requests for gender reassignment
  • Contract eligibility issues for Federal Employee Program members

Additional information. You can also call the Blue Cross after-hours urgent hotline at 313-448-3619 for any immediate or urgent need.

Additional resources related to the e-referral system are found elsewhere on this website.

Posted: January 2018
Line of business: Blue Cross