Archives 2021




December 2021

Cortrophin requires prior authorization for commercial members, starting Feb. 24

Updated TurningPoint Documentation Guideline for musculoskeletal procedures and related services

Updated questionnaires to open in the e-referral system, starting Dec. 19

Local rules for acute inpatient medical admissions won't change until March 1, 2022, for all members

Reminder: Starting Jan. 1, requests for commercial SNF admissions must be submitted through e-referral and not by fax

December holiday closures: How to submit inpatient authorization requests

In March, AIM Specialty Health® to update clinical guidelines for prostate cancer imaging

Ryplazim® to require prior authorization for Medicare Advantage members, starting Jan. 17

Medicare Advantage post-acute care: New 30-day limit on documents in naviHealth's nH Access portal

Behavioral health resources to discuss with patients

Additional drugs to require prior authorization for Blue Cross URMBT non-Medicare members, starting March 10

e-referral system out of service overnight Dec. 18-19 and possible performance issues Jan. 1-3

Assistance is available for post-acute care placements

Starting March 1, radiology procedure code *71271 requires prior authorization for most members

Overview of care management and utilization management programs now available

We've improved the commercial Blue Cross and BCN utilization management medical drug list

New and updated preview questionnaires and medical necessity criteria for the prior authorization program expansion, which begins Jan. 1

Urgent request: Contact us if you can offer behavioral health appointments for members affected by the Oxford High School tragedy

November 2021

Changes to the prior authorization list for medical benefit drugs for Medicare Advantage members

Clarifications on the CareCentrix home health care program for Medicare Advantage members

Changes to the medical oncology prior authorization list for URMBT members with Blue Cross non-Medicare plans, starting Feb. 21

Updated Bone-anchored hearing aid questionnaire to open in the e-referral system, starting Nov. 28

Nov. 25-26 holiday closures: How to submit inpatient authorization requests

e-referral system out of service for maintenance overnight Nov. 20-21

AIM Specialty Health® technical issue is resolved

Susvimo requires prior authorization for commercial members, starting Nov. 18

Additional autism interventions now payable via telemedicine on an ongoing basis and restrictions are removed from protocol modification (*97155)

Intensive outpatient program and partial hospital program services now payable via telemedicine on an ongoing basis

Behavioral health services delivered via synchronous telemedicine

October 2021

Additional drugs require prior authorization for UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans, starting Jan. 27

Due date extended for resubmitting some corrected SNF claims for Medicare Plus BlueSM members

Starting Oct. 24, updated questionnaire to open in the e-referral system

Update: CADC and CAADC credentials not required for facilities that treat substance use disorders

e-referral system out of service for maintenance overnight Oct. 16-17

Additional drugs require prior authorization for UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans, starting Jan. 3

Prior authorization requirements expanding for Medicare Plus Blue, BCN commercial and BCN AdvantageSM members on Jan. 1

TurningPoint to review sites of care for total hip and knee surgeries for some members, starting Jan. 3

AIM Specialty Health® delays are resolved

AIM to ask for clinical information for BCN commercial radiology and cardiology prior authorization requests starting Jan. 1

September 2021

Starting Dec. 27, additional drugs require prior authorization for URMBT members with Blue Cross non-Medicare plans

Nexviazyme and Saphnelo will have prior authorization and site-of-care requirements for commercial members, starting Sept. 24

Clinical review requirements suspended for admission to skilled nursing facilities from all Michigan hospitals due to latest COVID-19 surge

Starting Sept. 26, new questionnaires to open in the e-referral system

CareCentrix® home health care program: Updated training resources, new and updated documents available

e-referral system out of service for maintenance overnight Sept. 18-19

Ryplazim® requires prior authorization for commercial members starting Sept. 17

Darzalex Faspro, Polivy and Trodelvy require prior authorization for URMBT members with Blue Cross non-Medicare plans, starting Dec. 3

Panzyga® will no longer have requirements through NovoLogix® for URMBT members with Blue Cross non-Medicare plans, starting Sept. 3

New BCN rider for large groups in the Upper Peninsula will limit coverage outside Michigan

TurningPoint to allow additional substitutions for orthopedic procedure codes

Saphnelo and Nexviazyme to require prior authorization for Medicare Advantage members

August 2021

How to submit prior authorization requests for drugs that are managed by AIM when the drugs are prescribed for non-oncology diagnoses

Sept. 6 holiday closure: How to submit inpatient authorization requests

Starting Aug. 29, updated questionnaires to open in the e-referral system

New TurningPoint Documentation Guideline for musculoskeletal procedures and related services

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

Cosela and Libtayo® to require prior authorization for Blue Cross URMBT non-Medicare members, starting Nov. 1

Additional drugs require prior authorization for Blue Cross URMBT non-Medicare members, starting Nov. 1

July 2021

Rybrevant requires prior authorization for dates of service on or after Sept. 27 for most members

Asparlas to require prior authorization for Blue Cross URMBT non-Medicare members, starting Nov. 1

Starting July 25, we'll use clinical information to validate providers' answers to some questionnaires in the e-referral system

Starting July 25, updated questionnaires to open in the e-referral system

Musculoskeletal surgeries and related procedures: New steps for determining whether prior authorization is required for Blue Cross commercial members

CareCentrix®-assigned HIPPS codes for home health services for Medicare Plus BlueSM members who receive services in Michigan

Enteral nutrition questionnaire updated in the e-referral system

Medicare Advantage home health care: Clarifications about adding disciplines and substituting services provided by clinicians with lower-level credentials

AIM Specialty Health® technical issues are resolved

Some denied SNF claims for Medicare Plus Blue members will automatically process for payment after Nov. 26, 2021

Here's how to choose the correct servicing provider in e-referral to avoid denied claims

Aduhelm to require prior authorization for commercial members starting July and August

June 2021

July 5 holiday closure: How to submit inpatient authorization requests

Updated pain management questionnaires and Postservice change request form for submitting requests to TurningPoint coming in July

Starting June 27, updated questionnaires to open in the e-referral system

Empaveli to require prior authorization for commercial members starting June and August

Aduhelm, Empaveli and Arcalyst® to require prior authorization for Medicare Advantage members

Procedure codes *70554 and *70555 to require prior authorization from AIM starting Sept. 1 for Blue Cross commercial and Medicare Plus BlueSM members

Additional enhancements to the TurningPoint musculoskeletal surgical quality and safety management program

Four additional drugs to require prior authorization for Blue Cross URMBT non-Medicare members, for dates of service on or after Sept. 7

May 2021

On May 9, we updated three additional questionnaires in the e-referral system

May 31 holiday closure: How to submit inpatient authorization requests

Jemperli and Zynlonta require prior authorization for dates of service on or after July 26, 2021, for most members

We're using updated utilization management criteria for non-behavioral health services starting Aug. 2, 2021

We're using updated utilization management criteria for behavioral health services starting Aug. 2, 2021

For Medicare Advantage inpatient admissions, submit prior authorization requests for CAR-T cell therapy drugs to NovoLogix

Criteria used to make determinations on authorization requests for musculoskeletal procedures

Use the correct HCPCS code for Spravato®

e-referral system out of service on two weekends in May

Starting May 9, new and updated questionnaires in the e-referral system

April 2021

CareCentrix® home health care training and resources are now available

Issue resolved: Medical oncology drug claims were denying in error even with authorization from AIM

Updated Medicare local coverage determination for facet joint injections for Medicare Plus BlueSM and BCN AdvantageSM members, starting April 25, 2021

Abecma® to require prior authorization for commercial members starting April and May

Alacura's telephone number has changed, for non-emergency air transport of commercial members

Register for webinar training for the CareCentrix home health care program

Determining whether to submit prior authorization requests for musculoskeletal procedures to TurningPoint for Blue Cross commercial members

Spravato® and Panzyga® to require prior authorization starting July 12 for URMBT PPO non-Medicare members

Nulibry to require authorization for commercial members

Clinical review requirements suspended for admission to skilled nursing facilities from certain hospitals at higher inpatient bed occupancy

Updated clinical documentation requirements for musculoskeletal procedures

e-referral system out of service for maintenance overnight April 17-18

Providers must submit musculoskeletal authorization requests to TurningPoint for URMBT non-Medicare members

Update: Don’t use F codes when requesting prior authorization for inpatient medical admissions

Abecma to require prior authorization for Medicare Advantage members starting April 5

Additional medications will require prior authorization for most members starting May 24

Do's and don'ts when submitting commercial SNF requests using the e-referral system

March 2021

April 2 holiday closure: How to submit inpatient authorization requests

Starting this summer, some prior authorization requests for hyperbaric oxygen therapy will pend for clinical review

Code substitutions available for musculoskeletal surgical procedures authorized by TurningPoint

Starting in June, additional medical benefit drugs will require prior authorization for some Blue Cross commercial members

Starting March 28, new and updated questionnaires in the e-referral system

Amondys 45 and Evkeeza will require authorization for commercial members

Update: Changes coming to preferred products for drugs covered under the medical benefit for most members, starting April 1

Additional medications will require prior authorization for Medicare Advantage members, starting June 22

Easier access to RC Claim Assist

AIM Specialty Health® technical issues are resolved

e-referral system out of service for maintenance overnight March 20-21

Save time: Don't fax unnecessary information about inpatient stays

Starting in June, we'll use clinical information to validate providers' answers to some questionnaires in the e-referral system

Starting June 1, Blue Cross and BCN will cover only preferred hyaluronic acid products for GM, FCA and Ford commercial groups

eviCore will no longer mail Practice Profile Summaries and category information for outpatient physical therapy services starting in July

COVID-19 testing reminders and at-home testing

February 2021

Starting in May, additional medical benefit drugs will require prior authorization for some Blue Cross commercial members

Starting Feb. 28, a new questionnaire will open in the e-referral system for the pediatric feeding program for BCN commercial members

Starting Feb. 28, a new questionnaire will open in the e-referral system for procedures by providers who aren’t contracted with BCN

eviCore healthcare® will accept retroactive authorization requests for musculoskeletal procedures through April 30

e-referral system out of service for maintenance overnight Feb. 20-21

Breyanzi® to require prior authorization for Medicare Advantage members starting Feb. 11

Cardiac rehabilitation 2 questionnaire for BCN AdvantageSM will be removed from the e-referral system on Feb. 7

Updated questionnaire available in the e-referral system on Feb. 7

How to submit appeals of Medicare Advantage inpatient acute care admissions

Cardiology procedure code *33208 doesn't require authorization for most members

January 2021

Medical benefit specialty drug prior authorization list changing in April for most members

We're adding site-of-care requirements for Uplizna® for Blue Cross commercial members, starting Jan. 1, 2021

Radiology procedure code *71271 doesn’t require authorization for most members

AIM Specialty Health® call center closed on Jan. 18 holiday

e-referral system out of service for maintenance overnight Jan. 16-17

January holiday closure: How to submit inpatient authorization requests

Reminder: Submit prior authorization requests to TurningPoint for musculoskeletal procedures for most members

Check for messages in e-referral to expedite your requests


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.


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.

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.



Cortrophin requires prior authorization for commercial members, starting Feb. 24

Cortrophin (corticotropin), HCPCS code J3590, requires prior authorization for Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members starting Feb. 24, 2022.

Some Blue Cross commercial groups not subject to these requirements

For Blue Cross commercial groups, this requirement applies only to groups that currently participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list (PDF).

Note: Blue Cross and Blue Shield Federal Employee Program® members and UAW Retiree Medical Benefits Trust (non-Medicare) members don't participate in the standard prior authorization program.

When submitting requests on or after Feb. 24

Starting Feb. 24, 2022, submit prior authorization requests through the NovoLogix® online tool.

To learn how to submit requests through NovoLogix, do the following on this website:

  • For Blue Cross commercial members: Click Blue Cross and then click Medical Benefit Drugs. In the Blue Cross commercial column, see the "How to submit requests electronically using NovoLogix" section.
  • For BCN commercial members: Click BCN and then click Medical Benefit Drugs. In the BCN commercial column, see the "How to submit requests electronically using NovoLogix" section.

When submitting requests before Feb. 24

Prior to Feb. 24, 2022, fax your request for preservice review as follows:

  • For Blue Cross commercial members: Fax to Provider Inquiry at 1 866 311 9603.
  • For BCN commercial members: Fax to the Medical Drug Help Desk at 1 877 325 5979.

List of requirements

For a full list of requirements related to drugs covered under the medical benefit, see the Blue Cross and BCN utilization management medical drug list for Blue Cross PPO (commercial) and BCN HMO (commercial) members (PDF).

We'll update this list with the new Cortrophin requirement prior to the effective date.

Authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

Posted: December 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Updated TurningPoint Documentation Guideline for musculoskeletal procedures and related services

TurningPoint Healthcare Solutions LLC has updated the TurningPoint Documentation Guideline (PDF) for musculoskeletal and related services.

TurningPoint made the following changes:

  • Categorized the information within the document to make it easier to find what you need
  • Clarified criteria related to body mass index and smoking cessation
  • Clarified imaging requirements
  • For joint replacement procedures due to arthritis, added the following grading scales and descriptive criteria:
    • Kellgren-Lawrence Radiographic Grading Scale of OA
    • Tonnis Grading Scale of Hip Osteoarthritis

The updated document is available on the following pages of this website:

Posted: December 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Updated questionnaires to open in the e-referral system, starting Dec. 19

On Dec. 19, 2021, we'll update the following questionnaires in the e-referral system:

  • Gastric stimulation — For adult Medicare Plus BlueSM, Blue Care Network commercial and BCN AdvantageSM members. This questionnaire will open for the following additional procedure codes: *95980, *95981 and *95982.
  • Varicose vein treatment — For adult BCN commercial and BCN Advantage members. This questionnaire will open for the following additional procedure codes: *36465 and *37700. It will no longer open for *36469.

We'll also update the corresponding authorization criteria and preview questionnaires on this website.

As a reminder, we use our authorization criteria, our medical policies and your answers to the questionnaires in the e-referral system when making utilization management determinations on your authorization requests.

Preview questionnaires

You can access preview questionnaires on this website. They show the questions you'll need to answer in the questionnaires that open in the e-referral system so you can prepare your answers ahead of time.

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

Authorization criteria and medical policies

The pertinent authorization criteria and medical policies are also available on the Authorization Requirements & Criteria pages.

*CPT Copyright 2020 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

Posted: December 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Local rules for acute inpatient medical admissions won't change until March 1, 2022, for all members

The local rules for acute inpatient medical admissions of members with certain conditions won't change until March 1, 2022, for all Blue Cross Blue Shield of Michigan and Blue Care Network commercial and Medicare Advantage members. This means:

  • For any member who has certain conditions and who is admitted on or after March 1, 2022, facilities should wait until the member has been in the hospital for two days and then submit the authorization request on the third day.
  • Facilities must provide clinical documentation that demonstrates that the InterQual® criteria have been met at the time the request is submitted.

For a fuller account of the Local Rules for inpatient acute medical admissions of members with certain conditions admitted on or after March 1, including a list of those conditions, refer to the document Submitting acute inpatient authorization requests: Frequently asked questions for providers (PDF). In the table of contents, click What are the local rules that apply to members with certain conditions?

This is an update of earlier communications, in which we had said that this change in Local Rules would go into effect for Medicare Plus BlueSM and BCN AdvantageSM members with certain conditions admitted on or after Jan. 3, 2022; and for BCN commercial members with certain conditions admitted on or after Feb. 1, 2022.

In addition, as a clarification, the Local Rules provide instructions only on when to submit the authorization request. They don't direct providers about writing admission orders (observation vs. inpatient) or about determining the level of care for the member.

We'll publish articles about this change in later issues of The Record and BCN Provider News.

Posted: December 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Reminder: Starting Jan. 1, requests for commercial SNF admissions must be submitted through e-referral and not by fax

As a reminder, beginning Jan. 1, 2022, we'll require skilled nursing facilities to submit prior authorization requests through the e-referral system and not by fax. This applies to requests for our Blue Cross and Blue Care Network commercial members for:

  • Initial admissions
  • Additional days

We published details about this change in recent issues of our provider newsletters.

What's changing

Starting Jan. 1:

  • We'll stop accepting faxed requests as a general practice.
  • We'll accept faxes only for urgent requests when the e-referral system is not available. In those instances, fax the form using the instructions on the document titled e-referral system planned downtimes and what to do. (PDF)

If we receive a faxed form for a non-urgent admission when the e-referral system is available, we won't accept the request. We'll notify you by fax or phone that you must submit the request through the e-referral system.

Sign up now to use the e-referral system

Refer to our ereferrals.bcbsm.com website:

Do's and don'ts when submitting through the e-referral system

For tips on how to make it easier to use the e-referral system when submitting commercial SNF prior authorization requests, refer to the article we published in the May 2021 issue of The Record titled Do's and don'ts when submitting commercial SNF requests using the e referral system.

Submit Medicare Advantage requests to naviHealth

naviHealth manages prior authorization requests for SNF admissions for our Medicare Plus BlueSM and BCN AdvantageSM members.

Posted: December 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



December holiday closures: How to submit inpatient authorization requests

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will be closed on these upcoming holidays:

  • Christmas – Thursday, Dec. 23 and Friday, Dec. 24, 2021
  • New Year's – Thursday, Dec. 30 and Friday, Dec. 31, 2021

Refer to the document Holiday closures: How to submit authorization requests (PDF) for instructions on how to submit authorization requests for inpatient admissions during the closures.

You can access this document on the ereferrals.bcbsm.com website, on these webpages:

Posted: December 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



In March, AIM Specialty Health® to update clinical guidelines for prostate cancer imaging

Starting March 13, 2022, AIM Specialty Health will publish updated oncologic imaging clinical guidelines for prostate cancer to include indications for 18FDCFPyL (piflufolastat injection or Pylarify®) PET/CT imaging (radiology procedure code *78815).

In the future, these scans will be available for you to select when you submit prior authorizations requests to AIM.

Until you are able to select these scans, use the “free text” field in the prior authorization request and:

  • Enter “PET w/ Pylarify, tumor stage and prior treatment (prostatectomy and/or radiation)”
  • List the conventional imaging that has been completed (MRI prostate/pelvis, CT or bone scan) and the results of those procedures

This applies to the following members:

  • Blue Cross commercial
  • Medicare Plus BlueSM
  • Blue Care Network commercial
  • BCN AdvantageSM

Where to find AIM's clinical guidelines

You can find AIM's clinical guidelines for oncologic management at aimspecialtyhealth.com/**. Open the Radiology Guidelines webpage and search for “Oncologic Imaging.” Then scroll to find the Prostate Cancer guidelines.

Submitting prior authorization requests

Submit prior authorization requests to AIM. For information on how to submit requests and for other resources, visit these webpages on our ereferrals.bcbsm.com website:

*CPT Copyright 2020 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

**Clicking this link means you’re leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we’re not responsible for its content.

Posted: December 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Ryplazim® to require prior authorization for Medicare Advantage members, starting Jan. 17

For dates of service on or after Jan. 17, 2022, Ryplazim (plasminogen, human-tvmh), HCPCS code J3590, will require prior authorization through the NovoLogix® online tool.

This requirement applies to Medicare Plus BlueSM and BCN AdvantageSM members.

When prior authorization is required

We require prior authorization when this drug is administered in any site of care other than inpatient hospital (place of service code 21) and is billed as follows:

  • Electronically through an 837P transaction or on a professional CMS-1500 claim form
  • Electronically through an 837I transaction or by using the UB04 claim form for a hospital outpatient type of bill 013x

Submitting prior authorization requests

Submit prior authorization requests for these drugs through NovoLogix. It offers real-time status checks and immediate approvals for certain medications.

If you have access to Provider Secured Services, you already have access to NovoLogix.

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

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members (PDF).

We'll update the list to reflect these changes prior to the effective date.

Posted: December 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Medicare Advantage post-acute care: New 30-day limit on documents in naviHealth's nH Access portal

Effective Feb. 11, 2022, documents for Medicare Plus BlueSM and BCN AdvantageSM members will be available within nH Access for only 30 days from the day they were posted.

If you need access to a document after it’s been removed from nH Access, contact your naviHealth care coordinator.

If you have questions about this change, contact your local naviHealth provider relations manager. If you aren't sure who your naviHealth provider relations manager is, send an email to umproviderconcerns@bcbsm.com.

naviHealth is committed to improving the post-acute care experience for our Medicare Advantage members. As part of this commitment, naviHealth provides access to patient information and documentation during the prior authorization process by making documents available through nH Access.

As a reminder, naviHealth:

  • Authorizes patient-driven payment model levels during the patient's skilled nursing facility stay (from preservice through discharge).
  • Authorizes PDPM levels based on medical necessity review and their proprietary naviHealth Predict functional assessment.
  • Works with SNFs to ensure billers submit proper PDPM levels for reimbursement.

For more information, see Post-acute care services: Frequently asked questions for providers (PDF).

naviHealth Inc. is an independent company that manages authorizations for post-acute care services for Blue Cross Blue Shield of Michigan and Blue Care Network members who have Medicare Advantage plans.

Posted: December 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Behavioral health resources to discuss with patients

In the wake of the Oxford High School tragedy, and with the stresses of the holiday season, some of your patients may need to access behavioral health services.

We want to make sure you have information about resources that you can discuss with them.

Main numbers to call

To obtain assistance in finding a provider or to get a list of providers able to take patients with urgent needs, call:

  • Blue Cross commercial members: Call New Directions® at 1-800-762-2382. Press 1 and ask to speak to a behavioral health clinician.
  • Blue Care Network commercial members: Call Behavioral Health at 1-800-482-5982.
  • BCN AdvantageSM members: Call Behavioral Health at 1-800-431-1059.
  • Medicare Plus BlueSM members: Call Behavioral Health at 1-888-803-4960.

Callers will be connected to someone who can schedule a visit.

Online therapy

Online therapy is available for most Blue Cross and BCN members through Blue Cross Online VisitsSM. Members should check their benefits by logging into their bcbsm.com account and searching “online visits” in the What’s Covered tab. Members with coverage should include their Blue Cross or BCN enrollee ID when registering for Blue Cross Online Visits.

Other resources

For a handy printable document with the above phone numbers and additional resources, see the provider alert (PDF).

Encourage members to call

We understand that not everyone accesses behavioral health resources on a regular basis.

Your patients may not feel they need these resources, but it might be worthwhile to discuss this option, especially with those who may be affected by this tragedy.

We know prevention early on during crises like this can help patients see a path forward and provide hope that they and their loved ones will get through this.

Posted: December 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



e-referral system out of service overnight Dec. 18-19 and possible performance issues Jan. 1-3

We want to make you aware of two things you'll encounter when using the e-referral system in the next weeks. We're providing this information so you can plan ahead.

We apologize for any inconvenience you may experience while the e-referral system is down or when there are performance issues.

December 18-19: Routine maintenance downtime

The next planned downtime for the e-referral system is from 10 p.m. on Saturday, Dec. 18 to 10 a.m. on Sunday, Dec. 19, 2021. (All times are Eastern time.)

The e-referral system will not be available at all during these times. Here’s additional information:

  • On Sunday, the system will be available by 10 a.m. It may be available earlier if maintenance tasks are completed.
  • We expect the system to be available during the remaining time over the weekend, although you may experience minor performance issues.

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

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

January 1-3: Possible performance issues due to uploads

We'll be uploading updated member information to the e-referral system from 7 a.m. on Saturday, Jan. 1 to 7 a.m. on Monday, Jan. 3, 2022. (All times are Eastern time.)

While the uploads are occurring, you may experience minor performance issues with the e-referral system. The operating speed will return to normal during business hours on Monday, Jan. 3.

Posted: December 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Assistance is available for post-acute care placements

Blue Cross Blue Shield of Michigan, Blue Care Network and naviHealth recognize the strain that the rise in COVID-19 hospitalizations has placed on our hospital partners, and we’re here to help.

If you're struggling to find placements in skilled nursing facilities, inpatient rehabilitation facilities or long-term acute care hospitals for members with Blue Cross commercial, Medicare Plus BlueSM, BCN commercial or BCN AdvantageSM plans, follow these suggestions, which will allow us or naviHealth to support these transitions.

  • For Blue Cross commercial and BCN commercial members: Submit prior authorization requests for post-acute care through the e-referral system. Enter a note in the Notes section if you need help placing the patient.
  • For Medicare Advantage members (Medicare Plus Blue and BCN Advantage): Let naviHealth know that you're having trouble placing members when you submit prior authorization requests. naviHealth will assist you with placing members, using data they're collecting on post-acute care facility and hospital acceptance, placement and closures.

    Be sure to include the hospital face sheet with the following information: Member name and ID; name and NPI of the attending or ordering provider; requested level of care; and the preferred facility name, NPI and address.

    You can also request assistance by calling naviHealth at 1-855-851-0843 or by entering the request for assistance on the hospital face sheet that you send to naviHealth with the prior authorization request.

    For any questions, please reach out to your naviHealth provider relations manager. If you aren't sure who your naviHealth provider relations manager is, send an email to umproviderconcerns@bcbsm.com.

Skilled nursing facility information

Although clinical review requirements are temporarily suspended for admissions from acute-care hospitals to skilled nursing facilities, Blue Cross, BCN and naviHealth continue to be responsible for managing authorizations for members who meet waiver criteria once they're admitted to a post-acute care setting. (See this Provider Alert (PDF) for details about the temporary suspension of clinical review.)

When transferring members to SNFs, continue to notify Blue Cross, BCN or naviHealth via the appropriate prior authorization process.

Additional information

For more information, see the document titled Post-acute care: For skilled nursing, rehabilitation and long-term acute care facilities (PDF).

Thank you for your continued efforts to keep Michigan healthy and safe.

Posted: December 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Starting March 1, radiology procedure code *71271 requires prior authorization for most members

For radiology procedure code *71271, prior authorization is required by AIM Specialty Health®, to ensure that claims are eligible for reimbursement.

This is effective for dates of service on or after March 1, 2022, and applies to the following members:

  • Medicare Plus BlueSM
  • Blue Care Network commercial
  • BCN AdvantageSM

Note: Services associated with this procedure code already require prior authorization for most Blue Cross commercial members.

Submitting prior authorization requests

Submit prior authorization requests to AIM. For information on how to submit requests and for other resources, visit these webpages on our ereferrals.bcbsm.com website:

We've updated the list of Procedures that require prior authorization by AIM Specialty Health (PDF) to reflect this requirement.

Additional information

As a reminder, AIM manages authorizations for various Blue Cross commercial, Medicare Plus Blue, BCN commercial and BCN Advantage members for these services:

  • Select cardiology and radiology services
  • Medical oncology and supportive care drugs
  • High-tech radiology
  • In-lab sleep management
  • Radiation oncology

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2020 American Medical Association. All rights reserved.

AIM Specialty Health is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage authorizations for select services.

Posted: December 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Overview of care management and utilization management programs now available

Blue Cross Blue Shield of Michigan and Blue Care Network have implemented many care management programs for members and utilization management programs for providers.

  • Care management programs provide patient support by identifying patients with health risks and working with them to improve or maintain their health.
  • Utilization management programs focus on ensuring that patients get the right care at the right time in the right location through the authorization process.

These programs vary based on member coverage and may be administered by Blue Cross or BCN staff or by contracted vendors.

We recently published the Care management and utilization management programs: Overview for providers (PDF) document to help you navigate these programs. This information may help you to identify services that could be useful to your patients or to learn more about programs in which your patients are participating.

In the overview document, we've:

  • Categorized the programs and the services for which we have care management and utilization management programs
  • Listed who provides services within each category (Blue Cross or BCN staff, contracted vendors or both)
  • Indicated whether services are available to Blue Cross commercial, Medicare Plus BlueSM, BCN commercial or BCN AdvantageSM members.

To see more detail about the programs, click a category heading. A document will open that provides:

  • A summary of available services
  • The groups and individual members to which services are available
  • Resources for finding more information

You can access the overview document by clicking the Quick Guides link (under Additional Resources) on this website and then clicking the Care management and utilization management programs: Overview for providers link.

We announced the publication of the Care management and utilization management programs: Overview for providers document in the December 2021 issue of The Record. We’ll also report it in the January-February 2022 issue of BCN Provider News.

Posted: December 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



We've improved the commercial Blue Cross and BCN utilization management medical drug list

We've published updated documents with utilization management information about drugs covered under the medical benefit for Blue Cross Blue Shield of Michigan and Blue Care network commercial members.

Based on feedback we received from providers and others, we've made changes so the information will be more accessible, clear, transparent and streamlined:

  • The redesigned Blue Cross and BCN utilization management medical drug list (PDF):
    • Offers a fuller explanation of our medical-drug utilization management programs for commercial members
    • Indicates more clearly where to submit prior authorizations requests — to AIM Specialty Health® or through the NovoLogix® online tool
    • Continues to indicate which drugs have prior authorization and site-of-care requirements that apply to Blue Cross or BCN commercial members
    • Continues to show the preferred and nonpreferred products for drugs for which we've designated preferred products
    • No longer contains medical policy information or information about documentation requirements, which makes the list shorter and easier to use
  • The quantity limits information is in its own document, titled Blue Cross and BCN quantity limits for medical drugs (PDF):
    • This separate document provides easier access for providers who need only the quantity limits.
    • This document continues to indicate whether the quantity limits apply to in-state or out-of-state providers or both
    • The Blue Cross and BCN utilization management medical drug list includes a link to the Blue Cross and BCN quantity limits for medical drugs document in the introductory text and in the table heading on each page.

We've published both lists on bcbsm.com, on the page titled Why do I need prior authorization for a prescription drug? Under the "How do I find out if my medication needs prior authorization?" heading, click Medical coverage drugs.

We'll also make these lists available at ereferrals.bcbsm.com:

You'll also be able to find these lists behind the provider portal.

We appreciate the feedback we received from the provider community and encourage additional comments on the new documents. Blue Cross and BCN are committed to providing reliable, up-to-date, easy-to-use resources, to help navigate the medical-benefit drug utilization management programs we have in place.

Posted: December 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



New and updated preview questionnaires and medical necessity criteria for the prior authorization program expansion, which begins Jan. 1

In preparation for the upcoming expansion of the prior authorization program for Medicare Plus BlueSM, BCN commercial and BCN AdvantageSM members, we've added and updated preview questionnaires, authorization criteria and medical policies on this website. These documents apply to authorization requests submitted for dates of service on or after Jan. 1, 2022.

The preview questionnaires show:

  • The procedure codes and, if applicable, the diagnosis codes for which each questionnaire will open in the e-referral system
  • The questions you'll need to answer in the questionnaires that open in the e-referral system

We're publishing these documents now to help you prepare for the changes.

Note: To view the procedure codes that are affected by the expansion, see the preview questionnaires on this website or see the provider alert titled Prior authorization requirements expanding for Medicare Plus Blue, BCN commercial and BCN Advantage members (PDF), which we posted on Sept. 30, 2021.

New preview questionnaires

We added the following preview questionnaires for the members specified below.

  • Blepharoplasty, lower lid repair — For pediatric and adult Medicare Plus Blue, BCN commercial and BCN Advantage members
  • Endovenous ablation for the treatment of varicose veins — For adult Medicare Plus Blue, BCN commercial and BCN Advantage members
  • Implantable ambulatory event monitors — For pediatric and adult Medicare Plus Blue, BCN commercial and BCN Advantage members
  • Left atrial appendage closure — For adult BCN commercial members
  • Left atrial appendage closure — For adult Medicare Plus Blue and BCN Advantage members
  • Radiofrequency ablation (RFA), cardiac, trigger — For adult Medicare Plus Blue, BCN commercial and BCN Advantage members
  • Radiofrequency ablation (RFA), cardiac atrial fibrillation or atrial flutter — For adult Medicare Plus Blue, BCN commercial and BCN Advantage members
  • Radiofrequency ablation (RFA), cardiac frequent monomorphic premature ventricular contractions — For adult Medicare Plus Blue, BCN commercial and BCN Advantage members
  • Radiofrequency ablation (RFA), cardiac nonsustained ventricular tachycardia — For adult Medicare Plus Blue, BCN commercial and BCN Advantage members
  • Radiofrequency ablation (RFA), cardiac suspected AVNRT, AVRT or focal atrial tachycardia — For adult Medicare Plus Blue, BCN commercial and BCN Advantage members
  • Radiofrequency ablation (RFA), cardiac sustained (more than 30 seconds) ventricular tachycardia — For adult Medicare Plus Blue, BCN commercial and BCN Advantage members
  • Radiofrequency ablation (RFA), cardiac treatment for preexcitation syndrome or WPW syndrome — For adult Medicare Plus Blue, BCN commercial and BCN Advantage members
  • Septoplasty — For adult Medicare Plus Blue, BCN commercial and BCN Advantage members
  • Thyroidectomy, partial — For adult Medicare Plus Blue, BCN commercial and BCN Advantage members
  • Thyroidectomy, total — For adult Medicare Plus Blue, BCN commercial and BCN Advantage members

Updated preview questionnaires

We updated the following preview questionnaires to reflect that they'll apply to Medicare Plus Blue members. (They already apply to BCN commercial and BCN Advantage members.)

  • Blepharoplasty
  • Cosmetic or reconstructive surgery — The list of procedure codes for which the questionnaire will open differs depending on whether the member has Medicare Plus Blue or BCN coverage.
  • Rhinoplasty — The list of procedure codes for which the questionnaire will open differs depending on whether the member has Medicare Plus Blue or BCN coverage.

Accessing preview questionnaires, authorization criteria and medical policies

You can access the preview questionnaires, authorization criteria and medical policies on the following pages of this website:

As a reminder, we use our authorization criteria, our medical policies and your answers to the questionnaires in the e-referral system when making utilization management determinations on your authorization requests.

Posted: December 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Urgent request: Contact us if you can offer behavioral health appointments for members affected by the Oxford High School tragedy

In the wake of the tragedy at Oxford High School, Blue Cross Blue Shield of Michigan and Blue Care Network want to make sure that there are behavioral health appointments available for any members who urgently need care.

What we’re asking

We ask that our participating behavioral health professionals dedicate some time to see Blue Cross and BCN members who have been affected by this tragedy. This means that you’d make appointments available for these members on an urgent basis over the next few weeks — either face to face or via telemedicine.

We can use your help whether you’re located close to Oxford, Michigan, or farther away.

Action to take

If you're able to accommodate additional appointments and see these members within a day or two of a request, email William Beecroft, M.D., at WBeecroft@bcbsm.com with the following information:

  • The names, -NPIs and Tax IDs of your staff who will see these members
  • The contact information for these staff so we can do a “warm handoff” of our members
  • The number of members you might be able to accommodate in the next two or three weeks
  • The ages of the patients you can see
  • The general times that appointments might be available

Thank you

If you'll agree to accommodate one or more patients who have urgent needs, we'd be grateful for your help.

We expect the surge of patients will be most acute in the next two or three weeks. It's this acute stage we're most concerned about. The acute need may taper off after that, and you'll follow your usual triage procedure to prioritize patients who request appointments. We do, however, expect that more members will ask for care over the next year.

We appreciate your help in this time of crisis.

Posted: December 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Changes to the prior authorization list for medical benefit drugs for Medicare Advantage members

We're adding and removing prior authorization requirements for Medicare Plus BlueSM and BCN AdvantageSM members as follows.

Additional drug to require prior authorization

For dates of service on or after Dec. 27, 2021, Susvimo (ranibizumab injection, for ocular implant), HCPCS code J3590, will require prior authorization through the NovoLogix® online tool.

NovoLogix offers real-time status checks and immediate approvals for certain medications. If you have access to Provider Secured Services, you already have access to NovoLogix. If you need to request access to Provider Secured Services, complete the Provider Secured Access Application (PDF) form and fax it to the number on the form.

We require prior authorization for this drug when it’s administered by a health care professional in a provider office, at the member’s home, in an off-campus or on-campus outpatient hospital or in an ambulatory surgical center (place of service codes 11, 12, 19, 22 and 24) and billed as follows:

  • Electronically through an 837P transaction or on a professional CMS-1500 claim form
  • Electronically through an 837I transaction or by using the UB04 claim form for a hospital outpatient type of bill 013x

Drug that will no longer require prior authorization

For dates of service on or after Dec. 1, 2021, Tegsedi® (inotersen), HCPCS code J3490, no longer requires prior authorization.

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members (PDF).

We'll update the list to reflect these changes prior to the effective dates.

Posted: November 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Clarifications on the CareCentrix home health care program for Medicare Advantage members

CareCentrix® has managed authorizations for home health care services for Medicare Plus BlueSM and BCN AdvantageSM members since June 2021.

Based on feedback CareCentrix has received, we've added information about the following to the Home health care: Frequently asked questions for providers (PDF) document.

When to notify CareCentrix that a member has stopped receiving services prior to the end date on their authorization

Because CareCentrix can't approve a new prior authorization request for a member who has an active authorization for home health services, you need to notify CareCentrix when:

  • The member is discharged from a home health agency's care, is readmitted to an inpatient setting and then requires additional home health services following discharge
  • A member changes home health agencies during a 30-day authorization duration
  • A member’s health care coverage is terminated during a 30-day authorization duration

To notify CareCentrix, call 1-833-409-1280. Once CareCentrix modifies the authorization end date, they will make determinations on new prior authorizations you submit for the member.

How to search for members by last name in the HomeBridge® portal

To search for members by last name in the HomeBridge portal:

  1. Complete all required fields other than the Last Name Search field.
  2. In the Last Name Search field, do one of the following:
    • If the member's last name DOESN'T include spaces or special characters: Enter the member’s full last name.
    • If the member's last name includes spaces or special characters (such as hyphens, apostrophes or periods): Enter only the first alphabetic character of the member's last name.

      If you enter a space or special character in the Last Name Search field, you’ll receive an error message that reads “Patient last name cannot have characters other than alpha numeric.”

  3. Click Continue.

How to confirm the CareCentrix-generated HIPPS code to include on claims for services provided to members with Medicare Plus Blue plans

CareCentrix assigns HIPPS codes to authorizations for home health services received by Medicare Plus Blue members within Michigan. The HIPPS code that you submit on the claim must match the CareCentrix-generated HIPPS code that appears on the Service Registration Form, or SRF, or on the Authorization Status screen in the HomeBridge portal.

If you don't provide a HIPPS code or complete the HIPPS questionnaire when you submit the prior authorization request, CareCentrix will proceed with making a determination on the request. If they approve the request, they'll send a SRF form that doesn't include a HIPPS code. Once they've processed the approval, CareCentrix will assign a HIPPS code and send an updated SRF that includes the HIPPS code.

If you don’t receive an updated SRF, you can find the CareCentrix-assigned HIPPS code by checking the Authorization Status screen in the HomeBridge portal or by calling CareCentrix at 1-833-409-1280 from 8 a.m. to 11 p.m. Eastern time any day, excluding holidays.

CareCentrix is an independent company that manages the authorization of home health care services for Blue Cross Blue Shield of Michigan and Blue Care Network members who have Medicare Advantage plans.

Posted: November 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Nov. 25-26 holiday closures: How to submit inpatient authorization requests

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will be closed on for the Thanksgiving holidays on these days:

  • Thanksgiving Day – Thursday, Nov. 25, 2021
  • Day after Thanksgiving – Friday, Nov. 26, 2021

Refer to the document Holiday closures: How to submit authorization requests (PDF) for instructions on how to submit authorization requests for inpatient admissions during the closure.

You can access this document on the ereferrals.bcbsm.com website, on these webpages:

Here are the additional holiday closures that will occur during 2021, so you can plan ahead:

  • Christmas Holiday – Thursday, Dec. 23
  • Christmas Eve – Friday, Dec. 24
  • New Year's Holiday – Thursday, Dec. 30
  • New Year's Eve – Friday, Dec. 31

Posted: November 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



e-referral system out of service for maintenance overnight Nov. 20-21

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

From 10 p.m. on Saturday, Nov. 20 to 10 a.m. on Sunday, Nov. 21

Note: All times are Eastern time.

The e-referral system will not be available at all during these times. Here’s additional information:

  • On Sunday, the system will be available by 10 a.m. It may be available earlier if maintenance tasks are completed.
  • We expect the system to be available during the remaining time over the weekend, although you may experience minor performance issues.

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

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

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

Posted: November 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



AIM Specialty Health® technical issue is resolved

AIM Specialty Health has informed us that the technical issue they were having on Nov. 9 and 10, 2021, has been resolved.

This issue was causing some providers to be categorized as out of network when a prior authorization request was submitted.

Providers should now experience normal operations when submitting prior authorization requests through the AIM Contact Center and the AIM ProviderPortal.

As a reminder, AIM manages authorizations for various Blue Cross commercial, Medicare Plus Blue, BCN commercial and BCN Advantage members for these services:

  • Select cardiology and radiology services
  • Medical oncology and supportive care drugs
  • High-tech radiology
  • In-lab sleep management
  • Radiation oncology

Posted: November 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Susvimo requires prior authorization for commercial members, starting Nov. 18

Susvimo (ranibizumab injection, for ocular implant), HCPCS code J3590, requires prior authorization for Blue Cross and Blue Care Network group and individual commercial members starting Nov. 18, 2021.

Some Blue Cross commercial groups not subject to these requirements

For Blue Cross commercial groups, this authorization requirement applies only to groups that currently participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list (PDF).

Note: Blue Cross and Blue Shield Federal Employee Program® members and UAW Retiree Medical Benefits Trust (non-Medicare) members don't participate in the standard prior authorization program.

When submitting requests on or after Nov. 18, 2021

Starting Nov. 18, submit prior authorization requests through the NovoLogix® online tool.

To learn how to submit requests through NovoLogix, visit ereferrals.bcbsm.com and do the following:

  • For Blue Cross commercial members: Click Blue Cross and then click Medical Benefit Drugs. In the Blue Cross commercial column, see the "How to submit requests electronically using NovoLogix" section.
  • For BCN commercial members: Click BCN and then click Medical Benefit Drugs. In the BCN commercial column, see the "How to submit requests electronically using NovoLogix" section.

When submitting requests before Nov. 18, 2021

Prior to Nov. 18, fax your request for preservice review as follows:

  • For Blue Cross commercial members: Fax to Provider Inquiry at 1 866 311 9603.
  • For BCN commercial members: Fax to the Medical Drug Help Desk at 1 877 325 5979.

List of requirements

For a full list of requirements related to drugs covered under the medical benefit, see the Blue Cross and BCN utilization management medical drug list for Blue Cross PPO (commercial) and BCN HMO (commercial) members (PDF).

We'll update this list with the new Susvimo requirement prior to the effective date.

Authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

Posted: November 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Additional autism interventions now payable via telemedicine on an ongoing basis and restrictions are removed from protocol modification (*97155)

As previously communicated, Blue Cross Blue Shield of Michigan and Blue Care Network began allowing some services for autism spectrum disorder to be payable when delivered via telemedicine as a temporary measure during the COVID-19 pandemic.

Effective Nov. 1, 2021, we're updating our Autism Spectrum Disorder Services medical policy to allow those services to be payable via telemedicine on an ongoing basis. We're also removing restrictions on protocol modification (*97155).

These changes apply to members whose coverage includes an autism benefit.

Note: To determine which procedures can be performed via telehealth for Medicare Plus BlueSM members who have an autism benefit, see the Medicare-covered telehealth services for the COVID-19 PHE (PDF) document.

Services that are payable via telemedicine on an ongoing basis, effective Nov. 1

Per the updated medical policy, we'll allow the following autism services to be delivered via synchronous (real time) telemedicine on an ongoing (no longer temporary) basis:

  • Assessment, *97151
  • Applied behavior analysis, or ABA, *97153

    Note: This service is allowed via telehealth for children who meet appropriateness criteria. The Guidelines for autism interventions delivered via telemedicine (PDF) document offers guidance in determining which members can benefit from direct-line ABA interventions delivered via telemedicine.

  • Skills training, *97154
  • Intensive skills training, *97158

Restrictions lifted on protocol modification

Per the updated medical policy, protocol modification, *97155, will be allowed via real-time telemedicine visits 100% of the time. (Previously, this service was allowed to be delivered via telemedicine only 50% of the time.)

Note: During the COVID-19 pandemic for dates of service from April 14, 2020, through Oct. 31, 2021, we allowed licensed behavior analysts, or LBAs, to troubleshoot treatment protocols directly with the parent/caregiver functioning as the behavioral technician. With the Nov. 1, 2021, update to the Autism Spectrum Disorder medical policy, this temporary measure is no longer payable.

Reminder

The following services continue to be payable when delivered via real-time telemedicine: caregiver training (*97156), multi-family caregiver training (*97157), supervision (S5108) and caregiver training (S5111).

Note: S5108 and S5111 are payable only to Michigan providers who deliver services to out-of-state members and cannot use the American Medical Association category 1 codes.

Updated documents

By Nov. 1, we'll update the following documents to reflect this change:

  • Telehealth for behavioral health providers
  • Temporary changes due to the COVID-19 pandemic

You can find these documents on our public website at bcbsm.com/coronavirus or within Provider Secured Services.

You can view the updated Telemedicine Services medical policy through the BCN Medical Policy Manual. To do this:

  1. Log in as a provider at bcbsm.com/providers.
  2. Click the BCN Provider Publications and Resources link on the right.
  3. Click Medical Policy Manual on the left, under “Other Resources.”
  4. Click Policies by name on the right.
  5. Click A, scroll to Autism Spectrum Disorder Services and click the link.

Soon, the updated policy will also be available through our Medical Policy & Pre-Cert/Pre-Auth Router on bcbsm.com.

*CPT codes, descriptions and two-digit modifiers only are copyright 2020 American Medical Association. All rights reserved.

Posted: November 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Intensive outpatient program and partial hospital program services now payable via telemedicine on an ongoing basis

As previously communicated, Blue Cross Blue Shield of Michigan and Blue Care Network began allowing behavioral health IOP and PHP services to be payable when provided by contracted facilities via telemedicine as a temporary measure during the COVID-19 pandemic.

Effective Nov. 1, 2021, we're updating our Telemedicine Services medical policy to allow these services to be payable when delivered by contracted facility providers via synchronous (real time) telemedicine on an ongoing basis, rather than as a temporary measure. We're doing this to make it easier for members to receive these services beyond the COVID-19 pandemic.

For more information, including information about billing for these services, see the Telehealth for behavioral health providers document.

Reminders

  • Facilities can provide behavioral health IOP and PHP services to BCN commercial and BCN AdvantageSM members only when their contracts specifically include IOP and PHP services.
  • For Blue Cross commercial members, most plans don't cover IOP services for mental health or PHP services for substance use disorders. IOP services for substance use disorders must be delivered by a substance abuse treatment facility. Be sure to check member eligibility and benefits through web-DENIS or Provider Inquiry prior to performing services.
  • For Medicare Plus BlueSM members, follow Centers for Medicare & Medicaid Services guidance.

Updated documents

By Nov. 1, we'll update the following documents to reflect this change:

  • Telehealth for behavioral health providers
  • Temporary changes due to the COVID-19 pandemic

You can find these documents on our public website at bcbsm.com/coronavirus or within Provider Secured Services.

You can view the updated Telemedicine Services medical policy through the BCN Medical Policy Manual. To do this:

  1. Log in as a provider at bcbsm.com/providers.
  2. Click the BCN Provider Publications and Resources link on the right.
  3. Click Medical Policy Manual on the left, under “Other Resources.”
  4. Click Policies by name on the right.
  5. Click T and then click Telemedicine Services.

Soon, the updated policy will also be available through our Medical Policy & Pre-Cert/Pre-Auth Router on bcbsm.com.

Posted: November 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Behavioral health services delivered via synchronous telemedicine

With the Nov. 1, 2021, updates to the following medical policies, additional behavioral health and autism spectrum disorder, or ASD, services are payable when delivered via telemedicine:

  • Telemedicine Services
  • Autism Spectrum Disorder Services

Behavioral health and ASD services must be delivered synchronously (in real time), with the exception of *96130 and *96156, which can be delivered asynchronously.

Telemedicine asynchronous (store and forward) care is generally not payable for behavioral health services.

This applies to Blue Cross commercial, Medicare Plus BlueSM, BCN commercial and BCN AdvantageSM members.

For more information about providing behavioral health and ASD services via telemedicine, see the Telehealth for behavioral health providers document, which is available on our public website at bcbsm.com/coronavirus or within Provider Secured Services.

You can view the updated medical policies through the BCN Medical Policy Manual. To do this:

  1. Log in as a provider at bcbsm.com/providers.
  2. Click the BCN Provider Publications and Resources link on the right.
  3. Click Medical Policy Manual on the left, under “Other Resources.”
  4. Click Policies by name on the right.
  5. Do one of the following:
    • Click A, scroll to Autism Spectrum Disorder Services and click the link.
    • Click T and then click Telemedicine Services.

Soon, the updated policies will also be available through our Medical Policy & Pre-Cert/Pre-Auth Router on bcbsm.com.

*CPT codes, descriptions and two-digit modifiers only are copyright 2020 American Medical Association. All rights reserved.

Posted: November 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Starting Oct. 24, updated questionnaire to open in the e-referral system

On Oct. 24, 2021, we'll update the Endoscopy, upper gastrointestinal, for Gastroesophageal Reflux Disease (GERD) questionnaire for BCN commercial and BCN AdvantageSM members in the e-referral system.

We'll also update the corresponding authorization criteria and preview questionnaire on this website.

As a reminder, we use our authorization criteria, our medical policies and your answers to the questionnaires in the e-referral system when making utilization management determinations on your authorization requests.

Preview questionnaires

You can access preview questionnaires on this website to see the questions you'll need to answer in the e-referral system. This can help you prepare your answers ahead of time.

To find the preview questionnaires, click BCN and then click Authorization Requirements & Criteria. Scroll down and look under the “Authorization criteria and preview questionnaires” heading.

Authorization criteria and medical policies

The pertinent authorization criteria and medical policies are also available on the Authorization Requirements & Criteria page.

Posted: October 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Update: CADC and CAADC credentials not required for facilities that treat substance use disorders

Staff who work at facilities contracted with Blue Cross Blue Shield of Michigan and Blue Care Network for the treatment of substance use disorders are not required to have a Certified Alcohol and Drug Counselor (CADC) or Certified Advanced Alcohol and Drug Counselor (CAADC) credential.

This reverses our earlier communications on this topic, including an article in the August 2021 issue of The Record, an article in the September-October 2021 issue of BCN Provider News, a web-DENIS message posted July 1, 2021, and a news item posted in July on our ereferrals.bcbsm.com website.

Reason for the change

After we published the earlier communications, we had additional discussions with our contracted facilities and determined that requiring the CADC or CAADC credential creates hardships for facilities that are trying to recruit staff during the pandemic.

As a result, Blue Cross and BCN are dropping the CADC / CAADC requirement and will defer to the agencies that accredit our contracted facilities (the Commission on Accreditation of Rehabilitation Facilities, The Joint Commission and similar agencies) to ensure that standards related to the education and credentialing of facility staff are met.

It's our hope that this will provide some relief as the pandemic continues and our contracted facilities continue to face challenges in recruiting clinical staff.

Which providers this applies to

This applies to facilities that treat members who have coverage through these plans:

  • Blue Cross Blue Shield of Michigan commercial
  • Medicare Plus BlueSM
  • Blue Care Network commercial
  • BCN AdvantageSM

This applies to facilities that provide and bill for one or more of the following types of treatment for substance use disorders:

  • Subacute detoxification
  • Residential treatment
  • Partial hospital program
  • Intensive outpatient program
  • Individual treatment

Posted: October 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



e-referral system out of service for maintenance overnight Oct. 16-17

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

From 10 p.m. on Saturday, Oct. 16 to 10 a.m. on Sunday, Oct. 17

Note: All times are Eastern time.

The e-referral system will not be available at all during these times. Here's additional information:

  • On Sunday, the system will be available by 10 a.m. It may be available earlier if maintenance tasks are completed.
  • We expect the system to be available during the remaining time over the weekend, although you may experience minor performance issues.

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

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

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

Posted: October 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network

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Prior authorization requirements expanding for Medicare Plus Blue, BCN commercial and BCN AdvantageSM members on Jan. 1

We're expanding our prior authorization requirements for Medicare Plus Blue, BCN commercial and BCN Advantage members. You'll need to complete questionnaires in the e-referral system for additional procedure codes when you submit prior authorization requests for dates of service on or after Jan. 1, 2022.

To learn more about this change, see the detailed provider alert (PDF).

Posted: October 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



TurningPoint to review sites of care for total hip and knee surgeries for some members, starting Jan. 3

For dates of service on or after Jan. 3, 2022, TurningPoint Healthcare Solutions LLC will review the site of care for total hip and knee surgeries as part of each authorization determination. Based on medical necessity review, TurningPoint may approve authorization requests for select total hip and knee cases only when scheduled in an outpatient setting.

This applies to members with the following coverage:

  • Medicare Plus BlueSM
  • BCN commercial
  • BCN AdvantageSM

If TurningPoint approves an authorization for a hip or knee surgery in an outpatient setting and the member experiences a change in condition that requires an inpatient admission, you'll need to submit an authorization request for the inpatient admission (procedure code *99222) through the e-referral system; see the "Submit an inpatient authorization" section of the e-referral User Guide (PDF) for more information. Blue Cross or BCN will review the request using InterQual® criteria.

Performing total hip and knee surgeries in outpatient settings is supported by both evidence-based guidelines and the Centers for Medicare & Medicaid Services.

Additional information

We reported this change in the October 2021 issue of The Record. We'll also cover it in the November-December 2021 issue of BCN Provider News.

For more information about the TurningPoint musculoskeletal surgical quality and safety management program, see these pages on this website:

*CPT codes, descriptions and two-digit modifiers only are copyright 2020 American Medical Association. All rights reserved.

Posted: October 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



AIM Specialty Health® delays are resolved

AIM Specialty Health has informed us that the delays they were experiencing on Sept. 29 and 30 have been resolved.

Internet service provider issues across the country were causing delays in the AIM Contact Center (1-800-728-8008) and in the AIM ProviderPortal® (www.aimspecialtyhealth.com)*.

Providers should now experience normal operations when calling the AIM Contact Center and using the AIM ProviderPortal.

As a reminder, AIM manages authorizations for various Blue Cross commercial, Medicare Plus Blue, BCN commercial and BCN Advantage members for these services:

  • Select cardiology and radiology services
  • Medical oncology and supportive care drugs
  • High-tech radiology
  • In-lab sleep management
  • Radiation oncology

Posted: October 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Nexviazyme and Saphnelo will have prior authorization and site-of-care requirements for commercial members, starting Sept. 24

The following drugs will have prior authorization and site-of-care requirements for Blue Cross Blue Shield of Michigan and Blue Care Network group and individual commercial members, starting Sept. 24, 2021:

  • Saphnelo (aniforlumab-fnia), HCPCS code J3590
  • Nexviazyme (avaglucosidase alfa-ngpt), HCPCS code J3590

Some Blue Cross commercial groups not subject to these requirements

For Blue Cross commercial groups, this authorization requirement applies only to groups that currently participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list (PDF).

Note: Blue Cross and Blue Shield Federal Employee Program® members and UAW Retiree Medical Benefits Trust (non-Medicare) members don't participate in the standard prior authorization program.

When submitting requests on or after Sept. 24, 2021

Starting Sept. 24, 2021, submit prior authorization requests through the NovoLogix® online tool.

To learn how to submit requests through NovoLogix, visit ereferrals.bcbsm.com and do the following:

  • For Blue Cross commercial members: Click Blue Cross and then click Medical Benefit Drugs. In the Blue Cross commercial column, see the “How to submit requests electronically using NovoLogix” section.
  • For BCN commercial members: Click BCN and then click Medical Benefit Drugs. In the BCN commercial column, see the “How to submit requests electronically using NovoLogix” section.

When submitting requests before Sept. 24, 2021

Prior to Sept. 24, 2021, fax your request for preservice review as follows.

  • For Blue Cross commercial members: Fax to Provider Inquiry at 1 866 311 9603.
  • For BCN commercial members: Fax to the Medical Drug Help Desk at 1 877 325 5979.

List of requirements

For a full list of requirements related to drugs covered under the medical benefit, see the Blue Cross and BCN utilization management medical drug list for Blue Cross PPO (commercial) and BCN HMO (commercial) members (PDF).

We'll update this list with the new requirements prior to the effective date.

Authorization isn’t a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

Posted: September 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Clinical review requirements suspended for admission to skilled nursing facilities from all Michigan hospitals due to latest COVID-19 surge

Effective Sept. 20, 2021 and until further notice, Blue Cross Blue Shield of Michigan and Blue Care Network are temporarily suspending clinical review requirements for the first three days of admission to skilled nursing facilities from all Michigan hospitals due to the latest surge in COVID-19 cases. This temporary change applies to all lines of business, including Blue Cross Blue Shield of Michigan commercial, Blue Care Network commercial, Medicare Plus BlueSM and BCN AdvantageSM.

Blue Cross and BCN began suspending clinical review requirements for the first three days of admission to skilled nursing facilities Sept. 1, for those states most impacted by the surge in COVID-19 cases. For the list of states with this clinical review suspension, refer to the UPDATE: Clinical review requirements temporarily suspended for admissions to skilled nursing facilities from hospitals in certain states (PDF).

Information you need to know

  • Admissions to skilled nursing facilities from Michigan hospitals and hospitals in certain other states will auto-approve the first three days. Clinical documentation is not required until the continued stay review, starting on the fourth day of stay.
  • This temporary change does not apply to Blue Cross Blue Shield of Michigan commercial FlexLink® groups for which a third-party administrator makes authorization determinations. Facilities should check the back of the member's ID card to determine whether a third-party administrator needs to be contacted prior to an admission.
  • Long-term acute care hospital and inpatient rehabilitation facility admissions still require clinical review.

Posted: September 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



CareCentrix® home health care program: Updated training resources, new and updated documents available

CareCentrix manages prior authorizations for home health care services for Medicare Plus BlueSM and BCN AdvantageSM members as follows:

  • For episodes of care that start on or after June 1, 2021
  • For episodes of care that started prior to June 1, 2021, when one of the following occurs on or after June 1: recertification is needed, resumption of care is needed or there's a significant change in condition

Where to find CareCentrix home health care resources:

You can find the training resources and links to the documents related to this program on the following pages of this website:

More about the updated training resources

Based on provider feedback, we updated the webinar recording and the PDF of the webinar presentation. These updated resources are available on our dedicated provider training site.

For information about accessing this site, see the webpages that are linked above.

More about the new and updated documents

We added these documents:

  • Home health care: Clinical documentation requirements
  • Home health care: Submitting authorization requests to CareCentrix
  • Home health care: Linking your agency’s NPI(s) and TIN(s)

We clarified and added information in these documents:

  • Home health care: Frequently asked questions for providers
  • Home health care: Quick reference guide

Posted: September 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



e-referral system out of service for maintenance overnight Sept. 18-19

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

From 10 p.m. on Saturday, Sept. 18 to 10 a.m. on Sunday, Sept. 19

Note: All times are Eastern time.

The e-referral system will not be available at all during these times. Here's additional information:

  • On Sunday, the system will be available by 10 a.m. It may be available earlier if maintenance tasks are completed.
  • We expect the system to be available during the remaining time over the weekend, although you may experience minor performance issues.

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

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

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

Posted: September 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Ryplazim® requires prior authorization for commercial members starting Sept. 17

Ryplazim (plasminogen, human-tvmh), HCPCS code J3590, requires prior authorization for Blue Cross and Blue Care Network group and individual commercial members starting Sept. 17, 2021.

Some Blue Cross commercial groups not subject to these requirements

For Blue Cross commercial groups, this authorization requirement applies only to groups that currently participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list (PDF).

Note: Blue Cross and Blue Shield Federal Employee Program® members and UAW Retiree Medical Benefits Trust (non-Medicare) members don't participate in the standard prior authorization program.

When submitting requests on or after Sept. 17

Starting Sept. 17, submit prior authorization requests through the NovoLogix® online tool.

To learn how to submit requests through NovoLogix, visit ereferrals.bcbsm.com and do the following:

  • For Blue Cross members: Click Blue Cross and then click Medical Benefit Drugs. In the Blue Cross commercial column, see the “How to submit requests electronically using NovoLogix” section.
  • For BCN members: Click BCN and then click Medical Benefit Drugs. In the BCN commercial column, see the “How to submit requests electronically using NovoLogix” section.

When submitting requests before Sept. 17

Prior to Sept. 17, fax your requests for preservice review as follows.

  • For Blue Cross members: Fax to Provider Inquiry at 1 866 311 9603.
  • For BCN members: Fax to the Medical Drug Help Desk at 1 877 325 5979.

List of requirements

For a full list of requirements related to drugs covered under the medical benefit, see the Blue Cross and BCN utilization management medical drug list for Blue Cross PPO (commercial) and BCN HMO (commercial) members (PDF).

We'll update this list with the new Ryplazim requirement prior to the effective date.

Authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

Posted: September 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



TurningPoint to allow additional substitutions for orthopedic procedure codes

For dates of service on or after Sept. 10, 2021, TurningPoint Healthcare Solutions LLC will allow additional procedure code substitutions for orthopedic procedures.

This will affect claim submissions for Blue Cross commercial, Medicare Plus BlueSM, BCN commercial and BCN AdvantageSM members.

To learn more about this change, see the detailed provider alert (PDF).

Posted: September 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Saphnelo and Nexviazyme to require prior authorization for Medicare Advantage members

The following drugs will require prior authorization through the NovoLogix® online tool for dates of service on or after Sept. 1, 2021:

  • Saphnelo (anifrolumab-fnia), HCPCS code J3590
  • Nexviazyme (avalglucosidase alfa-ngpt), HCPCS code J3490

This requirement applies to Medicare Plus BlueSM and BCN AdvantageSM members.

When prior authorization is required

For Medicare Advantage members, we require prior authorization for these drugs when they're administered by a health care professional in a provider office, at the member's home, in an off-campus or on-campus outpatient hospital or in an ambulatory surgical center (place of service codes 11, 12, 19, 22 and 24) and billed as follows:

  • Electronically through an 837P transaction or on a professional CMS-1500 claim form
  • Electronically through an 837I transaction or by using the UB04 claim form for a hospital outpatient type of bill 013x

Important reminder

Submit prior authorization requests for these drugs through NovoLogix. It offers real-time status checks and immediate approvals for certain drugs.

If you have access to Provider Secured Services, you already have access to NovoLogix.

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

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members.

We'll update the list to reflect these changes prior to the effective date.

Posted: September 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



How to submit prior authorization requests for drugs that are managed by AIM when the drugs are prescribed for non-oncology diagnoses

AIM Specialty Health® manages authorizations for medical oncology drugs for most members. They don't manage those drugs when prescribed for non-oncology diagnoses.

When prescribing these drugs for non-oncology diagnoses, don't submit the prior authorization to AIM. Instead:

  • For Blue Cross commercial fully insured members and UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans: Fax all clinical documentation to the Blue Cross Pharmacy Help Desk at 1-866-915-9187.

    Note: This requirement doesn't apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714).

  • For BCN commercial members: Fax all clinical documentation to the Blue Cross Pharmacy Help Desk at 1-877-402-7695.
  • For Medicare Plus BlueSM and BCN AdvantageSM members: Call the Blue Cross Blue Shield of Michigan and Blue Care Network Pharmacy Clinical Help Desk at 1-800-437-3803.

To determine which drugs this applies to, see the following drug lists:

We're updating these drug lists and other documents to reflect this requirement.

Posted: August 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Sept. 6 holiday closure: How to submit inpatient authorization requests

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will be closed on Monday, Sept. 6, 2021, for the Labor Day holiday.

Refer to the document Holiday closures: How to submit authorization requests (PDF) for instructions on how to submit authorization requests for inpatient admissions during the closure.

You can access this document on the ereferrals.bcbsm.com website, on these webpages:

Here are the additional holiday closures that will occur during 2021, so you can plan ahead:

  • Thanksgiving Day – Thursday, Nov. 25
  • Day after Thanksgiving – Friday, Nov. 26
  • Christmas Holiday – Thursday, Dec. 23
  • Christmas Eve – Friday, Dec. 24
  • New Year's Holiday – Thursday, Dec. 30
  • New Year's Eve – Friday, Dec. 31

Posted: August 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Starting Aug. 29, updated questionnaires to open in the e-referral system

On Aug. 29, 2021, we'll update the following questionnaires in the e-referral system:

  • Orthognathic surgery — For adult and pediatric BCN commercial and BCN AdvantageSM members
  • Vascular embolization or occlusion of hepatic tumors (TACE/RFA) — For adult Medicare Plus BlueSM, BCN commercial and BCN Advantage members. This questionnaire will start opening for procedure code *75894. (It already opens for procedure codes *37242 and *37243.)

We'll also update the corresponding preview questionnaires on this website.

As a reminder, we use our authorization criteria, our medical policies and your answers to the questionnaires in the e-referral system when making utilization management determinations on your authorization requests.

Preview questionnaires

You can access preview questionnaires on this website to see the questions youl'l need to answer in the e-referral system. This can help you prepare your answers ahead of time.

To find the preview questionnaires:

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

Authorization criteria and medical policies

The pertinent authorization criteria and medical policies are also available on the Authorization Requirements & Criteria page.

Posted: August 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



New TurningPoint Documentation Guideline for musculoskeletal procedures and related services

The TurningPoint Documentation Guideline (PDF), which was developed by TurningPoint Healthcare Solutions LLC, is now available from the following pages of this website:

This document replaces the Clinical documentation requirements for musculoskeletal procedures document and provides more detailed information about TurningPoint’s documentation requirements.

As a reminder, TurningPoint manages authorizations for orthopedic, pain management and spinal procedures for the following:

  • Blue Cross commercial* — All fully insured groups, select self-funded groups and all members with individual coverage
  • Medicare Plus BlueSM members
  • BCN commercial members
  • BCN AdvantageSM members

*To determine whether you need to submit prior authorization requests for Blue Cross commercial members, see the document titled Determining whether Blue Cross commercial members require prior authorization for musculoskeletal surgeries and related procedures (PDF).

Posted: August 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



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

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

From 10 p.m. on Saturday, Aug. 21 to 10 a.m. on Sunday, Aug. 22

Note: All times are Eastern time.

The e-referral system will not be available at all during these times. Here's additional information:

  • On Sunday, the system will be available by 10 a.m. It may be available earlier if maintenance tasks are completed.
  • We expect the system to be available during the remaining time over the weekend, although you may experience minor performance issues.

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

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

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

Posted: August 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Rybrevant requires prior authorization for dates of service on or after Sept. 27 for most members

For dates of service on or after Sept. 27, 2021, Rybrevant (amivantamab-vmjw), HCPCS codes J9999, J3490, J3590 and C9399, will require prior authorization through AIM Specialty Health®. This drug is covered under the medical benefit.

Prior authorization requirements apply when this drug is administered in outpatient settings for:

  • Blue Cross and Blue Shield of Michigan commercial members who have coverage through fully insured groups and who have individual coverage

    Exceptions: This requirement doesn't apply to Michigan Education Special Services Association members or members who have coverage through the Michigan Blue Cross and Blue Shield Federal Employee Program®. This requirement also doesn't apply to UAW Retiree Medical Benefits Trust PPO non-Medicare members and other members with coverage through self-funded groups.

  • Medicare Plus BlueSM members
  • Blue Care Network commercial members
  • BCN AdvantageSM members

How to submit authorization requests

Submit authorization requests to AIM using one of the following methods:

More about the authorization requirements

Authorization isn't a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members.

For additional information on requirements related to drugs covered under the medical benefit, see:

We'll update the appropriate drug lists to reflect the information in this message prior to the effective date.

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're not responsible for its content.

Posted: July 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Starting July 25, we'll use clinical information to validate providers' answers to some questionnaires in the e-referral system

Starting July 25, 2021, we'll pend some authorization requests that would usually be auto-approved based on your answers to the questionnaires in the e-referral system. This will allow us to validate the answers you provided on the questionnaire.

This applies to authorization requests submitted for BCN commercial, Medicare Plus BlueSM and BCN AdvantageSM members.

When we pend a request, you'll get this message in the e-referral system: “Case requires validation. Medical records required. Please attach clinical information from the patient's medical record applicable to this request in the Case Communication field.”

For instructions on how to attach clinical information to the authorization request in the e-referral system, refer to the e-referral User Guide (PDF). Look in the section titled "Create New (communication)."

When we receive the clinical information, we'll review it to confirm that it supports the information you provided in the questionnaire and then we'll make a determination on the request.

If we don't receive the clinical information or if the clinical information you send doesn't support your answers in the questionnaire, we won't be able to approve the request.

As a reminder, on the preview questionnaires that we publish on this website, we state that we will retrospectively monitor compliance with this authorization requirement. You can access the preview questionnaires:

Note: This change was originally scheduled to take place in June, which we communicated in March 2021 via a web-DENIS message and a news item on this website and in May through articles in our provider newsletters.

Posted: July 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Medicare Advantage home health care: Clarifications about adding disciplines and substituting services provided by clinicians with lower-level credentials

Effective June 1, 2021, CareCentrix® manages authorizations for home health care services for Medicare Plus BlueSM and BCN AdvantageSM members.

Here are some clarifications on this new program:

  • For Medicare Plus Blue members who receive services in Michigan, you don't need to submit requests to add disciplines to existing 30-day episodic authorizations that have already been approved by CareCentrix.
  • For BCN Advantage members, you don't need to update approved authorizations when services are provided by a clinician with a lower-level credential than the clinician who was authorized by CareCentrix.

See the detailed provider alert to learn more about these clarifications, including information to help you determine which HCPCS codes are associated to revenue codes by discipline.

Posted: July 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



AIM Specialty Health® technical issues are resolved

AIM Specialty Health has informed us that the technical issues they were having on July 7 have been resolved.

These issues were causing delays in the AIM Contact Center and in the AIM ProviderPortal®.

Providers should now experience normal operations when calling the AIM Contact Center and using the AIM ProviderPortal.

As a reminder, AIM manages authorizations for various Blue Cross commercial, Medicare Plus Blue, BCN commercial and BCN Advantage members for these services:

  • Select cardiology and radiology services
  • Medical oncology and supportive care drugs
  • High-tech radiology
  • In-lab sleep management
  • Radiation oncology

Posted: July 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Here's how to choose the correct servicing provider in e-referral to avoid denied claims

To avoid any problems when submitting authorizations and referrals in e-referral, we're clarifying the steps for choosing the correct servicing provider.

Keep in mind that the provider you’re looking for may be listed multiple times. Here's how to make sure you're choosing the correct listing:

  1. When your servicing provider results are returned, select the listing based on where the member is going to see the provider.

  2. If the provider has several listings with the same address, select the listing that also shows a group affiliation. If there are multiple group affiliations listed, make sure to choose the correct one.
  3. Not all provider addresses will be considered in network. If you select a listing that shows the provider is out of network ("Out" in the Network column), you'll have to go through an out-of-network review.

This information, including screen examples, can be found in the following sections of the e-referral user guides:

  • e-referral User Guide (PDF)
    • "Submit a Global Referral"
    • "Submit a Referral"
    • "Submit an Inpatient Authorization"
    • "Submit an Outpatient Authorization"
  • Behavioral Health e-referral User Guide (PDF)
    • "Submitting Higher Levels of Care Inpatient Authorizations"
    • "Submitting Higher Levels of Care Outpatient Authorizations"
    • "Submitting an Electroconvulsive Therapy Authorization"
    • "Submitting a Transcranial Magnetic Stimulation Authorization"
    • "Submitting a Neurofeedback Authorization"
  • e-referral User Guide for Blue Cross® Physician Choice PPO (PDF)
    • "Submit a Referral"
    • "Submit an Inpatient Authorization"

It can also be found in the e-referral Quick Guide (PDF) under the "Select provider/patient" section. This information is also published on Page 30 of the July-August 2021 BCN Provider News (PDF) and the July 2021 issue of The Record.

Posted: July 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Aduhelm to require prior authorization for commercial members starting July and August

Aduhelm (aducanumab-avwa), HCPCS code J3590, will require prior authorization through the NovoLogix® online tool as follows:

  • For Blue Care Network commercial members: For courses of therapy starting on or after July 5, 2021
  • For Blue Cross Blue Shield of Michigan commercial members: For courses of therapy starting on or after Aug. 23, 2021

Some Blue Cross commercial groups not subject to these requirements

For Blue Cross commercial members, this authorization requirement applies only to groups that currently participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list (PDF).

Note: Blue Cross and Blue Shield Federal Employee Program® members and UAW Retiree Medical Benefits Trust (non-Medicare) members don't participate in the standard prior authorization program.

How to submit prior authorization requests

Submit prior authorization requests through NovoLogix. It offers real-time status checks and immediate approvals for certain medications.

To learn how to submit requests through NovoLogix, do the following on this website:

  • For BCN commercial members: Click BCN and then click Medical Benefit Drugs. In the BCN commercial column, see the "How to submit requests electronically using NovoLogix" section.
  • For Blue Cross commercial members: Click Blue Cross and then click Medical Benefit Drugs. In the Blue Cross commercial column, see the "How to submit requests electronically using NovoLogix" section.

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Blue Cross and BCN utilization management medical drug list for Blue Cross PPO (commercial) and BCN HMO (commercial) members (PDF) document. There are links to this document on the Medical Benefit Drug pages of this website.

We'll update this list with these new requirements prior to the effective dates.

Authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

Posted: July 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



July 5 holiday closure: How to submit inpatient authorization requests

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will be closed on Monday, July 5, 2021, for the Independence Day holiday.

Refer to the document Holiday closures: How to submit authorization requests (PDF) for instructions on how to submit authorization requests for inpatient admissions during the closure.

You can access this document on the ereferrals.bcbsm.com website, on these webpages:

Here are the additional holiday closures that will occur during 2021, so you can plan ahead:

  • Labor Day – Monday, Sept. 6
  • Thanksgiving Day – Thursday, Nov. 25
  • Day after Thanksgiving – Friday, Nov. 26
  • Christmas Holiday – Thursday, Dec. 23
  • Christmas Eve – Friday, Dec. 24
  • New Year's Holiday – Thursday, Dec. 30
  • New Year's Eve – Friday, Dec. 31

Posted: June 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Updated pain management questionnaires and Postservice change request form for submitting requests to TurningPoint coming in July

Blue Cross Blue Shield of Michigan, Blue Care Network and TurningPoint Health Care Solutions LLC continue to identify ways to enhance your experience with the TurningPoint surgical quality and safety management program.

We're currently working on the following enhancements, which will be available in July 2021:

  • For pain management procedures: We're updating the questions on the questionnaires you complete when you request authorizations.
  • For all orthopedic, pain management and spinal procedures: We're updating the Postservice change request form.

When the updated forms are available, we'll let you know through a web-DENIS message and a news item on this website.

Pain management questionnaires

To simplify the process of submitting prior authorization requests, we're updating most questions on the following questionnaires to require a "yes" or "no" response:

  • Epidural steroid injections
  • Facet joint injections
  • Neuroablation procedures
  • Sacroiliac joint injections

These questions appear on the questionnaires in the TurningPoint Provider Portal and in the fax forms for submitting prior authorization requests.

Postservice change request form

We're updating the Postservice change request fax form as follows:

  • Adding information about procedure code substitutions to help you identify situations where you can substitute a different procedure code for the procedure code TurningPoint authorized
  • Adding the following questions:
    • “Have you submitted a claim to Blue Cross or BCN?”
    • “Have you submitted an appeal to Blue Cross or BCN?”
    • Your answers to these questions will streamline the steps required to process postservice change requests.

Where to find fax forms for the TurningPoint program

You can find all fax forms for the TurningPoint program on the following pages of this website, along with other resources:

Information about previous enhancements to this program

To view other enhancements to the TurningPoint program, see:

Additional information

As a reminder, TurningPoint manages authorizations for orthopedic, pain management and spinal procedures for the following:

  • Blue Cross commercial* - All fully insured groups, select self-funded groups and all members with individual coverage
  • Medicare Plus BlueSM members
  • BCN commercial members
  • BCN AdvantageSM members

*To determine whether you need to submit prior authorization requests for Blue Cross commercial members, see the document titled Determining whether Blue Cross commercial members require prior authorization for musculoskeletal surgeries and related procedures (PDF).

Posted: June 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Starting June 27, updated questionnaires to open in the e-referral system

On June 27, 2021, we'll update the following questionnaires in the e-referral system:

  • Artificial heart, total - For adult and pediatric Blue Care Network commercial members. This questionnaire will no longer open for procedure code *33929. It will begin opening for procedure code *33995 and will continue to open for the other codes listed in the Artificial heart, total (PDF) preview questionnaire.
  • Hammertoe correction surgery - For adult Medicare Plus BlueSM, BCN commercial and BCN AdvantageSM members. This questionnaire will no longer open for procedure code *28160. It will continue to open for the other procedures codes listed in the Hammertoe correction surgery (PDF) preview questionnaire.
  • Pediatric feeding - For BCN commercial members ages 18 and younger

We'll also update the corresponding preview questionnaire on the ereferrals.bcbsm.com website.

As a reminder, we use our authorization criteria, our medical policies and your answers to the questionnaires in the e-referral system when making utilization management determinations on your authorization requests.

Preview questionnaires

You can access preview questionnaires at ereferrals.bcbsm.com. They show the questions you'll need to answer in the actual questionnaires that open in the e-referral system. This can help you prepare your answers ahead of time.

To find the preview questionnaires:

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

Authorization criteria and medical policies

The pertinent authorization criteria and medical policies are also available on the Authorization Requirements & Criteria page.

*CPT codes, descriptions and two-digit modifiers only are copyright 2020 American Medical Association. All rights reserved.

Posted: June 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Empaveli to require prior authorization for commercial members starting June and August

Empaveli (pegcetacoplan), HCPCS code J3590, will require prior authorization through the NovoLogix® online tool for the following members:

  • Blue Care Network commercial members, for courses of therapy starting on or after June 28, 2021
  • Blue Cross Blue Shield of Michigan commercial members, for courses of therapy starting on or after Aug. 2, 2021

Some Blue Cross commercial groups not subject to these requirements

For Blue Cross commercial members, these authorization requirements apply only to groups that currently participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list (PDF).

Note: Blue Cross and Blue Shield Federal Employee Program® members and UAW Retiree Medical Benefits Trust (non-Medicare) members don't participate in the standard prior authorization program.

How to submit prior authorization requests

Submit prior authorization requests through NovoLogix. It offers real-time status checks and immediate approvals for certain medications.

To learn how to submit requests through NovoLogix, do the following on this website:

  • For BCN commercial members: Click BCN and then click Medical Benefit Drugs. In the BCN commercial column, see the "How to submit requests electronically using NovoLogix" section.
  • For Blue Cross commercial members: Click Blue Cross and then click Medical Benefit Drugs. In the Blue Cross commercial column, see the "How to submit requests electronically using NovoLogix" section.

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Blue Cross and BCN utilization management medical drug list for Blue Cross PPO (commercial) and BCN HMO (commercial) members (PDF) document. There are links to this document on the Medical Benefit Drug pages on this website.

We'll update this list with these new requirements prior to the effective dates.

Authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

Posted: June 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Aduhelm, Empaveli and Arcalyst® to require prior authorization for Medicare Advantage members

The following medications will require prior authorization through the NovoLogix® online tool:

  • Aduhelm (aducanumab), HCPCS code J3590 — for dates of service on or after June 8, 2021
  • Empaveli (pegcetacoplan), HCPCS codes J3490, J3590 — for dates of service on or after June 14, 2021
  • Arcalyst (rilonacept), HCPCS code J2793 — for dates of service on or after Sept. 13, 2021

This applies to Medicare Plus BlueSM and BCN AdvantageSM members.

When prior authorization is required

For Medicare Advantage members, we require prior authorization for these drugs when they're administered by a health care professional in a provider office, at the member's home, in an off-campus or on-campus outpatient hospital or in an ambulatory surgical center (place of service codes 11, 12, 19, 22 and 24) and billed as follows:

  • Electronically through an 837P transaction or on a professional CMS-1500 claim form
  • Electronically through an 837I transaction or by using the UB04 claim form for a hospital outpatient type of bill 013x

Important reminder

Submit prior authorization requests for these drugs through NovoLogix. It offers real-time status checks and immediate approvals for certain medications.

If you have access to Provider Secured Services, you already have access to NovoLogix.

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

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members (PDF).

We'll update the list to reflect these changes.

Posted: June 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Additional enhancements to the TurningPoint musculoskeletal surgical quality and safety management program

Blue Cross Blue Shield of Michigan, Blue Care Network and TurningPoint have identified several opportunities to enhance the pain management portion of the TurningPoint Healthcare Solutions LLC musculoskeletal surgical quality and safety management program.

These changes affect most members.

To learn more about the changes, see the detailed provider alert (PDF).

Posted: June 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



On May 9, we updated three additional questionnaires in the e-referral system

In an earlier message, we notified you that we added and updated several questionnaires in the e-referral system. (See this news item at ereferrals.bcbsm.com for details.)

In addition to the questionnaires listed in our previous communications, we also updated the following questionnaires on May 9, 2021:

  • Bariatric surgery 2 - For adult BCN AdvantageSM members
  • Excess skin removal - For adult BCN commercial and BCN Advantage members
  • Sacral nerve neuromodulation/stimulation - For adult Medicare Plus BlueSM, BCN commercial and BCN Advantage members

In addition, we updated the corresponding preview questionnaires on this website.

As a reminder, we use our authorization criteria, our medical policies and your answers to the questionnaires in the e-referral system when making utilization management determinations on your authorization requests.

Preview questionnaires

You can access preview questionnaires on this website. They show the questions you'll need to answer in the questionnaires that open in the e-referral system so you can prepare your answers ahead of time.

To find the preview questionnaires:

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

Authorization criteria and medical policies

The pertinent authorization criteria and medical policies are also available on the Authorization Requirements & Criteria pages.

Posted: May 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



May 31 holiday closure: How to submit inpatient authorization requests

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will be closed on Monday, May 31, 2021, for the Memorial Day holiday.

Refer to the document Holiday closures: How to submit authorization requests (PDF) for instructions on how to submit authorization requests for inpatient admissions during the closure.

You can access this document on these webpages:

Here are the additional closures that will occur during 2021, so you can plan ahead:

  • Independence Day – Monday, July 5
  • Labor Day – Monday, Sept. 6
  • Thanksgiving Day – Thursday, Nov. 25
  • Day after Thanksgiving – Friday, Nov. 26
  • Christmas Holiday – Thursday, Dec. 23
  • Christmas Eve – Friday, Dec. 24
  • New Year's Holiday – Thursday, Dec. 30
  • New Year's Eve – Friday, Dec. 31

Posted: December 2020
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Jemperli and Zynlonta require prior authorization for dates of service on or after July 26, 2021, for most members

For dates of service on or after July 26, 2021, we're adding prior authorization requirements for the following drugs covered under the medical benefit:

  • Jemperli (dostarlimab-gxly), HCPCS codes J3490, J3590, J9999, C9399
  • Zynlonta (loncastuximab tesirine-lpyl), HCPCS codes J3490, J3590, J9999, C9399

Submit prior authorization requests through AIM Specialty Health®.

Prior authorization requirements apply when these drugs are administered in outpatient settings for:

  • Blue Cross and Blue Shield of Michigan commercial - Members who have coverage through fully insured groups and members with individual coverage

    Exceptions: The Blue Cross commercial requirements don't apply to members who have coverage through Michigan Education Special Services Association or the Blue Cross and Blue Shield Federal Employee Program®, or to UAW Retiree Medical Benefits Trust non-Medicare members.

  • Medicare Plus BlueSM members
  • Blue Care Network commercial members
  • BCN AdvantageSM members

How to submit authorization requests

Submit authorization requests to AIM using one of the following methods:

For information about registering for and accessing the AIM ProviderPortal, see the Frequently asked questions page* on the AIM website.

More about the authorization requirements

Authorization isn't a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members.

For additional information on requirements related to drugs covered under the medical benefit, see:

We'll update the appropriate drug lists to reflect the information in this message prior to the effective date.

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're not responsible for its content.

Posted: May 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



We're using updated utilization management criteria for non-behavioral health services starting Aug. 2, 2021

On Aug. 2, 2021, we'll begin using the 2021 InterQual® criteria to make utilization management determinations for non-behavioral health services.

In addition, certain types of determinations will be based on modifications of InterQual criteria or on local rules.

These changes will affect utilization management determinations for these members:

  • Blue Cross Blue Shield of Michigan commercial
  • Medicare Plus BlueSM
  • Blue Care Network commercial
  • BCN AdvantageSM

In early July, we'll have links to the updated versions of the modified criteria and local rules on this website, on these pages:

For additional information about these changes, look for articles in the July 2021 issue of The Record and the July-August 2021 issue of BCN Provider News.

Posted: May 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



We're using updated utilization management criteria for behavioral health services starting Aug. 2, 2021

On Aug. 2, 2021, we'll begin using the 2021 InterQual® criteria to make utilization management determinations for behavioral health services.

This change will affect determinations on behavioral health services for Medicare Plus BlueSM, Blue Care Network commercial and BCN AdvantageSM members.

To learn more about this change, see the detailed provider alert (PDF).

Posted: May 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



For Medicare Advantage inpatient admissions, submit prior authorization requests for CAR-T cell therapy drugs to NovoLogix

Before you begin administering CAR-T cell therapy drugs for Medicare Plus BlueSM or BCN AdvantageSM members in an inpatient setting, you must do the following:

  • Submit the request for the CAR-T cell therapy drug, including all relevant clinical documentation, as follows:
    • Through the NovoLogix® online tool. (See the "NovoLogix" section below for more information.)
    • By sending a fax to the Pharmacy Part B help desk at 1-866-392-6465
  • Submit a separate request for the inpatient admission and other inpatient services (not including the CAR-T cell therapy drug) through the e-referral system, as usual.

    For the inpatient admission, follow the steps in the "Submit an inpatient authorization" section of the e-referral User Guide (PDF).

If you've been submitting the prior authorization request for CAR-T cell therapy drugs through the e-referral system, this is a change. This change is effective immediately.

If you have questions, email us at MASRX@bcbsm.com.

As a reminder:

  • CAR-T cell therapy drugs are covered under the medical benefit. Examples of CAR-T cell therapy drugs are Yescarta®, Kymriah®, Tecartus, Breyanzi® and Abecma®.
  • Submit requests for outpatient administration of CAR-T cell drugs through NovoLogix. There is no change to how outpatient requests are submitted.
  • Prior authorization for CAR-T drugs is NOT managed by AIM Specialty Health®.

NovoLogix

NovoLogix offers real-time status checks and immediate approvals for certain medications. If you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

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

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members. (PDF)

Posted: May 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Criteria used to make determinations on authorization requests for musculoskeletal procedures

TurningPoint Healthcare Solutions LLC uses the following criteria to make determinations on authorization requests for musculoskeletal and pain management procedures:

  • For Blue Cross commercial and BCN commercial members: TurningPoint applies medical policy guidelines for musculoskeletal and pain management procedures that Blue Cross Blue Shield of Michigan, Blue Care Network and TurningPoint agreed on.
  • For Medicare Plus BlueSM and BCN AdvantageSM members: TurningPoint applies the Medicare national coverage determinations / Medicare local coverage determinations.

    If there is no Medicare NCD / LCD, TurningPoint applies medical policy guidelines for musculoskeletal and pain management procedures that Blue Cross, BCN and TurningPoint agreed on.

You can view the medical policies in the TurningPoint Provider Portal.

Additional information

For more information about the TurningPoint musculoskeletal surgical quality and safety management program, see the Musculoskeletal procedure authorizations: Frequently asked questions for providers (PDF) document. This and other documents are available from following pages of this website:

As a reminder, TurningPoint manages authorizations for orthopedic, pain management and spinal procedures for the following:

  • Blue Cross commercial* - All fully insured groups, select self-funded groups and all members with individual coverage
  • Medicare Plus Blue members
  • BCN commercial members
  • BCN Advantage members

*To determine whether you need to submit prior authorization requests for Blue Cross commercial members, see the document titled Determining whether Blue Cross commercial members require prior authorization for musculoskeletal surgeries and related procedures (PDF).

Posted: May 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Use the correct HCPCS code for Spravato®

Use the correct HCPCS code when requesting prior authorization or billing for Spravato (esketamine).

  • Use S0013 for dates of service on or after Jan. 1, 2021.
  • Use J3490 or J3590 for dates of service prior to Jan. 1, 2021.

We first communicated about this in the article titled HCPCS replacement codes established, in the March 2021 issue of The Record.

The Centers for Medicare & Medicaid Services, or CMS, established the permanent HCPCS code of S0013 for this medical benefit drug to be used for dates of service on or after Jan. 1, 2021. However, many providers are using the older codes for these newer dates of service. This has resulted in problems with reimbursing claims.

Prior authorization information

Providers must request prior authorization for Spravato when it is administered in outpatient settings for:

  • Members covered through Blue Cross commercial fully insured groups except for groups that have opted out of the prior authorization program
    Note: For groups that have opted out of the prior authorization program, Spravato is covered for the FDA approved indications.
  • Blue Cross commercial members with individual coverage
  • Medicare Plus BlueSM members
  • BCN commercial members
  • BCN AdvantageSM members

Additional information

For more information on requirements related to drugs covered under the medical benefit, see the following documents:

Posted: May 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



e-referral system out of service on two weekends in May

Here are the May 2021 planned downtimes for the e-referral system. All times are Eastern time.

  • Routine maintenance: From 10 p.m. on Saturday, May 15 to 10 a.m. on Sunday, May 16
    Note: The e-referral system will not be available at all during these times. On Sunday, May 15, the system will be available by 10 a.m. It may be available earlier if maintenance tasks are completed early. We expect the system to be available during the remaining time over that weekend, although you may experience minor performance issues.
  • Software upgrade: From 6 p.m. Friday, May 21 to 6 a.m. on Monday, May 24
    Note: The e-referral system will not be available at all during these times.
    To see the changes that will occur with this upgrade, see the detailed provider alert (PDF).

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

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

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

Posted: May 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



CareCentrix® home health care training and resources are now available

Providers can now sign up for training and access resources related to the CareCentrix home health care program.

As a reminder, CareCentrix will manage authorizations for home health care services for Medicare Plus BlueSM and BCN AdvantageSM members for episodes of care starting on or after June 1, 2021.

For episodes of care that start prior to June 1, 2021, and extend through or beyond June 1, 2021, you'll need to request authorization from CareCentrix when recertification or resumption of care is needed or when a significant change in condition occurs.

Home health care agencies will be able to submit prior authorization requests to CareCentrix starting on May 28, 2021.

Training

We're offering training webinars on the CareCentrix home health care program. There are training sessions for referring providers and for home health care agencies.

Training sessions are available on various dates in May.

To register for training, see the following articles:

Resources

The new Home health care: Frequently asked questions for providers (PDF) document and other resources are now available on these pages of this website:

Posted: April 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Issue resolved: Medical oncology drug claims were denying in error even with authorization from AIM

Our systems have been incorrectly denying some medical oncology drug claims for lack of authorization. These claims were denied despite providers having obtained prior authorization, as required, through AIM Specialty Health®.

We've identified and resolved an issue that was preventing authorizations from automatically transferring from the AIM system into the Blue Cross and BCN e-referral system. As a result:

  • When you submit these claims in the future, they will not deny incorrectly. The authorization will automatically transfer from the AIM system into the e-referral system.
  • We will reprocess claims that were incorrectly denied. You won’t need to resubmit them.

The problem was affecting medical oncology drug claims for:

  • Members covered through Blue Cross commercial fully insured groups except Michigan Education Special Services Association members
  • Blue Cross commercial members with individual coverage
  • BCN commercial members
  • BCN AdvantageSM members
  • Medicare Plus BlueSM members

If you have questions, call the Pharmacy Help Desk at 1-800-437-3803.

We apologize for the problems caused by this issue and we thank you for your patience while we resolved it.

Posted: April 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Updated Medicare local coverage determination for facet joint injections for Medicare Plus BlueSM and BCN AdvantageSM members, starting April 25, 2021

For dates of service on or after April 25, 2021, the updated Medicare local coverage determination for facet joint interventions for pain management (L38841) applies.

The changes to the LCD include, but aren't limited to, the following:

  • The patient's baseline pain and function must be documented using pain and disability scales. The scales must be updated after each diagnostic procedure and at each follow-up appointment.
  • The second diagnostic medical branch block must be performed at least 2 weeks after the first block.
  • Therapeutic facet joint injections are covered only when the patient is not a candidate for radiofrequency ablation. Rationale must be documented.
  • All procedures are limited to 1 or 2 levels per session.
    • For diagnostic / therapeutic facet joint injections, no more than 4 sessions are allowed per region (cervical / thoracic and lumbar) during a rolling 12-month period, for an absolute maximum of 8 injections.
    • For radiofrequency ablation, no more than 2 sessions are allowed per region during a rolling 12-month period, for an absolute maximum of 4 injections.
  • Only 1 spinal region can be treated per session (cervical / thoracic or lumbar).
  • Multiple types of interventions may not be performed on the same day. For example, epidural steroid injections, facet joint infections and trigger point injections cannot be performed on the same day.
  • Further exclusions on facet joint injections include intra-facet implants, facet joint interventions after anterior lumbar interbody fusion, and diagnostic procedures at the same level as prior successful radiofrequency ablation.

As a reminder

When making authorization determinations for Medicare Plus Blue and BCN Advantage members, TurningPoint applies Medicare national coverage determinations / Medicare local coverage determinations.

If there is no Medicare NCD / LCD, TurningPoint applies medical policy guidelines for musculoskeletal and pain management procedures that Blue Cross Blue Shield of Michigan, Blue Care Network and TurningPoint agreed on.

Additional information

For more information about the TurningPoint musculoskeletal surgical quality and safety management program, see the following pages of the ereferrals.bcbsm.com website:

TurningPoint manages authorizations for orthopedic, pain management and spinal procedures for the following:

  • Blue Cross commercial* — All fully insured groups, select self-funded groups and all members with individual coverage
  • Medicare Plus Blue members
  • BCN commercial members
  • BCN Advantage members

*To determine whether you need to submit prior authorization requests for Blue Cross commercial members, see "How do I know if I need to request prior authorization from TurningPoint for members who have coverage through Blue Cross commercial plans?" in the Musculoskeletal procedure authorizations: Frequently asked questions for providers (PDF) document.

Posted: April 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Abecma® to require prior authorization for commercial members starting April and May

Abecma (idecabtagene vicleucel), HCPCS code J9999, will require prior authorization through the NovoLogix® online tool for the following members:

  • Blue Care Network commercial members, for courses of therapy starting on or after April 20, 2021
  • Blue Cross commercial members, for courses of therapy starting on or after May 6, 2021

Some Blue Cross groups not subject to these requirements

For Blue Cross commercial members, these authorization requirements apply only to groups that currently participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list (PDF).

Note: Blue Cross and Blue Shield Federal Employee Program® members and UAW Retiree Medical Benefits Trust (non-Medicare) PPO members don't participate in the standard prior authorization program.

How to submit authorization requests

Submit prior authorization requests through the NovoLogix® online tool. It offers real-time status checks and immediate approvals for certain medications.

Providers can learn how to submit requests through NovoLogix as follows:

  • For BCN commercial members: On BCN's Medical Benefit Drug page on this website, in the BCN HMO (commercial) column, see the "How to submit authorization requests electronically using NovoLogix" section.
  • For Blue Cross commercial members: On the Blue Cross Medical Benefit Drugs page on this website, in the Blue Cross' PPO (commercial) column, see the "How to submit authorization requests electronically using NovoLogix" section.

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Blue Cross and BCN utilization management medical drug list for Blue Cross PPO (commercial) and BCN HMO (commercial) members (PDF) document. There are links to this document on the Medical Benefit Drug pages of this website.

We'll update this list with these new requirements prior to the effective dates.

Authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

Posted: April 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Alacura's telephone number has changed, for non-emergency air transport of commercial members

The telephone number for Alacura Medical Transport Management has changed to 1-844-425-2287.

We've updated the Air ambulance flight information (non-emergency) form to reflect the change. The fax number for Alacura is on the form as well; the fax number has not changed.

We're also updating other documents to reflect this change.

Providers should no longer call Alacura at their previous number, which was 1-844-608-3676.

As a reminder, prior authorization by Alacura is required for non-emergency air transport of Blue Cross Blue Shield of Michigan commercial members and Blue Care Network commercial members. You'll find more details about the authorization requirements on the form (linked above).

Posted: April 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Register for webinar training for the CareCentrix home health care program

For episodes of care starting on or after June 1, 2021, CareCentrix will manage authorizations for and support the coordination of home health care services, such as skilled nursing visits and physical, occupational and speech therapy, for Medicare Plus BlueSM and BCN AdvantageSM members.

For episodes starting before June 1, 2021, providers will need to request prior authorization when recertification is needed, when resumption of care is needed or when a significant change in condition occurs.

We're offering training webinars on the home health care program for services managed by CareCentrix. There are training sessions for referring providers and for home health care agencies.

Webinar for referring providers - This session will cover the CareCentrix home health care program and details about members' transitions from hospital to home.

Date Time Registration
Tuesday, May 11, 2021 10 to 11 a.m. Click here to register

Webinars for home health care agencies - These sessions will cover the CareCentrix home health care program; the steps required to request prior authorizations for home health care services; the intent to deny, peer-to-peer and appeal processes; and provider support and resources.

Date Time Registration
Tuesday, May 4, 2021 10 to 11:30 a.m. Click here to register
Tuesday, May 4, 2021 2 to 3:30 p.m. Click here to register
Tuesday, May 5, 2021 10 to 11:30 a.m. Click here to register
Tuesday, May 5, 2021 2 to 3:30 p.m. Click here to register
Tuesday, May 6, 2021 10 to 11:30 a.m. Click here to register
Tuesday, May 6, 2021 2 to 3:30 p.m. Click here to register
Tuesday, May 11, 2021 2 to 3:30 p.m. Click here to register
Tuesday, May 12, 2021 10 to 11:30 a.m. Click here to register
Tuesday, May 12, 2021 2 to 3:30 p.m. Click here to register
Tuesday, May 13, 2021 10 to 11:30 a.m. Click here to register
Tuesday, May 13, 2021 2 to 3:30 p.m. Click here to register

Posted: April 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Determining whether to submit prior authorization requests for musculoskeletal procedures to TurningPoint for Blue Cross commercial members

Providers are responsible for identifying the need for authorization through web-DENIS, Benefit Explainer or Provider Inquiry and for contacting vendors and obtaining authorization for services, as needed.

To determine whether you need to submit a prior authorization request to TurningPoint Healthcare Solutions LLC for a musculoskeletal procedure for a Blue Cross commercial member:

  1. Log in to bcbsm.com as a provider.
  2. Click the Musculoskeletal Service Authorization through TurningPoint link in the Provider Secured Services welcome page.
  3. Click the words Blue Cross' PPO in the blue bar at the top of the box on the right.
  4. Enter the member's contract number and click Enter.
  5. Click the Authorization And Referrals link for the appropriate member.
  6. You'll see one of the following:
    • If prior authorization IS required for the member: You'll see a message stating that you need to contact TurningPoint. Submit an authorization request to TurningPoint by entering the NPI, pressing Enter and following the prompts. You can also submit requests by fax or phone; see the Musculoskeletal procedure authorizations: Frequently asked questions for providers (PDF) document for details.
    • If prior authorization ISN'T required for the member: You'll receive a message stating that prior authorization isn't required.
    • Important! When authorization isn't required for the musculoskeletal procedure, you must still obtain prior authorization from Blue Cross for the inpatient admission. Submit the prior authorization request for the inpatient admission for procedure code *99222 through the e-referral system as outlined in the "Submit an inpatient authorization" section of the e-referral User Guide (PDF). In the request, attach the clinical information or insert notes that specify the procedure that will be performed. Do not submit musculoskeletal procedure codes.

You can find this same information in the question titled "How do I know if I need to request prior authorization from TurningPoint for members who have coverage through Blue Cross commercial plans?" in the Musculoskeletal procedure authorizations: Frequently asked questions for providers (PDF) document.

As a reminder, TurningPoint manages authorizations for orthopedic, pain management and spinal procedures for the following:

  • Blue Cross commercial - All fully insured groups, select self-funded groups and all members with individual coverage
  • Medicare Plus BlueSM members
  • BCN commercial members
  • BCN AdvantageSM members

*CPT codes, descriptions and two-digit modifiers only are copyright 2020 American Medical Association. All rights reserved.

Posted: April 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Nulibry to require authorization for commercial members

Blue Cross Blue Shield of Michigan and Blue Care Network are adding a prior authorization requirement for Nulibry (fosdenopterin), HCPCS codes J3490 and J3590, as follows:

  • For BCN commercial members: Prior authorization is required for courses of treatment starting on or after April 5, 2021.
  • For Blue Cross commercial members: Prior authorization is required for courses of therapy starting on or after May 3, 2021.

How to submit authorization requests

Submit authorization requests through the NovoLogix® online tool. It offers real-time status checks and immediate approvals for certain medications.

To learn how to submit requests through NovoLogix, do the following on this website:

  • For BCN commercial members: Click BCN and then click Medical Benefit Drugs. In the BCN HMO (commercial) column, see the "How to submit authorization requests electronically using NovoLogix" section.
  • For Blue Cross commercial members: Click Blue Cross and then click Medical Benefit Drugs. In the Blue Cross PPO (commercial) column, see the "How to submit authorization requests electronically using NovoLogix" section.

More about the authorization requirements

These authorization requirements apply only to groups that currently participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit.

To determine whether a group participates in the prior authorization program, see the Specialty Pharmacy Prior Authorization Master Opt-in/out Group list.

Note: The Blue Cross and Blue Shield Federal Employee Program® and the UAW Retiree Medical Benefits Trust (non-Medicare) don't participate in the standard prior authorization program.

Authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Blue Cross and BCN utilization management medical drug list for Blue Cross PPO (commercial) and BCN HMO (commercial) members document, which is available from these pages of this website:

We'll update the requirements list with this information prior to the effective date.

Posted: April 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Clinical review requirements suspended for admission to skilled nursing facilities from certain hospitals at higher inpatient bed occupancy

Effective April 12 through May 31, 2021, Blue Cross Blue Shield of Michigan and Blue Care Network are temporarily suspending clinical review requirements for admission to skilled nursing facilities from those hospitals most impacted by the current surge in COVID-19 cases.

This temporary change applies to all lines of business, including Blue Cross commercial, Blue Care Network commercial, Medicare Plus BlueSM and BCN AdvantageSM.

The suspending of clinical review for SNF admissions applies to patients transferring from a hospital with inpatient bed occupancy at 85% or higher. Blue Cross and BCN will monitor hospital occupancy based on data from the Michigan Department of Health & Human Services. This information can be found on the Statewide Available PPE and Bed Tracking webpage* on the Michigan.gov website (see the Patient Census chart at the bottom). Blue Cross and BCN will check this list weekly and add hospitals whose inpatient bed occupancy meets or exceeds 85%.

Please see the Temporary suspension of clinical review requirements to a skilled nursing facility (PDF) which lists the current hospitals who have the clinical review requirements suspended for admissions to SNFs. This document can be found within Provider Secured Services by clicking Coronavirus (COVID-19). It is posted under the Utilization management section.

Note:

  • Admissions to skilled nursing facilities from the hospitals that qualify for accommodations based on bed occupancy will auto-approve the first three days. For these admissions, clinical documentation will not be required until the continued stay review, starting on the fourth day of stay.
  • Long-term acute care hospital and inpatient rehabilitation facility admissions from the hospitals who qualify for accommodations based on bed occupancy will receive expedited processing requests submitted during normal business hours. Clinical review is still required.
  • This temporary change does not apply to FlexLink® groups for which a third-party administrator makes authorization determinations. Facilities should check the back of the member's ID card to determine whether a third-party administrator needs to be contacted prior to an admission.

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're required to let you know we're not responsible for its content.

Posted: April 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Updated clinical documentation requirements for musculoskeletal procedures

We recently published updated information about the clinical documentation you must include when submitting prior authorization requests to TurningPoint Healthcare Solutions LLC.

We updated or added information related to the specific clinical documentation requirements for:

  • Conservative therapies
  • Body mass index
  • Smoking status
  • Surgical plan

To view the updated requirements, see the Clinical documentation requirements for musculoskeletal procedures document, which is available on the Musculoskeletal Services pages of this website.

As a reminder, TurningPoint manages authorizations for orthopedic, pain management and spinal procedures for the following:

  • Blue Cross commercial - All fully insured groups, select self-funded groups and all members with individual coverage
  • Medicare Plus BlueSM members
  • BCN commercial members
  • BCN AdvantageSM members

Posted: April 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



e-referral system out of service for maintenance overnight April 17-18

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

From 10 p.m. on Saturday, April 17 to 10 a.m. on Sunday, April 18

Note: All times are Eastern time.

The e-referral system will not be available at all during these times. Here's additional information:

  • On Sunday, the system will be available by 10 a.m. It may be available earlier if maintenance tasks are completed.
  • We expect the system to be available during the remaining time over the weekend, although you may experience minor performance issues.

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

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

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

Posted: April 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Update: Don’t use F codes when requesting prior authorization for inpatient medical admissions

We're updating an earlier news item to indicate that this information applies to prior authorization requests for BCN commercial members in addition to those for Medicare Advantage members.

When requesting authorization for acute care inpatient medical (non-behavioral health) admissions, select a medical ICD-10 diagnosis code in the e-referral system - one that doesn’t begin with F.

If you select an ICD-10 diagnosis code that begins with F, the processing of your request will be delayed because:

  • You'll trigger a behavioral health questionnaire that you must complete.
  • Your request will be routed to the incorrect department for review.

Background

We've noticed that for members admitted to a medical unit for acute detoxification (such withdrawal from alcohol or other drugs), providers are sometimes submitting authorization requests with diagnosis codes that begin with F.

However, these are considered medical - not behavioral health - admissions, even though the member's condition involves the use of alcohol or other substances.

Members this applies to

This applies to:

  • BCN commercial members
  • Medicare Plus BlueSM members
  • BCN AdvantageSM members

Posted: April 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Abecma to require prior authorization for Medicare Advantage members starting April 5

For dates of service on or after April 5, 2021, the following CAR-T medication will require prior authorization through the NovoLogix® online tool:

  • Abecma (idecabtagene vicleucel), HCPCS code J9999

This applies to Medicare Plus BlueSM and BCN AdvantageSM members.

Places of service that require authorization

For Medicare Advantage members, we require authorization for all outpatient places of service when you bill these medications as either a professional or a facility service:

  • Electronically through an 837P transaction or on a professional CMS-1500 claim form
  • Electronically through an 837I transaction or by using the UB04 claim form for a hospital outpatient type of bill 013x

Important reminder

For this drug, submit authorization requests through NovoLogix. It offers real-time status checks and immediate approvals for certain medications. If you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

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

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members.

Posted: April 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Additional medications will require prior authorization for most members starting May 24

For dates of service on or after May 24, 2021, we're adding prior authorization requirements for the following drugs covered under the medical benefit:

  • Cosela (trilaciclib), HCPCS codes J3490, J3590, J9999, C9399
  • Pepaxto® (melphalan flufenamide), HCPCS codes J3490, J3590, J9999, C9399

The prior authorization requirements apply when these drugs are administered in outpatient settings for:

  • Members covered through Blue Cross commercial fully insured groups except Michigan Education Special Services Association members
  • Blue Cross commercial members with individual coverage
  • Medicare Plus BlueSM members
  • BCN commercial members
  • BCN AdvantageSM members

These requirements don't apply to Blue Cross commercial self-funded groups, including:

  • Blue Cross and Blue Shield Federal Employee Program® members
  • UAW Retiree Medical Benefits Trust non-Medicare members
  • All other Blue Cross commercial self-funded groups

How to submit authorization requests

Submit authorization requests to AIM using one of the following methods:

For information about registering for and accessing the AIM ProviderPortal, see the Frequently asked questions page* on the AIM website.

More about the authorization requirements

Authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

For additional information on requirements related to drugs covered under the medical benefit, see the following documents:

We'll update the requirements lists with the new information prior to May 24, 2021.

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're not responsible for its content.

Posted: April 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Do's and don'ts when submitting commercial SNF requests using the e-referral system

Starting Dec. 1, 2020, skilled nursing facilities were required to submit authorization requests for Blue Cross commercial and BCN commercial members through the e-referral system and not by fax.

You should fax the form only when the e-referral system is not available.

Here are important do's and don'ts when submitting your requests through the e-referral system:

  • On requests for initial admissions:
    • Do submit only one request for each member admitted. Don't submit a duplicate request while waiting to get the response.
    • Do include the admitting/attending physician in addition to the name of the facility.
  • On requests for additional days:
    • Do add an extension line so we know you're requesting the days. Follow the instructions in the e-referral User Guide (PDF) for "Extending an Inpatient Authorization."
    • Don't add more than one extension line.
  • On all requests:
    • Do complete the Skilled Nursing Facility Assessment Form (PDF) and attach it to the request in the e-referral system instead of faxing it.

      Note: Do include on the form the name and phone number of the person submitting the authorization request.

    • Do complete each field. Don't indicate "see attached" in lieu of completing the fields.
    • Don't request more than seven days.

Training resources for SNFs

It's important to use the available training resources to familiarize yourself with the e referral system, especially:

  • Checking member eligibility and benefits
  • Submitting an inpatient authorization request (requests for admissions and requests for additional SNF days)
  • Attaching a document to the authorization request

You can access a recorded webinar for SNFs and the webinar slides at ereferrals.bcbsm.com. Click Training Tools and scroll down to find the "e-referral Overview for Skilled Nursing Facilities presentation" - specifically:

Important next steps

If you haven't done so already, there are two important things you should do right away.

  1. Register now for access to the e-referral system

    We encourage you to register now for access to the e-referral system. It takes some time to process registration requests.

    To register, follow the instructions on the Sign Up or Change a User webpage on our ereferrals.bcbsm.com website.

  2. Use the online tools to learn the e-referral system

    Visit the Training Tools page of our ereferrals.bcbsm.com website for:

Posted: April 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



April 2 holiday closure: How to submit inpatient authorization requests

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will be closed on Friday, April 2, 2021, for the Good Friday holiday.

Refer to the document Holiday closures: How to submit authorization requests (PDF) for instructions on how to submit authorization requests for inpatient admissions during the closure.

You can access this document from the ereferrals.bcbsm.com website, on these webpages:

Here are the additional upcoming closures that will occur during 2021, so you can plan ahead:

  • Memorial Day – Monday, May 31
  • Independence Day – Monday, July 5
  • Labor Day – Monday, Sept. 6
  • Thanksgiving Day – Thursday, Nov. 25
  • Day after Thanksgiving – Friday, Nov. 26
  • Christmas Holiday – Thursday, Dec. 23
  • Christmas Eve – Friday, Dec. 24
  • New Year's Holiday – Thursday, Dec. 30
  • New Year's Eve – Friday, Dec. 31

Posted: March 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Code substitutions available for musculoskeletal surgical procedures authorized by TurningPoint

TurningPoint Healthcare Solutions LLC authorizes musculoskeletal procedures for most Blue Cross and BCN members.

In some situations, you may not know which orthopedic or spinal procedure will be required in advance of a surgery or the surgical plan may change intraoperatively. As a result, the procedure code TurningPoint authorized may not represent the procedure that was actually performed.

Prior to submitting claims for these procedures, you'll need to determine whether you can substitute the code for the procedure that was actually performed for the code TurningPoint authorized. If you can substitute the code, you won't need to contact TurningPoint to update the procedure coding.

To learn how to determine whether you can submit a substitute code and to view the list of codes that allow substitutions, see the Musculoskeletal procedure code substitutions for orthopedic and spinal surgeries (PDF) document.

As a reminder, TurningPoint manages authorizations for orthopedic, pain management and spinal procedures for the following:

  • Blue Cross commercial - All fully insured groups, select self-funded group and all members with individual coverage
  • Medicare Plus BlueSM members
  • BCN commercial members
  • BCN AdvantageSM members

Posted: March 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Amondys 45 and Evkeeza will require authorization for commercial members

Blue Cross Blue Shield of Michigan and Blue Care Network are adding prior authorization requirements for the following drugs covered under the medical benefit:

  • Amondys 45 (casimersen), HCPCS codes J3490 and J3590
  • Evkeeza (evinacumab-dgnb), HCPCS codes J3490 and J3590

This change will affect Blue Cross commercial and BCN commercial members.

To learn more about this change, see the detailed provider alert (PDF).

Posted: March 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Update: Changes coming to preferred products for drugs covered under the medical benefit for most members, starting April 1

This news item updates two news items that we posted to this website in December 2020. The same information was communicated through web-DENIS messages and in our provider newsletters.

For dates of service on or after April 1, 2021, we're designating certain medications as preferred products. This change will affect most Blue Cross Blue Shield of Michigan commercial, all Medicare Plus BlueSM, all Blue Care Network commercial and all BCN AdvantageSM members.

To learn more about this change, see the detailed provider alert.

Posted: March 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Additional medications will require prior authorization for Medicare Advantage members, starting June 22

For dates of service on or after June 22, 2021, the following medications will require prior authorization through the NovoLogix® online tool:

  • Oxlumo (lumasiran), HCPCS code C9074
  • Evkeeza (evinacumab-dgnb), HCPCS codes C9399, J3490, J3590
  • Nulibry (fosdenopterin), HCPCS codes C9399, J3490, J3590

This change will affect Medicare Plus BlueSM and BCN AdvantageSM members.

To learn more about this change, see the detailed provider alert.

Posted: March 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Easier access to RC Claim Assist

Starting May 1, 2021, you'll be able to access RC Claim Assist only through Provider Secured Services.

To do this, log in to bcbsm.com as a provider, click the RC Claim Assist link in the Provider Secured Services welcome page and follow the prompts.

As a reminder, RC Claim Assist is a web-based resource that's available to Blue Cross Blue Shield of Michigan and Blue Care Network contracted providers who bill for drugs covered under the medical benefit. RC Claim Assist provides an inclusive overview of medical drug products and a calculation tool to identify the correct National Drug Code and CPT codes to bill, along with the correct NDC quantity, unit of measure and HCPCS billable units according to the package information.

Posted: March 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



AIM Specialty Health® technical issues are resolved

AIM Specialty Health has advised us that the technical issues they were experiencing on March 15, 2021, are resolved. These issues were causing delays in their ProviderPortal® and in the AIM Contact Center.

If you were experiencing delays on March 15 when submitting prior authorization requests to AIM, you should be able to submit these requests without delays now.

For information on which types of authorization requests AIM manages for Blue Cross Blue Shield of Michigan and Blue Care Network, refer to the document titled Summary of utilization management programs for Michigan providers (PDF).

Posted: March 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



e-referral system out of service for maintenance overnight March 20-21

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

From 10 p.m. on Saturday, March 20 to 10 a.m. on Sunday, March 21

Note: All times are Eastern time.

The e-referral system will not be available at all during these times. Here's additional information:

  • On Sunday, the system will be available by 10 a.m. It may be available earlier if maintenance tasks are completed.
  • We expect the system to be available during the remaining time over the weekend, although you may experience minor performance issues.

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

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

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

Posted: March 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Save time: Don't fax unnecessary information about inpatient stays

We're receiving faxes related to inpatient stays from hospital utilization review departments. Most of these faxes are not required and you can save time by not sending them.

This applies to Blue Cross commercial, BCN commercial, Medicare Plus BlueSM and BCN AdvantageSM members.

To find out how to save time and submit various types of information correctly, see the detailed provider alert (PDF).

Posted: March 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Starting in June, we'll use clinical information to validate providers' answers to some questionnaires in the e-referral system

Beginning in June 2021, we'll pend some authorization requests that would usually be auto-approved based on your answers to the questionnaires in the e-referral system. This will allow us to validate the answers you provided on the questionnaire.

This applies to authorization requests submitted for BCN commercial, Medicare Plus BlueSM and BCN AdvantageSM members.

When we pend a request, you'll get this message in the e-referral system: "Case requires validation. Medical records required. Please attach clinical information from the patient's medical record applicable to this request in the Case Communication field."

For instructions on how to attach clinical information to the authorization request in the e-referral system, refer to the e-referral User Guide (PDF). Look in the section titled "Create New (communication)."

When we receive the clinical information, we'll review it to confirm that it supports the information you provided in the questionnaire and then we'll make a determination on the request.

If we don't receive the clinical information or if the clinical information you send doesn't support your answers in the questionnaire, we won't be able to approve the request.

As a reminder, on the preview questionnaires that we publish on our ereferrals.bcbsm.com website, we state that we will retrospectively monitor compliance with this authorization requirement. You can access the preview questionnaires:

Posted: March 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Starting June 1, Blue Cross and BCN will cover only preferred hyaluronic acid products for GM, FCA and Ford commercial groups

Blue Cross Blue Shield of Michigan and Blue Care Network will cover select hyaluronic acid products under the medical benefit for General Motors, Fiat Chrysler Automobiles and Ford commercial groups, starting June 1, 2021.

To learn more about this change, see the detailed provider alert.

Posted: March 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



eviCore will no longer mail Practice Profile Summaries and category information for outpatient physical therapy services starting in July

Beginning with July 2021 data, eviCore will no longer mail paper copies of the Practice Profile Summary, which includes information about your assigned category, to health care providers. Instead, eviCore will post category updates on the first business day of February and August each year beginning in August 2021.

Follow these steps to access your Practice Profile Summary and obtain your category:

  1. Access eviCore's provider portal and select Practitioner Performance Summary from the main menu.
  2. You may be prompted to select the health plan (select either Blue Cross or BCN) and enter your NPI.
  3. Click on the View PPS button to review your PPS.
  4. To find out your assigned category, click on the UM Category tab in the top left corner.

If you believe there are circumstances adversely affecting your utilization data, you may still request reconsideration within 15 days of eviCore's notification. Initiate your reconsideration request within the UM Category window.

Additional information is available on the evicore.com website as follows:

  1. From the Implementation Resources page* of evicore.com, click on the Solution Resources tab.
  2. Click on Musculoskeletal.
  3. Click on Practitioner Performance Summary & Utilization Management Categories Training Presentation.

You can also contact Provider and Client Services at 1-800-646-0418 for more information.

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're not responsible for its content.

Posted: March 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



COVID-19 testing reminders and at-home testing

We have updated our COVID-19 patient testing recommendations for physicians document to display testing codes more concisely and include information on at-home testing requirements.

As a reminder, all tests must be ordered by a health care provider who determines the test is medically appropriate. The only exception to this is members with Medicare Plus Blue or BCN Advantage coverage can have an initial test without a provider order, per the Centers for Medicare & Medicaid Services policy. Blue Cross Blue Shield of Michigan and Blue Care Network recommend that our members go to their health care providers for testing.

Posted: March 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



eviCore healthcare® will accept retroactive authorization requests for musculoskeletal procedures through April 30

As of Jan. 1, 2021, eviCore no longer manages authorizations for lumbar spine and pain management procedures for Blue Cross Blue Shield of Michigan or Blue Care Network members.

For procedures with dates of service on or before Dec. 31, 2020, you have until April 30, 2021, to submit retroactive authorization requests to eviCore for spinal procedures and pain management procedures.

To learn more, see the provider alert titled eviCore healthcare® will accept retroactive authorization requests for musculoskeletal procedures through April 30 (PDF).

Posted: February 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



e-referral system out of service for maintenance overnight Feb. 20-21

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

From 10 p.m. on Saturday, Feb. 20 to 10 a.m. on Sunday, Feb. 21

Note: All times are Eastern time.

The e-referral system will not be available at all during these times. Here's additional information:

  • On Sunday, the system will be available by 10 a.m. It may be available earlier if maintenance tasks are completed.
  • We expect the system to be available during the remaining time over the weekend, although you may experience minor performance issues.

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

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

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

Posted: February 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Breyanzi® to require prior authorization for Medicare Advantage members starting Feb. 11

For dates of service on or after Feb. 11, 2021, the following CAR-T medication will require prior authorization through the NovoLogix® online tool:

  • Breyanzi (lisocabtagene maraleucel), HCPCS code J9999

How to bill

For Medicare Plus BlueSM and BCN AdvantageSM, we require authorization for all outpatient places of service when you bill these medications as a professional service or as an outpatient facility service:

  • Electronically through an 837P transaction or on a professional CMS-1500 claim form
  • Electronically through an 837I transaction or by using the UB04 claim form for a hospital outpatient type of bill 013x

Important reminder

For this drug, submit authorization requests through NovoLogix. It offers real-time status checks and immediate approvals for certain medications. If you have access to Provider Secured Services, you already have access to enter authorization requests through NovoLogix.

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

List of requirements

For a list of requirements related to drugs covered under the medical benefit, please see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members (PDF).

We'll update the list to reflect this change before the effective date.

Posted: February 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



How to submit appeals of Medicare Advantage inpatient acute care admissions

For Medicare Plus BlueSM and BCN AdvantageSM members, submit appeals of denied authorization requests for inpatient acute care admissions (non-behavioral health) according to the process described in:

  • The denial letter we send you

  • Our provider manuals

To review the process for submitting these appeals, see the detailed provider alert titled How to submit appeals of Medicare Advantage inpatient acute care admissions (PDF).

Posted: February 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Cardiology procedure code *33208 doesn't require authorization for most members

Cardiology services associated with procedure code *33208 do not require authorization for these members:

  • BCN commercial
  • BCN AdvantageSM
  • Medicare Plus BlueSM

This code has been removed from the document Procedures that require prior authorization by AIM Specialty Health: Cardiology, radiology (high technology) and sleep studies (in lab). (PDF)

In addition, we'll reprocess and pay all claims related to this procedure code that were denied for lack of authorization.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2020 American Medical Association. All rights reserved.

Posted: February 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Medical benefit specialty drug prior authorization list changing in April for most members

Starting in April 2021, we're adding prior authorization requirements for some drugs covered under the medical benefit. Providers must request prior authorization through AIM Specialty Health®.

April 15 changes

For dates of service on or after April 15, 2021, the following drug will require prior authorization for UAW Retiree Medical Benefits Trust PPO non-Medicare members:

  • Kanjinti (trastuzumab-anns), HCPCS code Q5117

April 22 changes

For dates of service on or after April 22, 2021, the following drugs will require prior authorization for members covered through Blue Cross commercial fully insured members and for BCN commercial, Medicare Plus BlueSM and BCN AdvantageSM members:

  • Danyelza® (naxitamab-gqgk), HCPCS codes J3490, J3590, J9999, C9399
  • Margenza (margetuximab-cmkb), HCPCS codes J3490, J3590, J9999, C9399

These requirements don't apply to:

  • Blue Cross and Blue Shield Federal Employee Program® members
  • Michigan Education Special Services Association members

How to submit authorization requests

Submit authorization requests to AIM using one of the following methods:

For information about registering for and accessing the AIM ProviderPortal, see the Frequently asked questions page* on the AIM website.

More about the authorization requirements

Authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

For additional information on requirements related to drugs covered under the medical benefit, see:

We'll update these lists to reflect these changes prior to the effective dates.

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're not responsible for its content.

Posted: January 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Radiology procedure code *71271 doesn't require authorization for most members

Radiology services associated with procedure code *71271 do not require authorization for these members:

  • BCN commercial
  • BCN AdvantageSM
  • Medicare Plus BlueSM

This code has been removed from the document Procedures that require prior authorization by AIM Specialty Health: Cardiology, radiology (high technology) and sleep studies (in lab) (PDF).

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2020 American Medical Association. All rights reserved.

Posted: January 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



AIM Specialty Health® call center closed on Jan. 18 holiday

The AIM Specialty Health call center will be closed on Monday, Jan. 18, 2021, in observation of Martin Luther King Jr. Day. The call center will resume operations on Tuesday, Jan. 19.

While the call center is closed, providers can access the AIM provider portal to request prior authorization for any services for which AIM manages authorizations.

The portal is available 24 hours a day, seven days a week. To access AIM’s provider portal:

  1. Visit www.aimspecialtyhealth.com.*
  2. Click to open the menu at the upper right.
  3. Scroll down and click ProviderPortal Login.*

Here are the additional holidays during 2021 on which AIM's call center will be closed. We’re providing this information so you can plan ahead.

  • Memorial Day – Monday, May 31
  • Independence Day holidays – Friday, July 2 and Monday, July 5
  • Labor Day – Monday, Sept. 6
  • Thanksgiving Day – Thursday, Nov. 25
  • Day after Thanksgiving – Friday, Nov. 26
  • Christmas Eve – Friday, Dec. 24
  • New Year's Eve – Friday, Dec. 31

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're required to let you know we're not responsible for its content.

Posted: January 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



e-referral system out of service for maintenance overnight Jan. 16-17

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

From 10 p.m. on Saturday, Jan. 16 to 10 a.m. on Sunday, Jan. 17

Note: All times are Eastern time.

The e-referral system will not be available at all during these times. Here's additional information:

  • On Sunday, the system will be available by 10 a.m. It may be available earlier if maintenance tasks are completed.
  • We expect the system to be available during the remaining time over the weekend, although you may experience minor performance issues.

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

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

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

Posted: January 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



January holiday closure: How to submit inpatient authorization requests

Blue Cross Blue Shield of Michigan and Blue Care Network corporate offices will be closed on Monday, Jan. 18, 2021, for Martin Luther King, Jr., Day.

Refer to the document Holiday closures: How to submit authorization requests (PDF) for instructions on how to submit authorization requests for inpatient admissions during the closure.

You can access this document from the ereferrals.bcbsm.com website, on these webpages:

Here are the additional upcoming closures that will occur during 2021, so you can plan ahead:

  • Good Friday – Friday, April 2
  • Memorial Day – Monday, May 31
  • Independence Day – Monday, July 5
  • Labor Day – Monday, Sept. 6
  • Thanksgiving Day – Thursday, Nov. 25
  • Day after Thanksgiving – Friday, Nov. 26
  • Christmas Holiday – Thursday, Dec. 23
  • Christmas Eve – Friday, Dec. 24
  • New Year's Holiday – Thursday, Dec. 30
  • New Year's Eve – Friday, Dec. 31

Posted: January 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Reminder: Submit prior authorization requests to TurningPoint for musculoskeletal procedures for most members

For dates of service on or after Jan. 1, 2021, providers must submit prior authorization requests to TurningPoint Healthcare Solutions LLC for orthopedic, pain management and spinal surgical procedures for the following groups and individual members:

  • Blue Cross commercial - All fully insured groups, select self-funded groups and all members with individual coverage

    Note: To determine whether you need to submit prior authorization requests for Blue Cross commercial members, see "How do I know if I need to request prior authorization from TurningPoint for members who have coverage through Blue Cross commercial plans?" in the Musculoskeletal procedure authorizations: Frequently asked questions for providers (PDF) document.

  • Medicare Plus BlueSM - All groups and all members with individual coverage
  • BCN commercial - All fully insured groups, all self-funded groups and all members with individual coverage
  • BCN AdvantageSM - All groups and all members with individual coverage

Spinal surgical and pain management authorizations transition from eviCore to TurningPoint

For dates of service before Jan. 1, 2021, eviCore healthcare® manages:

  • Lumbar spine surgery authorizations for Blue Cross commercial fully insured groups, Blue Cross commercial members with individual coverage and Medicare Plus Blue members
  • Pain management procedures for the groups and individual members listed at the top of this message

For these services, eviCore will accept retroactive authorization requests through April 30, 2021.

For information about submitting retroactive authorization requests to eviCore, see:

TurningPoint training

Professional provider, facility and portal training webinars are available through mid-January. See the "Reminder: Providers must submit authorization requests to TurningPoint for musculoskeletal procedures for most members" article in:

More information about TurningPoint

For more information about TurningPoint, see the following pages on this website:

To view the lists of codes for which TurningPoint manages authorizations, see the Musculoskeletal procedure codes that require authorization by TurningPoint document.

For detailed information, see the Musculoskeletal procedure authorizations: Frequently asked questions for providers document.

Posted: January 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Check for messages in e-referral to expedite your requests

You can help us complete the processing and improve the turnaround time of your requests for authorization by checking the e-referral system for messages and responding quickly. We may reach out to you using the Case Communication feature in e-referral for additional information, including clinical documentation, that we need to process your requests.

Refer to the e-referral user guide (PDF) sections regarding Case Communication for instructions.

Posted: January 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network



Updated Bone-anchored hearing aid questionnaire to open in the e-referral system, starting Nov. 28

On Nov. 28, 2021, we'll update the Bone-anchored hearing aid questionnaire in the e-referral system for adult and pediatric BCN commercial and BCN AdvantageSM members.

We'll also update the corresponding preview questionnaire on the ereferrals.bcbsm.com website.

As a reminder, we use our authorization criteria, our medical policies and your answers to the questionnaires in the e-referral system when making utilization management determinations on your authorization requests.

Preview questionnaires

You can access preview questionnaires at ereferrals.bcbsm.com. They show the questions you'll need to answer in the questionnaires that open in the e-referral system so you can prepare your answers ahead of time.

To find the preview questionnaires, click BCN and then click Authorization Requirements & Criteria. Scroll down and look under the “Authorization criteria and preview questionnaires” heading.

Authorization criteria and medical policies

The pertinent authorization criteria and medical policies are also available on the Authorization Requirements & Criteria page.

Posted: November 2021
Line of business: Blue Care Network



AIM to ask for clinical information for BCN commercial radiology and cardiology prior authorization requests starting Jan. 1

Starting Jan. 1, 2022, AIM Specialty Health® may ask for clinical information for prior authorization requests submitted for Blue Care Network commercial members for the following services:

  • All outpatient high-technology radiology procedures
  • Some outpatient cardiology procedures — specifically, diagnostic cardiac angiography and percutaneous coronary intervention

AIM may request the additional information as part of the prior authorization process. You'll need to submit documentation from the member's medical record that verifies the member's condition.

AIM will review the clinical information and use it in determining the clinical appropriateness of the request. AIM is initiating this as part of their ongoing quality improvement efforts.

If the information you provide does not support the medical necessity of the request, AIM may deny the request.

This won't apply to prior authorization requests submitted for Blue Cross commercial, Medicare Plus BlueSM or BCN AdvantageSM members.

AIM is an independent company that manages authorization requests for high-technology radiology and other services for many Blue Cross and BCN members.

You can find information about AIM's requirements related to services for BCN members on our ereferrals.bcbsm.com website, on the BCN AIM-Managed Procedures webpage.

Posted: October 2021
Line of business: Blue Care Network



Starting Sept. 26, new questionnaires to open in the e-referral system

On Sept 26, 2021, we'll add the following questionnaires in the e-referral system for BCN commercial and BCN Advantage members:

  • Cognitive rehabilitation: Will open for adult and pediatric members
  • Hypoglossal nerve stimulator – condition trigger: Will open for members ages 10 through 21
  • Hypoglossal nerve stimulator — adolescent or young adult: Will open for members ages 18 through 21
  • Hypoglossal nerve stimulator — adolescents with Down syndrome: Will open for members ages 10 through 21 who have Down syndrome
  • Hypoglossal nerve stimulator — adults: Will open for members ages 22 and older

We'll also add preview questionnaires on this website.

As a reminder, we use our authorization criteria, our medical policies and your answers to the questionnaires in the e-referral system when making utilization management determinations on your authorization requests.

Preview questionnaires

You can access preview questionnaires on this website. They show the questions you'll need to answer in the actual questionnaires that open in the e-referral system. This can help you prepare your answers ahead of time.

To find the preview questionnaires, click BCN and then click Authorization Requirements & Criteria. Scroll down and look under the "Authorization criteria and preview questionnaires" heading.

Authorization criteria and medical policies

The pertinent authorization criteria and medical policies are also available on the Authorization Requirements & Criteria page.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2020 American Medical Association. All rights reserved.

Posted: September 2021
Line of business: Blue Care Network



New BCN rider for large groups in the Upper Peninsula will limit coverage outside Michigan

Effective Oct. 1, 2021, Blue Care Network large group plans will require a mandatory rider for group customers with locations in the Upper Peninsula.

The rider will limit coverage outside Michigan to urgent, emergency or accidental services. Non-urgent and nonemergency BlueCard® travel coverage outside of Michigan won't be covered.

When members have one of these riders, you'll see it listed in web-DENIS on the Benefits Description page under Certificate/Rider, as follows:

  • BCADD2 — for fully insured large groups
  • BCNUSF — for self-funded large groups

The rider will be added to all existing large groups upon renewal Oct. 1, 2021, and after and to new large group businesses upon the effective date of their plans.

For members with these riders, we'll issue new member ID cards:

  • The suitcase icon on the front of the card (which indicates coverage by BlueCard while traveling outside of Michigan) will be removed.
  • The language on the back of the card will read, "Members do not have coverage outside the state of Michigan except for emergency, urgent or accidental services."

See the article New rider for large groups in the Upper Peninsula will limit coverage outside Michigan (PDF) on page 5 of the September-October 2021 issue of BCN Provider News.

Posted: September 2021
Line of business: Blue Care Network



Starting July 25, updated questionnaires to open in the e-referral system

On July 25, 2021, we'll update the following questionnaires in the e-referral system for Blue Care Network commercial and BCN AdvantageSM members:

  • Out-of-network providers
  • Sleep studies

We'll also update the corresponding preview questionnaires on this website.

As a reminder, we use our authorization criteria, our medical policies and your answers to the questionnaires in the e-referral system when making utilization management determinations on your authorization requests.

Preview questionnaires

You can access preview questionnaires on this website to see the questions you'll need to answer in the e-referral system. This can help you prepare your answers ahead of time.

To find the preview questionnaires, click BCN and then click Authorization Requirements & Criteria. Scroll down and look under the “Authorization criteria and preview questionnaires” heading.

Authorization criteria and medical policies

The pertinent authorization criteria and medical policies are also available on the Authorization Requirements & Criteria page.

Posted: July 2021
Line of business: Blue Care Network



Enteral nutrition questionnaire updated in the e-referral system

On July 11, 2021, we updated the Enteral nutrition questionnaire in the e-referral system.

For questionnaires submitted on or after July 11, 2021, approved authorization requests are valid for six months. (For questionnaires submitted on or before July 10, approved authorization requests were valid for three months.)

We also updated the corresponding preview questionnaire on this website.

As a reminder, we use our authorization criteria, our medical policies and your answers to the questionnaires in the e-referral system when making utilization management determinations on your authorization requests.

Preview questionnaires

You can access preview questionnaires on this website. They show the questions you'll need to answer in the actual questionnaires that open in the e-referral system. This can help you prepare your answers ahead of time.

To find the preview questionnaires, click BCN and then click Authorization Requirements & Criteria. Scroll down and look under the "Authorization criteria and preview questionnaires" heading.

Authorization criteria and medical policies

The pertinent authorization criteria and medical policies are also available on the Authorization Requirements & Criteria page.

Posted: July 2021
Line of business: Blue Care Network



Starting May 9, new and updated questionnaires in the e-referral system

We use our authorization criteria, our medical policies and your answers to the questionnaires in the e-referral system when making utilization management determinations on your authorization requests.

On May 9, 2021, we'll add and update questionnaires in the e-referral system. We'll also add and update the corresponding preview questionnaires on this website.

New questionnaires

We're adding the following questionnaires:

  • Experimental and investigational services - This questionnaire will open for adult BCN commercial and BCN AdvantageSM members for all procedure codes that are configured as experimental and investigational in our systems.
  • Medical formula for inborn errors of metabolism - This questionnaire will open for adult and pediatric BCN commercial and BCN Advantage members for procedure codes B4157 and B4162 for certain diagnosis codes.
  • Not otherwise classified codes — This questionnaire will open for adult and pediatric BCN commercial and BCN Advantage members for all procedure codes that are configured as not otherwise classified in our systems.

Updated questionnaires

We're updating the following questionnaires:

  • Endoscopy, upper gastrointestinal, for GERD - For adult BCN commercial and BCN Advantage members. This questionnaire will no longer open for procedure code *43201. It will continue to open for all other procedure codes and all diagnoses listed in the Endoscopy, upper gastrointestinal, for GERD preview questionnaire (PDF).
  • Prostatic urethral lift - For adult BCN commercial and BCN Advantage members. This questionnaire will open for procedure code C9769. (It already opens for procedure codes *52441 and *52442.)

Preview questionnaires

You can access preview questionnaires on this website. They show the questions you'll need to answer in the actual questionnaires that open in the e-referral system. This can help you prepare your answers ahead of time.

To find the preview questionnaires, click BCN and then click Authorization Requirements & Criteria. Scroll down and look under the "Authorization criteria and preview questionnaires" heading.

Authorization criteria and medical policies

The pertinent authorization criteria and medical policies are also available on the Authorization Requirements & Criteria page.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2020 American Medical Association. All rights reserved.

Posted: May 2021
Line of business: Blue Care Network



Starting this summer, some prior authorization requests for hyperbaric oxygen therapy will pend for clinical review

Starting sometime this summer, prior authorization requests for hyperbaric oxygen therapy for wounds and osteomyelitis will pend for clinical review. Currently, some of these requests are auto-approved.

This change will apply to requests submitted for BCN commercial and BCN AdvantageSM members.

After this change occurs, you'll need to do the following when you submit these requests in the e referral system:

  1. Complete the questionnaire, as usual.
  2. Attach clinical information pertinent to the request. Some examples of information to include with the request are:
    • Serial wound measurements
    • The medical and surgical treatments that were attempted but that failed to improve the member's condition

These prior authorization requests cannot be approved in the absence of clinical information supporting the request.

How to attach clinical information to the request

To learn how to attach clinical information to the request in the e-referral system, refer to the e referral User Guide (PDF). Go to the section titled "Submit Outpatient Authorization" and look for "Create new (communication)."

Additional information about the questionnaires

You can access preview questionnaires related to hyperbaric oxygen therapy that show the questions you'll have to complete on the questionnaire that opens in the e-referral system. This can guide you in preparing the answers before you submit the request.

To access the preview questionnaires, visit BCN's Authorization Requirements & Criteria page on the ereferrals.bcbsm.com website. Scroll down and click to open:

Posted: March 2021
Line of business: Blue Care Network



Starting March 28, new and updated questionnaires in the e-referral system

We use our authorization criteria, our medical policies and your answers to the questionnaires in the e-referral system when making utilization management determinations on your authorization requests.

Starting March 28, 2021, we added and updated questionnaires in the e-referral system. We also added and updated corresponding preview questionnaires on the ereferrals.bcbsm.com website.

New questionnaires

We added the following questionnaires:

  • Gastric pacing / stimulation - This questionnaire now opens for BCN commercial members for procedure codes *43647, *43648, *43881, *43882, *64590 and *64595.

    Note: This questionnaire already opened for BCN AdvantageSM and Medicare Plus BlueSM members.

  • We replaced the Chemical peels questionnaire with the following two questionnaires for pediatric and adult BCN commercial and BCN Advantage members:
    • Dermal chemical peel - This questionnaire opens for procedure codes *15789 and *15793.
    • Epidermal chemical peel - This questionnaire opens for procedure codes *15788, *15792 and *17360.

Updated questionnaires

We updated the following questionnaires for BCN commercial and BCN Advantage members:

  • Bone-anchored hearing aid
  • Sleep studies

Preview questionnaires

You can access preview questionnaires on this website. They show the questions you'll need to answer in the actual questionnaires that open in the e-referral system. This can help you prepare your answers ahead of time.

To find the preview questionnaires, click BCN and then click Authorization Requirements & Criteria. Scroll down and look under the "Authorization criteria and preview questionnaires" heading.

Authorization criteria and medical policies

The pertinent authorization criteria and medical policies are also available on the Authorization Requirements & Criteria pages.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2020 American Medical Association. All rights reserved.

Posted: March 2021
Line of business: Blue Care Network



Starting Feb. 28, a new questionnaire will open in the e-referral system for the pediatric feeding program for BCN commercial members

Starting Feb. 28, 2021, a Pediatric feeding questionnaire will open in the e referral system for BCN commercial members who are 18 years of age or younger.

This questionnaire will open for procedure code S0317.

On this website, we'll add a preview questionnaire that shows the questions you'll need to answer in the Pediatric feeding questionnaire. To view the preview questionnaire, click BCN and then click Authorization Requirements & Criteria. Scroll down and look under the "Authorization criteria and preview questionnaires" heading.

For more information on pediatric feeding programs, see the article titled Update: BCN requires authorization for elective pediatric feeding programs (PDF) in the November-December 2020 issue of BCN Provider News.

As a reminder, we use our authorization criteria, our medical policies and your answers to the questionnaires in the e-referral system when making utilization management determinations on your authorization requests.

Posted: February 2021
Line of business: Blue Care Network



Starting Feb. 28, a new questionnaire will open in the e-referral system for procedures by providers who aren't contracted with BCN

Starting Feb. 28, 2021, an Out-of-network providers questionnaire will open in the e referral system when you submit a prior authorization request for a procedure to be performed by a provider who isn’t contracted with BCN.

This questionnaire will open for both BCN commercial and BCN AdvantageSM members.

In addition, if the prior authorization request is for a procedure that already requires you to complete a questionnaire, you'll need to complete two questionnaires:

  • The questionnaire for the procedure
  • The Out-of-network provider questionnaire

On the ereferrals.bcbsm.com website, we'll add a preview questionnaire that shows the questions you'll need to answer in the Out-of-network provider questionnaire. To view the preview questionnaire, click BCN and then click Authorization Requirements & Criteria. Scroll down and look under the "Authorization criteria and preview questionnaires" heading.

As a reminder, we use our authorization criteria, our medical policies and your answers to the questionnaires in the e-referral system when making utilization management determinations on your authorization requests.

Posted: February 2021
Line of business: Blue Care Network



Cardiac rehabilitation 2 questionnaire for BCN AdvantageSM will be removed from the e-referral system on Feb. 7

On Sunday, Feb. 7, 2021, we'll remove the Cardiac rehabilitation 2 questionnaire for BCN Advantage from the e-referral system.

The e-referral system will automatically approve requests for procedure codes *93797 and *93798 for BCN Advantage members until members meet the Medicare-established benefit limit of 72 sessions over a 36-week period. After a member reaches the benefit limit, the e-referral system will pend the requests for clinical review.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2020 American Medical Association. All rights reserved.

Posted: February 2021
Line of business: Blue Care Network



Updated questionnaire available in the e-referral system on Feb. 7

We use our authorization criteria, our medical policies and your answers to the questionnaires in the e-referral system when making utilization management determinations on your authorization requests.

Starting Feb. 7, 2021, an updated Cardiac rehabilitation 1 questionnaire will open in the e-referral system for BCN commercial members.

An updated preview questionnaire, which shows the questions you'll need to answer in the actual questionnaires, will also be available on this website. To find the preview questionnaires, click BCN and then click Authorization Requirements & Criteria. Scroll down and look under the "Authorization criteria and preview questionnaires" heading.

The pertinent authorization criteria and medical policies are also available on the Authorization Requirements & Criteria page.

Posted: February 2021
Line of business: Blue Care Network



Additional drugs to require prior authorization for Blue Cross URMBT non-Medicare members, starting March 10

For dates of service on or after March 10, 2022, we're expanding our prior authorization and site-of-care requirements to include additional drugs covered under the medical benefit.

These requirements will apply when these drugs are administered in an outpatient setting for Blue Cross UAW Retiree Medical Benefits Trust, or URMBT, non-Medicare members.

Submit prior authorization requests using the NovoLogix® online tool.

To learn more about this change, see the detailed provider alert (PDF).

Posted: December 2021
Line of business: Blue Cross Blue Shield of Michigan



Changes to the medical oncology prior authorization list for URMBT members with Blue Cross non-Medicare plans, starting Feb. 21

For dates of service on or after Feb. 21, 2022, additional drugs will require prior authorization and some drugs will no longer require prior authorization for UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans.

Additional drugs to require prior authorization

For dates of service on or after Feb. 21, 2022, we're adding prior authorization requirements for the following drugs covered under the medical benefit for URMBT members with Blue Cross non-Medicare plans:

  • Khapzory (levoleucovorin), HCPCS code J0642
  • Neupogen® (filgrastim), HCPCS code J1442

Submit prior authorization requests through AIM Specialty Health® using one of the following methods:

Notes:

  • Prior authorization requirements apply when these drugs are administered in an outpatient setting.
  • This requirement doesn't apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714).
  • AIM is an independent company that contracts with Blue Cross Blue Shield of Michigan to provide benefit management services.

Drugs that will no longer require prior authorization

For dates of service on or after Feb. 21, 2022, we're removing prior authorization requirements for the following drugs covered under the medical benefit for URMBT members with Blue Cross non-Medicare plans:

  • Nivestym® (filgrastim-aafi), HCPCS code Q5110
  • Udenyca® (pegfilgrastim-cbqv), HCPCS code Q5111
  • Ziextenzo® (pegfilgrastim-bmez), HCPCS code Q5120

More about authorization requirements

Authorization isn't a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members.

For additional information on requirements related to drugs covered under the medical benefit for UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans, see:

We'll update the appropriate drug lists to reflect the information in this message prior to the effective date.

Note: Accredo, an independent company that works with the URMBT on specialty pharmacy services, manages prior authorization requests for additional medical benefit drugs.

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're not responsible for its content.

Posted: November 2021
Line of business: Blue Cross Blue Shield of Michigan



Additional drugs require prior authorization for UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans, starting Jan. 27

For dates of service on or after Jan. 27, 2022, we're adding prior authorization requirements for the following drugs covered under the medical benefit for UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans:

  • Blenrep (belantamab mafodotin-blmf), HCPCS code J9037
  • Jemperli (dostarlimab-gxly), HCPCS codes J3490, J3590, J9999, C9082
  • Monjuvi® (tafasitamab-cxix), HCPCS code J9349
  • Zynlonta® (loncastuximab tesirine-lpyl), HCPCS codes J3490, J3590, J9999, C9084

Submit prior authorization requests through AIM Specialty Health®.

Notes:

  • Prior authorization requirements apply when these drugs are administered in an outpatient setting.
  • This requirement doesn’t apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714).

How to submit authorization requests

Submit prior authorization requests to AIM using one of the following methods:

More about the authorization requirements

Authorization isn't a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members.

For additional information on requirements related to drugs covered under the medical benefit for UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans, see:

We'll update the appropriate drug lists to reflect the information in this message prior to the effective date.

Note: Accredo manages prior authorization requests for additional medical benefit drugs.

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're not responsible for its content.

Posted: October 2021
Line of business: Blue Cross Blue Shield of Michigan



Due date extended for resubmitting some corrected SNF claims for Medicare Plus BlueSM members

As we communicated through a web-DENIS message on July 1, 2021, Blue Cross Blue Shield of Michigan and Blue Care Network reviewed paid skilled nursing facility claim records with dates of service from Oct. 1, 2019, through Dec. 16, 2020, for our Medicare Advantage members. During the review, we found that some claims included overbilled services or services that didn't match those that naviHealth had authorized.

We sent letters to the affected providers that specified the due dates for correcting and resubmitting claims.

News about due dates, including an extension

While the due dates specified in the letter still apply to all BCN AdvantageSM claims, we're extending the resubmission date for some Medicare Plus BlueSM claims:

  • For Medicare Plus Blue and BCN Advantage claims with dates of service from Oct. 1, 2019, through Sept. 30, 2020, the due date hasn't changed; you must correct and resubmit claims by Oct. 26, 2021.
  • For claims with dates of service from Oct. 1, 2020, through Dec. 16, 2020:
    • For Medicare Plus Blue claims, we're extending the resubmission deadline to Jan. 26, 2022.
    • For BCN Advantage claims, the due date hasn't changed; you must correct and resubmit claims by Nov. 26, 2021.

Reminder

As noted in previous communications, our systems will deny some resubmitted claims for Medicare Plus Blue members due to untimely filing. This occurs because our systems are set up to automatically issue denials for claims that are submitted more than one year after the date of service.

If you receive a denial, you don’t need to take any action. We're identifying these claims and will process them for payment after Jan. 26, 2022.

This issue doesn't affect resubmissions of corrected SNF claims for BCN Advantage members.

Additional information

As a reminder, naviHealth manages post-acute care services for Medicare Plus Blue and BCN Advantage members. For more information about naviHealth, see the Post-acute care services: Frequently asked questions for providers (PDF) document.

Posted: October 2021
Line of business: Blue Cross Blue Shield of Michigan



Additional drugs require prior authorization for UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans, starting Jan. 3

For dates of service on or after Jan 3, 2022, we're adding prior authorization requirements for the following drugs covered under the medical benefit for UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans:

  • Enhertu® (fam-trastuzumab deruxtecan-nxki), HCPCS code J9358
  • Jelmyto® (mitomycin), HCPCS code J9281
  • Lumoxiti® (moxetumomab pasudotox-tdfk), HCPCS code J9313
  • Padcev® (enfortumab vedotin-ejfv), HCPCS code J9177
  • Phesgo (pertuzumab, trastuzumab and hyaluronidase–zzxf), HCPCS code J9316
  • Sarclisa® (isatuximab-irfc), HCPCS code J9227
  • Zepzelca (lurbinectedin), HCPCS code J9223

Submit prior authorization requests through AIM Specialty Health®.

Notes:

  • Prior authorization requirements apply when these drugs are administered in an outpatient setting.
  • This requirement doesn't apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714).

How to submit authorization requests

Submit prior authorization requests to AIM using one of the following methods:

More about the authorization requirements

Authorization isn't a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members.

For additional information on requirements related to drugs covered under the medical benefit for UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans, see:

We’ll update the appropriate drug lists to reflect the information in this message prior to the effective date.

Note: Accredo manages prior authorization requests for additional medical benefit drugs.

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're not responsible for its content.

Posted: October 2021
Line of business: Blue Cross Blue Shield of Michigan



Starting Dec. 27, additional drugs require prior authorization for URMBT members with Blue Cross non-Medicare plans

For dates of service on or after Dec. 27, 2021, we're adding requirements for the following drugs covered under the medical benefit:

  • Nulibry (fosdenopterin), HCPCS code J3590, will have a prior authorization requirement.
  • Avsola (infliximab-axxq), HCPCS code Q5121, will have both prior authorization and site-of-care requirements.
  • Lemtrada® (alemtuzumab), HCPCS code J0202, already requires prior authorization. We're adding a site-of-care requirement.
  • Tysabri® (natalizumab), HCPCS code J2323, already requires prior authorization. We're adding a site-of-care requirement.

These requirements apply when the drugs are administered in an outpatient setting for Blue Cross UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans.

How to submit authorization requests

Submit prior authorization requests through NovoLogix. It offers real-time status checks and immediate approvals for certain medications.

To learn how to submit requests through NovoLogix, visit the Blue Cross Medical Benefit Drugs page on the ereferals.bcbsm.com website. Scroll to the Blue Cross commercial column and review the information in the “How to submit authorization requests electronically using NovoLogix” section.

More about the authorization requirements

Authorization isn't a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members.

For additional information on requirements related to drugs covered under the medical benefit for UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans, see:

We'll update the appropriate drug lists to reflect the information in this message prior to the effective date.

Note: Accredo manages prior authorization requests for additional medical benefit drugs.

Posted: September 2021
Line of business: Blue Cross Blue Shield of Michigan



Darzalex Faspro, Polivy and Trodelvy require prior authorization for URMBT members with Blue Cross non-Medicare plans, starting Dec. 3

For dates of service on or after Dec. 3, 2021, the following drugs covered under the medical benefit will require prior authorization through AIM Specialty Health®:

  • Darzalex Faspro (daratumumab and hyaluronidase-fihj), HCPCS code J9144
  • Polivy (polatuzumab vedotin-piiq), HCPCS code J9309
  • Trodelvy (sacituzumab govitecan-hziy), HCPCS code J9317

Prior authorization is required when these drugs are administered to UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans in outpatient settings.

Note: This requirement doesn't apply to the UAW Retiree Health Care Trust (group number 70605) or the UAW International Union (group number 71714).

How to submit authorization requests

Submit prior authorization requests to AIM using one of the following methods:

More about the authorization requirements

Authorization isn't a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members.

For additional information on requirements related to drugs covered under the medical benefit for UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans, see:

We'll update the appropriate drug lists to reflect the information in this message prior to the effective date.

Note: Accredo manages prior authorization requests for additional medical benefit drugs.

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're not responsible for its content.

Posted: September 2021
Line of business: Blue Cross Blue Shield of Michigan



Panzyga® will no longer have requirements through NovoLogix® for URMBT members with Blue Cross non-Medicare plans, starting Sept. 3

For dates of service on or after Sept. 3, 2021, we're updating the NovoLogix online tool to remove prior authorization, site of care and quantity limit requirements for Panzyga (immune globulin, human-ifas), HCPCS code J1599.

This change affects UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans.

As a reminder, we require prior authorization for Panzyga through the NovoLogix® online tool for dates of service from July 12, 2021, through Sept. 2, 2021.

For additional information on requirements related to drugs covered under the medical benefit, refer to the document Medical Drug Management with Blue Cross for UAW Retiree Medical Benefit Trust PPO non-Medicare Members.

We'll update this list with the new information about these drugs prior to the effective date.

Posted: September 2021
Line of business: Blue Cross Blue Shield of Michigan



Cosela and Libtayo® to require prior authorization for Blue Cross URMBT non-Medicare members, starting Nov. 1

For dates of service on or after Nov. 1, 2021, the following drugs will require prior authorization through AIM Specialty Health®:

  • Cosela (trilaciclib), HCPCS code C9078
  • Libtayo (cemiplimab-rwic), HCPCS code J9119

These drugs are covered under the medical benefit.

Prior authorization requirements apply when these drugs are administered in an outpatient setting for Blue Cross UAW Retiree Medical Benefits Trust non-Medicare members.

How to submit authorization requests

Submit prior authorization requests to AIM using one of the following methods:

More about the authorization requirements

Authorization isn't a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members.

For additional information on requirements related to drugs covered under the medical benefit for Blue Cross URMBT non-Medicare members, see:

Note: Accredo manages prior authorization requests for additional medical benefit drugs.

We'll update the appropriate drug lists to reflect the information in this message prior to the effective date.

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're not responsible for its content.

Posted: August 2021
Line of business: Blue Cross Blue Shield of Michigan



Additional drugs require prior authorization for Blue Cross URMBT non-Medicare members, starting Nov. 1

For dates of service on or after Nov. 1, 2021, we're adding prior authorization requirements for the following drugs covered under the medical benefit:

  • Abecma® (idecabtagene vicleucel), HCPCS code J3590
  • Breyanzi® (lisocabtagene maraleucel), HCPCS codes J3590, C9076
  • Beovu® (brolucizumab-dbll), HCPCS code J0179
  • Tepezza® (teprotumumab-trbw), HCPCS code J3241
  • Onpattro® (patisiran), HCPCS code J0222

Submit prior authorization requests through the NovoLogix® online tool.

Prior authorization requirements apply when these drugs are administered in an outpatient setting for Blue Cross UAW Retiree Medical Benefits Trust, or URMBT, non-Medicare members.

How to submit authorization requests

Submit prior authorization requests through NovoLogix. It offers real-time status checks and immediate approvals for certain medications.

To learn how to submit requests through NovoLogix, do the following:

  1. Click the Blue Cross link on this website.
  2. Click Medical Benefit Drugs.
  3. Scroll to the Blue Cross commercial column.
  4. Review the information in the “How to submit requests electronically using NovoLogix” section.

More about the authorization requirements

Authorization isn't a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members.

For additional information on requirements related to drugs covered under the medical benefit for Blue Cross URMBT non-Medicare members, see:

Note: Accredo manages prior authorization requests for additional medical benefit drugs.

We'll update the appropriate drug lists to reflect the information in this message prior to the effective date.

Posted: August 2021
Line of business: Blue Cross Blue Shield of Michigan



Asparlas to require prior authorization for Blue Cross URMBT non-Medicare members, starting Nov. 1

For dates of service on or after Nov. 1, 2021, Asparlas (calasparagase pegol-mknl), HCPCS code J9118, will require prior authorization through AIM Specialty Health®. This drug is covered under the medical benefit.

Prior authorization requirements apply when this drug is administered in an outpatient setting for Blue Cross UAW Retiree Medical Benefits Trust non-Medicare members.

How to submit authorization requests

Submit prior authorization requests to AIM using one of the following methods:

More about the authorization requirements

Authorization isn’t a guarantee of payment. As always, health care practitioners need to verify eligibility and benefits for members.

For additional information on requirements related to drugs covered under the medical benefit for Blue Cross URMBT non-Medicare members, see:

Note: Accredo manages prior authorization requests for additional medical benefit drugs.

We'll update the appropriate drug lists to reflect the information in this message prior to the effective date.

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're not responsible for its content.

Posted: July 2021
Line of business: Blue Cross Blue Shield of Michigan



Musculoskeletal surgeries and related procedures: New steps for determining whether prior authorization is required for Blue Cross commercial members

We added details to the Determining whether Blue Cross commercial members require prior authorization for musculoskeletal surgeries and related procedures (PDF) document that walk through the steps required to determine whether Blue Cross commercial is a member's primary coverage.

We did this because:

  • When Blue Cross commercial is a member's primary coverage, Blue Cross Blue Shield of Michigan requires providers to submit a prior authorization request to TurningPoint Healthcare Solutions LLC for musculoskeletal surgeries and related procedures.
  • When Blue Cross commercial isn't the member’s primary coverage, Blue Cross doesn't require you to do this. However, be sure to check the requirements for the member's primary coverage.

As a result of this difference and other considerations that are specific to Blue Cross commercial plans, it's important to know how to determine whether the service requires prior authorization.

Determining whether prior authorization is required for musculoskeletal procedures

The full process for determining whether a Blue Cross commercial member requires prior authorization for these procedures is:

  1. Determine whether the procedure code requires authorization by TurningPoint. If yes…
  2. Determine whether the member's primary coverage is through a Blue Cross commercial plan. If yes…
  3. Determine whether the member requires prior authorization for musculoskeletal surgeries and related procedures.

See the document linked above for details on each piece of this process.

Additional information

For additional information about the TurningPoint musculoskeletal surgical quality and safety management program, see the Blue Cross Musculoskeletal services page or the BCN Musculoskeletal services page on this website.

As a reminder, TurningPoint manages authorizations for orthopedic, pain management and spinal procedures for the following:

  • Blue Cross commercial - All fully insured groups, select self-funded groups and all members with individual coverage
  • Medicare Plus BlueSM members
  • BCN commercial members
  • BCN AdvantageSM members

Posted: July 2021
Line of business: Blue Cross Blue Shield of Michigan



CareCentrix®-assigned HIPPS codes for home health services for Medicare Plus BlueSM members who receive services in Michigan

As we communicated previously, you must include the health insurance prospective payment system, or HIPPS, code CareCentrix assigned when submitting claims for home health care services for Medicare Plus Blue members who receive services in Michigan.

Notes:

  • For Medicare Plus Blue members who receive services outside of Michigan, follow the reimbursement guidelines for the local Blue Cross plan.
  • This requirement doesn't apply to BCN AdvantageSM members.

Preferred methods to obtain a CareCentrix-assigned HIPPS code

These are the preferred methods:

  • When possible, complete the HIPPS questionnaire within the CareCentrix HomeBridge® portal when you submit the prior authorization request. If you do this, you will find the HIPPS code for the approved authorization in the following locations:
    • The Authorization Status screen in the HomeBridge portal.
    • The Service Registration Form, or SRF, that CareCentrix sends via fax.

    Refer to your Outcome and Assessment Information Set, or OASIS, assessment to complete the HIPPS questionnaire.

  • If the OASIS isn't available when you submit the authorization request, fax it to CareCentrix at 1-877-414-1087 as soon as it's available. CareCentrix will assign a HIPPS code, which you can find on the Authorization Status screen in the HomeBridge portal.

    If you submitted an OASIS and haven't received a HIPPS code, call CareCentrix at 1-833-409-1280 to request the code prior to submitting the claim or check the Authorization Status screen in the HomeBridge portal.

CareCentrix monitors authorizations for missing HIPPS codes

If you don't obtain the HIPPS code using one of the preferred methods by day 25 of the episode of care, CareCentrix will make two attempts to call you.

  • When CareCentrix contacts you and you supply the information needed to assign the HIPPS code, CareCentrix will update the authorization to include the HIPPS code.
  • If you contact CareCentrix to obtain a HIPPS code after the 30-day episode of care has ended and you provide the necessary information, CareCentrix will update the authorization to include the CareCentrix-assigned HIPPS code.

In both cases, you'll be able to find the CareCentrix-assigned HIPPS code on the Authorization Status screen in the HomeBridge portal.

Additional information

For more information about the CareCentrix home health care program, see the document titled Home health care: Frequently asked questions for providers.

As a reminder, CareCentrix manages prior authorizations for home health care services for Medicare Plus Blue and BCN Advantage members as follows:

  • For episodes of care that start on or after June 1, 2021
  • For episodes of care that started prior to June 1, 2021, when one of the following occurs on or after June 1: recertification is needed, resumption of care is needed or there's a significant change in condition

Posted: July 2021
Line of business: Blue Cross Blue Shield of Michigan



Some denied SNF claims for Medicare Plus Blue members will automatically process for payment after Nov. 26, 2021

Blue Cross Blue Shield of Michigan and Blue Care Network recently reviewed paid skilled nursing facility claim records with dates of service from Oct. 1, 2019, through Dec. 16, 2020, for our Medicare Advantage members. The purpose of the review was to verify that the billed services matched the services naviHealth authorized.

During the review, we found that some claims included overbilled or unauthorized services. For these claims, we sent letters to the affected providers to let them know they have 90 days to submit corrected claims that align with the services naviHealth authorized.

Note that our systems will deny some corrected claims for Medicare Plus Blue members due to untimely filing. This occurs because our systems are set up to automatically issue denials for claims that are submitted more than one year after the date of service.

You don't need to take any action as a result of the denial. We're identifying these claims and will process them for payment after Nov. 26, 2021.

This issue doesn't affect submissions of corrected SNF claims for BCN AdvantageSM members.

As a reminder, naviHealth manages post-acute care services for Medicare Plus Blue and BCN Advantage members. For more information about naviHealth, see the Post-acute care services: Frequently asked questions for providers document.

Posted: July 2021
Line of business: Blue Cross Blue Shield of Michigan



Procedure codes *70554 and *70555 to require prior authorization from AIM starting Sept. 1 for Blue Cross commercial and Medicare Plus BlueSM members

For dates of service on or after Sept. 1, 2021, the services associated with radiology codes *70554 and *70555 will require prior authorization from AIM Specialty Health®.

This applies to:

  • All Blue Cross commercial members, including UAW Retiree Medical Benefits Trust non-Medicare members and Blue Cross and Blue Shield Federal Employee Program® Michigan members
  • All Medicare Plus Blue members

Note: For BCN commercial and BCN AdvantageSM members, these services already require prior authorization from AIM.

We'll update the AIM codes lists with this new information prior to the effective date of the change.

You can find the AIM codes lists and additional information about submitting prior authorization requests to AIM on the Blue Cross AIM-Managed Procedures webpage at ereferrals.bcbsm.com.

*CPT codes, descriptions and two-digit modifiers only are copyright 2020 American Medical Association. All rights reserved.

Posted: June 2021
Line of business: Blue Cross Blue Shield of Michigan



Four additional drugs to require prior authorization for Blue Cross URMBT non-Medicare members, for dates of service on or after Sept. 7

For dates of service on or after Sept. 7, 2021, four additional drugs will require prior authorization when administered in an outpatient setting for Blue Cross UAW Retiree Medical Benefits Trust, or URMBT, non-Medicare members. These drugs are:

  • Crysvita® (burosumab), HCPCS code J0584
  • Luxturna® (voretigene neparvovec), HCPCS code J3398
  • Ultomiris® (ravulizumab), HCPCS code J1303
  • Poteligeo® (mogamulizumab), HCPCS code J9204

Two of these drugs will also be subject to site-of-care requirements and quantity limits.

To learn more about this change, see the detailed provider alert.

Posted: June 2021
Line of business: Blue Cross Blue Shield of Michigan



Spravato® and Panzyga® to require prior authorization starting July 12 for URMBT PPO non-Medicare members

We're expanding the prior authorization requirements for drugs covered under the medical benefit for UAW Retiree Medical Benefits Trust, or URMBT, PPO non-Medicare members.

For dates of service on or after July 12, 2021, the following drugs will require prior authorization:

  • Spravato (esketamine), HCPCS code S0013
  • Panzyga (immune globulin, human-ifas), HCPCS code J1599

How to submit authorization requests

Submit prior authorization requests through the NovoLogix® online tool. It offers real-time status checks and immediate approvals for certain medications.

To learn how to submit requests through NovoLogix visit the Blue Cross Medical Benefit Drugs page on this website. Scroll down to the Blue Cross' PPO (commercial) column and review the information in the "How to submit authorization requests electronically using NovoLogix" section.

More about the authorization requirements

Authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

For additional information on requirements related to drugs covered under the medical benefit, refer to the document Medical Drug Management with Blue Cross for UAW Retiree Medical Benefit Trust PPO non-Medicare Members (PDF).

We'll update this list with the new information about these drugs prior to the effective date.

Posted: April 2021
Line of business: Blue Cross Blue Shield of Michigan



Providers must submit musculoskeletal authorization requests to TurningPoint for URMBT non-Medicare members

Last year, we announced that health care providers needed to submit prior authorization requests for all orthopedic, pain management and spinal procedures to TurningPoint as part of Blue Cross' Musculoskeletal Surgical Quality & Safety Management Program. This originally affected most Blue Cross and all BCN members.

UAW Retiree Medical Benefits Trust, or URMBT, non-Medicare members will need prior authorization requests for these procedures that are scheduled on or after May 31, 2021. Health care providers will be able to submit prior authorization requests to TurningPoint starting May 3, 2021.

Where to find more information

As a reminder about the details of the program, see this article in the January 2021 issue of The Record and this article from the July 2020 issue of The Record.

For more information about TurningPoint, see the following pages on the ereferrals.bcbsm.com website:

To view the lists of codes for which TurningPoint manages authorizations, see Musculoskeletal procedure codes that require authorization by TurningPoint (PDF).

For detailed information, see Musculoskeletal procedure authorizations: Frequently asked questions for providers (PDF).

Posted: April 2021
Line of business: Blue Cross Blue Shield of Michigan



Starting in June, additional medical benefit drugs will require prior authorization for some Blue Cross commercial members

Starting in June 2021, we're adding prior authorization requirements for additional drugs covered under the medical benefit for UAW Retiree Medical Benefits Trust PPO non-Medicare members.

For dates of service on or after June 24, 2021, submit prior authorization requests to AIM Specialty Health® for these drugs:

  • Nivestym® (filgrastim-aafi), HCPCS code Q5110
  • Udenyca® (pegfilgrastim-cbqv), HCPCS code Q5111
  • Ontruzant® (trastuzumab-dttb), HCPCS code Q5112
  • Ziextenzo® (pegfilgrastim-bmez), HCPCS code Q5120
  • Zirabev (bevacizumab-bvzr), HCPCS code Q5118

How to submit requests

You can submit requests through the AIM ProviderPortal* or by calling the AIM Contact Center at 1-844-377-1278.

For information about registering for and accessing the AIM ProviderPortal, see the Frequently Asked Questions page* on the AIM website.

More about the authorization requirements

Authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

For more information on requirements related to drugs covered under the medical benefit for these members, refer to the Medical oncology prior authorization list for UAW Retiree Medical Benefits Trust PPO non-Medicare members. We'll update this list to reflect these changes prior to the effective date.

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're not responsible for its content.

Posted: March 2021
Line of business: Blue Cross Blue Shield of Michigan



Starting in May, additional medical benefit drugs will require prior authorization for some Blue Cross commercial members

Starting in May 2021, we're adding prior authorization requirements for additional drugs covered under the medical benefit for UAW Retiree Medical Benefits Trust PPO non-Medicare members.

For dates of service on or after May 24, 2021, submit prior authorization requests to AIM Specialty Health® for these drugs:

  • Herceptin Hylecta (trastuzumab and hyaluronidase-oysk), HCPCS code J9356
  • Herzuma® (trastuzumab-pkrb), HCPCS code Q5113
  • Ogivri (trastuzumab-dkst), HCPCS code Q5114
  • Trazimera (trastuzumab-qyyp), HCPCS code Q5116

How to submit requests

You can submit requests through the AIM ProviderPortal* or by calling the AIM Contact Center at 1-844-377-1278.

For information about registering for and accessing the AIM ProviderPortal, see the Frequently Asked Questions page* on the AIM website.

More about the authorization requirements

Authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

For more information on requirements related to drugs covered under the medical benefit for these members, refer to the Medical Drug Management with Blue Cross for UAW Retiree Medical Benefit Trust PPO non-Medicare members. We'll update this list to reflect these changes prior to the effective date.

*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're not responsible for its content.

Posted: February 2021
Line of business: Blue Cross Blue Shield of Michigan



We're adding site-of-care requirements for Uplizna® for Blue Cross commercial members, starting Jan. 1, 2021

Starting Jan. 1, 2021, we're adding site-of-care requirements for the following drug covered under the medical benefit for Blue Cross commercial members:

  • Uplizna (inebilizumab-cdon), HCPCS code J1823

What you need to do

Encourage your patients who have Blue Cross commercial coverage to select one of the following infusion locations instead of using a hospital outpatient facility:

  • A doctor's office or other health care provider's office
  • An ambulatory infusion center
  • The member's home, from a home infusion therapy provider

If members currently receive infusions for these drugs at a hospital outpatient facility, providers must:

  • Obtain prior authorization for receiving the infusion at the hospital outpatient facility location.
  • Check the directory of participating home infusion therapy providers and infusion centers to see where the member may be able to continue infusion therapy. To do this, go to bcbsm.com, click Find a Doctor, click the Search without logging in link, click Places by type, enter Home infusion therapy or Ambulatory infusion therapy center in the search field and press ENTER.

Override for infusions received from Jan. 1 through Feb. 18

If a member who has a prior authorization that doesn't include a site-of-care requirement receives an infusion of Uplizna at an outpatient hospital facility from Jan. 1 through Feb. 18, 2021, the claim will be rejected for a noncovered site of care. However, you'll be able to receive an override for these dates of service so the claim will pay. To inquire about an override, call the Pharmacy Clinical Help Desk at 1-800-437-3803.

For dates of service on or after Feb. 19, all members must receive infusions at a covered infusion location, unless the provider obtains prior authorization for receiving the infusion at a hospital outpatient facility location.

More about authorization requirements

These authorization requirements apply only to groups that currently participate in the standard commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit.

Note: Uplizna already has site-of-care requirements for BCN commercial members for dates of service on or after Aug. 1, 2020.

Authorization isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members.

List of requirements

For requirements related to drugs covered under the medical benefit, see the:

Additional information

This change doesn’t apply to:

  • BCN AdvantageSM members
  • Medicare Plus BlueSM members

Posted: January 2021
Line of business: Blue Cross Blue Shield of Michigan