03/20/2018
BCBSM/BCN
Recent Oncology Related News
Provided by MSHO Managed Care Committee Members:
Blue Cross to update ClaimsXtenTM with additional professional and outpatient facility edits in June
Starting in June 2018, Blue Cross will update ClaimsXten to edit additional professional and outpatient services. These new edits will promote correct coding and simplify our claims payment systems.
- New patient services that are billed for established patients by professional providers within the established timeframes will deny for correct established patient code.
- Anesthesia services reported with non-anesthesia codes that are not eligible to be reported for anesthesia providers will deny for resubmission with the correct anesthesia code.
- Procedures that allow global component billing that are reported by more than one provider for the same component will deny. Blue Cross payment policy only pays up to the global component fee.
- Claim lines with services considered unbundled according to CMS National Correct Coding Initiative will deny. Unbundled services are not recommended for reimbursement.
Additional reminders of these new ClaimsXten edits will be published in future web-DENIS and Record articles.
Effective immediately, two CAR T-cell therapies require authorization for Medicare Advantage members
Effective immediately, the following CAR (chimeric antigen receptor) T-cell therapies require authorization for Blue Cross Medicare Plus BlueSM PPO and BCN AdvantageSM members:
| HCPCS Code | Brand Name | Generic Name |
| Q2041 | YescartaTM | axicabtagene ciloleucel |
| Q2040 | KymriahTM | tisagenlecleucel |
To request authorization for these therapies:
- Complete the Medication Authorization Request Form on this page for the medication you’re requesting.
- Gather the following supporting clinical documentation:
- The member’s eligibility for autologous hematopoietic stem cell transplant
- Testing for CD19 tumor expression
- Previous gene therapy
- Detailed information about the therapies the member has already received
- Fax the completed form and the clinical documentation to 1-866-392-6465.
Since these requests require thorough review, we ask that you request an expedited review only if the standard review time frame could place the member’s health in serious jeopardy.
Most immune globulin infusions will not be covered at outpatient hospital facilities starting April 1, 2018
Beginning April 1, 2018, Blue Cross Blue Shield of Michigan will require prior authorization for members who seek infusions or are currently receiving infusions in a hospital outpatient facility for select immune globulin medical drugs prior to being administered. Members must receive their infusions in a professional office setting, a professional infusion center or in the member’s home.
All drugs included in this program already require prior authorization for payment. Approved authorizations will be payable at professional settings and through home infusion with no further action required.
If your patient currently receives IVIG infusions at a hospital outpatient facility:
- Submit a prior approval request for your patient to Blue Cross for a hospital outpatient facility. If this request isn’t submitted and approved, the patient will be responsible for the full cost of the medicine.
- Check the directory of participating home infusion therapy providers and infusion centers where your patient may be able to continue infusion therapy.
- Tell your patient to contact any of the listed infusion therapy providers. If they’re able to accommodate your patient, they will work with your patient and you to make this change easy. We’re also sending this information to your patient.
- Help your patient switch infusion therapy to your office, infusion center or home infusion therapy provider by April 1.
For the ordering provider:
If a member must receive IVIG infusion in a hospital outpatient facility, please follow the normal steps for a prior authorization request and include:
- The authorization number previously approved
- Rationale that clearly describes the reason the infusion must be administered in a hospital setting
- Supporting chart notes
The IVIG drugs subject to this requirement include:
Note: A new authorization is not required when a member changes to a different IVIG product and an active prior authorization is already approved for the location where the infusion will be administered.
For more information about hospital outpatient infusion therapy, view the previous articles in the October and December issues of The Record.
March 2018 – Issue
- You can join our Physician Group Incentive Program as an organized system of care
- Updated Provider Training webpage offers all the learning resources you need
- Changes coming to the way we handle provider audits
- Blue Cross and BCN will no longer cover Alvesco®
- Prevent unnecessary delays: Include key information for oncology pharmacy prior authorization drug requests
- Most immune globulin infusions will not be covered at outpatient hospital facilities starting April 1, 2018
CHECK OUT THESE ARTICLES AND MUCH MORE HERE!