05/14/2018
BCBSM/BCN
Recent Oncology Related News
Provided by MSHO Managed Care Committee Members:
REMINDER FROM MSHO:
Offices have reported problems with some drugs denying by BCBSM when the Z51.11 ICD-10 code is in the first position (which would be correct under the ICD-10 Guidelines).
BCBSM requires the Cancer Diagnosis in the FIRST DIAGNOSIS POSITION. This includes secondary claims.
To avoid denials, remember to put the Cancer Diagnosis in the first position for all Blue Cross claims (including any secondary). For further questions on this update, contact Michelle Weiss at billing@msho.org.
Reminder: EDI Professional Commercial Payer List - Updated payer IDs effective April 23, 2018
We updated our Commercial Payer List on April 23, 2018, eliminating the requirement of a claim office number for some payers. We are experiencing a high volume of rejected claims due to this change. As a reminder, claims reporting the payer ID and a claim office number will reject with an edit of:
- P017 Commercial Payer ID and or Claim Office Number is Invalid.
Rejected claims must be corrected and rebilled with the appropriate Payer ID without a claim office number.
Please reference the revised Commercial Payer List on bcbsm.com for a complete list of commercial payers. A claim office number should only be reported when one is listed on our Commercial Payer List for a specific payer ID.
Please note the following payer IDs no longer require a claim office number. (SEE web-DENIS FOR LIST)
Medicare Plus BlueSM PPO weekly claims-reprocessing report: May 19 (Oncology Related)
After resolving system defects, Medicare Plus Blue PPO will reprocess and adjust the following, estimated quantities of claims over the weekend of May 19, 2018:
1,100 Local claims, 200 ITS home claims
What happened: Claims for HCPCS codes J0881 and J0885 were improperly denied by coverage guidelines outlined in national coverage determination ID 110.21 when billed with diagnosis codes covered by local coverage determination ID L34633. CMS amended the NCD to prevent it from being affected by the LCD.
Impacts: Claims that processed between April 1, 2016, to April 30, 2018.
We’ll adjust the claims to remove the improper denials.
Status update on observation care claims we're reprocessing
As promised, here's an update of the May 2, 2018, broadcast message, "We're reprocessing some observation care claims."
We finished the interim fix on May 4, 2018, as planned. And, we expect a permanent fix will be complete on June 3, 2018.
We’ll keep you posted on our progress.
Medicare Plus BlueSM PPO weekly claims-reprocessing report: May 12 (Oncology Related)
After resolving system defects, Medicare Plus Blue PPO will reprocess and adjust the following, estimated quantities of claims over the weekend of May 12, 2018:
590 Local claims, 100 ITS home claims
What happened: Outpatient facility claims for IV therapy (service codes *96413, *96360, *96365 and *96374) denied when more than one of these service codes are submitted on the same claim although the services occurred on different dates.
Impacts: Local and ITS home claims processed between Oct. 1, 2017, and April 6, 2018.
Payment recovery for discarded drug claims starting immediately
Blue Cross Blue Shield of Michigan will immediately begin recovering full payment for Medicare Plus BlueSM PPO claims where the Centers for Medicare & Medicaid Services JW modifier guidance for discarded drugs isn't met.
What you need to know
- Multi-use vials aren’t subject to payment for discarded amounts of drugs or biologicals. Claims must be billed using drug dosage formulations or unit dose sizes that minimize waste. Providers are expected to use drugs or biologicals in the most efficient way possible. The units billed must correspond with the smallest dose vial available for purchase from the manufacturer that could provide the appropriate dose for the patient.
- When the HCPCS unit is equal to or greater than the total of the actual dose and the amount discarded, use of the JW modifier isn’t permitted. If the quantity of drug administered is less than a full unit, the billed unit is rounded to the appropriate unit.
- The discarded drug should be billed on a separate line with the JW modifier. The unit field should reflect the amount of drug discarded.
- Don’t report one claim line with combined units for the amount of drug administered and wasted.
Need more details?
Review the Medicare Claims Processing Manual "Chapter 17 — Drugs and Biologicals," section 40.
Provider manual Utilization Management changes coming June 28; Specialty Medication Prior-Authorization Program adding outpatient facility sites of care
On June 28, 2018, we’re adding outpatient facilities with sites of care 19, 22 and 24 to the Medicare Plus Blue PPO Specialty Medication Prior-Authorization Program. Currently, we only require prior authorization for professional claims with site of care 11 (physician office).
We’ll update this information in the Utilization Management section of the Medicare Plus BlueSM PPO manual.
What you need to know
- For dates of service on or after June 28, 2018, use the NovoLogix® online tool to get a preservice prior authorization for certain specialty medications (such as medications administered in the physician’s office or at an outpatient facility that are billed as a professional service and covered under the Medicare Part B medical benefit).
- We’ll notify you when you can begin entering cases for prior authorization through the medical prior authorization e-tool.
- A drug list and details regarding the Prior Authorization Program can be found at Medicare Advantage PPO medical drug policies and forms.
Effective July 1, BCN won’t accept late claims
Effective July 1, 2018, BCN will no longer accept claims that we receive after the filing limit. We first communicated about this in the BCN Provider News, on page 1 of the May-June 2018 issue, in an article titled Blue Care Network won’t accept late claims, effective July 1.
The filing limit for claims is 12 months from the date of service or discharge date, for both initial submissions and replacement (corrected or adjusted) claims, unless the claim qualifies as an eligible exception as identified by the Centers for Medicare & Medicaid Services. This applies to both BCN HMOSM (commercial) and BCN AdvantageSM claims.
In the past, we’ve allowed providers to submit claims after our filing limits. Effective July 1, we’ll no longer accept claims received after the filing limit.
We’ve updated the Claims chapter of the BCN Provider Manual with this information. We strongly encourage providers to submit claims within the filing limits to avoid rejection.
Clinical Quality Corner tip sheets updated for 2018
Our Clinical Quality Corner tip sheets have been updated for 2018 and posted on web-DENIS.
They’re part of our ongoing efforts to give you the tools you need to improve health care quality. Each of the 27 tips sheets focuses on a specific HEDIS® measure.*
This year, they’ve been posted in both the BCBSM Provider Publications and Resources section of web-DENIS as well as the BCN Provider Publications and Resources section. You can access them in one of two ways:
From the homepage of web-DENIS:
- Click on BCBSM Provider Publications and Resources
- Click on Newsletters & Resources.
- Click on Clinical Quality Corner on the left-hand side of the page.
or
From the homepage of web-DENIS:
- Click on BCN Provider Publications and Resources.
- Under What’s New, click on Clinical Quality Corner.
*HEDIS, which stands for Healthcare Effectiveness Data and Information Set, is a registered trademark of the National Committee for QualityAssurance, or NCQA.
More medical drugs added to site of care infusion requirement, beginning July 1
Starting July 1, 2018, additional pre-authorized medical drugs will be added to the Blue Cross Blue Shield of Michigan site of care requirement. Most infusions for these drugs won’t be covered at outpatient hospital facilities without prior authorization for an approved location, starting July 1.
All drugs included in this program already need prior authorization for payment. Approved authorizations will be payable for professional locations (such as physician’s offices and approved infusion therapy centers) and home infusions, with no further action required.
If your patient now receives one of these infusions at a hospital outpatient facility:
- Send Blue Cross a prior-approval request for his or her hospital outpatient facility. If this request isn’t submitted and approved, your patient will be responsible for the full cost of the medicine.
- Find out where your patient can continue his or her infusion therapy. Check the directory of participating home infusion therapy providers and infusion centers.
- Tell your patient to contact any of the listed infusion therapy providers. If they’re able to accommodate your patient, they’ll work with you and your patient to make the change easy. We’re also sending this information toyour patient.
- Help your patient switch his or her infusion therapy to your office, infusion center or home infusion therapy provider by July 1.
The following HCPCS codes and medical drugs are subject to this requirement:
J3380 — EntyvioTM
J2507 — Krystexxa®
Q9989 — Stelara IV
J3357 — Stelara®
We’ve modified provider appeal time frames, effective June 1
In a March Record article, we let you know that changes were coming to how we’re handling provider audits and appeals. Here are the time frames associated with the provider audit appeals process for professional and non-hospital facility providers, beginning June 1, 2018.
For reconsideration appeal:
- The health care provider must request an appeal within 30 calendar days of the date on the reporting letter.
- The provider will receive a response to his or her appeal within 30 calendar days of the date the appeal is received.
- We’ll adjust claims as needed if we don’t receive a reconsideration appeal within 30 calendar days of the date of the audit finding.
For independent external review:
- We must receive the request for a review within 30 calendar days of the date of the reconsideration appeal letter.
- An external peer review of records will take place within 45 calendar days.
- The provider will be notified of the peer review decision within 30 calendar days of the date that the peer review decision is received.
- The provider will pay the cost of the peer review if our audit decision is upheld. If our audit decision is reversed, then we’ll absorb the cost. If our findings are partially reversed and partially upheld, we will share the peer review cost proportionate to the results.
- We’ll adjust claims as needed if we don’t receive a request for an independent external review within 30 calendar days of the date of the appeal uphold letter.
Note: Providers may incur attorney fees and other expenses in preparation for the external peer review; these costs are the providers’ responsibility. The external review ends the appeal process for both Blue Cross Blue Shield of Michigan and the provider.
May 2018 – Issue
- HCPCS update: New codes added (Includes Biosimilars and C-codes)
- Billing chart: Blues highlight medical, benefit policy changes
- Here are more details about changes to our professional provider consultant model
- We’ve modified provider appeal time frames, effective June 1
- Here’s how to accurately code for immunosuppression and immunodeficiency
- Provider forums kick off in May
- Clarification: Authorizations for outpatient infusions
CHECK OUT THESE ARTICLES AND MUCH MORE HERE!