06/05/2018
BCBSM/BCN
Recent Oncology Related News
Provided by MSHO Managed Care Committee Members:
Blue Cross won’t cover 4 more infusion drugs at outpatient hospital sites without approval, starting July 1
Beginning July 1, 2018, Blue Cross Blue Shield of Michigan is adding four drugs to its infusion site of care requirement for groups currently participating in the commercial Medical Drug Prior Authorization Program:
| HCPCS | Drug |
| J3380 | Entyvio™ |
| J2507 | Krystexxa® |
| J3358 | Stelara IV |
| J3357 | Stelara® |
Blue Cross won’t cover infusions for these drugs at a hospital outpatient facility without a prior authorization for that approved location. If the member now receives his or her infusions in a professional location (such as a physician’s office or an approved infusion center) or the patient’s home, the only requirement is approval of the drug.
Help your patient switch his or her infusion therapy location by July 1
If your patient gets one of these drug infusions in a hospital outpatient facility, follow these steps to switch him or her to your office, an infusion center or home:
- Submit your patient’s prior approval request to Blue Cross. If this request isn’t submitted and approved, he or she will be responsible for the full cost of the medicine.
- Find out where your patient can continue infusion therapy. Check the directory of participating home infusion therapy providers and infusion centers.
- Tell your patient to contact any in-network infusion therapy providers (we’re sending this information to your patient as well). If the chosen provider can accommodate your patient, they’ll work with you and your patient to make the change easy.
- Confirm network participation for your patient before his or her infusion.
If a patient must receive one of these infusions in a hospital outpatient facility, follow the normal steps for a prior authorization request and include:
- The previously approved authorization number
- Clear rationale describing the reason the infusion must be administered in a hospital setting
- Supporting chart notes
For more information about hospital outpatient infusion therapy, view our previous October 2017, December 2017 and March 2018 articles in The Record.
IMPORTANT - Medicare Advantage PPO adding outpatient facilities to specialty medical medications prior authorization program beginning June 28, 2018
Beginning June 28, 2018, Blue Cross Blue Shield of Michigan will expand its prior authorization program for Medicare Plus BlueSM PPO specialty medical medications for professional claims to include outpatient facilities, place of service 19, 22 and 24 that are billed on a professional claim form. Currently, only place of service 11 is part of this program.
What you need to know
- Select specialty medications are covered under the Medicare Part B medical benefit. The selected medications aren't self-administered and must be administered (via injection or infusion) by a doctor or health care professional. In addition to current place of service 11, expansion to include outpatient facilities with place of service 19, 22, and 24 will begin June 28, 2018.
- Place of service definitions:
- 11 – Provider Office
- 19 – Off-campus Outpatient Hospital
- 22 – On-campus Outpatient Hospital
- 24 – Ambulatory Surgical Center
- Prior authorization is required for professional claims submitted on HCFA 1500 form or ANSI 837P electronic submission with place of service 11, 19, 22 and 24. Facility claims submitted using UB claim submission aren't in scope.
- Providers must obtain prior authorization and verify patient benefits to be eligible for payment for administering these services. If a prior authorization isn't obtained before services are rendered, the claim will be denied for no authorization on file. At that time, a provider may submit a retroactive authorization request within 90 days of the date of service. Patient must meet all requirements and have the necessary coverage for the claim to be payable.
- Authorization isn't a guarantee of payment. Benefits and eligibility must be determined at the time services are rendered. Providers will submit Part B medical drug requests for dates of service on or after June 28, 2018, electronically through NovoLogix®, a secure online tool. NovoLogix allows providers to obtain real-time status checks on prior authorizations and to obtain immediate approvals for certain medications when patients meet the criteria. Submitting these requests electronically is the preferred method because it saves time and allows you to view the status of the request at any time. If your patient has an existing prior authorization for a provider administered drug on file, an additional authorization for place of service care 19, 22 or 24 isn't required.
Future notifications will be sent that will provide you with the date when you can begin entering cases through the medical prior authorization e-tool, if the patient doesn't have an existing prior authorization on file for the provider office. Look for more information about NovoLogix training and other program details on web-DENIS and in future issues of The Record.
Sign up for a webinar on the Medicare Plus Blue PPO outpatient facility authorization requirements for specialty medical drugs
We invite you to register for one of the educational webinars we’re hosting about the upcoming changes to the Blue Cross Medicare Plus BlueSM PPO specialty medication prior authorization program. This change is effective for dates of service on or after June 28, 2018, and affects select drugs covered under the medical benefit (Part B medications) administered at outpatient facilities and billed on a professional claim form.
What you’ll learn at the webinar
You’ll learn about how Medicare Plus Blue is expanding its specialty medication authorization requirements to include outpatient facilities that bill with Place of Service 19, 22 or 24. Currently, only providers that bill with Place of Service 11 are subject to these requirements.
We first communicated about this change in a web-DENIS message posted on May 1, 2018.
How to register for the webinar
To sign up for a webinar, decide which webinar day and time is best for you:
- Tuesday, June 19, 2018, from 9 to 9:30 a.m. (RSVP by Monday, June 18.)
- Wednesday, June 20, 2018, from 1 to 1:30 p.m. (RSVP by Monday, June 18.)
Then, complete the registration form and fax it to 1-866-652-8983 or email it as an attachment to ProviderInvitations@bcbsm.com. Instructions will be emailed to you a day or two prior to the webinar.
Cancellation of modifier 25 payment adjustment for evaluation and management services
In the April 2018 Record, we announced that evaluation and management services billed with modifier 25 would pay at 80 percent when billed with a surgery on the same day by the same provider, effective July 1, 2018. However, based on new information and provider feedback, we are cancelling implementation of the policy.
Medicare Plus BlueSM PPO weekly claims-reprocessing report: June 2
After resolving system defects, Medicare Plus Blue PPO will reprocess the following, estimated quantities of claims over the weekend of June 2, 2018:
400 Local claims
What happened: In February 2018, a file-loading error caused some back-end data issues that we couldn’t resolve until May 2018. We corrected most claims prior to completion of processing, but some claims denied as duplicates.
Impacts: Claims processed between Feb. 20, 2018, to April 26, 2018.
We’ll adjust affected claims to remove improper denials.
10,000 Local claims, 40 ITS home claims
What happened: The Centers for Medicare & Medicaid Services recently issued instructions via Transmittal 1969 to Medicare administrative contractors about the distribution of settlement amounts resulting from Two-Midnight Rule-related lawsuits.
Impacts: Inpatient hospital claims paid from June 1, 2017, to May 31, 2018.
We’ll adjust affected claims to receive an increase in allowed amounts, per CMS guidance.
200 Local claims
What happened: Fee updates to the 2018 carrier-priced codes weren’t ready in our claims system until Jan. 18, 2018.
Impacts: Claims processed from Jan. 1, 2018, to Jan. 18, 2018.
We’ll adjust claims to apply proper fees.
Updated clinical practice guidelines now available at MQIC.org
The Michigan Quality Improvement Consortium has released the following updated clinical practice guidelines:
- Management and Prevention of Osteoporosis
- Management of Adults with Depression
- Advance Care Planning
- Management of Acute Low Back Pain in Adults
- Prevention of Pregnancy in Adolescents 12-17 Years
- Management of Uncomplicated Acute Bronchitis in Adults
Please visit mqic.org to see the new guidelines. To access them on Android and iOS devices, an MQIC app is available at Google Play and the App Store.
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.
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.
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.
June 2018 – Issue
- We’ve streamlined the Blue Cross, BCN e-referral systems
- Provider forums continue in June
- Medical record signatures: What’s acceptable?
- Blue Cross won’t cover 4 more infusion drugs at outpatient hospital sites without approval, starting July 1
- New billing requirements for telemedicine services start June 1
CHECK OUT THESE ARTICLES AND MUCH MORE HERE!