09/05/2018
BCBSM/BCN
Recent Oncology Related News
Provided by MSHO Managed Care Committee Members:
Reminder: Follow these guidelines when billing medical drugs that haven’t been purchased
Some health care providers have questioned what to do when billing certain medical drugs that were administered by a medical professional but supplied by our specialty pharmacy.
Here are guidelines to follow in professional and hospital settings:
- When professional providers administer a drug they didn’t purchase, they should bill for the administration code only and not include the drug or NDC code on the claim.
- When professional providers administer a medical drug that was purchased, notes should be documented and a copy of the purchase order included in the member’s chart.
- Identical NDC codes billed within 14 days of a specialty pharmacy claim will be recovered and the provider will need proof of purchase to have the claim repaid.
- When a hospital administers a drug in an outpatient setting that isn’t purchased by the hospital, the hospital should bill for the administration. However, the hospital should include the revenue code and corresponding procedure code for the medical drug with total charges of $.01.
For more information, see the May 2016 and July 2016 Record articles.
Register for the September PGIP Quarterly Meeting Today
Online registration is open through September 7, 2018 for the 2018 PGIP quarterly meeting on September 14, 2018.
All attendees, including speakers and invited guests, must register.
Meeting location:
Radisson Hotel
111 N. Grand Avenue
Lansing, MI 48933
Attendance is limited to current PO staff, PO leadership and Blue Cross-invited guests only.
Click here for the online registration form and agenda.
Medicare Plus BlueSM PPO manual update coming in October
Blue Cross Blue Shield of Michigan will update its Medicare Plus BlueSM PPO manual for an October 1 effective date. Key changes include:
- Added language in the Eligibility and Coverage section
- Updated language in the Durable Medical Equipment, Prosthetic & Orthotic section
- Deletion of language in the Medical Management and Quality Improvement section
- Added language in the Medicare Diabetes Prevention Program section
- Deletion of language and updated language in the Utilization Management section
- Updated language in the Claim Filing section
- Added language in the Medical Records section
This message serves as notice of these changes to the Medicare Plus Blue PPO manual, per the terms of the Blue Cross Medicare Advantage PPO provider agreement.
Renflexis® requires authorization for BCN AdvantageSM starting Oct. 1
For dates of service on or after Oct. 1, 2018, Renflexis requires authorization for BCN Advantage members.
This medication is not self-administered. It must be given by injection or infusion by a physician or health care professional in the office, home or outpatient facility setting.
This medication requires authorization when it is billed on either a professional HCFA 1500 claim form (or submitted electronically using an 837P transaction) or on a facility claim form such as the UB-04 (or submitted electronically using an 837I transaction), for the following places of service:
- Physician office (Place of Service code 11)
- Home (Place of Service code 12)
- Outpatient facility (Place of Service codes 19 and 22)
Submit authorization requests for this medication through the Novologix online tool. Authorization must be obtained prior to the medication being administered.
Change to Provider Taxonomy Code field – New name, same information
The name of the Provider Taxonomy Code electronic field has been changed to Provider Specialty Code for all Internet Claim Tool professional CMS-1500 forms. The location of the field hasn't changed.
If you're required to report a taxonomy code, follow these steps:
- Select Electronic Fields at the top of the claim form.
- Select the Billing Provider category from the electronic fields screen.
- Enter the taxonomy code in the Provider Specialty Code field (the field will not be highlighted red).
For questions about taxonomy code reporting and billing requirements, contact your provider consultant.
Phone numbers change for BCN Case Management and Care Transition programs
The phone numbers for BCN's Case Management and Care Transition to Home programs have changed. To reach staff in these programs, call 1-800-775-2583. Wait to hear the prompts and press the number for the prompt that matches your request.
Please update your files to show the following:
- Instead of the 1-800-943-9744 number for BCN Case Management, call 1-800-775-2583.
- Instead of the 1-800-728-3010 number for the BCN Care Transition to Home program, call 1-800-775-2583.
The Care Management and BCN Advantage chapters of the BCN Provider Manual are being updated to reflect the new 1-800-775-2583 phone number.
We're working on a system update to allow new patient evaluations, management services
We've found an issue with an edit related to new patient services, and we've started fixing the system. Tentatively in September: The system will continue to allow reimbursement for new patient evaluations and management services provided by different providers; and, we'll reprocess impacted claims.
In the meantime, thanks for your patience.
National drug code (NDC) unit or basis for measurement code (code qualifier)
To ensure correct processing, Blue Cross Blue Shield of Michigan requests that the national drug code (NDC) unit or basis for measurement code (code qualifier) reported in Loop 2410 CTP05-1 for source of payment BL be one of the following:
- Report UN (unit) for drugs that come in a vial in powder form that need to be reconstituted before administration
- Report ML (milliliter) for drugs that come in a vial in a liquid form
- Report GR (gram) for topical forms of medicine (e.g., cream, ointment and bulk powder in a jar)
International units should be converted to standard measurements (UN).
Please note use of any other unit or basis for measurement code (code qualifier) in Loop 2410 CTP05-1 could result in a payment modification. For additional information, please refer to the February 2015 Record article or the 837 Professional Health Care Claim Companion Document.
Medicare Advantage compliance audits to begin Oct. 1
On Oct. 1, 2018, Blue Cross Blue Shield of Michigan will begin its Medicare policy audits to ensure that providers are responding to medical records request letters.
Changes to audit policy
Previously, Blue Cross wouldn't always act when providers didn't respond to requests for additional documentation.
Starting Oct. 1, 2018, Blue Cross will notify providers if it issues a noncompliance denial for a claim or service due to an outstanding records request. Providers who don't respond to the request in the allotted timeframe, or by the extension timeframe, will have their entire claim or service denied as not reasonable or necessary. And, Blue Cross will recoup the claim from future payments.
More information will be available in the September issue of The Record.
Starting Oct. 1, additional specialty medications require authorization for BCN AdvantageSM members
For dates of service on or after Oct. 1, 2018, additional specialty medications covered under the Medicare Part B medical benefit require authorization for BCN Advantage members.
We first communicated about this in the article Starting Oct. 1, additional specialty medications require authorization for BCN Advantage members, on page 28 of the July-August 2018 BCN Provider News.
Please review the article to see which drugs require authorization starting October 1.
Exception: Vivaglobin® (HCPCS code J1562) will not require authorization because it is being discontinued. This is a change from what we communicated in the newsletter article.
These medications are not self administered. They must be given by injection or infusion by a physician or health care professional in the office or outpatient facility setting.
Authorization is required for these medications when they are billed on a professional HCFA 1500 claim form or when the claim is submitted electronically via an 837P transaction, for the following sites of care:
- Physician office (Place of Service code 11)
- Outpatient facility (Place of Service codes 19, 22 and 24)
Note: In the July-August 2018 newsletter article, we mentioned only Place of
Service codes 19 and 22 for outpatient facilities, but authorization is also required
for Place of Service code 24.
Authorization is not required for these medications when they are billed on a facility claim form (such as the UB 04) or electronically via an 837I transaction.
Please review the July-August newsletter article for additional information.
In addition, look for an article in the September-October 2018 BCN Provider News, which will clarify these changes.
We’ve canceled the 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’ve canceled implementation of this policy.
Register for a medical specialty drug prior-authorization web tool refresher course
What's in it for you?
In this course, you'll refresh your skills with the NovoLogix® web tool, and learn how to create prior-authorization requests for provider-administered specialty medical drugs.*
Register for one of the following Blue Cross Medicare Plus BlueSM PPO webinars:
Once the host approves your registration, you'll receive a confirmation email with instructions for joining the session.
*In July 2017, Blue Cross Medicare Plus Blue PPO launched a prior-authorization program for select provider-administered specialty medical drugs.
Effective Oct. 1, Prolia® and Xgeva® are subject to a site-of-care requirement for BCN HMOSM members
Effective Oct. 1, 2018, BCN is adding the following two drugs to its site-of-care optimization program:
- Prolia
- Xgeva
For both medications, the generic name is denosumab and the HCPCS code is J0897.
The site-of-care requirement applies only to BCN HMO (commercial) members. It does not apply to BCN AdvantageSM members.
The site-of-care program redirects members receiving select drugs in an outpatient hospital setting to a lower-cost, alternate site of care, such as the physician’s office or the member’s home.
If a provider feels a member is not a candidate to receive these drugs at a site other than the outpatient hospital, documentation supporting medical necessity must be provided to the plan for review. Those requests will be evaluated on a case-by-case basis.
Requests for Prolia and Xgeva must meet applicable authorization criteria in addition to the site-of-care requirement. This applies to first-time and current users of these medications.
For additional requirements related to drugs covered under the medical benefit, including all drugs identified as subject to site-of-care requirements, refer to the Medical Benefit Drugs – Pharmacy page in the BCN section at ereferrals.bcbsm.com. Click Requirements for drugs covered under the medical benefit – BCN HMO under the heading "For BCN HMO (commercial) members."
The new site-of-care requirement for Prolia and Xgeva will be added to the list in late September.
September 2018 – Issue
- ICD-10-CM and PCS 2019 code updates are now available
- Physician assistants required to re-enroll earlier this year
- Prolia® and Xgeva® won’t be covered in outpatient hospitals without approval, starting Oct. 1
- We’ve added ‘All Cases’ search field to e-referral; tips for reviewing the results of medical drug authorization requests
- Medicare Advantage non-compliance audits to begin Oct. 1, 2018
- Register for a medical specialty drug prior-authorization web tool refresher course
CHECK OUT THESE ARTICLES AND MUCH MORE HERE!