Provided by MSHO Managed Care Committee Members:
December 13, 2018 ICT Webinar: You’ve submitted a few claims; now what?
Have you submitted a few claims, but need help with the next step? If so, join us for an Internet Claim Tool webinar on Thursday, December 13, 2018, from 10 a.m. to 11 a.m. This webinar is designed for new professional ICT users. We will focus on how to assign claims to a new payer; the Payer Response Report; viewing transmitted claims; and resending edited claims. Please note attendees should have already submitted claims; this session is not intended as a first-time user’s tutorial.
If you would like to participate, please click here to send an email with your first and last name, web-DENIS ID, company name, billing NPI and unique email address information to edicustmgmt@bcbsm.com. We will supply login details prior to the training session.
Correction: List of medical drugs in commercial Medical Drug Prior Authorization Program
The commercial Medical Drug Prior Authorization Program list that was in the November Record contained some incorrect information. The article has been revised to include the correct information. Please click here to see the revised article.
Keep in mind that this prior authorization requirement doesn't apply to Federal Employee Program®, Medicare or Medicare Advantage members. Refer to the Opt-out List for a list of all groups that don't require members to participate in the program.
Blue Cross reserves the right to change the prior authorization/site of care list at any time.
Enhancements to the 835
The following enhancements will be made to the 835 for Medicare Advantage PPO and PFFS beginning December 15, 2018:
If you have any questions, please contact the EDI Help Desk at 1-800-542-0945.
Continuity of Care in place for URMBT members in the medical or radiation oncology programs
Beginning Jan. 1, 2019, Blue Cross Blue Shield of Michigan will begin two new utilization management programs for oncology services delivered to UAW Retiree Medical Benefits Trust members. The programs require prior authorization for some outpatient medical and radiation oncology treatments through AIM Specialty Health®. We announced this in an October Record article.
Trust members who are in a current course of medical oncology or radiation oncology treatment (as described in the October article) as of Jan. 1, 2019, won’t need a prior authorization for six months. We’re doing this to ensure that these members don’t have an interruption in their care.
If treatment continues beyond six months or if a patient’s treatment path changes, a prior authorization will be required.
We’ll send additional communications directly to providers who are treating these members 30 days before the end of the six-month period to remind them that authorizations will be required.
For more information about these programs, go to the AIM ProviderPortal** or call AIM at 1-800-728-8008. You can also go to bcbsm.com.
**Blue Cross Blue Shield of Michigan doesn’t own or control this website.
Attention CT, MRI specialists: Sign up for OptiNet® webinar, opt in for patient referrals
Beginning Jan. 1, 2019, Blue Cross Blue Shield of Michigan and AIM Specialty Health® will offer a new program, Special Care Shopper, to UAW Retiree Medical Benefits Trust members. The program offers Trust members high-quality, cost-effective radiology treatment from a select group of health care providers.
What does this mean for you?
It's an opportunity to become a select diagnostic imaging provider for URMBT patient referrals. Learn more: Read the November Record and sign up for an upcoming webinar.
Register for a webinar now
Two OptiNet®, shopper program training webinars are available to providers who order or render CT or MRI services to PPO members. Click one of the dates below to register:
Once you're approved by the host, you'll receive a confirmation email with instructions for joining the session.
Cinqair, Nucala, Xolair added to site of care infusion requirement, beginning Jan. 1
Blue Cross Blue Shield of Michigan is adding three medical drugs to its commercial site of care requirement. Starting Jan. 1, 2019, Blue Cross won't cover most infusions for Cinqair®, Nucala® or Xolair® at outpatient hospital facilities without an approved location prior authorization.
These changes don't apply to BCN AdvantageSM, Blue Cross Medicare Plus BlueSM PPO or Federal Employee Program® members.
Since all drugs in this program already need prior authorization for payment, you don't need to take any further action. Approved authorizations will be payable for the following professional locations:
If your patient now receives one of these infusions at a hospital outpatient facility:
The following HCPCS codes and medical drugs are subject to this requirement:
J2786 — Cinqair®
J2182 — Nucala®
J2357 — Xolair®
Reminder - New Institutional Blue Care Network edit: NDC DRUG QUANTITY MUST BE GREATER THAN ZERO
On Nov. 12, 2018, BCBSM EDI will implement a new institutional edit for BCN. The edit below will be applied when loop 2410, CPT04 is zero.
F954 NDC DRUG QUANTITY MUST BE GREATER THAN ZERO
If you receive edit F954 on a R277CAF report or A3:476:216 in the 277CAP transaction, you must correct and resubmit your claims.
If you have questions, please contact the EDI help desk at 1-800-542-0945.
Medicare Part B medical specialty drug prior authorization lists changing in 2019
Some updates are coming for the Part B medical specialty medical prior authorization drug list for Blue Cross Medicare Plus BlueSM PPO and BCN AdvantageSM members. These changes include additions and removals from the prior authorization program as follows.
Medicare Plus Blue PPO
Removals — for dates of service starting Jan. 1, 2019:
J0202 Lemtrada®
J2323 Tysabri®
J2350 Ocrevus®
Additions — for dates of service starting Feb. 1, 2019:
J2840 Kanuma®
J2860 Sylvant®
J3357 Stelara® SQ
J3358 Stelara® IV
J3490/C9399 OnpattroTM
J3590 TrogarzoTM
J9022 Tecentriq®
J9023 Bavencio®
J9042 Adcetris®
J9176 Empliciti®
J9308 Cyramza®
J9352 Yondelis®
For Medicare Plus Blue, we require prior authorization for these medications when you bill them on a professional CMS-1500 claim form or by electronic submission via an 837P transaction, for the following sites of care:
We do not require authorization for these medications when you bill them on a facility claim form (such as a UB04) or electronically via an 837I transaction.
BCN Advantage
Removals — for dates of service starting Jan. 1, 2019:
J0897 Xgeva®
J9032 Beleodaq®
J9310 Rituxan®
Additions — for dates of service starting Feb. 1, 2019:
J2860 Sylvant®
J3357 Stelara® SQ
J3358 Stelara® IV
J3490/C9399 OnpattroTM
J3590 TrogarzoTM
J9022 Tecentriq®
J9023 Bavencio®
J9042 Adcetris®
J9176 Empliciti®
J9352 Yondelis®
For BCN Advantage, we require prior authorization for these medications when you bill them on a professional CMS-1500 claim form (or submit them electronically via an 837P transaction) or on a facility claim form such as a UB04 (or submit them electronically via an 837I transaction), for the following sites of care:
Important reminder
You must get authorization prior to administering these medications. Use the Novologix® online web tool to quickly submit your requests.
AllianceRx Walgreens Prime specialty pharmacy program starts Jan. 1
AllianceRx Walgreens Prime has become the exclusive provider of specialty pharmacy services for some Blue Cross Blue Shield of Michigan and Blue Care Network commercial (non-Medicare) members. Blue Cross has notified the affected members about this change.
To ensure there's no interruption in therapy, you'll need to write a new prescription for your affected patients before Jan. 1, 2019, if:
Take no action for patients with remaining refills for prescriptions currently filled at Walgreens retail or AllianceRx Walgreens Prime.
About AllianceRx Walgreens Prime
AllianceRx Walgreens Prime will help patients with complex health conditions get convenient access to medications you prescribe that:
AllianceRx Walgreens Prime will:
In addition, patient care coordinators will regularly contact your patients to offer helpful information.
For more information, visit alliancerxwp.com/hcp.*
*Blue Cross Blue Shield of Michigan doesn't control this website or endorse its general content.
We're telling BCN Advantage members they don't need referrals
We're letting BCN AdvantageSM members know they don't need a referral from their primary care physician for covered services with a specialist who's in the provider network for the member's health plan. Authorizations are still required for certain services.
For details, see the article in the November-December BCN Provider News, Page 10.
BCBSM grants MOC exceptions
Blue Cross Blue Shield of Michigan will continue to verify board certification statuses of practitioners in their Blue Cross and Blue Care Network managed care networks. Effective Jan. 1, 2019, the board certification status of family medicine, internal medicine and pediatric practitioners will be reviewed annually. If their board certification status has lapsed and they are a designated patient centered medical home physician, Blue Cross will grant an exception and allow the practitioner to remain in their Blue Cross and BCN managed care networks. READ MORE
Onpattro, Poteligeo, Signifor LAR added to medical benefit specialty drug prior authorization program for commercial members
The prior authorization program for specialty drugs covered under the medical benefit is expanding for BCN HMOSM and Blue Cross® PPO commercial members as follows:
Brand name HCPCS code | Prior authorization requirements for all dates of service on or after: |
OnpattroTM J3490 |
HMO — Nov. 1, 2018 PPO — Dec. 1, 2018 |
Poteligeo® J9999 |
HMO — Nov. 1, 2018 (only for members starting treatment on or after that date) PPO — None required |
Signifor LAR® J2502 |
HMO — Feb. 1, 2019 PPO — Already required |
These changes don't apply to BCN AdvantageSM, Blue Cross Medicare Plus BlueSM PPO or Federal Employee Program® members.
How to submit authorization requests
Submit authorization requests prior to the start of services for medical benefit drugs that require authorization using the NovoLogix® web tool within Provider Secured Services.
Always verify benefits
Approval of a prior authorization request isn't a guarantee of payment. You need to verify each member's eligibility and benefits. Members are responsible for the full cost of medications not covered under their medical benefit coverage.
Some medical benefit drugs for Medicare Advantage members need step therapy, starting January 1
In the new year, according to Centers for Medicare & Medicaid Services guidance, certain Medicare Part B specialty drugs will have additional step therapy authorization requirements. This will apply to Medicare Plus BlueSM PPO and BCN AdvantageSM members for dates of service on or after Jan. 1, 2019.
Step therapy is treatment for a medical condition that starts with the most preferred drug therapy and progresses to other drug therapies only if necessary. The goal of step therapy is to encourage better clinical decision-making.
What's changing?
For drugs requiring step therapy, authorization request questions will be different from the ones you currently answer. Some examples of drugs that require step therapy are:
Use NovoLogix® to submit authorization requests
We encourage you to send prior authorization requests for Medicare Part B specialty drugs through the NovoLogix web tool via Provider Secured Services. It's the most efficient way to get a determination.
Look for more information on step therapy requirements in upcoming issues of The Record and BCN Provider News.
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:
For more information, see the May 2016 and July 2016 Record articles.
November 2018 – Issue
CHECK OUT THESE ARTICLES AND MUCH MORE HERE!