04/17/2018

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.

Medicare Outpatient Observation Notice requirements clarified

We’re clarifying the requirements for notifying Medicare Advantage members using the Medicare Outpatient Observation Notice form.

Here’s when hospitals need to notify members

Hospitals must use the Medicare Outpatient Observation Notice form, available on the CMS website* under Downloads, to notify Blue Cross Medicare Plus Blue^SM PPO and BCN Advantage^SM members that they’re receiving outpatient, rather than inpatient, services — when a member is:

• In the emergency department and is being considered for inpatient admission but has not yet been approved for admission by Blue Cross or BCN 
• Being moved to observation status within the hospital from any other status or source 
• In observation status for 24 hours or more, if the member has not already received the form before being admitted for observation

For Medicare Advantage members in these circumstances, hospitals must present the member with a completed Medicare Outpatient Observation Notice. This is a Centers for Medicare & Medicaid Services requirement.

Hospitals should also review the instructions for notifying members using the Medicare Outpatient Observation Notice.

Here’s when hospitals do not need to notify members

When Blue Cross or BCN has approved an inpatient admission, there’s no need to notify the member using the form. When the member is not being considered for inpatient care, there’s no need to notify either the member or the plan.

*Blue Cross Blue Shield of Michigan doesn’t own or control this website.

Update on the two-midnight rule, provider audits

On July 31, 2017, Blue Cross Blue Shield of Michigan launched a prior authorization request process that’s outlined in the Medicare Plus Blue PPO manual. This process takes precedence over the original Medicare coverage determination process and the “two-midnight” rule.

What you need to know

• Our audit vendor, HMS^®, isn’t conducting short-stay or place-of-service audits.
• Documentation and compliance audits of valid inpatient orders and Medicare Outpatient Observation Notice, or MOON, forms are still in process.
• Follow documentation and compliance requirements closely to avoid funds recovery during claims processing and post-payment audits.
• We’ll continue auditing for procedures on the CMS inpatient-only list.
• Joint replacement surgery admission audits are on hold for the short term.

Read more in the May Record, which publishes on April 30.

UPDATE: Professional claims – front-end edits on NPI

On April 10, 2018, we notified you that some professional claims were experiencing the following incorrect front-end edits:

• P542 = NPI not valid for reported service date
• P540 = Exact match cannot be made using NPI and Taxonomy reported
• P531 = Billing NPI not present on corporate crosswalk

The issue has been resolved. Blue Cross Blue Shield of Michigan will be resubmitting the claims that received the front-end edits above from April 4 – April 12, 2018. If any claims were rejected in the claims processing system, those will need to be resubmitted by each provider. We apologize for any inconvenience.

Effective July 1, no authorization is required for multiple sclerosis medications for Blue Cross, BCN commercial members

Effective for dates of service on or after July 1, 2018, multiple sclerosis medications covered under the medical benefit will not require authorization, for Blue Cross PPO (commercial) and BCN HMO^SM (commercial) members.

This change applies to the following medications:

For Blue Cross and BCN commercial members with an active authorization for one of these medications, no additional action is required by the member or the provider.

This change does not apply to BCN Advantage^SM, Blue Cross Medicare Plus Blue^SM PPO or Federal Employee Program^® members. The requirements for these products are as follows:

• For BCN Advantage and Federal Employee Program members, no authorization is currently required.
• For Medicare Plus Blue members, authorization is currently required and will continue to be required.

For additional information on the change related to commercial members, look for articles in the following upcoming newsletters:

• May 2018 issue of The Record
• May-June 2018 issue of BCN Provider News

Clarification about hospital outpatient infusions

To make a clarification about our October 2017, December 2017 and March 2018 Record articles on the subject of medical drug prior-authorization requirements for hospital outpatient infusions:

The prior-authorization requirement for hospital outpatient infusions only applies to groups currently in the Medical Drug Prior-Authorization Program for drugs administered under the medical benefit.

To find a listing of groups not participating in the Medical Drug Prior-Authorization program, click:

1. BCBSM Provider Publications and Resources
2. Newsletters & Resources
3. Forms (under the left-navigation menu, Other Resources)
4. Physician administered medications
5. BCBSM Medical Drug Prior Authorization Program list of groups that have opted out

Be sure to review the message and notes on the first page.

MOQC expands to include gynecologic cancers – targets improvement in quality of ovarian cancer care delivery

The Michigan Oncology Quality Consortium, launched in 2009, is a statewide Collaborative Quality Initiative that focuses on improving the quality of cancer care across hematology and oncology. Dr. Jennifer Griggs is the program director. Approximately 85 percent of eligible oncologists from 50 PGIP oncology practices across Michigan participate in MOQC. READ MORE.

April 26, 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, April 26, 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 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. 

EDI Customer Management

Blue Cross to update ClaimsXten^TM 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.

April 2018 – Issue

• PGIP allocation amount to increase for most codes
• Blue Cross changing practitioner fees July 1
• New opportunities for CQI value-based reimbursement: Find out how to become eligible
• What you need to know about Blue Cross

CHECK OUT THESE ARTICLES AND MUCH MORE HERE!