05/01/2018

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.

Clarification: Authorizations for outpatient infusions

In previous Record articles (October 2017, December 2017 and March 2018), we indicated that certain medical drugs can no longer be administered in an outpatient hospital facility without authorization for the medical drug and location. We wanted to clarify the following:

This authorization requirement only applies to groups that are currently participating in the commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit.

You can find the list of groups that opted out of the Medical Drug Prior Authorization Program on web-DENIS by following these steps:

1. After logging in to web-DENIS, click on BCBSM Provider Publications and Resources.
2. Click on Newsletters & Resources.
3. Under Other Resources,click on Forms.
4. Click on Physician administered medications.
5. Click on BCBSM Medical Drug Prior Authorization Program list of groups that have opted out.

Be sure to review the message and notes that precede the list.

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 HMO^SM (commercial) and BCN Advantage^SM 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:

1. 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.
2. Find out where your patient can continue his or her infusion therapy. Check the directory of participating home infusion therapy providers and infusion centers.
3. 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.
4. 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!