06/19/2018

BCBSM/BCN

Recent Oncology Related News

Provided by MSHO Managed Care Committee Members:

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.

2018 InterQual® criteria to be implemented starting Aug. 1

Blue Cross Blue Shield of Michigan and Blue Care Network will implement the 2018 InterQual® criteria starting Aug. 1, 2018, for all levels of care. Until that date, the 2017 InterQual criteria will be used.
 
The InterQual criteria are used to make utilization management and care management determinations for the services subject to review, for the following members:

• Blue Cross PPO (commercial)
• Blue Cross Medicare Plus Blue^SM PPO
• BCN HMOSM (commercial)
• BCN Advantage^SM

Blue Cross and BCN also use local rules - modifications of InterQual criteria - in making utilization management and care management determinations. The 2018 local rules will be implemented as follows:

• For behavioral health determinations, the 2018 local rules will be used starting Aug. 1. The updated rules will be available at the end of July on the Blue Cross Behavioral Health page and the BCN Behavioral Health page at ereferrals.bcbsm.com. This applies to BCN HMO (commercial), BCN Advantage and Medicare Plus Blue PPO requests.
  Note: Determinations on Blue Cross PPO (commercial) behavioral health services are handled by New Directions, a Blue Cross vendor.
• For non-behavioral health determinations, the 2018 local rules will be implemented starting Oct. 1. We'll let you know through our standard communication channels how to access those rules, once they're available.
   

Until the 2018 local rules are implemented, the 2017 local rules will be used.

We're reprocessing some observation care claims

As promised, here's an update to the May 9, 2018, broadcast message "Status update on observation care claims we're reprocessing."
 
The permanent fix was implemented on June 8, 2018. Thank you for your patience.

Effective June 22, submit appeals of eviCore decisions on BCN Advantage requests to BCN, not to eviCore

Effective June 22, 2018, providers must submit appeals of eviCore healthcare's decisions on BCN Advantage authorization requests to the BCN Advantage Grievances and Appeals Unit and not to eviCore. Here's where to submit:
 
By mail:
Blue Care Network
ATTN: BCN Advantage Grievances and Appeals Unit
P.O. Box 284
Southfield MI 48076-5043
 
By fax: 1-866-522-7345
 
BCN will process these appeals using the normal BCN Advantage appeal process for standard and expedited appeals. For information on that process, refer to the BCN Advantage chapter of the BCN Provider Manual. Look in the section titled "BCN Advantage provider appeals."
 
Appeals of eviCore decisions on BCN HMOSM (commercial) authorization requests should continue to be submitted to eviCore.

June 27, 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 Wednesday, June 27, 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.
 
EDI Customer Management

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.

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:

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 Blue^SM 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.

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!