07/24/2018

BCBSM/BCN

Recent Oncology Related News

Provided by MSHO Managed Care Committee Members:

New radiation oncology program benefits providers offering ‘gold standard’ of care

The Michigan Radiation Oncology Quality Consortium, a Collaborative Quality Initiative, and Blue Cross Blue Shield of Michigan have partnered to launch an automatic authorization program for radiation procedures. Read more.

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 Blue^SM PPO webinars:

• Wednesday, Oct. 3, 2018, 1 to 2 p.m.
• Friday, Oct. 5, 2018, 10 to 11 a.m.

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.

Erroneous WPS 277CA reports and transactions

Wisconsin Physicians Service distributed 277CA reports and transactions on June 29, 2018 that contained erroneous data. Medicare Part B trading partners may have received two response files for claims submitted June 27. WPS indicates that you can disregard the R277CAW files without rejections codes and 277CAP transactions with STC A8 error code 746.

We apologize for anyinconvenience.

e-referral system is pending outpatient authorization requests for patients with the Blue Cross Blue Shield of Michigan plans

Recently, an error in the e-referral system has been causing Blue Cross outpatient authorization requests that should not have been entered into the system to pend. Upon submission, providers submitting these authorizations in error receive a case ID and a pending message.

As a reminder, please check requirements before submitting outpatient cases to e-referral:

• For Blue Cross Medicare Plus Blue^SM PPO, requirements are outlined in the Services That Require Authorization (PDF).
• Some Blue Cross PPO^SM (commercial) member outpatient procedures may require authorization. Visit the eviCore-Managed Procedures page.
• For Blue Cross PPO (commercial) behavioral health requirements, see the For Blue Cross PPO (commercial) members section on ereferrals.bcbsm.com under Blue Cross then the Behavioral Health section.

While this issue is being resolved, we are voiding these cases manually and sending a message to providers why the case has been voided.

Monthly status report for Medicare Plus BlueSM professional, facility claims

To keep you informed of billing issues and solutions, Blue Cross Blue Shield of Michigan posts its Monthly status report for Medicare Advantage professional and facility claims on web-DENIS. This month’s report is ready for your review.

>> Get the current report here

To navigate to the report when logged in to web-DENIS, click on:

1. BCBSM Provider Publications and Resources
2. Newsletters & Resources
3. Medicare Plus Blue PPO (Medicare Advantage)

As a reminder, continue sending your claims as usual (unless Blue Cross communicates otherwise). This applies even in instances where a defect or issue may exist.

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.

Don't miss this months RECORD to review policy changes/updates on:

• Cinvanti™ (aprepitant)
• FDA approves Lutathera
• Positron emission tomography for oncologic conditions
• Genetic testing – analysis of MGMT promoter methylation in malignant gliomas
• Genetic testing — Human platelet antigen genotyping
• Miscellaneous genetic and molecular diagnostic tests

July 2018 – Issue

• Outpatient facilities added to Medicare Plus Blue prior authorization program
• Members who don’t meet criteria for covered services pay only the amount allowed by Blue Cross
• HCPCS update: New codes added
• Effective July 1, use new procedure code Q9995 for anti-hemophilia drug

CHECK OUT THESE ARTICLES AND MUCH MORE HERE!