08/07/2018

BCBSM/BCN

Recent Oncology Related News

Provided by MSHO Managed Care Committee Members:

Commercial Medical Drug Prior Authorization Program adds 3 groups, as of Sept. 1

Beginning Sept. 1, 2018, the following employee groups will participate in the Medical Drug Prior Authorization Program.

• Michigan Laborers' Health Care Fund
• Michigan Trowel Trades
• Flint Plumbing and Pipefitting Industry Health Care Fund

Members of any of these groups will need a medical drug prior authorization for certain medications.

Find the current list of medications in the program in this June 2018 Record article.

A prior authorization approval isn't a guarantee of payment. The prior authorization program is a clinical review. Health care practitioners need to verify eligibility and benefits for members. Members are responsible for the full cost of medications not covered under their medical benefit coverage.

Don't forget to refer to the opt-out list for the groups that don't require members to participate in the program.

The prior authorization requirement doesn't apply to Federal Employee Program^® members.

Medicare Advantage compliance audits to begin Oct. 1

On Oct. 1, 2018, Blue Cross Blue Shield of Michigan will begin its Medicare policy audits to ensure that providers are responding to medical records request letters.

Changes to audit policy
Previously, Blue Cross wouldn't always act when providers didn't respond to requests for additional documentation.

Starting Oct. 1, 2018, Blue Cross will notify providers if it issues a noncompliance denial for a claim or service due to an outstanding records request. Providers who don't respond to the request in the allotted timeframe, or by the extension timeframe, will have their entire claim or service denied as not reasonable or necessary. And, Blue Cross will recoup the claim from future payments.

More information will be available in the September issue of The Record.

Additional fee schedules added to web-DENIS

Blue Cross Blue Shield of Michigan recently added the following "entire fee schedules" to web-DENIS, reflecting fee updates effective August 1, 2018:

Professional: Injection Fee Schedule

• Injections minimum fee schedule (08/01/2018)

Note: Effective for dates of service on or after 2/1/14, professional providers, who want accurate payment at the NDC level, are requested to also provide the NDC and NDC quantity when submitting an injection HCPCS code and HCPCS quantity. Otherwise, the claim will be priced at the minimum fee, which is displayed in the professional fee schedule listed above.

Facility: Hospital Outpatient

• Drug fees effective 08/01/2018

These and other fee schedules are available on web-DENIS under BCBSM Provider Publications and Resources selecting Entire Fee Schedules and Fee Changes.

Starting Oct. 1, additional specialty medications require authorization for BCN Advantage^SM members

For dates of service on or after Oct. 1, 2018, additional specialty medications covered under the Medicare Part B medical benefit require authorization for BCN Advantage members.

We first communicated about this in the article Starting Oct. 1, additional specialty medications require authorization for BCN Advantage members, on page 28 of the July-August 2018 BCN Provider News.

Please review the article to see which drugs require authorization starting October 1.

Exception: Vivaglobin^® (HCPCS code J1562) will not require authorization because it is being discontinued. This is a change from what we communicated in the newsletter article.

These medications are not self administered. They must be given by injection or infusion by a physician or health care professional in the office or outpatient facility setting.

Authorization is required for these medications when they are billed on a professional HCFA 1500 claim form or when the claim is submitted electronically via an 837P transaction, for the following sites of care:

• Physician office (Place of Service code 11)
• Outpatient facility (Place of Service codes 19, 22 and 24)

        Note: In the July-August 2018 newsletter article, we mentioned only Place of 
        Service codes 19 and 22 for outpatient facilities, but authorization is also required 
        for Place of Service code 24.

Authorization is not required for these medications when they are billed on a facility claim form (such as the UB 04) or electronically via an 837I transaction.

Please review the July-August newsletter article for additional information.

In addition, look for an article in the September-October 2018 BCN Provider News, which will clarify these changes.

Billing chart: Blues highlight medical, benefit policy changes

We’ve canceled the modifier 25 payment adjustment for evaluation and management services

In the April 2018 Record, we announced that evaluation and management services billed with modifier 25 would pay at 80 percent when billed with a surgery on the same day by the same provider, effective July 1, 2018. However, based on new information and provider feedback, we’ve canceled implementation of this policy.

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.

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.

August 2018 – Issue

• Appealing Medicare Plus Blue PPO acute inpatient authorization decisions
• What’s new about authorization criteria and e-referral questionnaires for certain services
• We’ve canceled the modifier 25 payment adjustment for evaluation and management services
• Find out how to request peer-to-peer reviews for inpatient admissions
• Announcing updates to our Prepayment Utilization Review policy
• Coding corner: How to handle coagulopathy
• Learn more about our new process for auditing paid claims

CHECK OUT THESE ARTICLES AND MUCH MORE HERE!