09/05/2018

BCBSM/BCN Recent MSHO Q & A

Regarding Outpatient Hospital Site of Service Drugs

August 2018
BCBSM Outpatient Hospital Question and BCBSM Responses:
 

QUESTION FROM MSHO MEMBER:

I was just notified by BCBS  that our patient, who had authorization thru 2099 for XGeva due to Bone Mets, now has to receive her XGeva via Home Care, Professional Provider office or Ambulatory Infusion Center (and it is noted that this doesn’t include Hospital Outpatient Facility Administration).  This patient is scheduled next week for Lupron and Xgeva.  So now the question is, if she orders it through a Specialty Pharmacy before her appointment, can she have it delivered here to get the injections since she will be coming here for the other injection?  Can we bill the injection charge to BCBS for this supplied drug?
 
BCBSM Response:
“If they are a provider office based practice  (and hospital bills for them) then I think that the specialty pharmacy is a good option. Here is the number for our specialty pharmacy Alliance Walgreens Prime 1-866-515-1355 and the fax is 1-866-515-1356 so they can order drug on a member specific basis; and the specialty pharmacy will submit the drug claim to the health plan.
 
The office (the hospital billing office) would only bill for the administration----they need to make sure that the billing office has a clear understanding on that.
 
Manager-Operation, Medical Benefit Drug Management
Blue Cross Blue Shield of Michigan” 
 
Follow-up Question:
When they say “The office (the hospital billing office)” are they saying we need to bill with Office location 11 or can we still bill with location Off-Campus 19 or On-Campus 22 for our Outpatient Hospital Facility?  Since our nursing staff will be administering the drugs, we would prefer to bill location 19 since they are part of the Off-Campus Infusion Staff and not part of the Office Staff.
 
BCBSM RESPONSE:
19 or 22
 
Follow-up Question:
Will the Specialty Pharmacy be billing the patient’s Pharmacy Benefit or continue to go through the Medical Benefit?  That will make a big difference to some of our patients due to the cost sharing on their Prescription Drugs versus Medical Benefit.
 
Response from BCBSM:
For healthcare professional administered medications it is medical benefit and they bill under that. 
 
We do have a couple of groups that have carve out some select healthcare professional administered medications from medical benefit to their carved out RX benefit.
 
Self administered medications is RX benefit when the member has BCBM RX benefits. There are groups that do carve out their RX benefit from BCBSM.
 
Alliance Walgreens Prime will validate the eligibility for the member also, so they may come back and explain they may not be the specialty pharmacy that can provide because of the member’s group benefits and requirements.
 

ADDITIONAL IMPORTANT NOTE FOR ALL MSHO MEMBERS:
 
BCBSM advised MSHO when a patient is in your outpatient facility receiving medication that is not on the site of service denial list, they will allow a listed site of service drug as they do not want to make the patient have to go to a different facility to receive that drug on the same day of treatment.  They stated you should receive authorization as long as you indicate they are already going to be there for treatment on that SAME DAY.
 
If you have any trouble obtaining the authorization, please contact MSHO at billing@msho.org and we will have your case reviewed by upper management to obtain approval!!