07/03/2019

BCBSM/BCN

Recent Oncology Related News

Provided by MSHO Managed Care Committee Members:

NovoLogix^® user interface enhancements coming soon

If you use NovoLogix^® to submit electronic prior authorizations for certain Part B medical specialty drugs, you'll soon see an enhanced user interface when you log in to the online web tool. The enhancements will streamline the process of creating authorization requests.

The interface changes are minimal and easy to navigate, and you'll be able to switch between the current and enhanced interfaces while you adjust to the changes. We'll provide more information, such as user guides and training videos, as we get closer to the release date.

As a reminder, you can always find information about authorization requirements for these drugs on the ereferrals.bcbsm.com website:

• Blue Cross page: Medical Benefit Drugs — Pharmacy
• Blue Care Network page: Medical Benefit Drugs — Pharmacy

Register now for an AIM Specialty Health^® oncology management program webinar

Beginning Aug. 1, 2019, Blue Care Network will implement a new utilization management program for medical oncology for BCN commercial members. Authorizations must be obtained from AIM Specialty Health for some medical oncology and supportive care medications.

Learn about the new oncology management program and how to use the AIM ProviderPortal^SM by attending a webinar (intended for non-clinical provider staff). Webinar dates and registration links are available on Page 26 of the May-June 2019 BCN Provider News. More information will be available on Page 26 of the July-August 2019 BCN Provider News published on June 26.

Providers receiving ineligible for inquiries error will need group NPI to access Medicaid information

As of May 28, 2019, providers receiving provider ineligible for inquiries error will now need to use their group national provider identifier to access Medicaid eligibility and benefit information.

We apologize for any inconvenience.

Comprehensive lists of requirements for medical specialty drugs and pharmacy benefit drugs available

We’ve developed comprehensive lists of requirements for medical specialty drugs and pharmacy benefit drugs for Blue Cross Blue Shield of Michigan PPO and Blue Care Network HMO^SM commercial members. These lists, which are typically updated monthly, include the most current information on utilization management requirements.

Medical benefit drugs

The medical specialty drug list identifies medical drugs targeted in the prior authorization and site-of-care programs, and includes the following information about them:

• Medical necessity criteria
• Quantity limits
• Step therapy requirements

The medical specialty drug list is available online in the following locations:

• On the Blue Cross Medical Benefit Drugs-Pharmacy page within the ereferrals.bcbsm.com website. Look under the For Blue Cross commercial members heading.
• On the BCN Medical Benefit Drugs-Pharmacy page on the ereferrals.bcbsm.com website
• Within Provider Secured Services:
  • Log in.
  • Click BCBSM Provider Publications and Resources (on the right).
  • Click Newsletters and Resources.
  • Click Forms.
  • Click Physician administered medications.
  • Click Requirements for drugs covered under the medical benefit – BCN HMO and Blue Cross PPO.
• In the medical policy, precertification and preauthorization router, enter quantity limit in the Keyword/Phrase field and click Search.

HCPCS, CPT updates and early release codes

2019 second quarter HCPCS update
Injections

Medication reconciliation reimbursement increases to $35 for Medicare Advantage members

When medication reconciliation is conducted within 30 days of a hospital discharge and a claim is submitted for CPT II code *1111F, Blue Cross Blue Shield of Michigan will reimburse providers $35 for its Medicare Advantage products: Medicare Plus BlueSM and BCN AdvantageSM. READ MORE

2019 InterQual criteria to be implemented Aug. 1

Each year, Blue Cross Blue Shield of Michigan and Blue Care Network update InterQual^® criteria. We use these criteria to make utilization management determinations regarding requests to authorize behavioral health and non-behavioral health services. We'll implement 2019 criteria starting Aug. 1, 2019. The July Record and the July – August issue of BCN Provider News will provide you with details on how to access the new criteria.

Medicare Part B medical specialty drug prior authorization list changing July 22, 2019

We’re making changes to the Medicare Plus Blue^SM PPO and BCN Advantage^SM Part B specialty prior authorization drug list, as follows:

• For dates of service on or after July 22, 2019, Darzalex^® (J9145) will require prior authorization.
• Effective immediately, Myozyme^® (J0220) is removed from the prior authorization list because it is no longer available in the U.S. market.

Here’s some additional information you need to know about the change for Darzalex.

Medicare Plus Blue PPO
For Medicare Plus Blue, we require prior authorization for Darzalex when you bill electronically through an 837P transaction or on a professional CMS-1500 claim form, for the following sites of care:

• Physician office (place of service code 11)
• Outpatient facility (place of service code 19, 22 or 24)

BCN Advantage
For BCN Advantage, we require prior authorization for Darzalex when you bill it as a professional service or an outpatient facility service electronically through an 837P transaction or on a professional CMS-1500 claim form for:

• Physician office (place of service code 11)
• Outpatient facility (place of service code 19, 22 or 24)
• Home (place of service code 12)

We also require prior authorization when you bill electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x.

Important reminder
You must get authorization prior to administering these medications. Use the Novologix^® online web tool to quickly submit your requests. It offers real-time status checks and immediate approvals for certain medications. Also note:

• For Medicare Plus Blue, you can fax an Addendum P form to gain access to the Novologix online web tool.
• For BCN Advantage, if you have access to Provider Secured Services, you already have access to submit authorization requests through Novologix.