11/06/2018

BCBSM/BCN

Recent Oncology Related News

Provided by MSHO Managed Care Committee Members:

Continuity of Care in place for URMBT members in the medical or radiation oncology programs

Beginning Jan. 1, 2019, Blue Cross Blue Shield of Michigan will begin two new utilization management programs for oncology services delivered to UAW Retiree Medical Benefits Trust members. The programs require prior authorization for some outpatient medical and radiation oncology treatments through AIM Specialty Health®. We announced this in an October Record article.

Trust members who are in a current course of medical oncology or radiation oncology treatment (as described in the October article) as of Jan. 1, 2019, won’t need a prior authorization for six months. We’re doing this to ensure that these members don’t have an interruption in their care.

If treatment continues beyond six months or if a patient’s treatment path changes, a prior authorization will be required.

We’ll send additional communications directly to providers who are treating these members 30 days before the end of the six-month period to remind them that authorizations will be required.

For more information about these programs, go to the AIM ProviderPortal** or call AIM at 1-800-728-8008. You can also go to bcbsm.com.

**Blue Cross Blue Shield of Michigan doesn’t own or control this website.

REMINDER: EDI Professional Commercial Payer List – Updates

The Blue Cross clearinghouse is making changes to our commercial payer list. Please reference the complete EDI Professional Commercial Payer Listing at bcbsm.com for the current combination of payer IDs and claim office numbers used for claims submitted through the Blue Cross clearinghouse.
Effective November 13, 2018, the Blue Cross clearinghouse is adding two new payer IDs:

Effective January 1, 2019, the following commercial payer IDs will be deleted and no longer accepted through the Blue Cross clearinghouse. After January 1, claims reporting these deleted IDs will reject with an edit of a 'P017 Commercial Payer ID and or Claim Office Number is Invalid.'

For information about billing commercial payer claims electronically, review our 837 Professional Companion Document on bcbsm.com. If you have questions about payer IDs or submitting electronic commercial claims, call the EDI help desk at 1-800-542-0945.

Attention CT, MRI specialists: Sign up for OptiNet^® webinar, opt in for patient referrals

Beginning Jan. 1, 2019, Blue Cross Blue Shield of Michigan and AIM Specialty Health® will offer a new program, Special Care Shopper, to UAW Retiree Medical Benefits Trust members. The program offers Trust members high-quality, cost-effective radiology treatment from a select group of health care providers.

What does this mean for you?
It's an opportunity to become a select diagnostic imaging provider for URMBT patient referrals. Learn more: Read the November Record and sign up for an upcoming webinar.

Register for a webinar now
Two OptiNet®, shopper program training webinars are available to providers who order or render CT or MRI services to PPO members. Click one of the dates below to register:

• Wednesday, Nov. 7 from 10-11 a.m. Eastern time
• Wednesday, Dec. 12 from 10-11 a.m. Eastern time

Once you're approved by the host, you'll receive a confirmation email with instructions for joining the session.

Cinqair, Nucala, Xolair added to site of care infusion requirement, beginning Jan. 1

Blue Cross Blue Shield of Michigan is adding three medical drugs to its commercial site of care requirement. Starting Jan. 1, 2019, Blue Cross won't cover most infusions for Cinqair®, Nucala® or Xolair® at outpatient hospital facilities without an approved location prior authorization.

These changes don't apply to BCN AdvantageSM, Blue Cross Medicare Plus BlueSM PPO or Federal Employee Program® members.

Since all drugs in this program already need prior authorization for payment, you don't need to take any further action. Approved authorizations will be payable for the following professional locations:

• Physician's offices or other health care provider's offices
• Ambulatory infusion centers
• The member's home, from a home infusion therapy provider

If your patient now receives one of these infusions at a hospital outpatient facility:

1. Send Blue Cross a prior-approval request for his or her hospital outpatient facility. If this request isn't submitted and approved, your patient will be responsible for the full cost of the medicine.
2. Find out where your patient can continue his or her infusion therapy. Check the directory of participating home infusion therapy providers and infusion centers.
3. Tell your patient to contact any of the listed infusion therapy providers. If they're able to accommodate your patient, they'll work with you and your patient to make the change easy. We're also sending this information to your patient.
4. Help your patient switch his or her infusion therapy to your office, infusion center or home infusion therapy provider by Jan. 1, 2019.

The following HCPCS codes and medical drugs are subject to this requirement:
 
J2786 — Cinqair^®
J2182 — Nucala^®
J2357 — Xolair^®

Reminder - New Institutional Blue Care Network edit: NDC DRUG QUANTITY MUST BE GREATER THAN ZERO

On Nov. 12, 2018, BCBSM EDI will implement a new institutional edit for BCN. The edit below will be applied when loop 2410, CPT04 is zero.

F954 NDC DRUG QUANTITY MUST BE GREATER THAN ZERO

If you receive edit F954 on a R277CAF report or A3:476:216 in the 277CAP transaction, you must correct and resubmit your claims.

If you have questions, please contact the EDI help desk at 1-800-542-0945.

Medicare Part B medical specialty drug prior authorization lists changing in 2019

Some updates are coming for the Part B medical specialty medical prior authorization drug list for Blue Cross Medicare Plus BlueSM PPO and BCN AdvantageSM members. These changes include additions and removals from the prior authorization program as follows.

Medicare Plus Blue PPO

Removals — for dates of service starting Jan. 1, 2019: 

J0202 Lemtrada®
J2323 Tysabri®
J2350 Ocrevus® 

Additions — for dates of service starting Feb. 1, 2019: 

J2840 Kanuma®
J2860 Sylvant®
J3357 Stelara® SQ
J3358 Stelara® IV
J3490/C9399 OnpattroTM
J3590 TrogarzoTM
J9022 Tecentriq®
J9023 Bavencio®
J9042 Adcetris®
J9176 Empliciti®
J9308 Cyramza®
J9352 Yondelis®

For Medicare Plus Blue, we require prior authorization for these medications when you bill them on a professional CMS-1500 claim form or by electronic submission via an 837P transaction, for the following sites of care:

• Physician office (Place of Service Code 11)
• Outpatient facility (Place of Service Code 19, 22 or 24)

We do not require authorization for these medications when you bill them on a facility claim form (such as a UB04) or electronically via an 837I transaction.

BCN Advantage

Removals — for dates of service starting Jan. 1, 2019: 

J0897 Xgeva®
J9032 Beleodaq®
J9310 Rituxan® 

Additions — for dates of service starting Feb. 1, 2019: 

J2860 Sylvant®
J3357 Stelara® SQ
J3358 Stelara® IV
J3490/C9399 OnpattroTM
J3590 TrogarzoTM
J9022 Tecentriq®
J9023 Bavencio®
J9042 Adcetris®
J9176 Empliciti®
J9352 Yondelis®

For BCN Advantage, we require prior authorization for these medications when you bill them on a professional CMS-1500 claim form (or submit them electronically via an 837P transaction) or on a facility claim form such as a UB04 (or submit them electronically via an 837I transaction), for the following sites of care:

• Physician office (Place of Service Code 11)
• Outpatient facility (Place of Service Code 19, 22 or 24)
• Home (Place of Service Code 12)

Important reminder
You must get authorization prior to administering these medications. Use the Novologix® online web tool to quickly submit your requests.

AllianceRx Walgreens Prime specialty pharmacy program starts Jan. 1

AllianceRx Walgreens Prime has become the exclusive provider of specialty pharmacy services for some Blue Cross Blue Shield of Michigan and Blue Care Network commercial (non-Medicare) members. Blue Cross has notified the affected members about this change.

To ensure there's no interruption in therapy, you'll need to write a new prescription for your affected patients before Jan. 1, 2019, if:

• They have Blue Cross insurance coverage that requires them to get specialty medications from AllianceRx Walgreens Prime.
• They're currently using a pharmacy other than Walgreens retail or AllianceRx Walgreens Prime (formerly Walgreens Specialty Pharmacy) for a specialty medication.

Take no action for patients with remaining refills for prescriptions currently filled at Walgreens retail or AllianceRx Walgreens Prime.

About AllianceRx Walgreens Prime
AllianceRx Walgreens Prime will help patients with complex health conditions get convenient access to medications you prescribe that:

• Need injections
• Need to be taken on a strict schedule
• Have special storage needs

AllianceRx Walgreens Prime will:

• Reduce the demands on your time
• Help simplify the referral process
• Handle insurance verification, prior authorization and financial assistance coordination
• Provide a team of pharmacists, nurses and patient care coordinators to help ensure your patients get the specialty pharmacy care they deserve

In addition, patient care coordinators will regularly contact your patients to offer helpful information.
For more information, visit alliancerxwp.com/hcp.*

*Blue Cross Blue Shield of Michigan doesn't control this website or endorse its general content.

We're telling BCN Advantage members they don't need referrals

We're letting BCN Advantage^SM members know they don't need a referral from their primary care physician for covered services with a specialist who's in the provider network for the member's health plan. Authorizations are still required for certain services.

For details, see the article in the November-December BCN Provider News, Page 10.

BCBSM grants MOC exceptions

Blue Cross Blue Shield of Michigan will continue to verify board certification statuses of practitioners in their Blue Cross and Blue Care Network managed care networks. Effective Jan. 1, 2019, the board certification status of family medicine, internal medicine and pediatric practitioners will be reviewed annually. If their board certification status has lapsed and they are a designated patient centered medical home physician, Blue Cross will grant an exception and allow the practitioner to remain in their Blue Cross and BCN managed care networks.  READ MORE

Onpattro, Poteligeo, Signifor LAR added to medical benefit specialty drug prior authorization program for commercial members

The prior authorization program for specialty drugs covered under the medical benefit is expanding for BCN HMOSM and Blue Cross® PPO commercial members as follows:

These changes don't apply to BCN Advantage^SM, Blue Cross Medicare Plus Blue^SM PPO or Federal Employee Program^® members.

How to submit authorization requests
Submit authorization requests prior to the start of services for medical benefit drugs that require authorization using the NovoLogix^® web tool within Provider Secured Services.

Always verify benefits
Approval of a prior authorization request isn't a guarantee of payment. You need to verify each member's eligibility and benefits. Members are responsible for the full cost of medications not covered under their medical benefit coverage.

Some medical benefit drugs for Medicare Advantage members need step therapy,  starting January 1

In the new year, according to Centers for Medicare & Medicaid Services guidance, certain Medicare Part B specialty drugs will have additional step therapy authorization requirements. This will apply to Medicare Plus Blue^SM PPO and BCN Advantage^SM members for dates of service on or after Jan. 1, 2019.

Step therapy is treatment for a medical condition that starts with the most preferred drug therapy and progresses to other drug therapies only if necessary. The goal of step therapy is to encourage better clinical decision-making.

What's changing?
For drugs requiring step therapy, authorization request questions will be different from the ones you currently answer. Some examples of drugs that require step therapy are:

• Botox^® for migraines and over active bladder 
• Eylea^®,Lucentis^® and Macugen^® for neovascular age-related macular edema 
• Prolia^® for osteoporosis

Use NovoLogix^® to submit authorization requests
We encourage you to send prior authorization requests for Medicare Part B specialty drugs through the NovoLogix web tool via Provider Secured Services. It's the most efficient way to get a determination.

Look for more information on step therapy requirements in upcoming issues of The Record and BCN Provider News.

Reminder: Follow these guidelines when billing medical drugs that haven’t been purchased

Some health care providers have questioned what to do when billing certain medical drugs that were administered by a medical professional but supplied by our specialty pharmacy.

Here are guidelines to follow in professional and hospital settings:

• When professional providers administer a drug they didn’t purchase, they should bill for the administration code only and not include the drug or NDC code on the claim.
  • When professional providers administer a medical drug that was purchased, notes should be documented and a copy of the purchase order included in the member’s chart.
  • Identical NDC codes billed within 14 days of a specialty pharmacy claim will be recovered and the provider will need proof of purchase to have the claim repaid.
• When a hospital administers a drug in an outpatient setting that isn’t purchased by the hospital, the hospital should bill for the administration. However, the hospital should include the revenue code and corresponding procedure code for the medical drug with total charges of $.01.

For more information, see the May 2016 and July 2016 Record articles.

November 2018 – Issue

• Training available for new medical and radiation oncology programs for URMBT members
• Reminder: Update your practice information, complete your attestation
• Continuity of Care in place for URMBT members in the medical or radiation oncology programs
• New program for UAW Retiree Medical Benefits Trust members provides options for some diagnostic services
• Commercial Medical Drug Prior Authorization Program adding Onpattro
• AllianceRx Walgreens Prime specialty pharmacy program starts Jan. 1

CHECK OUT THESE ARTICLES AND MUCH MORE HERE!