01/08/2019

BCBSM/BCN

Recent Oncology Related News

Provided by MSHO Managed Care Committee Members:

2019 benefit information delayed for some groups

Due to an issue with loading benefits, detailed benefit information isn't displaying in web-DENIS for some groups. Should you receive an incomplete benefit response, please contact Provider Servicing directly.

We apologize for any inconvenience.

NASCO starting payment recovery for small business groups, including MPSERS, ITS Home

On Dec. 27, 2018, NASCO will begin a payment recovery for small business groups, including MPSERS and ITS Home claims. The recovery will process professional and facility claims that weren't applying cost share correctly.

New user-friendly prompts coming to Pharmacy Prior Authorization Help Desk

As of Dec. 14, 2018, the Pharmacy Prior Authorization Help Desk toll-free number has new, clear and simple call prompts. It will direct you to the proper line of business for eligible Blue Cross Blue Shield of Michigan and Blue Care Network members.

Here's how it works:

1. Call 1-800-437-3803. 
2. Enter a valid member contract number to authenticate and speak with a live representative. The automated system will find contracts by line of business. This will end the need to give an answer if the contract is commercial or Medicare. Without an eligible contract, you won't be able to speak to a live agent.
3.  Choose the pharmacy or medical drug benefit you’re calling about. You'll hear the following prompt: 
   1. "There are two options for drug prior authorizations. For medications taken by the patient themselves and billed to the pharmacy benefit, say 'pharmacy.' For infusions or injectable drugs given by a health care professional, billed to the medical benefit, say 'medical'"
   2. "Pharmacy" covers self-administered oral, topical or self-injected drugs the member picks up at a retail pharmacy.
   3. "Medical" covers drugs administered by a health care professional, often in a home, office or outpatient facility.
4. Choose the appropriate option for fast and correct service.

Updated clinical practice guidelines now available at MQIC.org

The Michigan Quality Improvement Consortium has released the following updated clinical practice guidelines:

• Opioid Prescribing in Adults Excluding Palliative and End of Life Care
• Management of Diabetes Mellitus
• Adolescent and Young Adult Health Risk Behavior Assessment
• Diagnosis and Management of Adults with Chronic Kidney Disease
• Medical Management of Adults with Hypertension

Please visit mqic.org to see the guidelines. To access them on Android and iOS devices, an MQIC app is available at Google Play and the App Store.

Don't issue referrals for BCN Advantage members staying in network

BCN Advantage^SM members don't need a referral to see a specialist within their health plan's network. However, authorizations and plan notifications are still required for certain services. Also, all services with a provider who's not in the member's health plan network require an authorization. More information is available in the Jan-Feb 2019 BCN Provider News.

Updates to our PPO clinical editing appeals process

We're updating our PPO clinical editing appeals process.

What you need to know now:

• Starting on Jan. 1, 2019, you'll need to send PPO appeals by fax or mail to: 
  • Fax:   1-866-392-7191 
  • Mail:   Clinical Editing Appeals
  • Mail Code G820
  • 611 Cascade West Parkway, SE
  • Grand Rapids, MI 49546-2143
• You must send appeals within 180 days of the clinical editing denial
• Your appeal submission must include the clinical editing appeal form.
• Make sure all required form fields are filled in and all necessary information is included with the appeal.
• Continue sending the clinical information that supports your appeal request.

Look for more information in the January 2019 Record and in the Provider Manual.

Clarification about AllianceRx Walgreens Prime specialty program

The November Record announced that starting Jan. 1, 2019, AllianceRx Walgreens Prime will be the exclusive provider of specialty pharmacy services for some Blue Cross Blue Shield of Michigan commercial, non-Medicare members.

This applies only to specialty drugs filled under pharmacy benefits. We sent letters to affected members telling them to contact you for new prescriptions. AllianceRx Walgreens Prime will call members and help them get their prescriptions moved.

We'll update the current list of specialty drugs in this program monthly.

To find the list at bcbsm.com:

1. Go to bcsbm.com/pharmacy.
2. Click What are specialty drugs?
3. Click Specialty Drug Program Rx Benefit Member Guide (PDF).

January 2019 – Issue

• Certain infusion drugs won’t be covered in outpatient hospitals, starting Jan. 1
• Medicare Part B medical specialty drug prior authorization lists changing in 2019
• Starting Feb. 1, eviCore managing two radiopharmaceutical drugs

CHECK OUT THESE ARTICLES AND MUCH MORE HERE!