01/23/2019

BCBSM/BCN

Recent Oncology Related News

Provided by MSHO Managed Care Committee Members:

New prior authorization for opioid dosages over 90 morphine mg equivalents per day

Starting Feb. 1, 2019, Blue Cross Blue Shield of Michigan and Blue Care Network will require prior authorization the first time a member’s opioid dosage exceeds 90 morphine milligram equivalents per day. This change affects commercial members only and doesn’t apply to members with an oncology diagnosis, terminal illness or members with Medicare.

These opioids are commonly prescribed at 90 morphine milligram equivalents per day:

• 90 mg of hydrocodone (nine tablets of hydrocodone/acetaminophen 10/325 mg)
• 60 mg of oxycodone (two tablets of oxycodone extended-release 30 mg)

To help reduce overdose risk, we encourage providers to review their patients’ total daily dose of opioids. This helps to identify patients who may benefit from closer monitoring, reduction or tapering of opioids, a naloxone prescription or other measures.

February 11, 2019 ICT Webinar: You've submitted a few claims; now what?

Have you submitted a few claims, but need help with the next step? If so, join us for an Internet Claim Tool webinar on Monday, February 11, 2019, from 10 a.m. to 11 a.m. This webinar is designed for new professional ICT users. We will focus on how to assign claims to a new payer; the Payer Response Report; viewing transmitted claims; and resending edited claims. Please note attendees should have already submitted claims; this session is not intended as a first-time user's tutorial.

If you would like to participate, please click here to send an email with your first and last name, web-DENIS ID, company name, billing NPI and unique email address information to  edicustmgmt@bcbsm.com. We will supply login details prior to the training session.

EDI Customer Management

NASCO conducting payment recovery for General Motors

On Jan. 16, 2019, NASCO will begin a payment recovery for incorrect rejections of GM group, professional chemotherapy office visit claims. The recovery includes:

• CPT codes *99211 through *9915 with specific chemotherapy diagnosis
• B422 — Your patient's health care coverage doesn't pay for this service for the reported diagnosis. The subscriber is liable for your charge.
• M620 — Chemotherapeutic agent
• M718 — Payment for this service was included in a previously paid service
• Claims made between Jan. 1, 2017 through Oct. 11, 2018

We're currently reprocessing these claims. When you're adjusting your patients' accounts with the correct payment the subscriber may become liable for the charge.

*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2018 American Medical Association. All rights reserved.

Payment recovery, rebilling advice for incorrect 340B modifier drug claims

Effective immediately, Blue Cross Blue Shield of Michigan will recover full payments for Medicare Plus BlueSM PPO drug claims that were sent to us with the incorrect 340B program modifier (TB*).

Reminder

You must use the JG* modifier for drugs acquired through the 340B program for facilities not designated as a rural (sole-community) hospital, children's hospital or a Prospective-Payment-System-exempt cancer hospital.

Please correct your claims and resubmit them using the proper modifier, according to Medicare guidelines.

References

Medicare Claims Processing Manual, chapter 17, "Drugs and Biologicals," section 90.2.E "Biosimilars"

Medicare-Fee-For-Service Program Billing 340B Modifiers under the Hospital Outpatient Prospective Payment System (OPPS) Frequently Asked Questions

Medicare Plus Blue PPO drug administration coding

Blue Cross Medicare Plus BlueSM has found many examples of claims for non-chemotherapy drugs submitted with a chemotherapy administration code. Effective immediately, Blue Cross will recover the full payment when chemotherapy administration codes are submitted in error.

How to correct these claims
You can submit a corrected claim using the appropriate non-chemotherapy administration code (in accordance with Wisconsin Physicians Service Insurance Corporation, Article A54176).

If the chemotherapy administration was quantity-billed because multiple drugs (chemotherapy and non-chemotherapy) were provided during the same visit, submit a corrected claim separating out the administration-unit billed for the chemotherapy drug and the administration unit that shouldn't be billed with the non-chemotherapy administration code.

Refer to Wisconsin Physicians Service Insurance Corporation Article A54176.

For billing code J2357
Per Local Coverage Determination 34741 billing and coding guidelines, it isn't appropriate to bill more than one unit for the administration code regardless of the number of vials or syringes used for Xolair.

AIM Specialty Health outage

Last week, there was an issue with AIM's provider portal and phone systems and providers were unable to obtain authorizations for a period of time. This affected authorization requests for both Blue Cross and Blue Care Network business. Since then, all issues have been resolved. You can obtain authorizations for services from AIM through their phone and the web. If you were unable to obtain an authorization due to this outage, you can submit your request now. We apologize on behalf of AIM for any inconvenience.

Not all Blue Cross members require AIM authorization

Prior authorization for any medical diagnostic service through AIM Specialty Health isn't required for UAW Retiree Medical Benefits Trust (group number 70605) and UAW National Staff (group number 71714) members with Blue Cross Blue Shield of Michigan coverage.

As always, make sure you check the authorization requirements when you check eligibility and benefits for your patients. If you input the patient's contract number and procedure code for the service, Benefit Explainer will let you know if the service requires authorization.

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!