03/18/2019

BCBSM/BCN

Recent Oncology Related News

Provided by MSHO Managed Care Committee Members:

A message from Dr. S. George Kipa

Reducing the need for medical record reviews

One of the main complaints I hear from physicians when I meet with them involves requests for medical record reviews. These reviews are very time-consuming, both for Blue Cross Blue Shield of Michigan and for the health care providers who receive these requests. READ MORE

Use form to request criteria for BCN authorization decisions (non-behavioral health)

To obtain the review criteria used to make a determination on a specific authorization request for a BCN HMO^SM (commercial) or BCN Advantage^SM member, complete the BCN Criteria Request Form (for non-behavioral health cases) and fax it to 1-866-373-9468.

This applies to non-behavioral health authorization requests only.

You can access the BCN Criteria Request Form by completing the following steps:

• Visit ereferrals.bcbsm.com.
• Click BCN.
  Click Authorization Requirements & Criteria.
  Look under the "Referral and authorization information" heading.

Previously, you called BCN's Utilization Management department to request the criteria. Now you use the form to submit the request. The BCN Provider Manual has been updated to reflect the change.

Additional changes to BCN process for requesting peer-to-peer review of non-behavioral health cases

We're making additional changes to the process of asking for a peer-to-peer review of a denied authorization of a non-behavioral health service for BCN HMO^SM (commercial) or BCN Advantage^SM members.

The request for a peer-to-peer review:

• Must be submitted within the time frame available for filing an appeal for that determination. Once the appeal time frame has expired, the provider can no longer request a peer-to-peer review.
• Cannot be submitted if a provider appeal of that denial has already been submitted
• May be submitted only for denials based on medical necessity
• Cannot be submitted for a denial of a member's appeal or grievance

We have outlined these requirements — and additional information about them — in Section 1 of the document How to request a peer-to-peer review with a BCN medical director.

These requirements apply to authorization requests for both inpatient and outpatient services. They are in addition to the change we communicated in December 2018, which was that you must use the Physician peer-to-peer request form (for non-behavioral health cases) to submit the peer-to-peer review request.

You can access both documents — the description of the process for submitting a peer-to-peer review request and the form — by completing the following steps:

• Visit ereferrals.bcbsm.com.
• Click BCN.
• Click Authorization Requirements & Criteria.
• Look under the "Referral and authorization information" heading.

April 4, 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 Thursday, April 4, 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 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

Starting April 1, Fasenra, Radicava part of site-of-care requirement for HMO members

Starting April 1, 2019, Blue Care Network is adding two medications to its site-of-care optimization program for BCN HMO^SM commercial members only (BCN Advantage^SM members are excluded.) Without prior authorization at an approved location, we won't cover most infusions for Fasenra^TM and Radicava^® at outpatient hospital facilities.

• Fasenra (benralizumab) HCPCS J0517
• Radicava (edaravone) HCPCS J1301

We still have contracts with University of Michigan Health System and Lakeland Hospital, so members may continue outpatient infusions at these two facilities.

Also, before April 1, we'll have the new site-of-care requirements available in our Blue Cross and BCN utilization management medical drug list.

By April 1
Doctors should encourage BCN commercial members to select one of the following infusion locations instead of an outpatient hospital facility:

• A doctor's or other health care provider's office
• Ambulatory infusion center
• Member's home, from a home infusion therapy provider

If members currently receive infusions for these drugs at a hospital outpatient facility:

• Obtain prior approval from BCN for thatlocation.
• Check the directory of participating home infusion therapy providers and infusion centers where the member may be able to continue infusion therapy.

If the infusion therapy provider can accommodate the member, they'll work with him or her and the member's doctor to make this change easy. The member may also contact ordering doctor directly for help with the change.

Medicare Plus Blue PPO manual update coming in April

Blue Cross Blue Shield of Michigan will update its Medicare Plus Blue^SM PPO manual, effective April 1. Key changes include updated language in the following sections:

• Added and updated language in the Billing members section
• Updated language in the Pharmacy treatment improvement opportunities section
• Added and updated language in the Utilization management section

This message serves as notice of these changes to the Medicare Plus Blue PPO manual, per the terms of the Blue Cross Medicare Advantage PPO provider agreement.

Start transitioning adult HMO members using infliximab products to Inflectrata

Starting May 1, 2019, Blue Care Network prefers the infliximab product, Inflectra^® (infliximab-dyyb), for its adult BCN HMO^SM commercial members. This change doesn't apply to:

• BCN Advantage^SM members
• Blue Cross Blue Shield of Michigan PPO commercial members
• Pediatric members 15 years old or younger
• Pediatric members 18 years old or younger, weighing 50 kg or less

Please refer to the current medical policy for all criteria, and begin taking steps to:

• Transition adult members with active authorizations for non-Inflectra infliximab products to Inflectra by May 1, 2019.
• Prescribe or fill Inflectra when possible instead of Remicade^® (infliximab) HCPCS code J1745, or Renflexis^® (infliximab-abda) HCPCS code Q5104.
• Bill Inflectra with HCPCS code Q5103.

Quick links to helpful resources

• Current Medical Policy search tool
• Requirements for drugs covered under the medical benefit

Prior-authorization changes coming to AIM authorization program

Beginning May 1, 2019, the PPO radiology management program, administered by AIM Specialty Health, will be adding a cardiology and in-lab sleep study prior authorization program for Medicare Plus Blue^SM PPO members. AIM is also adding prior authorization procedure codes for its high-tech radiology breast MRI program.

Please note that UAW Retiree Medical Benefits Trust members with Medicare Plus Blue coverage are also included in this program.

For more details please see the February Record article.

Request authorization through AIM's ProviderPortal or call 1-800-728-8008.

March 2019 – Issue

• Rollout of CAQH Direct Assure 2.0 continues in 2019
• Certain infusion drugs won’t be covered in outpatient hospitals, starting April 1
• Improve HEDIS scores through claims coding
• Policy Clarifications DO NOT MISS THIS ARTICLE
  • J9035 - Basic benefit and medical policy - Avastin (bevacizumab)

CHECK OUT THESE ARTICLES AND MUCH MORE HERE!