05/07/2019

BCBSM/BCN

Recent Oncology Related News

Provided by MSHO Managed Care Committee Members:

PGIP and risk allocations apply to most procedure codes, effective April 1

The Physician Group Incentive Program and risk allocations apply to most professional procedure codes regardless of the billed provider charge. READ MORE

The Michigan Radiation Oncology Quality Consortium: A publishing powerhouse

The Michigan Radiation Oncology Quality Consortium submitted nine abstracts in 2018 that were accepted by the American Society of Clinical Oncology and the American Society for Radiation Oncology for poster discussions and presentations. READ MORE

Enhancements to the 835

In an April 29, 2019 broadcast message, we told you that enhancements were being made to the 835 beginning with check date May 2. We are aware that the changes that were implemented for the IKA 835 caused issues for some providers. We have reversed those changes and this week's checks will reflect the previous options.

We apologize for any inconvenience this may have caused.

If you have any questions, please contact the EDI Help Desk at 1-800-542-0945.

Molina commercial payer claims edit 277CA in error

Molina commercial payer claims beginning 5/2/19 are receiving the following edit in the 277CA in error:

• A7:21 PAYER ID SUBMITTED IN NM109 OF LOOP 2010BB IS MISSING OR INVALID!

We are currently investigating and will provide additional information as we receive it.

We apologize for any inconvenience.

SCIO Health Analytics' post-pay outpatient audits start on May 1

SCIO Health Analytics®, a vendor for Blue Cross Blue Shield of Michigan, will begin auditing outpatient claims for the commercial business on May 1, 2019.

The audits will:

• Start with claims paid on or after Jan. 1, 2018.
• Focus on ambulatory payment classification, observation and outpatient services
• Confirm commercial compliance with Blue Cross' guidelines and policy
• Validate appropriate billing of revenue, CPT and HCPCS codes, modifiers and units
• Ensure services are documented
• Detect, prevent and correct waste and abuse
• Facilitate accurate claim payments

You'll need to provide the proper medical charts for review. After an audit, SCIO will send you its findings and instructions for appeal, if necessary.

Questions?
Call your Blue Cross provider consultant. If you need to speak to a SCIO representative during the audit, call 1-866-628-3488, ext. 7525.

Blue Cross updated phone line servicing prompts for medical drug authorizations

We've made enhancements to the Medical Benefit Drug Authorization phone line. To better serve you, we've changed our prompts to help you verify benefits or start an authorization for a member.

Please be sure to listen to the prompt selections to ensure you're directed to the correct area. We're excited to introduce this new servicing option to you and appreciate your partnership.

Additional fee schedules added to web-DENIS

Blue Cross Blue Shield of Michigan recently added the following "entire fee schedules" to web-DENIS, reflecting fee updates effective May 1, 2019:

Professional: Injection Fee Schedule

• Injections minimum fee schedule (5/01/2019)

Note: Effective for dates of service on or after 2/1/14, professional providers, who want accurate payment at the NDC level, are requested to also provide the NDC and NDC quantity when submitting an injection HCPCS code and HCPCS quantity. Otherwise, the claim will be priced at the minimum fee, which is displayed in the professional fee schedule listed above.

Facility: Hospital Outpatient

• Drug fees effective 05/01/2019

These and other fee schedules are available on web-DENIS under BCBSM Provider Publications and Resources selecting Entire Fee Schedules and Fee Changes.

Blue Care Network updates professional fees July 1

Blue Care Network will update fee schedules, effective with dates of service on or after July 1, 2019. This change applies to services provided to Blue Care Network commercial members.

We will use the 2019 Medicare resource-based relative value scale for most relative value unit-priced procedures for dates of service on and after July 1.

In alignment with Blue Cross, the conversion factor used to calculate anesthesia base units for anesthesia procedures will increase 1.5% to $60.72 throughout Michigan.

Commercial payer - AARP missing edit in 277CA report

Starting April 1, commercial payer AARP payer ID 36273 may be missing an edit message in the 277CA UNSOLICITED RPT COMMERCIAL O.

If your rejected claim is returned in the 277CA report with no edit message and it is a secondary claim to this payer, please check to see if you included the federal sequestration adjustment amount (CARC 253). This must be included on all electronic Medicare Supplement claims submissions for AARP.

We expect this issue to be corrected on June 4.

We apologize for any inconvenience this may have caused. If you have questions call the EDI help desk at 1-800-542-0945.

Re-authorize Blue Cross as your billing agent in new system by May 24

If you don't use Blue Cross web-DENIS or EDI to check Medicaid eligibility, this notification doesn't apply to you.

Starting in May, the routing of Medicaid eligibility transactions between Blue Cross Blue Shield of Michigan and the Michigan Department of Health & Human Services will change. If you currently use Blue Cross to check Medicaid eligibility, you'll need to add us as an authorized billing agent through the MDHHS portal.

To ensure no disruption of your Medicaid eligibility through Blue Cross, before May 24, please:

• Log into the MDHSS portal.
• Click the CHAMPS link.
• Verify Blue Cross is associated as your billing agent for Medicaid eligibility (270/271) — no change is required for claims (837) and remittance (835).
• Use one of the agent codes below:
  • Professional providers, use CHAMPS Billing Agent ID 1200009.
  • Institutional providers, use CHAMPS Billing Agent ID 1200018.
• If Blue Cross isn't listed and you want to continue submitting Medicaid eligibility transactions through us, please associate us as your billing agent using one of the BillingAgent IDs listed above.
• Don't delete your current billing agent.

If your new billing agent information isn't complete before the transition is final, your Medicaid eligibility inquiries may not be accepted at MDHSS.

Got questions?
Refer to the MDHHS Billing Agent website and use the step-by-step instructions on associating a billing agent ID.

If you have questions about completing the Billing Agent form, call Medicaid provider support at 1-800-292-2550 option 4.

If you have general questions about this change, email Blue Cross EDI Customer Management at EDICustMgmt@bcbsm.com.

Thank you for your cooperation as we work through this update.

Medicare Plus Blue^SM PPO claim reimbursements

Effective July 1, 2019, Medicare Plus Blue^SM PPO will implement new reimbursement policies for the following claims billed with Healthcare Common Procedure Coding System or Current Procedural Terminology codes that don’t have an assigned Medicare fee.

General reimbursements (for non-durable medical equipment and non-laboratory claims)

• Medicare Plus Blue PPO will reimburse providers 65 percent of the charged amount for all non-DME and non-lab claims that don’t have an assigned Medicare fee.
• For drug claims, pharmacy pricing resources, if available, will be used before reimbursing at 65 percent of charges. For unlisted surgery codes, reimbursement will be made at the rate of a comparable surgery code.

Note: This payment policy doesn’t apply to procedure codes that currently require an invoice for payment by the Centers for Medicare & Medicaid Services. Also, any CPT codes that are carrier priced will continue to be paid accordingly.

Effective July 1, KhapzoryTM and Fusilev® will be added the prior authorization program for PPO commercial members

Effective July 1, 2019, Khapzory^TM and Fusilev^® will be added to the Medical Drug Prior Authorization Program for Blue Cross Blue Shield of Michigan PPO commercial members. This applies to any members starting therapy on or after July 1.

• Fusilev (levoleucovorin calcium, HCPCS code J0641)
• Khapzory (levoleucovorin sodium, HCPCS code J3490)

These drugs are currently included in the prior authorization program for Blue Care Network HMO^SM commercial members.

The authorization requirement only applies to groups that are currently participating in the commercial Medical Drug Prior Authorization Program for drugs administered under the medical benefit. These changes don't apply to BCN Advantage^SM, Blue Cross Medicare Plus Blue^SM PPO or Federal Employee Program^® members.

A prior authorization approval isn't a guarantee of payment. Health care practitioners need to verify eligibility and benefits for members. Members are responsible for the full cost of medications not covered under their medical benefit coverage.

For a list of requirements related to drugs covered under the medical benefit, do the following:

• Visit the Medical Benefit Drugs – Pharmacy page in the Blue Cross section at ereferrals.bcbsm.com.
• Click Requirements for drugs covered under the medical benefit – BCN HMO and Blue Cross PPO under the heading For Blue Cross (commercial) members.

The new prior authorization requirement for Khapzory and Fusilev will be reflected in the requirements list before the July 1 effective date.

May 2019 – Issue

• How to request retroactive prior authorization for commercial PPO Radiology Management Program
• Billing chart: Blues highlight medical, benefit policy changes
  • Genetic testing: Molecular analysis for targeted therapy of non-small cell lung cancer
  • Hycamtin (topotecan)
• Medical drug prior authorization program expanding
  • Khapzory (levoleucovorin sodium, HCPCS code J3490)
  • Fusilev (levoleucovorin calcium, HCPCS code J0641)
• Reminder: New approach aims to educate, promote appropriate use of evaluation and management codes
• Tips for billing medical drugs correctly

CHECK OUT THESE ARTICLES AND MUCH MORE HERE!