05/21/2019

BCBSM/BCN

Recent Oncology Related News

Provided by MSHO Managed Care Committee Members:

Medicare Part B medical specialty drug prior authorization list changing July 22, 2019

We’re making changes to the Medicare Plus Blue^SM PPO and BCN Advantage^SM Part B specialty prior authorization drug list, as follows:

• For dates of service on or after July 22, 2019, Darzalex^® (J9145) will require prior authorization.
• Effective immediately, Myozyme^® (J0220) is removed from the prior authorization list because it is no longer available in the U.S. market.

Here’s some additional information you need to know about the change for Darzalex.

Medicare Plus Blue PPO
For Medicare Plus Blue, we require prior authorization for Darzalex when you bill electronically through an 837P transaction or on a professional CMS-1500 claim form, for the following sites of care:

• Physician office (place of service code 11)
• Outpatient facility (place of service code 19, 22 or 24)

BCN Advantage
For BCN Advantage, we require prior authorization for Darzalex when you bill it as a professional service or an outpatient facility service electronically through an 837P transaction or on a professional CMS-1500 claim form for:

• Physician office (place of service code 11)
• Outpatient facility (place of service code 19, 22 or 24)
• Home (place of service code 12)

We also require prior authorization when you bill electronically through an 837I transaction or using a UB04 claim form for a hospital outpatient type of bill 013x.

Important reminder
You must get authorization prior to administering these medications. Use the Novologix^® online web tool to quickly submit your requests. It offers real-time status checks and immediate approvals for certain medications. Also note:

• For Medicare Plus Blue, you can fax an Addendum P form to gain access to the Novologix online web tool.
• For BCN Advantage, if you have access to Provider Secured Services, you already have access to submit authorization requests through Novologix.

NASCO conducting payment recovery for URMBT retiree groups

On May 29, 2019, NASCO will begin a retro-recovery benefit change for any professional and facility claims to reject not-otherwise-classified medical drug codes as not a covered benefit.

We’ll reprocess claims for UAW Retiree Medical Benefits Trust members from Jan. 1, 2019 through March 18, 2019.

When you adjust your patients’ accounts with the correct payment, the subscriber may become liable for the charge.

2 employer groups joining the PPO commercial medical drug prior authorization program

Two groups are joining the Blue Cross PPO Commercial Medical Drug Prior Authorization Program as follows:

• June 1, 2019, Detroit & Vicinity Trowel Trades Health & Welfare Fund
• July 1, 2019, Iron Workers Union of Eastern Michigan
   

Members within any of these groups will need a prior authorization for select medications. A complete list of medications included in the program can be viewed using the Blue Cross and BCN Utilization Management Medical Drug List.

As a reminder, approval of an authorization request 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.

Don’t forget to refer to the opt-out list for the groups that don’t require members to participate in the program.

The prior authorization requirement doesn’t apply to Federal Employee Program® and Medicare Plus Blue^SM PPO members.

Blue Cross tackling cost of prescription drugs

A message from Atheer Kaddis, vice president, Pharmacy Services

Drug costs continue to rise — one of the many challenges we face in trying to keep health care costs affordable. READ MORE.

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 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.

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!