12/18/2018
BCBSM/BCN
Recent Oncology Related News
Provided by MSHO Managed Care Committee Members:
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:
- Go to bcsbm.com/pharmacy.
- Click What are specialty drugs?
- Click Specialty Drug Program Rx Benefit Member Guide (PDF).
Xgeva® to require authorization for BCN AdvantageSM members
On Nov. 1, 2018, a web-DENIS message and a news item at ereferrals.bcbsm.com were posted indicating that Xgeva would not require authorization starting Jan. 1, 2019, for BCN Advantage members.
However, you'll need to continue to submit authorization requests for this drug. We apologize for any inconvenience this may cause.
We've updated the earlier communications, titled "Medicare Part B medical specialty drug prior authorization lists changing in 2019," to reflect the change. You may want to review the earlier communications to refresh your memory on the other changes that will take place.
Additional information
For BCN Advantage, we require prior authorization for Xgeva when you bill it as a professional service or an outpatient facility service based on the following:
- Professional CMS-1500 claim form (or electronically via an 837P transaction) for the following sites of care:
- Physician office (Place of Service Code 11)
- Home (Place of Service Code 12)
- Facility UB04 claim form (or electronically via an 837I transaction):
- Outpatient facility (Type of Bill 013x)
Enhancements to the 835 - delayed
On November 14, we posted a broadcast message informing you that we would be making enhancements to the 835 for Medicare Advantage PPO and PFFS beginning on December 15, 2018. These enhancements have been delayed. We will update you when additional information is available.
If you have any questions, please contact the EDI Help Desk at 1-800-542-0945.
Medical records requests coming soon for risk adjustment audit
Blue Cross Blue Shield of Michigan is participating in a government audit for Medicare Advantage PPO. We expect the audit to begin soon and will need to submit medical records documentation related to risk adjustment. These medical records will help verify the diagnosis data previously submitted to the Centers for Medicare & Medicaid Services for 2014 and 2015 dates of service.
You may receive a request from one of Blue Cross' contracted vendors (Tessellate or CIOX) requesting documentation for some members who received services between Jan. 1, 2014, through Dec. 31, 2014, and Jan. 1, 2015, through Dec. 31, 2015.
Please alert your offices about this upcoming request and the importance of sharing these medical records within five business days.
We'll give you more details soon.
NASCO starting payment recovery for all URMBT groups
On Dec. 4, 2018, NASCO is starting a payment recovery for all URMBT groups. The recovery will process duplicate claims with the same date of service (to no longer pay for professional Medicare services).
Medicare Plus BlueSM PPO manual update coming in January
Blue Cross Blue Shield of Michigan will update its Medicare Plus BlueSM PPO manual effective Jan. 1, 2019. Key changes include updated language in the following sections:
- Updated language in the Lab Services section
- Added language in the Benefits section
- Added language in the Medical Management and Quality Improvement section
- Deletion of language and updated language in the Utilization Management section
- Deletion of language and updated language in the Provider Dispute Resolution Process 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.
Blue Cross Complete lab services update
Effective January 1, 2019, Blue Cross Complete of Michigan will partner with Joint Venture Hospital Laboratories on an exclusive arrangement for laboratory services. The arrangement requires all outpatient laboratory services to be provided by JVHL, with the following exceptions for the providers where the JVHL coverage is not yet adequate:
- Genesys Physician Hospital Organization
- Professional Medical Corporation Provider Organization
Blue Cross Complete will continue to work with Quest Diagnostics for lab services for these exception provider groups for a period of one year. At the end of one year, Blue Cross Complete will evaluate JVHL's coverage area to determine whether to remove or extend the exceptions.
If you have any questions, please contact Blue Cross Complete Provider Inquiry at 1-888-312-5713 or your Blue Cross Complete provider account executive. Thank you for the quality care your team provides to the Blue Cross Complete members.
eviCore to manage two radiopharmaceutical drugs, starting Feb. 1
For dates of services on or after Feb. 1, 2019, the following radiopharmaceutical drugs require authorization through eviCore healthcare:
- Lutathera® (lutetium Lu 177 dotatate, HCPCS code C9031)
- Xofigo® (radium Ra 223 dichloride, HCPCS code A9606)
This applies to members covered by:
- Blue Cross PPO (commercial) and Blue Cross Medicare Plus BlueSM PPO
- Note: eviCore already manages procedures associated with code A9606 for Blue Cross PPO and Medicare Plus Blue members. eviCore will begin managing procedures associated with code C9031 on Feb. 1.
- BCN HMOSM (commercial) and BCN AdvantageSM
- Note: Lutathera was previously managed for BCN HMO members under the prior authorization program for drugs covered under the medical benefit. eviCore already manages procedures associated with code C9031 for BCN Advantage members. For BCN HMO members, C codes aren't payable. However, services associated with the administration of an approved treatment plan with Lutathera are payable for BCN HMO members. eviCore will begin managing procedures associated with code A9606 for both BCN HMO and BCN Advantage on Feb. 1.
Submit authorization requests to eviCore online at evicore.com or by telephone at 1-855-774-1317.
We'll update the Procedures that require authorization by eviCore healthcare document prior to the effective date of the change.
Tips to differentiate home health care from home infusion services
Home health and home infusion are separate services
In practice, you may use the terms "home health" and "home infusion" synonymously. However, when it comes to your patients' benefits with Blue Cross Blue Shield of Michigan and Blue Care Network, they have very different meanings and coverage requirements.
Home health care
Home health care is a benefit. It's an alternative to long-term hospital care for patients that are medically certified by the physician as non-ambulatory or homebound and allows them to receive certain services in their home.
If it's part of your patients' plan, we cover it when they meet a specific set of criteria.
We cover these home health services:
- Skilled Nursing
- Physical therapy
- Speech therapy
- Nutritional therapy
- Occupational therapy
- Social service guidance
We don't cover:
- Custodial care, such as: 24 hour a day care at home, meals delivered to the home, homemaker services, shopping, cleaning and laundry.
- Personal care given by home health aides (bathing, dressing, using bathroom) as a stand-alone service.
Correction: List of medical drugs in commercial Medical Drug Prior Authorization Program
The commercial Medical Drug Prior Authorization Program list that was in the November Record contained some incorrect information. The article has been revised to include the correct information. Please click here to see the revised article.
Keep in mind that this prior authorization requirement doesn't apply to Federal Employee Program®, Medicare or Medicare Advantage members. Refer to the Opt-out List for a list of all groups that don't require members to participate in the program.
Blue Cross reserves the right to change the prior authorization/site of care list at any time.
Continuity of Care in place for URMBT members in the medical or radiation oncology programs
Beginning Jan. 1, 2019, Blue Cross Blue Shield of Michigan will begin two new utilization management programs for oncology services delivered to UAW Retiree Medical Benefits Trust members. The programs require prior authorization for some outpatient medical and radiation oncology treatments through AIM Specialty Health®. We announced this in an October Record article.
Trust members who are in a current course of medical oncology or radiation oncology treatment (as described in the October article) as of Jan. 1, 2019, won’t need a prior authorization for six months. We’re doing this to ensure that these members don’t have an interruption in their care.
If treatment continues beyond six months or if a patient’s treatment path changes, a prior authorization will be required.
We’ll send additional communications directly to providers who are treating these members 30 days before the end of the six-month period to remind them that authorizations will be required.
For more information about these programs, go to the AIM ProviderPortal** or call AIM at 1-800-728-8008. You can also go to bcbsm.com.
**Blue Cross Blue Shield of Michigan doesn’t own or control this website.
Attention CT, MRI specialists: Sign up for OptiNet® webinar, opt in for patient referrals
Beginning Jan. 1, 2019, Blue Cross Blue Shield of Michigan and AIM Specialty Health® will offer a new program, Special Care Shopper, to UAW Retiree Medical Benefits Trust members. The program offers Trust members high-quality, cost-effective radiology treatment from a select group of health care providers.
What does this mean for you?
It's an opportunity to become a select diagnostic imaging provider for URMBT patient referrals. Learn more: Read the November Record and sign up for an upcoming webinar.
Register for a webinar now
Two OptiNet®, shopper program training webinars are available to providers who order or render CT or MRI services to PPO members. Click one of the dates below to register:
Once you're approved by the host, you'll receive a confirmation email with instructions for joining the session.
Cinqair, Nucala, Xolair added to site of care infusion requirement, beginning Jan. 1
Blue Cross Blue Shield of Michigan is adding three medical drugs to its commercial site of care requirement. Starting Jan. 1, 2019, Blue Cross won't cover most infusions for Cinqair®, Nucala® or Xolair® at outpatient hospital facilities without an approved location prior authorization.
These changes don't apply to BCN AdvantageSM, Blue Cross Medicare Plus BlueSM PPO or Federal Employee Program® members.
Since all drugs in this program already need prior authorization for payment, you don't need to take any further action. Approved authorizations will be payable for the following professional locations:
- Physician's offices or other health care provider's offices
- Ambulatory infusion centers
- The member's home, from a home infusion therapy provider
If your patient now receives one of these infusions at a hospital outpatient facility:
- Send Blue Cross a prior-approval request for his or her hospital outpatient facility. If this request isn't submitted and approved, your patient will be responsible for the full cost of the medicine.
- Find out where your patient can continue his or her infusion therapy. Check the directory of participating home infusion therapy providers and infusion centers.
- Tell your patient to contact any of the listed infusion therapy providers. If they're able to accommodate your patient, they'll work with you and your patient to make the change easy. We're also sending this information to your patient.
- Help your patient switch his or her infusion therapy to your office, infusion center or home infusion therapy provider by Jan. 1, 2019.
The following HCPCS codes and medical drugs are subject to this requirement:
J2786 — Cinqair®
J2182 — Nucala®
J2357 — Xolair®
Reminder - New Institutional Blue Care Network edit: NDC DRUG QUANTITY MUST BE GREATER THAN ZERO
On Nov. 12, 2018, BCBSM EDI will implement a new institutional edit for BCN. The edit below will be applied when loop 2410, CPT04 is zero.
F954 NDC DRUG QUANTITY MUST BE GREATER THAN ZERO
If you receive edit F954 on a R277CAF report or A3:476:216 in the 277CAP transaction, you must correct and resubmit your claims.
If you have questions, please contact the EDI help desk at 1-800-542-0945.
Medicare Part B medical specialty drug prior authorization lists changing in 2019
Some updates are coming for the Part B medical specialty medical prior authorization drug list for Blue Cross Medicare Plus BlueSM PPO and BCN AdvantageSM members. These changes include additions and removals from the prior authorization program as follows.
Medicare Plus Blue PPO
Removals — for dates of service starting Jan. 1, 2019:
J0202 Lemtrada®
J2323 Tysabri®
J2350 Ocrevus®
Additions — for dates of service starting Feb. 1, 2019:
J2840 Kanuma®
J2860 Sylvant®
J3357 Stelara® SQ
J3358 Stelara® IV
J3490/C9399 OnpattroTM
J3590 TrogarzoTM
J9022 Tecentriq®
J9023 Bavencio®
J9042 Adcetris®
J9176 Empliciti®
J9308 Cyramza®
J9352 Yondelis®
For Medicare Plus Blue, we require prior authorization for these medications when you bill them on a professional CMS-1500 claim form or by electronic submission via an 837P transaction, for the following sites of care:
- Physician office (Place of Service Code 11)
- Outpatient facility (Place of Service Code 19, 22 or 24)
We do not require authorization for these medications when you bill them on a facility claim form (such as a UB04) or electronically via an 837I transaction.
BCN Advantage
Removals — for dates of service starting Jan. 1, 2019:
J0897 Xgeva®
J9032 Beleodaq®
J9310 Rituxan®
Additions — for dates of service starting Feb. 1, 2019:
J2860 Sylvant®
J3357 Stelara® SQ
J3358 Stelara® IV
J3490/C9399 OnpattroTM
J3590 TrogarzoTM
J9022 Tecentriq®
J9023 Bavencio®
J9042 Adcetris®
J9176 Empliciti®
J9352 Yondelis®
For BCN Advantage, we require prior authorization for these medications when you bill them on a professional CMS-1500 claim form (or submit them electronically via an 837P transaction) or on a facility claim form such as a UB04 (or submit them electronically via an 837I transaction), for the following sites of care:
- Physician office (Place of Service Code 11)
- Outpatient facility (Place of Service Code 19, 22 or 24)
- Home (Place of Service Code 12)
Important reminder
You must get authorization prior to administering these medications. Use the Novologix® online web tool to quickly submit your requests.
BCBSM grants MOC exceptions
Blue Cross Blue Shield of Michigan will continue to verify board certification statuses of practitioners in their Blue Cross and Blue Care Network managed care networks. Effective Jan. 1, 2019, the board certification status of family medicine, internal medicine and pediatric practitioners will be reviewed annually. If their board certification status has lapsed and they are a designated patient centered medical home physician, Blue Cross will grant an exception and allow the practitioner to remain in their Blue Cross and BCN managed care networks. READ MORE
Some medical benefit drugs for Medicare Advantage members need step therapy, starting January 1
In the new year, according to Centers for Medicare & Medicaid Services guidance, certain Medicare Part B specialty drugs will have additional step therapy authorization requirements. This will apply to Medicare Plus BlueSM PPO and BCN AdvantageSM members for dates of service on or after Jan. 1, 2019.
Step therapy is treatment for a medical condition that starts with the most preferred drug therapy and progresses to other drug therapies only if necessary. The goal of step therapy is to encourage better clinical decision-making.
What's changing?
For drugs requiring step therapy, authorization request questions will be different from the ones you currently answer. Some examples of drugs that require step therapy are:
- Botox® for migraines and over active bladder
- Eylea®,Lucentis® and Macugen® for neovascular age-related macular edema
- Prolia® for osteoporosis
Use NovoLogix® to submit authorization requests
We encourage you to send prior authorization requests for Medicare Part B specialty drugs through the NovoLogix web tool via Provider Secured Services. It's the most efficient way to get a determination.
Look for more information on step therapy requirements in upcoming issues of The Record and BCN Provider News.
Reminder: Follow these guidelines when billing medical drugs that haven’t been purchased
Some health care providers have questioned what to do when billing certain medical drugs that were administered by a medical professional but supplied by our specialty pharmacy.
Here are guidelines to follow in professional and hospital settings:
- When professional providers administer a drug they didn’t purchase, they should bill for the administration code only and not include the drug or NDC code on the claim.
- When professional providers administer a medical drug that was purchased, notes should be documented and a copy of the purchase order included in the member’s chart.
- Identical NDC codes billed within 14 days of a specialty pharmacy claim will be recovered and the provider will need proof of purchase to have the claim repaid.
- When a hospital administers a drug in an outpatient setting that isn’t purchased by the hospital, the hospital should bill for the administration. However, the hospital should include the revenue code and corresponding procedure code for the medical drug with total charges of $.01.
For more information, see the May 2016 and July 2016 Record articles.
December 2018 – Issue
- Blue Cross Rewards program will help members compare costs while earning e-gift cards
- Online health services available to Medicare Plus Blue PPO members, starting Jan. 1
- We’re offering prizes to providers who submit feedback about our utilization management services
- HCPCS update: Code added
- New approach aims to educate and promote appropriate use of evaluation and management codes
- Here are guidelines for billing medical drugs correctly
CHECK OUT THESE ARTICLES AND MUCH MORE HERE!