06/18/2019
BCBSM/BCN
Recent Oncology Related News
Provided by MSHO Managed Care Committee Members:
NASCO conducting payment recovery for Trinity Health
On June 13, 2019, NASCO will begin a payment recovery to allow professional claims with a no-choice provider to process as Tier 1.
We'll reprocess claims for Trinity Health from May 1, 2017 through Jan. 1, 2018.
When you adjust your patients' accounts with the correct payment, the subscriber may become liable for the charge.
Dart Container, group number 71750, changing its prior authorization vendor
On April 1, 2019, the Dart Container Corporation changed its prior authorization vendor to INETICO, LLC for the following services:
Chemotherapy Prior Authorization
Dart Container requires prior authorization of all chemotherapy drugs and treatment. And while Blue Cross Blue Shield of Michigan provides prior authorization services for chemotherapy, some chemotherapy medications and treatments don't require prior authorization. Therefore, any chemotherapy drugs and treatment not requiring prior authorization through Blue Cross should be referred to INETICO for approval.
High cost injections exceeding $500
Any injection medication exceeding $500 that doesn't require prior authorization through Blue Cross should be referred to INETICO.
Questions on pre-certifications and high cost imaging approvals
INETICO will also manage prior authorizations for air ambulance services, except for ambulance services related to specified organ transplants and bone marrow transplants.
You can reach INETICO at 1-877-224-6700.
Blue Cross is still handling prior authorization for specified organ transplants, bone marrow transplants and specialty drugs. If you have questions or need assistance, call 1-800-242-3504.
HCPCS update: New codes added
The Centers for Medicare & Medicaid Services recently added several new codes as part of its quarterly Health Care Procedure Coding System updates. The codes, effective date and Blue Cross Blue Shield of Michigan’s coverage decisions are below.
Outpatient prospective payment system — Injections
None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.
Billing chart: Blues highlight medical, benefit policy changes
New Payable Procedures Include:
- J9999 - Libtayo (cemiplimab-rwlc)
- J3590 - JIVI (antihemophilic factor [recombinant] Pegylated-aucl)
- J9171 - Docefrez (docetaxel)
- J9271 - Keytruda (pembrolizumab)
***See the June RECORD for additional information!
Medication reconciliation reimbursement increases to $35
Effective April 29, 2019, Blue Cross Blue Shield of Michigan and Blue Care Network reimburses $35 for medication reconciliation for Medicare Plus BlueSM and BCN AdvantageSM members when conducted within 30 days of a hospital discharge and billed with CPT II code *1111F.
How to receive reimbursement
- Perform medication reconciliation within 30 days of a discharge by comparing the discharge medications against the list of medications the patient was taking before hospitalization.
- Medication reconciliation can be conducted by physicians, physician assistants, pharmacists and registered nurses.
- One example of acceptable documentation in the outpatient medical record is "Current and discharge medications were reconciled."
- Submit *1111F with the post-discharge office visit claim within 30 days of the discharge.
Other information
- *1111F can be billed alone.
- *1111F can't be billed with transitional care management codes (*99495 or *99496) or *99483.
- Blue Cross commercial reimbursement remains at $35.
The information in this message is also included in a June Record article. Click here to see the Medication Reconciliation Post-Discharge star measure tip sheet. It includes claims coding information and documentation and billing tips.
If you have questions, contact Laurie Latvis at 313-225-7778 or email her at llatvis@bcbsm.com.
*CPT codes, descriptions and two-digit modifiers only are copyright 2018 American Medical Association. All rights reserved.
2019 InterQual criteria to be implemented Aug. 1
Each year, Blue Cross Blue Shield of Michigan and Blue Care Network update InterQual® criteria. We use these criteria to make utilization management determinations regarding requests to authorize behavioral health and non-behavioral health services. We'll implement 2019 criteria starting Aug. 1, 2019. The July Record and the July – August issue of BCN Provider News will provide you with details on how to access the new criteria.
NaviNet replacing Blue Exchange for online eligibility and claims inquiries; register for access now
In August, Blue Exchange inquiries will no longer be available for Blue Cross Complete providers. If you're using the bcbsm.com Provider Secured Services portal to access Blue Exchange for Blue Cross Complete eligibility and claims information, use NaviNet instead.
Got questions?
The Blue Cross Complete Provider Resource Guide is a great resource. Or, reach out to your Blue Cross Complete provider account executive.
Medicare Part B medical specialty drug prior authorization list changing July 22, 2019
We’re making changes to the Medicare Plus BlueSM PPO and BCN AdvantageSM 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.
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 BlueSM PPO claim reimbursements
Effective July 1, 2019, Medicare Plus BlueSM 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, KhapzoryTM 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 HMOSM 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 AdvantageSM, Blue Cross Medicare Plus BlueSM 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.
June 2019 – Issue
- New care management program to launch in 2020
- SCIO Health Analytics auditing outpatient claims for commercial business
- HCPCS update: New codes added
- Billing chart: Blues highlight medical, benefit policy changes
- New Payable Procedures Include: J9999 - Libtayo (cemiplimab-rwlc), J3590 - JIVI (antihemophilic factor [recombinant] Pegylated-aucl), J9171 - Docefrez (docetaxel), J9271 - Keytruda (pembrolizumab)
- You must use network laboratories for your Blue Cross and BCN patients
- Medicare Part B medical specialty drug prior authorization list changing
- Here’s helpful information about clinical editing appeals for Blue Cross PPO and Medicare Plus Blue claims
CHECK OUT THESE ARTICLES AND MUCH MORE HERE!