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1 2 3 4 5 BCNprovidernews 6 7 NOVEMBER–DECEMBER 2014 8 Cover Story 9 The Blues to offer a variety 10 11 of individual products for 2015 12 Network Operations 13 When the Health Insurance Marketplace opens Nov. 15, Blue Care Network 14 and Blue Cross Blue Shield of Michigan will have many new products available 15 for coverage beginning Jan. 1, 2015, or later. 16 BCN Advantage 17 Blue Cross and BCN are offering 41 individual products; 24 of them are BCN 18 HMO plans and 17 are Blue Cross PPO plans. All of the products sold on the 19 Blue Cross Complete Marketplace will be sold with Blue Cross names. (Please see the article on 20 Page 8 for some tips to identify Blue Cross and BCN plans by their names.) 21 22 Blue Care of Michigan's Personal PlusSM will remain open in 2015, but it will 23 Patient Care not be open to new contracts. Some changes to Personal Plus were made 24 to comply with certain Federal and State mandates. For example, elective 25 26 abortion was added as a rider and, for the applied behavioral analysis Inside this issue… 27 Behavioral Health benefit for autism, the line therapy hour limit to treat autism spectrum 28 disorders will be removed effective January 2015. 29 n Blue Cross Metro Detroit HMO Some plans are discontinuing. 30 provides new low-cost coverage to 31 Quality Counts • BCBSM’s Keep FitSM will no longer be offered. Keep Fit members will individuals in Southeast Michigan...... Page 3 32 need to have purchased another individual plan that becomes effective 33 January 2015. 34 n Blue Care Network provides 35 Pharmacy News • Blue Cross Partnered Value and Blue Cross Preferred Value plans are office staff incentives for tobacco 36 discontinued effective Dec. 31, 2014. cessation campaign...... Page 12 37 38 New plans will be offered for 2015: 39 Billing Bulletin • Blue Cross® Metro Detroit HMO – a local network HMO in three counties n BCN Advantage introduces 40 offered by Blue Care Network. Members must reside in Wayne, Oakland ConnectedCare HMO 41 or Macomb counties. (More information on Page 3.) local network...... Page 20 42 43 ® Referral Roundup • Blue Cross Metro Detroit EPO – an exclusive provider organization in 44 six counties offered by Blue Cross. (More information is on Page 5.) n From the medical director: 45 Help Blue Care Network reduce • New “Extra” plans – these plans include a basic individual product benefit 46 childhood obesity...... Page 30 47 Index design plus the following: 48 -- The plan pays the first four specialist office visits per member before the 49 deductible (copayments will apply) 50 -- The plan pays Tier 1A and Tier 1B generic prescription drugs before the 51 deductible (copays will apply.) 52 Feedback | Subscribe BCN Provider News User Guide PDF Blue Care Network of Michigan is a nonprofit corporation and Please see Blues products, continued on Page 2 independent licensee of the Blue Cross and Blue Shield Association. network operations 2 1 2 3 Blues products, continued from Page 1 4 5 Highlights of cost sharing changes for the BCN Extra New Medicare Advantage product 6 plans include: 7 BCN Advantage ConnectedCare HMO is a new individual 8 Cover Story • Simplified cost sharing by removing copays for imaging Medicare Advantage HMO product with an exclusive 9 services, such as CTs, PET scans or MRIs. provider network developed primarily around Southeast 10 Michigan and Kalamazoo County. Open enrollment for 11 • Removed copays for mental health and substance abuse Medicare Advantage began on Oct. 1, 2014 for a Jan. 1, 12 Network Operations 13 outpatient services. 2015 effective date. (For details about BCN Advantage  14 • Inpatient copay – No $500 copay for a stay in a hospital, ConnectedCare HMO, see the article on Page 20.) 15 mental health, substance abuse and skilled nursing 16 BCN Advantage facility. Also no copay for delivery and all inpatient Check member eligibility and benefits 17 maternity services. Coinsurance will continue to apply. Providers should be sure to check eligibility and benefits 18 19 before providing services. It’s important to check both the • Office visits – Primary care physician office copay 20 Blue Cross Complete plan name and the network associated with the plan. For reduced to $20 for Silver and Gold Extra plans. 21 local plans, such as the Metro Detroit HMO, providers 22 For Bronze Extra plans the PCP office copay is $40 and need to refer within the local network. For information 23 the specialist office copay is $75. (Applies to Blue Care about how to find the Blues plans you are contracted to 24 Patient Care Network only.) provide services for, see the PDF below. 25 26 Blue Cross will continue to offer the Premier and Multi‑State 27 Behavioral Health PPO. The plan gives members a broad choice of doctors 28 and hospitals in the Blue Cross statewide PPO network, Finding your 29 including nationwide coverage. Members may receive Blues plans PDF 30 services from hospitals or doctors outside the network, but 31 Quality Counts 32 will pay less if they use in-network providers. 33 34 35 Pharmacy News 36 37 Provider Communications Market Communications Editor Elizabeth Donoghue Colvin 38 Cindy Palese Catherine Vera-Burgos, Jennifer Fry Publications 39 Billing Bulletin [email protected] Manager Tracy Petipren Cathy Rauckis 40 41 42 Contributors: 43 Belinda Bolton; Terri Brady; Richard Cook; Laura Cornish; Jeniene Edwards; Mary Ellison; Moira Horne; Mary McFarlane; Dani Sokoloski; Referral Roundup 44 Michelle Smith 45 46 47 BCBSM and BCN maintain BCBSM.com, hcbo.com and theunadvertisedbrand.com. The Blues do not control any other websites referenced in this publication or endorse their Index 48 general content. 49 References to “Blue Care Network” and “BCN” in this publication refer to all Blue Care Network of Michigan, Blue Care of Michigan, Inc., BCN Services Company and Blue Cross 50 Complete of Michigan products, except where noted otherwise. Clinical information in this issue is consistent with BCN Clinical Practice Guidelines and applies to the care of BCNprovidernews BCN and BCN subsidiary/affiliate corporation members regardless of product. More information is available in the BCN Provider Manual on web‑DENIS. Specific benefit information 51 NOVEMBER–DECEMBER 2014 is available on web‑DENIS, CAREN or by calling Provider Inquiry. 52 No portion of this publication may be copied without the express written permission of Blue Care Network of Michigan, except that BCN-participating health care providers may make Feedback copies for their personal use. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by any party other than BCN. network operations 3 1 2 3 Blue Cross Metro Detroit HMO provides new low-cost 4 5 coverage to individuals in Southeast Michigan 6 7 Blue Care Network is offering a new, affordable HMO The new Blue Cross Metro Detroit HMO product is priced 8 Cover Story 9 individual coverage option for 2015, Blue Cross® Metro to appeal to people in the three counties seeking affordable 10 Detroit HMO. The product will be offered to individuals health insurance and care coordinated through local doctors 11 residing in three counties – Oakland, Macomb and Wayne and hospitals. Metro Detroit HMO has a local network that 12 Network Operations – with gold, silver and bronze options. The HMO product is a subset of the larger BCN provider network. The local 13  will be offered both on and off the Health Insurance network includes primary care physicians from the medical 14 Marketplace. Individuals can purchase the product during care groups listed below. Members must select a PCP 15 16 BCN Advantage open enrollment, Nov. 15, 2014 through Feb. 15, 2015, contracted within the local network. The PCP will coordinate 17 with coverage beginning Jan. 1, 2015, or later depending care with local network specialists and hospitals. 18 on the date of purchase. 19 Blue Cross Complete 20 The Metro Detroit HMO local network includes PCPs from these medical care groups: 21 22 • Accountable Healthcare Advantage • Oakwood Accountable Care Organization 23 Patient Care • Macomb St. Clair Primary Physicians Group • Providence Partners in Mission 24 • Medical Network One • St. John Macomb PHO 25 26 • Midwest Medical Center, P.C. • St. John Physician Hospital Organization 27 Behavioral Health • Oakland General Associates • St. John River District 28 • Oakland Southfield Physicians Group • United Physicians 29 30 31 Quality Counts 32 33 34 35 Pharmacy News 36 37 38 39 Billing Bulletin 40 41 42 43 Referral Roundup 44 45 46 47 Index 48 49 50 BCNprovidernews 51 NOVEMBER–DECEMBER 2014 52 Feedback Please see Metro Detroit HMO, continued on Page 4 network operations 4 1 2 3 Metro Detroit HMO, continued from Page 3 4 5 6 The Metro Detroit HMO local network includes these When Metro Detroit HMO members are referred for 7 hospital systems and hospitals: services within the Metro Detroit HMO local network, 8 Cover Story 9 • St. John Providence Health/Ascension standard BCN referral and clinical review requirements 10 apply. Services performed outside the Metro Detroit -- St. John Hospital and Medical Center (Detroit) 11 HMO local network require authorization by BCN, even 12 Network Operations -- Providence Hospital (Southfield) if the providers are in the larger BCN network. The only 13  -- St. John Macomb – Oakland Hospital Macomb Center exception to this is for urgent and emergent services. 14 15 -- St. John Macomb – Oakland Hospital Oakland Center 16 BCN Advantage Women are required to use obstetrician-gynecologist -- St. John River District Hospital (East China) providers in the network. If they wish to visit an OB-GYN 17 18 • Oakwood Healthcare System outside the network, services require clinical review. 19 -- Oakwood Hospital and Medical Center Pharmacy coverage uses the Custom Select Drug List. The 20 Blue Cross Complete 21 SM -- Oakwood Southshore Medical Center ID card will feature MyBlue in the upper right portion of 22 -- Oakwood Annapolis Hospital the card, signifying that this is an individual Blues product, 23 Patient Care -- Oakwood Heritage Hospital with the full product name in the lower left. The Metro 24 Detroit HMO product names include: 25 26 • Trinity Health ® • Blue Cross Metro Detroit HMO Gold Extra 27 -- St. Joseph Mercy Hospital Ann Arbor Behavioral Health • Blue Cross® Metro Detroit HMO Silver Extra 28 -- St. Joseph Livingston Hospital (Howell) 29 ® -- St. Mary Mercy Hospital Livonia • Blue Cross Metro Detroit HMO Silver 30 31 • Blue Cross® Metro Detroit HMO Bronze Extra Quality Counts -- St. Joseph Mercy Oakland Hospital (Pontiac) 32 • Blue Cross® Metro Detroit HMO Bronze 33 • Detroit Medical Center 34 -- Huron Valley – Sinai Hospital See also these related articles: 35 Pharmacy News -- Sinai-Grace Hospital 36 • Blue Cross introduces Metro Detroit EPO 37 -- Harper University/Hutzel Women’s • BCN Advantage introduces ConnectedCare HMO 38 -- Children’s Hospital of Michigan local network 39 Billing Bulletin 40 -- Detroit Receiving Hospital • The Blues to offer a variety of individual products 41 -- Rehabilitative Institute of Michigan for 2015 42 43 Referral Roundup • Botsford Hospital 44 45 You can view network doctors and specialists in more 46 Index detail by doing a search on the Find a Doctor feature on 47 bcbsm.com. 48 49 50 BCNprovidernews 51 NOVEMBER–DECEMBER 2014 52 Feedback network operations 5 1 2 3 Blue Cross introduces Metro Detroit EPO 4 5 6 The Blues are partnering with health care providers in Participating hospitals include: 7 Southeast Michigan to offer cost-conscious consumers • Detroit Medical Center 8 Cover Story affordable, coordinated care through localized networks. 9 -- DMC – Sinai Grace 10 The Metro Detroit exclusive provider organization, or EPO, -- DMC – Rehab Institute of Michigan 11 12 Network Operations network includes 25 hospitals and more than 6,300 doctors -- DMC – Huron Valley Sinai located in Livingston, Macomb, Oakland, St. Clair, Washtenaw 13 -- DMC – Children’s Hospital 14  and Wayne counties. It’s part of our ongoing efforts to increase -- DMC – Harper-Hutzel 15 access to high-quality, lower cost health care for Michigan 16 BCN Advantage residents. -- DMC – Detroit Receiving 17 • Oakwood Healthcare 18 Here are three important points to keep in mind: 19 -- Oakwood Hospital Dearborn 20 Blue Cross Complete • Other than eligible emergency services and accidental -- Oakwood Hospital Southshore 21 injuries, members who have enrolled in a Metro Detroit 22 EPO plan do not have coverage if they visit a doctor or -- Oakwood Hospital Taylor 23 Patient Care hospital that is outside the network. -- Oakwood Hospital Wayne 24 25 • Be sure to always refer members to health care • St. John Providence Health System 26 providers that are in the network. You can use the -- St. John Macomb – Oakland Hospital Macomb Center 27 Behavioral Health Find a Doctor search tool on bcbsm.com to verify that -- St. John Macomb – Oakland Hospital Oakland Center 28 a doctor or hospital is in this network. 29 -- St. John River District Hospital 30 • Be sure your office staff knows if you are in this -- St. John Hospital and Medical Center 31 Quality Counts localized network. 32 -- Providence Park Hospital 33 -- Providence Hospital 34 35 Pharmacy News Product names include: • Saint Joseph Mercy Health System/ Trinity Health 36 37 ® -- St. Joseph Mercy – Oakland -- Blue Cross Metro Detroit EPO Gold Extra 38 -- Blue Cross® Metro Detroit EPO Silver Extra -- St. Joseph Mercy – Ann Arbor 39 Billing Bulletin -- Blue Cross® Metro Detroit EPO Silver -- St. Joseph Mercy – Livingston 40 41 ® -- Blue Cross Metro Detroit EPO Bronze Extra -- St. Joseph Mercy – Port Huron 42 ® -- St. Mary Mercy Hospital – Livonia 43 Referral Roundup -- Blue Cross Metro Detroit EPO Bronze -- St. Joseph Mercy – Chelsea 44 These products will be available to consumers beginning 45 Nov. 15, when open enrollment begins, for coverage • Botsford Hospital 46 effective Jan. 1, 2015. They can be purchased on the 47 Index • Garden City Hospital 48 Health Insurance Marketplace and directly through • Stonecrest Center for Behavioral Health 49 Blue Cross or independent insurance agents. 50 BCNprovidernews • Straith Hospital for Special Surgery 51 NOVEMBER–DECEMBER 2014 52 Feedback network operations 6 1 2 3 Blue Care Network continues to offer PCP Focus in 2015 4 5 Blue Care Network will continue to offer its local network BCN first introduced the PCP Focus network in 2011 in 6 plan, PCP Focus. It will continue to be available on the Health seven Southeast counties. Members must select a primary 7 Insurance Marketplace to individuals and groups with 50 or care physician from the PCP Focus network in order for 8 Cover Story fewer full‑time equivalent employees, and off the Marketplace services to be covered. The primary care physician can refer 9 to groups with one to 99 employees with a physical location in the member to any BCN‑affiliated hospital and specialist. 10 11 one of the defined counties. The network product also will be Providers can identify members who have the PCP Focus 12 Network Operations offered to individuals on and off the Marketplace. When it is sold 13 option by checking eligibility and benefits on web‑DENIS. For as an individual product, it is identified as Blue Cross® Select. 14  members who have this option, “FOCUS” or FOCUS1 will be 15 The network can be paired with many different BCN listed as one of the riders in the Certificate/Rider area of the 16 BCN Advantage products and offers members a choice of more than 3,000 Medical Benefits screen. The FOCUS rider applies to group and 17 primary care physicians located across these 21 counties: the FOCUS1 rider applies to individual coverage. ID cards for 18 Bay, Kalamazoo, Ottawa, Calhoun, Kent*, Saginaw, individual members identify the product as Blue Cross Select. 19 20 Blue Cross Complete Clinton, Livingston, Shiawassee, Eaton, Macomb, St. * In these two counties (Kent and Muskegon), the PCP Focus network is 21 Clair, Genesee, Monroe, Van Buren, Ingham, Muskegon*, available only for groups, not individual members. 22 Washtenaw, Jackson, Oakland and Wayne. 23 Patient Care 24 25 26 27 Behavioral Health 28 29 Embedded coinsurance maximum introduced for 2015 30 31 Quality Counts 32 Beginning Jan. 1, 2015, groups can add a new rider to You will know whether a member has an embedded 33 their benefits to include something new – an embedded coinsurance maximum by looking at the medical benefits 34 coinsurance maximum. description page on web‑DENIS. If the member has a 35 Pharmacy News coinsurance maximum, you will see “coinsurance maximum” 36 What is an embedded coinsurance maximum? listed along with the specific dollar amounts for that contract 37 Coinsurance is a percentage of the cost of a service that and the list of exclusions noted below. 38 39 the member is responsible for paying. A coinsurance Billing Bulletin Items that are exempt from the coinsurance maximum include: 40 maximum provides a maximum dollar amount that the 41 member will pay for coinsurance. Once the coinsurance • Deductible amounts • Services with a flat dollar 42 maximum is reached, the member will no longer pay 43 Referral Roundup • Diabetic supplies copayment coinsurance for the rest of the benefit year, with the 44 • Orthognathic surgery 45 exception of certain services that are exempt from the • Durable medical 46 coinsurance maximum (see list at right). The coinsurance equipment • Prosthetics and orthotics Index 47 maximum is considered to be “embedded” because • Elective abortion • Reduction mammoplasty 48 one member on a two-person or family contract cannot (if covered) 49 contribute more than the individual maximum amount. • Temporomandibular joint 50 BCNprovidernews • Infertility services dysfunction 51 NOVEMBER–DECEMBER 2014 The embedded coinsurance maximum will also count 52 toward the out‑of‑pocket maximum along with the • Male mastectomy • Weight reduction procedures Feedback deductible and all other cost-sharing. • Male sterilization network operations 7 1 2 3 Checking member eligibility and benefits is crucial 4 We’ve always stressed the importance of checking member eligibility and benefits every time you provide services. 5 6 With health care reform, checking eligibility and benefits is even more crucial because more members are purchasing their 7 health care coverage directly from the Blues or through the Health Insurance Marketplace. 8 Cover Story 9 These individuals will receive ID cards once they enroll, but their coverage will not be active until they pay their first month’s 10 premium and their effective date occurs. 11 12 Network Operations • Effective date – In some cases, these members will have their ID cards a month or two 13  before the effective date. If they try to use their cards before the effective date, they will not 14 have coverage. 15 16 BCN Advantage • Premium unpaid – If a member does not pay the first monthly premium, the coverage will 17 not become effective. If a member pays the first payment but later becomes delinquent, 18 19 coverage could cease. Note that there are special regulations regarding members with 20 Blue Cross Complete government subsidized premiums. 21 22 • Coverage changes – A member can sign up for coverage but later change 23 Patient Care that coverage. Individual members can change coverage for any reason during 24 the open enrollment period. This year, the open enrollment period runs from 25 Nov. 15, 2014 through Feb. 15, 2015. After that, members with a qualifying 26 27 event may still be able to change coverage. So a member may not keep Behavioral Health 28 coverage but could still present an ID card for services. 29 30 Always check your patients’ eligibility 31 Quality Counts 32 The bottom line is that possession of a Blues ID card does 33 not necessarily mean the member has coverage that is 34 currently in effect. While this has always been the case, you 35 Pharmacy News may find more situations where ID cards are presented for 36 coverage that is not in effect. Be aware that the Blues will 37 not reimburse claims for treatment that is not in effect at the 38 39 Billing Bulletin time of service. 40 41 As a reminder, there are three ways to check eligibility and 42 benefits: 43 Referral Roundup • Online using web‑DENIS 44 45 • By calling our automated phone system, PARS 46 (formerly CAREN) 47 Index 48 • By calling Provider Inquiry 49 50 BCNprovidernews For more information, open the BCN Provider 51 NOVEMBER–DECEMBER 2014 Resource Guide and click on Benefits and Eligibility. 52 Feedback network operations 8 1 2 How to tell if you’re providing services for a 3 4 5 BCN or Blue Cross member 6 7 You may remember that in 2014, all plans listed on the Marketplace carried the name “Blue Cross” whether they were 8 Cover Story actually a Blue Cross plan or a Blue Care Network plan. On occasion, this caused some confusion for members and 9 providers. Here’s a chart that shows the plan names for Blue Cross and BCN for 2015. You can check which plans 10 you accept by using the Find a Doctor feature on bcbsm.com. You should always check the name of the plan on the 11 member’s ID card and confirm that you accept that plan before providing services. 12 Network Operations 13 14  BCBSM Plans BCN Plans 15 Blue Cross® Premier Blue Cross® Select 16 BCN Advantage 17 Blue Cross® Metro Detroit EPO Blue Cross® Partnered 18 19 Blue Cross® Multi-State Plans Blue Cross® Preferred Blue Cross Complete 20 Blue Cross® Premier Value (Catastrophic) Plans Blue Cross® Metro Detroit HMO 21 22 23 • BCBSM plans have the word “Premier” or “EPO” or “Multi-State Plan” in their names. Patient Care 24 • BCN plans have the word “Select” or “Partnered,” or “Preferred” or “HMO” in their names. 25 26 27 Behavioral Health 28 29 30 31 Quality Counts 32 33 34 35 Pharmacy News 36 37 38 39 Billing Bulletin 40 41 42 43 Referral Roundup 44 45 46 47 Index 48 49 50 BCNprovidernews 51 NOVEMBER–DECEMBER 2014 52 Feedback network operations 9 1 2 3 4 The Blues make it easier for members to manage their own 5 6 health plan at bcbsm.com 7 8 Cover Story To help your Blues patients understand and better manage their health coverage, we encourage them to register at 9 bcbsm.com, so you and your staff can spend less time handling benefit questions and more time providing quality health 10 11 care. You may want to remind them too. 12 Network Operations 13  When members create an account at bcbsm.com and log in, 14 they have access to: 15 16 BCN Advantage 17 Personal snapshot of their plan: Your patients with Blues 18 coverage can go online and check out easy-to-understand charts 19 Blue Cross Complete that show deductible and coinsurance information, recent claims 20 activity and other important cost information that will help them 21 better understand what they may owe you after visiting your office. 22 23 They can access their claims information on-demand and retrieve Patient Care 24 Explanation of Benefits statements before they arrive in the mail. 25 26 Virtual ID card: Now, when members forget to bring their Blues 27 Behavioral Health ID cards to their appointments, they can easily log in to their account 28 at bcbsm.com through their mobile device and show their virtual 29 30 ID card to you as proof of coverage. Access to this great feature and 31 Quality Counts other plan information is available 24 hours a day, seven days week 32 with a mobile device. 33 34 Powerful doctor and hospital search: Members can find 35 Pharmacy News doctors or hospitals that accept their coverage with our Find a Doctor 36 37 feature at bcbsm.com. They can search by location, specialty, 38 extended office hours, languages spoken and more, and even read 39 Billing Bulletin reviews from other patients and leave reviews of their own. Plus, 40 we’ve made it easy for them to compare quality for more than 400 41 health services across the country. Our Find a Doctor has the ability 42 43 Referral Roundup to bring you additional patients more suited to your specialty. 44 45 If you would like more information about the benefits of our site for 46 your Blues patients, contact your provider consultant. 47 Index 48 49 50 BCNprovidernews 51 NOVEMBER–DECEMBER 2014 52 Feedback network operations 10 1 2 3 4 CAREN has been replaced by improved IVR system 5 6 called PARS 7 8 Cover Story A new and enhanced interactive voice response system Updated PARS “Navigating with Ease” brochures are 9 called the Provider Automated Response System, also available on web‑DENIS. . To access them: 10 11 known as PARS, has replaced CAREN. • From the web‑DENIS homepage, click on 12 Network Operations 13 We’ve transitioned to PARS in phases: BCBSM Provider Publications and Resources.  14 • On Sept. 15, 2014, the vision and hearing lines of • Click on Newsletters & Resources. 15 business moved to PARS. • Click on Provider Training. 16 BCN Advantage 17 • On Sept. 23, 2014, professional, facility, BCN and • Go to the “Job Aids, 18 Medicare Advantage moved to PARS. FAQs, Tips, Q&A 19 documents, brochures 20 Blue Cross Complete • The Federal Employee Program® will move to PARS 21 and flyers” section during the first quarter of 2015. We’ll notify you of the 22 date as we get closer to the transition. of the page. 23 Patient Care 24 25 All phone numbers will remain the same and the format 26 of the calls will be similar, although you will hear a new 27 Behavioral Health “voice.” And some categories will have different names; 28 for example, OB/GYN will become “Women’s Health.” 29 30 PARS features many enhancements to improve your 31 Quality Counts experience, including: 32 33 • Speech recognition 34 35 Pharmacy News • Improved process for collecting and associating email 36 addresses with your fax number. If you already set up 37 your email address, it will carry over to PARS. 38 39 Billing Bulletin • An improved format for fax and email documents 40 (Please note that BCN does not have the fax and 41 email options.) 42 43 Referral Roundup • Multiple Inquiry Routing Selection — If you request 44 a transfer after multiple inquiries on the IVR, you can 45 select the specific contract you want to transfer to for 46 accurate routing. 47 Index 48 49 50 BCNprovidernews If you have any questions or feedback about PARS, 51 NOVEMBER–DECEMBER 2014 contact us at [email protected]. 52 Feedback network operations 11 1 2 Reminder: Members in Blue Elect Plus plan do not 3 4 need referrals 5 6 Providers do not need to give referrals to Blue Care Care Management requirements 7 SM 8 Cover Story Network members enrolled in the Blue Elect Plus The requirements for plan notification and benefit and 9 product. Members covered by this product select a primary clinical review apply whether services are performed 10 care physician and may choose to self-refer to any in- by in-network or out‑of‑network providers. Please refer 11 network or out-of network Michigan provider. Members to the Blue Care Network Referral and Clinical Review 12 Network Operations 13 have the lowest out‑of‑pocket costs when their care is program for guidance.  provided by their primary care physician or by another 14 In addition, the following requirements may apply: 15 provider in the BCN network. 16 BCN Advantage • If a specific service is not available from an 17 If a member self-refers to a provider outside the BCN 18 network, but within Michigan, the member is responsible in‑network provider and the member wishes to see an out‑of‑network provider, the provider must 19 for a higher deductible and coinsurance and for any amount 20 Blue Cross Complete charged by the nonparticipating provider that exceeds the request clinical review and receive approval from 21 BCN-approved amount. BCN Care Management for the member to receive 22 the in‑network benefit. 23 24 Patient Care Members may also see any primary care physician in • If a member wishes to see an out‑of‑network provider BCN’s network, but will pay a specialist copayment when 25 for a service that normally requires clinical review, 26 seeing a PCP who is not affiliated with the primary care the out‑of‑network provider must contact Care 27 Behavioral Health physician they select. Management to obtain clinical review prior to obtaining 28 the service. 29 The member’s provider information card gives an overview 30 of the billing and care management requirements for • Clinical review is required for members to see a 31 Quality Counts participating and nonparticipating providers. Providers neurosurgeon or orthopedic surgeon as part of the 32 should place a copy of both the member’s ID card and the Spine Care Referral Program. 33 provider information card in the member’s file. You can 34 35 access the provider information card on the web‑DENIS Plan notification or clinical review is also required for the Pharmacy News following services: 36 BCN Products page. 37 • Maternity: up to 48 hours following routine delivery or 38 Tips: 96 hours following C-section 39 Billing Bulletin 40 • BCN requires benefit or clinical review in advance, • Chiropractic services 41 regardless of network affiliation. • Spine Care Referral Program — Clinical review is 42 43 Referral Roundup • Check member benefits on web‑DENIS under required for all members for the initial visit to a spine 44 Subscriber Info. care specialist and for office visits and procedures. 45 46 • Check clinical review requirements on web‑DENIS in If you have questions, call BCN Provider Inquiry: 47 Index BCN Provider Publications and Resources on the Care 48 Management and Referrals page or on our e-referral 1‑800‑255-1690 49 website at ereferrals.bcbsm.com by clicking on 50 BCNprovidernews Clinical Review & Criteria Charts. 51 NOVEMBER–DECEMBER 2014 52 Feedback network operations 12 1 2 3 Reminder: 4 5 Healthy Blue Living members who complete 6 7 their requirements move to the enhanced benefit level 8 Cover Story 9 retroactively 10 11 SM 12 Network Operations We told you in the Nov.-Dec. 2013 issue that Blue Care Network changed its Healthy Blue Living products as of Jan. 1, 2014, to comply with the Affordable Care Act. 13  14 As a reminder to our providers, renewing members who began the plan year at the standard level and achieve the 15 enhanced level during the qualification period are being retroactively moved to the enhanced level effective the first day 16 BCN Advantage 17 of their plan year. 18 19 Previously, these members would have moved to the enhanced benefit level effective the 91st day of the plan year. Blue Cross Complete 20 You should be aware that BCN has continued to process claims for members who moved to an enhanced benefit level 21 22 after the first 90 days in the plan. That means you may be responsible for returning money to some members because 23 their deductibles, copayments and coinsurance have been retroactively adjusted. Patient Care 24 25 26 27 Behavioral Health 28 29 30 Blue Care Network provides office staff incentives 31 Quality Counts 32 for tobacco cessation campaign 33 34 Blue Care Network is offering incentives for members, office staff and providers to distribute information to patients 35 Pharmacy News about tobacco cessation resources. 36 37 The incentives are part of our healthy lifestyle campaign aimed at decreasing the percentage of our members who 38 smoke and use tobacco. 39 Billing Bulletin 40 Provider office staffs have a chance to win $500 in gift cards just by handing out our Quit Guide and Tobacco Use 41 surveys. Every month, Blue Care Network will choose a member from the completed surveys to receive the $250 42 43 Referral Roundup gift card. When the member verifies the PCP office they visited through the survey, the staff members at that office automatically win $500 in gift cards. See the FAQs PDF below for details about the contest. 44 45 Information about the smoking cessation program can be found in the Sept.-Oct. issue, Page 1. 46 47 Index 48 49 50 BCNprovidernews Office staff contest FAQs PDF 51 NOVEMBER–DECEMBER 2014 52 Feedback network operations 13 1 2 3 BCN offices closed for holiday 4 5 Blue Care Network offices will be closed on Nov. 27 and 28 for the Thanksgiving holiday and 6 on Dec. 24 – 26 for the Christmas holidays. 7 8 Cover Story When Blue Care Network offices are closed, call the BCN The after‑hours care manager 9 After‑Hours Care Manager Hot Line at 1‑800‑851-3904 and phone number can also be 10 11 listen to the prompts for help with: used after normal business hours to discuss urgent or 12 Network Operations • Determining alternatives to inpatient admissions and triage emergency situations with a plan medical director. 13 14  to alternative care settings Do not use this number to notify BCN of an admission for 15 • Arranging for emergent home health care, home infusion commercial or BCN AdvantageSM HMO‑POS members. 16 BCN Advantage services and in-home pain control Admission notification for these members can be done by 17 e-referral, fax or phone the next business day. 18 • Arranging for durable medical equipment 19 Blue Cross Complete • Emergent discharge planning coordination and authorization When an admission occurs through the emergency 20 room, contact the primary care physician to discuss the 21 • Expediting appeals of utilization management decisions 22 member’s medical condition and coordinate care before 23 admitting the member. Patient Care Note: Precertifications for admissions to skilled nursing 24 25 facilities and other types of transitional care services should 26 be called in during normal business hours unless there are 27 Behavioral Health extenuating circumstances that require emergency admission. 28 29 30 31 Quality Counts 32 33 34 BCN releases videos to improve member experience 35 Pharmacy News 36 Blue Care Network has developed our last educational video for the year to help improve members’ experiences. Earlier in 37 the year, we produced Getting Started and About Your Primary Care Physician which we highlighted in the May‑June 38 issue. Two additional videos were featured in our September-October issue: Healthy Blue LivingTM and Provider Networks. 39 Billing Bulletin 40 The newest video, Pharmacy, stars BCN employees and gives members important information about how our pharmacy 41 programs work and how to get the most from their pharmacy benefit. 42 43 Referral Roundup The video is located on bcbsm.com 44 and will also be available on the 45 46 BCBSM YouTube channel. We will 47 Index be sharing these videos on BCN’s 48 Facebook page and through email 49 alerts to members. 50 BCNprovidernews 51 NOVEMBER–DECEMBER 2014 Feel free to share the links with your 52 BCN patients. Feedback network operations 14 1 2 3 4 Making changes or updates 5 Don’t forget to 6 to facilities 7 reattest with CAQH 8 Cover Story 9 If you are making changes to your primary or additional every 120 days 10 locations or you need to add an additional location, the 11 following credentialing elements and documentation ® 12 Network Operations Did you know that if you don’t reattest with CAQH must be submitted along with your change request: every 120 days, you won’t be included in our 13 14  provider directories, including our “Find a Doctor” • Completed and signed Facility or Allied Change Form 15 search tool? 16 BCN Advantage • Medical director (M.D., D.O. or physical therapist 17 for occupational physical therapy) with a valid state That’s one of the main reasons it’s so important to 18 license and in good standing take the time to perform this task. 19 20 Blue Cross Complete • Valid facility state license Here are some other reasons to reattest with 21 CAQH, a nonprofit alliance of health plans and trade 22 • Valid pharmacy license (for ambulatory infusion associations focused on simplifying health care 23 Patient Care centers) administration: 24 25 • Both general and professional liability malpractice • To ensure that your affiliation with the Blues 26 insurance isn’t interrupted 27 Behavioral Health 28 • Accreditation or a current Centers for Medicare • To update your CAQH information if you change 29 & Medicaid Services certification your practice location 30 31 • CLIA Certificate, if applicable Quality Counts • To ensure that claims payment isn’t interrupted 32 33 Changes can be made at bcbsm.com. Blue Cross Blue Shield of Michigan uses CAQH to 34 gather and coordinate our practitioner credentialing 35 36 Pharmacy News Reminder: Upon recredentialing, completion of the information. application is a BCBSM/BCN program requirement. All 37 All health care practitioners, including hospital- 38 requested documents along with the recredentialing 39 Billing Bulletin application must be received within 30 days of receipt of based health care providers and nurse practitioners, 40 the request. need to be registered with CAQH. 41 42 For questions about recredentialing only, please email If you have any questions about CAQH, call the 43 Referral Roundup [email protected]. CAQH help desk at 1-888-599-1771 or go to 44 CAQH.org. For information about the credentialing 45 process, contact your provider consultant. 46 47 Index 48 49 50 BCNprovidernews 51 NOVEMBER–DECEMBER 2014 52 Feedback network operations 15 1 2 3 New physical therapy laws won’t change Blues’ policy 4 5 Michigan legislation related to direct access to physical Here’s additional background about the laws: 6 therapy was signed into law in July 2014. Public Act • PA 260 will take effect on Jan. 1, 2015. Treatment 7 260 allows physical therapists to treat patients without 8 Cover Story allowed under this act is covered for 21 days or up to 9 a prescription from a licensed health care professional. 10 treatments, whichever occurs first. Treatment is also 10 But Public Acts 261-264 permit insurers to cover only covered when the patient seeks therapy to prevent injury 11 prescribed physical therapy services. or promote fitness. 12 Network Operations 13  As a result, the Blues will continue to adhere to our current • PA 261-264, which took effect on July 1, 2014, overrides 14 medical policy and existing processes by requiring a PA 260 by allowing an insurer to require a prescription for 15 prescription for physical therapy services. physical therapy services to be covered. 16 BCN Advantage 17 18 19 Blue Cross Complete 20 Private duty nursing is a covered benefit for State 21 22 of Michigan employees 23 Patient Care 24 Private duty nursing is a covered benefit for State of Michigan employees. To be eligible for private duty nursing, the 25 26 member’s care must be individualized, required on a 24-hour basis and be more intense than services typically provided 27 Behavioral Health under the home health care benefit. 28 29 The goal of private duty nursing is to facilitate the transition of care, helping the family and caregivers to be as competent 30 and independent as possible in the care of the patient. It is expected the family and caregivers will provide a minimum of 31 Quality Counts eight hours of care each day. 32 33 Private duty nursing requires clinical review and services must be ordered by a licensed physician. Beginning Oct. 1, 2014, 34 private duty nursing care must also be preauthorized by BCN. 35 Pharmacy News 36 37 38 39 Billing Bulletin Blue Care Network pays the lesser of our rate or your 40 41 submitted charges for PT, OT, ST therapy 42 43 Referral Roundup Blue Care Network is changing the way we pay for physical, occupational and speech therapy. Starting Oct. 1, 44 2014 for BCN commercial and Jan. 1, 2015 for BCN AdvantageSM members, we will pay the lesser of our rate or 45 your submitted charges. While this “lesser of” payment policy is already specified in provider contracts, BCN had 46 47 Index previously paid our rate even when the provider had billed at a lower rate for these services. 48 The change applies to all providers who are reimbursed following the BCN professional fee schedule and the BCN 49 50 BCNprovidernews Advantage physician fee schedule. 51 52 NOVEMBER–DECEMBER 2014 This change does not apply to PT, OT or ST for autism spectrum diagnoses. Feedback network operations 16 1 2 Enrollment for BCBSM and BCN’s new freestanding 3 4 5 radiology center networks began Oct. 1 6 7 8 As part of the enrollment process, Cover Story Blue Care Network and Blue Cross Blue Shield of Michigan are establishing 9 freestanding radiology center networks that will create the capability to Blue Cross providers will be required 10 uniquely recognize and reimburse freestanding diagnostic imaging services to enroll in the AIM Specialty 11 providers. BCN and BCBSM members will have access to the new Health OptiNet assessment tool. 12 Network Operations networks, beginning Jan. 1, 2015. OptiNet collects information on the 13  provider’s imaging equipment, staffing 14 15 Eligible freestanding radiology centers, including those owned by credentials, and safety and quality hospitals, are encouraged to begin applying for enrollment in the BCN 16 BCN Advantage assurance programs. For information, 17 Freestanding Radiology Centers and BCBSM Traditional networks on see the October issue of The Record. 18 Oct. 1, 2014. All freestanding radiology centers participating in the BCBSM 19 Traditional network will be considered in‑network for PPO members, and 20 Blue Cross Complete out‑of‑network sanctions will be waived. 21 22 • Participating freestanding radiology centers will be included in provider 23 Patient Care directories at bcbsm.com and on the Blue Cross and Blue Shield 24 Association® website. 25 26 • Provider‑specific freestanding radiology center cost information, 27 Behavioral Health by procedure, will be available using the provider search function 28 on bcbsm.com. 29 30 • Members will be able to search for freestanding radiology 31 Quality Counts centers and their cost information in the provider directories. 32 • Freestanding radiology centers will be reimbursed for all 33 34 diagnostic imaging services that are approved by the plan and 35 Pharmacy News are covered benefits using the applicable plan’s professional 36 fee schedule. 37 38 • Diagnostic imaging services performed in freestanding 39 Billing Bulletin radiology centers in the BCBSM Traditional network 40 will be subject to the current Radiology Management 41 Program preauthorization and privileging requirements 42 for members whose groups have the Radiology 43 Referral Roundup 44 Management Program. 45 • Freestanding radiology centers participating in the BCN 46 network will need to follow requirements specified in 47 Index 48 the Blue Care Network Referral and Clinical Review 49 Program for standard radiology services. In addition, 50 BCNprovidernews BCN freestanding radiology centers also will be subject 51 NOVEMBER–DECEMBER 2014 to high‑tech radiology services preauthorization 52 requirements administered by CareCore National. Feedback BCN advantage 17 1 2 3 BCN Advantage open enrollment period has begun 4 5 6 The Centers for Medicare & Medicaid Services annual enrollment period for Medicare Advantage began on Oct. 15 and 7 8 Cover Story runs through Dec. 7, 2014 for Jan. 1, 2015 coverage. 9 10 SM Please be aware that members may be calling your office to see if you participate in BCN Advantage . 11 12 Network Operations We have made changes to some of our plans for 2015. We have also introduced a new plan, BCN Advantage 13 14 ConnectedCare HMO, and have discontinued BCN Advantage Local. Members who were in BCN Advantage Local will 15 be transitioned to ConnectedCare. (See articles on Page 20 for details.) 16 BCN Advantage 17  18 19 20 Blue Cross Complete 21 22 23 Patient Care 24 25 26 27 Behavioral Health 28 29 30 31 Quality Counts 32 33 34 35 Pharmacy News 36 37 38 39 Billing Bulletin 40 41 42 43 Referral Roundup 44 45 46 47 Index 48 49 50 BCNprovidernews 51 NOVEMBER–DECEMBER 2014 52 Feedback BCN advantage 18 1 2 BCN Advantage benefit changes for 2015 3 4 BCN AdvantageSM is offering six plans for 2015, including 5 ConnectedCare, a new plan that replaces BCN Advantage My Choice Wellness HMO 6 local. In addition, we are making some changes to 7 This HMO will continue to be offered in Kent, Muskegon 8 deductibles, copayments and supplemental benefits that Cover Story and Oceana counties. The network includes Mercy- 9 providers should be aware of. affiliated providers and network hospitals. There is no 10 The plans for 2015 are: copayment for office visits and no deductible. 11 • Elements 12 Network Operations MyChoice is a provider-specific network. The following 13 • Basic Mercy Health-affiliated provider network hospitals are 14 • Classic included: 15 • Prestige 16 BCN Advantage • My Choice Wellness HMO • Mercy Health — Mercy Campus, Muskegon 17  • BCN Advantage ConnectedCare HMO – BCN Local • Mercy Health — Hackley Campus, Muskegon 18 members will be transitioned to the new ConnectedCare • Mercy Health — Lakeshore Campus, Shelby/Hart 19 • Mercy Health — Saint Mary’s Campus, Grand Rapids 20 Blue Cross Complete plan unless they choose another plan. See Page 20 for 21 details about ConnectedCare. It includes the following benefits: 22 23 Most of the plans have certain benefits in common: • MTM Transportation — 36 round trip non-emergency Patient Care transportation 24 • Members in any BCN Advantage plan can purchase 25 • SilverSneakers fitness benefits optional supplemental dental/vision/hearing benefits. 26 • Worldwide urgent care and emergency benefits The hearing benefit was removed from base coverage 27 • Preventive dental 28 Behavioral Health but added for 2015 to the optional supplemental buy-up. • Routine eye exams 29 It includes non-Medicare covered hearing benefits. 30 • All plans include MTM Transportation benefit. The benefit For plan details, benefit specifics, premiums and payment 31 Quality Counts was added to the Basic plan for 2015. tables, please refer to the BCN Advantage Web pages. 32 33 • All plans include bathroom safety items through Northwood 34 (see sidebar). Bathroom safety items 35 Pharmacy News • The SilverSneakers fitness benefit is included is all plans, All BCN Advantage plans include non-Medicare covered 36 bathroom safety items. The in-network benefit for 37 except for Elements. 38 bathroom safety items is 50 percent coinsurance for up to Here are some of the medical benefit changes to the plans: 39 Billing Bulletin $100 combined annual maximum. 40 • Although the copay amount for inpatient care is not Members can obtain one or a combination of five safety 41 changing, in 2015 members will be assessed the copay for 42 items. The items include 43 Referral Roundup days 1-6 instead of 1-5. Cardio and pulmonary rehabilitation • Shower grab bar has moved from specialist to therapy copayments, which 44 • Bath tub grab bar 45 results in a lower copayment for these services • Bench 46 Index • Copayments are increasing for skilled nursing benefits. • Commode rails 47 For days 21 to 100, copayments have increased from 48 • Elevated toilet seat 49 $130 to $150 A physician’s order is required for the benefit. Safety 50 BCNprovidernews • The copayment for ambulance services are increasing to bars can only be purchased through our durable medical 51 52 NOVEMBER–DECEMBER 2014 $100 for Classic and Prestige equipment supplier, Northwood. The benefit does not include installation. Feedback Please see BCNA benefit changes, continued on Page 19 BCN advantage 19 1 2 BCNA benefit changes, continued from Page 18 3 4 5 Elements and Basic plans 6 • We removed $25 copayment for days 1 to 20 for skilled Prescription drug benefits 7 8 Cover Story nursing benefits for both plans. There are several changes in prescription drugs benefits 9 that will affect individual BCN AdvantageSM members. • We added a transportation benefit through MTM for 10 Basic Plan (36 round trips). 11 We encourage providers to check members’ drug lists 12 Network Operations • Members who enroll in Basic will receive a Part B before prescribing. Some drugs were removed from 13 premium credit of $3.50, which will be reflected in their our drug lists. Others may require step therapy or prior 14 Social Security checks. authorization for new prescriptions. 15 16 BCN Advantage Classic and Prestige Transition period for members 17  Physicians can use the 90-day transition period for 18 • The embedded vision benefit no longer has a $10 patients whose formularies are changing. BCN allows 19 copayment for eyeglasses (lenses and frames) and 20 Blue Cross Complete members to obtain one 34-day fill for prescriptions that contact lenses. 21 now require prior authorization, step therapy or quantity 22 Part D accumulators and coverage gap changing limits or that are non-formulary. Members or physicians 23 Patient Care • The initial coverage limit or threshold before members can request formulary exceptions during this 90-day 24 period or switch to another formulary medication so the 25 enter into the Part D gap, otherwise known as the donut 26 hole, is changing from $2,850 to $2,960. The True-Out patient’s drug therapy is not interrupted. 27 Behavioral Health Of-Pocket threshold to be reached before members exit 28 the Part D gap and enter the Catastrophic phase of the 29 Part D benefit, is changing from $4,550 to $4,700 30 31 Quality Counts 32 33 34 35 Pharmacy News BCN Advantage has expanded its service area 36 37 for Individual and Group plans 38 39 Billing Bulletin We are expanding the service area for BCN Advantage Individual plans 40 for 2015. Effective Jan. 1, 2015, BCN Advantage plans will be offered in BCN Advantage 41 Service Area Map PDF 42 six additional counties and one partial county (St. Joseph.) The six counties 43 Referral Roundup are Alpena, Benzie, Charlevoix, Emmett, Leelanau and Lenawee. 44 45 St. Joseph County includes only the following Zip codes: 49011, 49030, 46 49052, 49072, 49093 and 49097. BCN Advantage ConnectedCare 47 Index Service Area Map PDF 48 In addition, the Centers for Medicare & Medicaid Services has approved 49 an expansion of our group service area to the entire Upper Peninsula. 50 BCNprovidernews 51 BCN Advantage currently has almost 62,000 members enrolled in 59 NOVEMBER–DECEMBER 2014 BCN Advantage MyChoice 52 counties throughout Michigan. As of 2015, BCN Advantage will service Service Area Map PDF Feedback members in 66 counties, including one partial county (St. Joseph). BCN advantage 20 1 2 3 BCN Advantage introduces ConnectedCare HMO local network 4 5 BCN AdvantageSM is introducing a new plan for 2015 Members must select a ConnectedCare primary care 6 enrollment, called BCN Advantage ConnectedCare HMO. physician. Any referrals for services should remain within 7 ConnectedCare is an individual Medicare Advantage the local ConnectedCare network whenever possible. 8 Cover Story local HMO offered in seven counties in southeast Standard BCN Advantage referral and clinical review 9 10 Michigan and Kalamazoo. The counties include Genesee, program requirements apply as long as the provider is in the 11 Kalamazoo, Livingston, Macomb, Oakland, St. Clair, ConnectedCare network. Clinical review is required for any 12 Network Operations Washtenaw and Wayne. Members must reside in service provided outside of the ConnectedCare network, 13 these counties for at least six months of the year. even if the provider is part of the larger BCN Advantage 14 Open enrollment began in October for a January 2015 network. Exceptions to this requirement include urgent and 15 16 BCN Advantage effective date. emergent care, ambulance services, out‑of‑area dialysis and 17 Part B vaccine services; normal copayments apply.  BCN Advantage is closing BCN Local, a local network 18 19 HMO for Wayne County members. Current BCN Local Providers can check their network status at 20 Blue Cross Complete members will be automatically enrolled in ConnectedCare bcbsm.com/find-a-doctor. The provider page lists the 21 unless they choose another plan. plans accepted by the provider. Contact your provider 22 consultant if you need assistance. 23 Patient Care ConnectedCare is a partnership backed by local doctors 24 and hospitals affiliated with Oakwood ACO — a partnership Members can find providers on bcbsm.com. 25 between Oakwood Healthcare and affiliated, private and • Go to Provider Search 26 employed physicians — and Together Health Network, 27 Behavioral Health • Click on BCN Advantage 28 an integrated group of physicians in partnership with • Click on ConnectedCare HMO 29 Ascension Health Michigan and CHE Trinity Health, two 30 of the largest health systems in Michigan. The product Remember to always check member eligibility and benefits 31 Quality Counts includes more than 5,000 providers and 20 hospitals before providing services. Local networks do not permit 32 across the state. referrals outside of the specific network. 33 34 35 Pharmacy News BCN www.bcbsm.com/bcn a 36 AdvantageSM 37 HMO 38 ConnectedCare 39 Billing Bulletin 40 41 Enrollee Name RxBIN: Bl u e Care Network of MI Customer Service: 800-450-3680 610014 A nonprofit corporation and independent licensee 42 FIRST M LASTNAME JR of the Blue Cross and Blue Shield Association TTY/TDD: 711 RxPCN: 43 Enrollee ID MEDDPRIME Providers in Michigan, le hospital and If you suspect fraud: 888-650-8136 Referral Roundup med ica l cla ims w ith : 44 XYK888888888 RxGrp: Mental health/substance BCNRXPD BCN Advantage abuse treatment: 800-431-1059 45 Issuer (80840) Rx ID: P.O. Box 68753 46 9101000021 XXXXXXXXXXX Grand Rapids, MI 49516-8753 Prov iders Only : Provider Services: 800-255-1690 47 Group Number CMS Plan P h a rma cy cla ims, le w ith P B M: Medical Authorizations: 800-392-2512 Index Rx Authorizations: 800-437-3803 48 00277566 H5883 007 ATTN: Medicare Part D Pharmacy Services: 800-922-1557 P.O. Box 2858 49 Clinton, IA 52733-2858 Use of this card is subject to terms of applicable contracts, conditions and user 50 MEDICARE Medicare limiting charges apply. agreements. Misuse may result in prosecution. BCNprovidernews ADVANTAGE|HMO 51 NOVEMBER–DECEMBER 2014 52 Feedback Please see ConnectedCare HMO, continued on Page 21 BCN advantage 21 1 2 ConnectedCare HMO, continued from Page 20 3 ConnectedCare Participating Ascension, 4 Trinity and Oakwood Hospitals 5 ConnectedCare does not have the BlueCard travel benefit. 6 However, emergency, urgent care, ambulance and dialysis 7 Together Health Hospitals 8 Cover Story services are covered worldwide. There are no other 9 services provided outside of Michigan as a benefit for • Saint Joseph Mercy Health System 10 ConnectedCare. 11 -- St. Joseph Mercy – Ann Arbor 12 Network Operations ConnectedCare has no medical or pharmacy deductibles, -- St. Joseph Mercy Chelsea 13 $0 copay for primary care visits, and includes Part D 14 coverage. Benefits also include extras such as routine -- St. Joseph Mercy – Livingston (Howell) 15 vision exams, preventive dental, non-emergency -- St. Joseph Mercy – Oakland (Pontiac) 16 BCN Advantage 17 transportation, SilverSneakers® fitness benefit and  -- St. Joseph Mercy – Port Huron 18 coverage for bathroom safety bars. 19 -- St. Mary Mercy Hospital – Livonia 20 Blue Cross Complete Some of the plan’s features include the following: 21 • Borgess Health • No charge for primary care office visits 22 -- Borgess Medical Center (Kalamazoo) 23 Patient Care • No deductibles 24 -- Borgess Pipp Hospital (Plainwell) 25 • Low out‑of‑pocket costs 26 -- Borgess Lee Memorial Hospital (Dowagiac) • Prescription drug coverage with no deductible 27 Behavioral Health 28 • Eye exams • Genesys Regional Medical Center (Grand Blanc) 29 • Preventive dental 30 • St. John Providence Health System 31 Quality Counts • Transportation to medical appointments (36 round trips) -- Providence Hospital (Southfield) 32 • SilverSneakers fitness membership 33 -- Providence Park Hospital (Novi) 34 • Ascension, Trinity and Oakwood provider network -- St. John Hospital and Medical Center (Detroit) 35 Pharmacy News 36 • More than 20 hospitals and 5,000 physicians -- St. John Macomb – Oakland Hospital Macomb Center 37 (see sidebar) (Warren) 38 39 Billing Bulletin ConnectedCare features prescription drug coverage -- St. John Macomb – Oakland Hospital Oakland Center 40 with no deductible through network pharmacies and a (Madison Heights) 41 90-day supply of most prescription drugs through retail -- St. John River District Hospital (East China) 42 43 Referral Roundup network pharmacies or mail order from Walgreens or Express Scripts. 44 Oakwood Health System 45 46 -- Oakwood Annapolis Hospital Index 47 -- Oakwood Heritage Hospital 48 49 -- Oakwood Hospital and Medical Center 50 BCNprovidernews -- Oakwood Southshore Medical Center 51 NOVEMBER–DECEMBER 2014 52 Feedback BCN advantage 22 1 2 Reminder: Conduct patient visits by year-end to close 3 4 diagnosis gaps for 2014 incentive program 5 6 7 Blue Cross Blue Shield of Michigan and Blue Care Network The suspected or historic condition must be addressed 8 Cover Story are nearing the conclusion of this year’s Diagnosis Closure during a patient visit and you must confirm that the 9 Incentive Program for primary care physicians who close patient no longer has the condition or that the suspected 10 diagnosis and treatment opportunity gaps for their Blues condition does not exist. 11 Medicare Advantage patients. Here are the details you 12 Network Operations All the diagnosis gaps included in the 2014 Diagnosis 13 need to know. Closure Incentive for Jan. 1 through Sept. 30, 2014, 14 Be sure to see your Blues Medicare Advantage patients are listed on Health e‑BlueSM under Panel – Diagnosis 15 before the end of the year to document and close diagnosis Evaluation. To earn incentives, physicians must close all 16 BCN Advantage 17  and treatment opportunity gaps. It’s important that all the diagnosis gaps (identified through Sept. 30, 2014) 18 member conditions are addressed each year during an office that exist for a patient through a face‑to‑face visit before 19 Blue Cross Complete visit and that diagnosis code data is accurately documented the end of 2014. Following a face-to-face visit, you can 20 and reported, following MEAT (manage, evaluate, assess also confirm that the patient does not have the condition, 21 and treat) guidelines to support medical necessity. if applicable. 22 23 Patient Care Information about gap closures should be submitted via Diagnosis gaps will continue to appear on Health e-Blue 24 Health e‑BlueSM under Panel – Diagnosis Closure and from Oct. 1 through Dec. 31, 2014. While we’ll continue 25 26 Treatment Opportunities by Condition/Measure Panel to display new gaps, physicians are responsible for closing 27 Behavioral Health by Jan. 22, 2015. You may also submit a claim as part of diagnosis gaps identified prior to Oct. 1 for purposes of 28 your documentation. In addition, if you received a paper earning an incentive. 29 Member Diagnosis Closure and Treatment Opportunities 30 More information is available in the Resources section of report in the mail, you should fax it to 1‑866‑707-4723. 31 Quality Counts Health e-Blue; select 2014 Diagnosis Closure Incentive 32 Be sure that you are closing a diagnosis gap only if you Program. An FAQ and fact sheet can also be found on 33 have conducted an office visit and the patient no longer web‑DENIS in the Newsletters and Resources section by 34 has the suspected (or historic) condition. A gap cannot be clicking on Medicare Advantage resources. 35 Pharmacy News 36 closed because you are not actively treating the condition. 37 38 Diagnosis and treatment opportunity closures must be submitted to the Blues by the following dates: 39 Billing Bulletin 40 Method Deadline 41 Claim submission Received by Feb. 27, 2015 42 43 Referral Roundup Health e-Blue Entered by Jan. 22, 2015 44 Paper Member Diagnosis Evaluation and Treatment Opportunities report Faxed or postmarked by Jan. 30, 2015 45 46 (for BCBSM out‑of‑state physicians and in-state physicians without access 47 Index to Health e-Blue) 48 Paper medical record (for BCBSM physicians) 49 50 -- Diagnosis closure submission Faxed or postmarked by Jan. 30, 2015 BCNprovidernews 51 NOVEMBER–DECEMBER 2014 -- Treatment opportunities submission Faxed or postmarked by Jan. 15, 2015 52 Feedback Please see Diagnosis gaps, continued on Page 23 BCN advantage 23 1 2 Diagnosis gaps, continued from Page 22 3 4 If you don’t have access to Health e‑Blue, go to Important note about closing 5 6 bcbsm.com, click on Providers; then click on Provider diagnosis gaps 7 Secured services and then click on Health-e-Blue to When using Health e-Blue’s Diagnosis Evaluation 8 Cover Story sign up. If you have questions, contact your provider panel or other methods to indicate that a diagnosis 9 consultant. 10 gap is closed because the condition does not exist, 11 Physicians who close 100 percent of all identified gaps for be sure that you are closing a diagnosis gap only 12 Network Operations each attributed patient will receive $100 per patient. Your if you have conducted an office visit and the patient 13 incentive payment will be mailed to you by the end of third no longer has the suspected (or historic) condition. 14 A gap cannot be closed solely for the reason that 15 quarter 2015. 16 BCN Advantage you are not actively treating the condition. The 17 New information about the Diagnosis Closure Incentive  suspected or historic condition must be addressed 18 program will be announced next year. In the meantime, during a patient visit and you must confirm that 19 physicians are encouraged to continue to check Health 20 Blue Cross Complete the patient no longer has the condition or that the e-Blue for patient conditions, schedule face-to-face office suspected condition does not exist. 21 visits and close historical or suspected patient diagnosis 22 and treatment opportunity gaps in the coming year. 23 Patient Care 24 25 26 27 Behavioral Health 28 29 BCN and BCBSM offer $200 incentive for each 30 31 Quality Counts 32 Medicare Advantage member with diabetes and 33 34 hypertension started on an ACEI or ARB 35 Pharmacy News 36 The Blues are offering a $200 incentive to BCN AdvantageSM The benefits of ACEI/ARB therapy in diabetics include: 37 38 primary care physicians and BCBSM Medicare Plus Blue • Inhibited renal function decline SM 39 Billing Bulletin PPO prescribing physicians for each member with diabetes and hypertension who starts on treatment with an ACEI • Decreased cardiovascular risk 40 41 or ARB between Sept. 24, 2014, and Dec. 31, 2014. The • Decreased mortality 42 member must have one new pharmacy claim for an ACEI • Decreased microvascular diabetic complications 43 Referral Roundup or ARB within the designated time frame to qualify for the 44 incentive. Payments will be made in the first quarter of 2015. While ACEI/ARBs may not be appropriate for some 45 patients due to adverse effects, most side effects can be 46 Blue Care Network of Michigan, Blue Cross Blue Shield 47 Index managed using an alternative medication within one of the 48 of Michigan and the Centers for Medicare & Medicaid drug classes, dose reduction, or close monitoring during Services endorse angiotensin converting enzyme inhibitor 49 the initiation of therapy. Talk to your patients about the risks 50 BCNprovidernews and angiotensin receptor blocker therapy as a best practice versus benefits for each individual to determine if an ACEI 51 in treating patients with diabetes and hypertension. NOVEMBER–DECEMBER 2014 or ARB is best for them. 52 CMS considers this therapy so important that it monitors Feedback adherence among Medicare Advantage patients. BCN advantage 24 1 2 Blue Care Network supports physicians with cholesterol 3 4 management efforts 5 6 7 We’re well into the third year of our Chronic Care We recognize that our physicians and their staffs are the 8 Cover Story Improvement program. The program helps to prevent first line of defense in the battle against high cholesterol 9 cardiovascular disease in BCN AdvantageSM members, in our members. We’re committed to supporting you in 10 emphasizes member self-management strategies and your efforts to manage high cholesterol levels and prevent 11 12 Network Operations partnership with physicians. Our program focuses on the cardiovascular disease in our members.Here are a few 13 ABCS, the clinical interventions championed by the CMS tools from the American Heart Association website that 14 Million Hearts™ Initiative. you can download and share with your patients who are 15 working on cholesterol management: 16 BCN Advantage The Million Hearts ABCS are: 17 • Heart360® is an online tool which helps patients track  • Aspirin use 18 and manage heart health and provides helpful advice and 19 Blue Cross Complete • Blood pressure control information. 20 • Medicine Chart is a one-page tool that that patients 21 • Cholesterol management 22 can use to record their medications. • Smoking cessation 23 Patient Care • How can I monitor my cholesterol, blood pressure and 24 In this article, we’ll address cholesterol management. It’s weight? A patient friendly fact sheet from the American 25 26 an important topic because high cholesterol affects many Heart Association has information about cholesterol management, controlling blood pressure and the 27 Behavioral Health Americans and is a risk factor for heart disease, the leading 28 cause of death in the United States. importance of healthy eating and weight control. 29 30 Here are a few facts about the prevalence of high Additional resources 31 Quality Counts cholesterol: Michigan Quality Improvement Consortium guidelines 32 provide up to date evidence-based recommendations for 33 • Seventy-one million American adults (33.5 percent) 34 1 cholesterol management. have high low-density lipoprotein, or “bad,” cholesterol. 35 Pharmacy News • Only one out of every three adults with high LDL Performance recognition 36 37 1 cholesterol has the condition under control. BCN’s 2014 Performance Recognition Program for BCN 38 • Less than half of adults with high LDL cholesterol get Advantage rewards physicians who encourage their 39 Billing Bulletin treatment.1 patients to get preventive screenings and physicians who 40 help patients control their cholesterol. More information 41 • People with high total cholesterol have approximately about this program is available in BCN Health e‑BlueSM. 42 43 Referral Roundup twice the risk of heart disease as people with The document is located in the Resources section under optimal levels. 44 Incentive Documents. If you have any questions, please 45 • The average total cholesterol level for adult Americans is contact your medical care group leadership or your 46 2 Index about 200 mg/dL, which is borderline high risk. BCBSM/BCN provider consultant. We appreciate your 47 continued support of our physician incentive programs. 48 49 50 BCNprovidernews 1 – CDC. Vital signs: prevalence, treatment, and control of high levels of low-density lipoprotein cholesterol. United States, 1999–2002 and 2005–2008. 51 NOVEMBER–DECEMBER 2014 MMWR. 2011;60(4):109–14. 52 2 – Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics—2012 update: a report from the American Heart Association. Circulation. Feedback 2012;125(1):e2–220. BCN advantage 25 1 2 3 What to do when a service is not covered and your patient 4 5 still wants it 6 7 8 When a service is not covered or may not be covered by With these steps completed and assuming the member’s Cover Story 9 SM SM Blue Care Network HMO or BCN Advantage but your agreement to pay, you should feel comfortable billing the 10 patient is still interested in getting it, you can submit a patient for the service. 11 clinical review request to us. Submit the request through 12 Previously, BCN and BCN Advantage offered the Patient Network Operations the normal channels, either through the e-referral system 13 Advance Notice of Noncovered Service(s) form for providers 14 or by calling BCN Care Management. to use in these situations, to get written confirmation of 15 If the request is approved by BCN Care Management, you’re the member’s agreement to pay for services that were 16 BCN Advantage 17 all set to provide the service and bill BCN or BCN Advantage. not covered by the plan. That form is no longer available  18 If the request is denied, Care Management sends written because CMS guidelines restrict the use of this form 19 notification of the denial to both you and your patient. You can by Medicare Advantage plans. Except for the Notice of 20 Blue Cross Complete also see the denial in the e-referral system. Medicare Non-Coverage, other advanced beneficiary 21 notifications involving written agreement from the member 22 Once you have the denial, take the following steps: to pay for services to be performed are also not compliant. 23 24 Patient Care 1. Let the patient know the service is denied. Instead of using these forms, providers must follow the 25 2. Ask whether the patient wants to appeal the denial 26 process described in this article and keep the denial letters 27 or is willing to pay for the service out of pocket. Behavioral Health from BCN or BCN Advantage in the member’s record before 28 performing a service not covered by the plan. 29 Ultimately, if the patient agrees to pay and 30 you provide the service, it’s important that you 31 Quality Counts keep the following denial notices in the 32 member’s file: 33 34 • The denial notice sent by BCN Care 35 Pharmacy News Management to you as the provider 36 37 • The copy you receive of the denial letter 38 BCN sent to the member 39 Billing Bulletin 40 41 These documents 42 confirm that the request 43 Referral Roundup was denied before the 44 service was rendered 45 and that the denial 46 47 Index was communicated to 48 the member. 49 50 BCNprovidernews 51 NOVEMBER–DECEMBER 2014 52 Feedback Blue Cross Complete 26 1 2 3 4 Provider Recognition Program changes coming for 2015 5 In 2015, Blue Cross Complete will be implementing changes to the Performance Recognition Program. These changes 6 7 will focus on population-based care and offer greater incentives for managing populations. 8 Cover Story 9 We appreciate providers working with Blue Cross Complete to improve the quality of care for our members. More details 10 will be provided in a future issue. 11 12 Network Operations 13 14 15 Blue Cross Complete 16 BCN Advantage 17 offers incentives 18 19 20 Blue Cross Complete for preventive 21  22 health services 23 Patient Care Blue Cross Complete encourages primary 24 25 care providers to identify gaps in care for 26 their patients. It is important to identify 27 Behavioral Health patients with chronic conditions and to 28 provide them with preventive health care 29 services. 30 31 Quality Counts Blue Cross Complete offers quality 32 incentive payments for providing and 33 34 reporting a number of preventive health 35 Pharmacy News services. Please visit the provider site at 36 Navinet to access Care Gap reports. 37 38 Please call your provider consultant for 39 Billing Bulletin more information or if you have questions. 40 41 42 43 Referral Roundup 44 45 State of Michigan requires providers to include BMI 46 Index 47 in registry 48 49 Family practice and pediatric providers need to include body mass index in the Michigan Care Improvement Registry 50 BCNprovidernews when reporting immunizations. It is required by the State of Michigan. Enter this information on mcir.org. 51 NOVEMBER–DECEMBER 2014 52 Feedback Blue Cross Complete 27 1 2 Blue Cross Complete offers incentive program for 3 4 5 postpartum and well‑child visits 6 7 In September, Blue Cross Complete of Michigan began Research has found that parents experiencing material 8 Cover Story offering a new incentive program for eligible members. hardship are subject to increased parenting stress. Families 9 10 Through this program, members who attend their without diapers may be unable to obtain child care and 11 postpartum visit between 21 and 56 days after delivery are have limited parental activities such as attendance at 12 Network Operations eligible to receive a free pack of diapers. This postpartum school and work. In addition to parental stress, a lack of 13 visit is especially important to new mothers because it diapers may result in parents stretching diapers when the 14 gives doctors the opportunity to assess the physical and supply is running short. This may lead to diaper dermatitis 15 emotional well being of the mother. and urinary tract infections in small children. Such 16 BCN Advantage 17 infections are responsible for numerous pediatric office and Additionally, parents who take their children for their six 18 emergency department visits per year.1 19 well‑child visits before the age of 15 months are eligible for 20 Blue Cross Complete a free pack of diapers. Well‑child visits start within days of Since diapers play such an important role in the well-being 21  a child’s birth. Each visit provides important screenings and of the child and the mental health of parents, Blue Cross 22 helps to educate parents on the developmental needs of Complete projects that the new diaper incentive program 23 Patient Care their children. will reduce unnecessary doctor visits ultimately improving 24 overall health outcomes for mothers and children. 25 We hope that this new diaper incentive will promote 26 healthy behaviors among members and lead to 27 Behavioral Health 28 an increase in the postpartum care and well‑child 29 visit, two important Health Effectiveness Data and 30 Information Set® quality of care measures. 31 Quality Counts 32 Currently, Blue Cross Complete ranks 33 in the 50th percentile (63.99 percent) 34 among other HMOs nationally for 35 Pharmacy News postpartum care. Blue Cross Complete 36 th 37 is currently ranked in the 75 percentile 38 (70.9 percent) among other HMOs 39 Billing Bulletin nationally for well‑child visits before 40 15 months of age. These measures 41 have been steady since 2012. The goal 42 is to move the postpartum visits into 43 Referral Roundup 44 th the 75 percentile (70.2 percent) and 45 well‑child visits into the 90th percentile 46 Index (77.44 percent) and eventually sustain 47 rates above Michigan’s HMO average. 48 49 50 BCNprovidernews 51 NOVEMBER–DECEMBER 2014 1 Smith, M., Kruse, A., Weir, A., & Goldblum, J. Diaper Need and 52 Its Impact on Child Health. Pediatrics, 132, 253-259. Retrieved Feedback June 6, 2014, from pediatrics.aappublications.org Blue Cross Complete 28 1 2 3 Complete a health risk assessment for members 4 5 Under the Healthy Michigan Plan, primary care physicians must complete a health risk assessment form for members 6 at the time of the appointment. Blue Cross Complete members receive a copy of the HRA form in their welcome 7 packets and should bring it to their appointments. The form is also available on mibluecrosscomplete.com/providers 8 Cover Story 9 and on NaviNet. 10 Please follow these guidelines: 11 12 Network Operations • Complete the HRA form legibly and in its entirety. 13 14 • Please Note: When completing Section 4 Member Results, be sure to include all required information if a diagnosis 15 is checked “yes.” Incomplete assessments will not be eligible for the incentive payment. 16 BCN Advantage 17 • A member of the clinical team can complete the health risk assessment, but the PCP will need to sign it. 18 19 • Fax the entire form to 1‑855‑287-7886 within five business days of the appointment. Blue Cross Complete 20 • Submit a claim with CPT code *99420 with modifier 25 to indicate that an assessment was completed. 21  22 • Direct any questions about the status of the health risk assessment to 1-888-312-5713. 23 Patient Care 24 Blue Cross Complete will pay a $15 incentive upon receipt of the claim. 25 26 *CPT codes, descriptions and two-digit modifiers only are copyright 2013 American Medical Association. All rights reserved. 27 Behavioral Health 28 29 30 31 Quality Counts 32 33 Where to locate pharmacy 34 35 Pharmacy News 36 information and formulary changes 37 38 Throughout the year, the Blue Cross Complete Pharmacy and 39 Billing Bulletin 40 Therapeutics Committee approves formulary changes. These changes 41 are published as a Pharmacy Update document, which can be found 42 under the Pharmacy section at mibluecrosscomplete/providers. 43 Referral Roundup 44 Please visit the site regularly to keep up to date with 45 the latest changes. You can also access the Online 46 Drug Search Tool and prior authorization documents in 47 Index 48 this section. 49 50 BCNprovidernews 51 NOVEMBER–DECEMBER 2014 52 Feedback Blue Cross Complete 29 1 2 3 4 Reminder: In some instances, Blue Cross Complete 5 6 7 combines two admissions into one for DRG reimbursement 8 Cover Story 9 Blue Cross Complete’s Utilization Management department Note: For dual-eligible members (those with Original 10 reviews inpatient readmissions that occur within 15 days Medicare, BCN AdvantageSM or BCBSM’s Medicare Plus 11 of discharge from a facility that is reimbursed by diagnosis Blue PPO as their primary plan and Blue Cross Complete 12 Network Operations 13 related groups, when the member has the same or a as their secondary plan), inpatient readmissions will be 14 similar diagnosis for each admission. Blue Cross Complete reviewed according to the requirements of the member’s 15 16 BCN Advantage reviews each readmission to determine whether it resulted primary plan. from one or more of the following: 17 The 15-day readmissions policy is a Medicaid policy that 18 • A premature discharge or a continuity is implemented by all Medicaid health plans. We have an 19 Blue Cross Complete of care issue appeals process in place for providers who disagree with 20 our determination to combine admissions for payment. 21  • A lack of a discharge plan or inadequate 22 discharge planning BCN commercial and BCN Advantage have a 14‑day 23 Patient Care 24 • A planned readmission policy. Those guidelines can be found in the Claims and 25 Care Management chapters of the BCN Provider Manual. 26 • Surgical complications 27 Behavioral Health 28 In some instances, Blue Cross Complete will combine 29 two admissions into one for the purposes of the DRG 30 reimbursement. The facility’s discharge planning process 31 Quality Counts is a key factor in determining whether the two admissions 32 33 can be reimbursed separately. More information is included 34 in the Blue Cross Complete Provider Manual. 35 Pharmacy News 36 37 38 39 Billing Bulletin 40 41 42 43 Referral Roundup Use Emdeon enrollment for EFT 44

® 45 Blue Cross Complete uses Emdeon for electronic payments. If you are already enrolled with Emdeon through 46 another health plan, you can access Emdeon and select Blue Cross Complete using BCC Payer ID 32002. 47 Index For providers not already enrolled with Emdeon, visit emdeon.com/epayment. 48 49 50 BCNprovidernews 51 NOVEMBER–DECEMBER 2014 52 Feedback patient care 30 1 2 3 ...from the 4 medical 5 6 7 Help Blue Care Network reduce 8 Cover Story director 9 childhood obesity 10 11 By Hashim Yar, M.D. 12 Network Operations 13 Obesity affects 17 percent activity. American children are exposed to environments 14 of all children and that promote increased consumption of less healthy food 15 adolescents in the United and physical inactivity in their homes, child care centers, 16 BCN Advantage States, according to the schools and communities. 17 2007-2008 National Health 18 Blue Care Network has taken an active role to try to reduce 19 and Nutrition Examination childhood obesity. Here are a few of the initiatives we’re 20 Blue Cross Complete Survey. That’s triple taking to address childhood obesity endemic: 21 the rate from just one 22 generation ago. • BCN is supporting the “We Are For Children” program, 23 Patient Care a primary care obesity prevention and treatment program 24 Rates of overweight and in 2 to 5 year old children in West Michigan. The 25  obese children worldwide 26  program assesses changes in the health behaviors of the rose by nearly 50 percent 27 Behavioral Health child and the family, including dietary, physical activity 28 between 1980 and 2013. and sedentary habits, as well as changes in the child 29 In 2013, more than growth patterns. 30 22 percent of girls and 31 Quality Counts nearly 24 percent of boys • BCN will start a pilot program with the University of 32 in developed nations were Michigan Pediatric Outpatient Weight Evaluation and 33 overweight or obese. The rates in developing nations were Reduction Program. It offers a comprehensive range of 34 35 nearly 13 percent for both boys and girls evidence-based pediatric obesity treatment programs Pharmacy News for families with obese adolescents (BMI>95 percentile) 36 37 The financial cost of childhood obesity tops $3 billion annually. who are 12 to 18 years old. This is a multidisciplinary 38 Obese and overweight children are at risk for elevated program with the goal of reducing BMI in this age 39 Billing Bulletin blood pressure, cholesterol, diabetes, sleep apnea, fatty group and alleviating the complications associated with 40 liver disease, gallstones and gastroesophageal reflux. childhood obesity. 41 42 What’s more, these children are vulnerable to social and • Incentives are included in the BCN 2014 Physician psychological problems, such as discrimination and poor 43 Referral Roundup Recognition Program to provide specific codes that 44 self-esteem and to becoming obese adults. demonstrate BMI, nutritional counseling and counseling 45 46 Beside genetic factors, childhood obesity is the result of for physical activity were completed by the provider. Index 47 eating too many calories and not getting enough physical We strongly believe that the providers have a critical role 48 in combating this epidemic by educating and counseling 49 50 their pediatric patients and families for a healthier and BCNprovidernews 51 Dr. Yar is a medical director at productive life. 52 NOVEMBER–DECEMBER 2014 Blue Care Network. Feedback patient care 31 1 2 3 Screen kids early to avoid 4 5 cardiovascular disease 6 7 Atherosclerosis begins in childhood and progresses slowly into adulthood, 8 Cover Story leading to coronary heart disease. Children are also at risk for developing 9 hypertension, metabolic syndrome and type 2 diabetes. 10 11 The American Academy of Pediatrics recommends that all children be 12 Network Operations screened for high cholesterol at least once between the ages of 9 and 13 14 11 years, and again between ages 17 and 21 years.* 15 Michigan Quality Improvement Consortium guidelines recommend 16 BCN Advantage 17 screening for children older than 2 who are at increased risk for genetic 18 forms of hypercholesterolemia. The best method for testing is a fasting 19 lipid profile. If the child has values within the normal range, testing Blue Cross Complete 20 should be repeated in three to five years. 21 22 Children 8 years and older with abnormal cholesterol readings may 23 Patient Care be considered for cholesterol-reducing medications. Younger children 24 with abnormal readings should focus on weight reduction, healthy 25  eating habits and food selection, and an active exercise program. 26 27 Behavioral Health For younger patients who are overweight or obese and have a 28 high triglyceride concentration or low HDL concentration, weight 29 30 management is the primary treatment. 31 Quality Counts During the office visit, the primary care physician should address the 32 33 following risk factors with the child and his or her family: 34 • Family history of heart disease 35 Pharmacy News • Family history of obesity 36 37 • Family history of high blood pressure 38 • Family history of diabetes 39 Billing Bulletin 40 • Height and weight measurement; body mass index calculation 41 • Blood pressure measurement at age 3; then yearly if normal 42 • Lipid screening if indicated 43 Referral Roundup 44 • Diet and daily physical activity review 45 • History of tobacco use by parents and by the child (beginning at age 12); 46 offer counseling for smoking cessation 47 Index 48 Blue Care Network’s Care Management team provides parents and caregivers 49 of overweight children with information about hypertension, nutrition and other 50 BCNprovidernews 51 factors related to cardiovascular disease. You may call the Care Management 52 NOVEMBER–DECEMBER 2014 nurse line at 1‑800‑392-4247 and ask to speak with a nurse. Feedback *Guidelines sponsored by the National Heart, Lung and Blood Institute (NHLBI) patient care 32 1 2 Type 2 diabetes in children can be prevented 3 4 5 While type 2 diabetes is usually diagnosed in adults, For additional information about prevention and 6 it’s increasingly diagnosed in children and adolescents, identification of childhood overweight and obesity refer to 7 particularly in American Indians, African-Americans and the updated MQIC guidelines. 8 Cover Story Hispanic or Latinos, according to the Centers for Disease 9 Overweight or obese children may benefit from weight 10 Control and Prevention. loss supervision from their health care practitioners. 11 Obesity is a major risk factor for type 2 diabetes in children. 12 Network Operations Young people and their families should receive counseling 13 Type 2 diabetes mellitus can remain asymptomatic for a about nutrition, weight control and physical activity, as well 14 long time. According to the National Institutes of Health, 15 as an individualized plan of care. The child may also need obesity in children may be attributed to the following 16 BCN Advantage treatment for hypertension and hyperlipidemia, including modifiable habits: 17 follow-up every three months. Pharmacologic therapy for 18 • High-calorie food choices weight loss isn’t recommended for children until more 19 • Lack of physical activity safety and efficacy data have been obtained. 20 Blue Cross Complete 21 • Parental obesity 22 23 • Irregular eating habits that include skipping meals and Patient Care 24 overeating Medical policy updates 25  • Parents with poor nutritional habits and sedentary lifestyles 26 27 Blue Care Network’s medical policy updates Behavioral Health The Michigan Quality Improvement Consortium guidelines 28 are posted on web‑DENIS. Go to BCN Provider recommend that children be assessed at each periodic 29 Publications and Resources and click on Medical 30 health exam. These key components should be addressed: Policy Manual. Recent updates to the medical 31 Quality Counts • Education of parents with children under 2 years old policies include: 32 about obesity risk and prevention 33 Noncovered services 34 • Assessment of body mass, risk factors for overweight 35 Pharmacy News and excessive weight gain relative to linear growth in • Negative oral pressure therapy for the treatment 36 children age 2 or older of obstructive sleep apnea 37 38 • Continuous subcutaneous insulin infusion (insulin • Prevention to promote healthy weight in children age 39 Billing Bulletin 2 years or older with a body mass index less than the pumps) and transdermal insulin delivery systems 40 85th percentile for age 41 Covered services 42 43 Referral Roundup For children 2 years or older, guidelines recommend that • Genetic testing of CADASIL syndrome the general assessment include: 44 • Light therapy for vitiligo 45 • Performing a history (including focused family history) • Genetic testing 46 47 Index and physical exam for alpha-1 Medical Policy 48 • Measuring and recording weight and height on CDC antitrypsin Updates PDF 49 BMI-for-age growth chart deficiency 50 BCNprovidernews 51 • Assessing risk factors, including pattern of weight 52 NOVEMBER–DECEMBER 2014 change. Watch for increases of three to four BMI Feedback units/year. patient care 33 1 2 3 Criteria corner 4 Diabetes patients require 5 Blue Care Network uses McKesson’s InterQual Level of certain tests 6 Care when conducting admission and concurrent review 7 8 activities for acute care hospitals. To ensure that providers Blue Care Network is commemorating American Diabetes Cover Story 9 and health plans understand the application of the criteria Month in November by reminding physicians about the 10 and local rules, BCN provides clarification from McKesson assessment and treatment of their diabetic patients. 11 on various topics. 12 Network Operations The Michigan Quality Improvement Consortium guidelines 13 recommend periodic medical assessments, laboratory 14 tests and education to guide effective self-management 15 Question: 16 BCN Advantage in patients with type 1 and type 2 diabetes mellitus. The Why does the criteria for deep vein thrombosis or 17 following tests are recommended: 18 pulmonary embolism exclude medications like Xarelto • Hemoglobin A1C (two to four times annually based on 19 (rivaroxaban) or Pradaxa (dabigatran) in the criteria individual therapeutic goal) 20 Blue Cross Complete for the treatment of DVT or PE? 21 • Urine microalbumin measurement (annually) 22 Answer: 23 • Serum creatinine and calculated glomerular filtration rate 24 Patient Care InterQual’s inpatient admission criteria for deep vein (annually) thrombosis are limited to those patients who are experiencing 25  • Fasting lipid profile (annually) 26 a complication or are at risk for a complication. The only 27 Behavioral Health published study of rivaroxaban for the treatment of DVT • Dilated eye exam by ophthalmologist or optometrist or 28 specifically excluded patients at high risk for complications, digiscope evaluation 29 including bleeding. The use of rivaroxaban or dabigatran 30 in this patient population is further complicated by the For more information about treating diabetic patients, refer 31 Quality Counts to the MQIC guidelines. 32 risk of bleeding and the lack of any agent to reverse the 33 anticoagulant effect. McKesson consultants don’t recommend The level of HbA1c may be reduced with lifestyle choices 34 oral agents for the initial treatment of pulmonary embolism. including diet, weight loss and physical activity. Members 35 Pharmacy News As these medications are relatively new to the market and that continue to be challenged with HbA1c levels >9 percent 36 randomized control trials may be ongoing regarding their use 37 may benefit from working with a BCN nurse case manager. 38 in specialized populations, McKesson will continue to evaluate Blue Care Network’s Chronic 39 Billing Bulletin them for inclusion in the criteria for future releases. 40 Condition Management program 41 Question: provides members with tools they 42 need to make informed health 43 Referral Roundup How can I apply the criteria point “Comorbid pneumonia in a hospitalized patient”? choices and manage their conditions. 44 To refer members to the diabetes 45 Answer: 46 chronic condition management 47 Index The criteria point “Comorbid pneumonia in a hospitalized program, call Chronic Condition 48 patient” can only be applied to patients who have Management at 1‑800‑392‑4247, 49 developed pneumonia as a complication of their current TTY 1‑800‑257‑9980. Our chronic 50 BCNprovidernews inpatient stay in an acute care facility. The criteria points condition management specialists 51 52 NOVEMBER–DECEMBER 2014 can’t be applied for patients who have been either are available Monday through Friday, discharged to home or transferred to a post-acute facility. from 8:30 a.m. to 5 p.m. Feedback patient care 34 1 2 3 4 Blue Care Network partners with Alere management 5 6 for CHF and COPD members 7 8 Cover Story 9 Blue Care Network, in partnership with Alere Health, Alere Health staff monitors members’ adherence with daily 10 continues to offer members and practitioners an innovative weights, medications, blood pressure, tobacco cessation, 11 12 Network Operations approach to the management of commercial and BCN alcohol use, and flu and pneumonia vaccinations. Alere also AdvantageSM members with congestive heart failure. Alere monitors member outcomes related to inpatient and ER 13 14 Health also offers disease management services to BCN visits, medication use and quality of life surveys. 15 Advantage members with chronic obstructive pulmonary Members with COPD may also receive a DayLink Monitor 16 BCN Advantage disease. 17 to transmit symptoms once a day. Alere staff also provides 18 Alere Health program education to members to help them understand their 19 COPD symptoms, use self-management techniques, 20 Blue Cross Complete The Alere Health program identifies problems early and adhere to physician’s care plan and medication regimen, 21 alerts the treating physician with timely information on learn about the use of spacers for metered dose inhalers 22 changes in the patient’s symptoms while they are at home. 23 and monitor sputum. Smoking cessation is emphasized for Patient Care 24 Key features include: those members who smoke. 25  • Home biometric monitoring with DayLink® Monitor 26 Member satisfaction 27 technology Behavioral Health NCQA’s disease management standards for health plans 28 29 • Nurse review of symptom information 365 days a year require that the organization annually measure satisfaction and comparison of this information to parameters preset 30 with its disease management program by obtaining 31 for each patient Quality Counts feedback from members. In an effort to improve member 32 • Notification to the member’s practitioner by fax when satisfaction, Alere implemented an enhancement called 33 the patient’s symptoms exceed the preset parameters The Healthcard. The tool allows Alere to measure clinical 34 35 effectiveness monthly, helps evaluate the impact of Pharmacy News 36 BCN identifies members who are eligible to participate in interventions and provides a mechanism to provide and 37 Alere programs through a predictive model database using focus clinical care. Alere‘s 2013 member satisfaction 38 claims and demographic data. Alere contacts the members survey aggregate overall score was 95.6 percent, an 39 Billing Bulletin directly to engage them in the program. If the member increase from the 2012 overall score of 88.1. 40 accepts the program, Alere notifies providers of their 41 enrollment. To learn more about Alere Health programs or to refer one 42 43 Referral Roundup of your members, contact BCN’s case management team Members with congestive heart failure may have a DayLink 44 at 1‑800‑392-2512. They are available 8 a.m. to 5 p.m., 45 Monitor placed in their home to record their weight and Monday through Friday. 46 heart failure symptoms. This information is transmitted to 47 Index Alere Health through a telephone line and reviewed daily by 48 licensed professional staff. 49 50 BCNprovidernews 51 NOVEMBER–DECEMBER 2014 52 Feedback patient care 35 1 2 3 4 5 6 Great American Smokeout 7 8 Cover Story is in November 9 10 11 The American Cancer Society marks the Great 12 Network Operations American Smoke out on the third Thursday of 13 November each year by encouraging smokers to 14 use that date to make a plan to quit using tobacco. 15 16 BCN Advantage In the United States, tobacco use is responsible 17 18 for nearly one in five deaths; this equals about 19 480,000 early deaths each year, according to Blue Cross Complete 20 the American Cancer Society. This includes 21 both tobacco users and those exposed to the 22 second hand smoke. Quitting smoking alleviates 23 Patient Care 24 exposure to second hand smoke that is harmful 25  to others. Tobacco contains more than 7,000 26 chemicals, including hundreds that are toxic and 27 Behavioral Health about 70 that cause cancer. 28 29 30 Blue Care Network offers Quit the Nic, a 31 Quality Counts smoking cessation program to help members 32 to successfully quit smoking cigarettes or 33 using smokeless tobacco. Members may call 34 1‑800‑811‑1764 to schedule a time to speak with 35 Pharmacy News 36 a health coach. 37 38 We encourage physicians to use each visit to 39 Billing Bulletin counsel all patients who smoke (or use smokeless 40 tobacco) to quit. You can also refer to the article, 41 Blue Care Network to kick off smoking cessation 42 43 Referral Roundup campaign this fall, in the Sept.‑Oct. issue for 44 information about BCN’s tobacco cessation campaign. 45 46 47 Index 48 49 50 BCNprovidernews 51 NOVEMBER–DECEMBER 2014 52 Feedback behavioral health 36 1 2 Reminder: Blue Care Network’s Behavioral Health Incentive 3 4 Program documents are on web‑DENIS 5 6 Blue Care Network’s Behavioral Health Incentive Program launched in January of 2014 and is specifically designed for 7 psychiatrists, fully‑licensed psychologists and clinically‑licensed certified social workers. 8 Cover Story 9 If you are not familiar with the program, we strongly encourage you to access it on web‑DENIS. 10 11 • Go to BCN Provider Publications and Resources 12 Network Operations • Click the link for Behavioral Health in Resources 13 • Documents are located in the Behavioral Health Incentive Program section 14 15 The following is a snapshot of the measures and payment information. 16 BCN Advantage 17 Provider Measure Provider type Intake period Payment Projected payout 18 action 19 20 Blue Cross Complete All qualified Follow – up after Flat fee None – 21 mental health 1/1/14 – 10/31/14 Second quarter of 2015 hospitalization $100 Claims data 22 providers 23 Patient Care Anti – depressant 24 Prescribing Flat fee None – 25 medication management 1/1/14 – 4/30/14 Second quarter of 2015 providers $40 Claims data 26 – Acute 27 Behavioral Health Anti – depressant 28 Prescribing Flat fee None – 29 medication management 1/1/14 – 4/30/14 Second quarter of 2015  providers $60 Claims data 30 – Continuation 31 Quality Counts Prescribing Per script None – 32 Generic substitution rate 1/1/14 – 12/31/14 Second quarter of 2015 providers $1.50 Claims data 33 34 Pharmacotherapy 35 Prescribing Flat fee None – Pharmacy News adherence for bipolar 1/1/14 – 12/31/14 Second quarter of 2015 36 providers $80 Claims data disorder 37 38 Non-prescribing Flat fee Third quarter of 2014; Therapeutic alliance 1/1/14 – 12/31/14 Submit forms 39 Billing Bulletin providers $10 second quarter of 2015 40 Prescribing and 41 Primary care physician Flat fee Third quarter of 2014; 42 non-prescribing 1/1/14 – 12/31/14 Submit forms contact $20 second quarter of 2015 43 Referral Roundup providers 44 45 Note: BCN retains the right to modify BHIP at any time. Modifications may include, but are not limited to, 46 changes to the program’s scoring and calculation methodologies. 47 Index 48 Please understand that if you are not participating in the self-reported measures at this point, you are forgoing incentive 49 money from a large allocated budget. 50 BCNprovidernews 51 BCN would like to know your thoughts regarding BHIP. Please complete the following survey, which addresses familiarity NOVEMBER–DECEMBER 2014 52 with the program, any barrier to participating and general feedback. If you have already responded to the survey, please do Feedback not complete it again. The survey will close on January 15. We look forward to your feedback. behavioral health 37 1 2 3 4 5 ABA limit to be removed 6 7 in 2015 for treatment 8 Cover Story 9 10 of autism 11 Effective Jan. 1, 2015, BCN will remove the hourly 12 Network Operations 13 limit for the treatment of autism utilizing applied 14 behavior analysis, but will continue to apply medical 15 necessity criteria when authorizing these services. 16 BCN Advantage This will be effective for all non-grandfathered 17 individual, small group and large group plans with 18 19 effective dates beginning on or after Jan. 1. 20 Blue Cross Complete 21 Psychiatric and psychological services are already 22 without limits but are managed using medical 23 Patient Care necessity criteria. 24 25 26 27 Behavioral Health 28 29  BCN clarifies 30 31 Quality Counts behavioral health 32 33 34 provider requirements 35 Pharmacy News 36 As a behavioral health provider for Blue Care Network, 37 you can refer to the new document Requirements for 38 providing behavioral health services to BCN members 39 Billing Bulletin for information related to your work in solo and group 40 practices and in substance abuse and outpatient 41 42 psychiatric clinic settings. 43 Referral Roundup 44 This document is available on BCN’s e-referral website. 45 Visit ereferrals.bcbsm.com, click Behavioral Health and 46 Index then click Requirements for providing behavioral 47 health services to BCN members. 48 49 50 BCNprovidernews 51 NOVEMBER–DECEMBER 2014 52 Feedback behavioral health 38 1 2 3 Seasonal affective disorder can be treated 4 5 Seasonal affective disorder is a type of depression that According to NAMI, SAD is sometimes misdiagnosed as 6 tends to occur and recur as the days grow shorter during hypothyroidism, hypoglycemia, infectious mononucleosis 7 the fall and winter months. SAD can seriously affect or other viral conditions because of the similarity of some 8 Cover Story 9 work and relationships. The disorder may have its onset of the symptoms, such as fatigue, lack of energy, problem 10 in adolescence or early adulthood and like other forms concentrating or memory loss. All of these can affect 11 of depression, occurs more frequently in women than patient presentation and detection by the primary care 12 Network Operations men. The cause of SAD is unknown, but it’s thought to physician. 13 be related to numerous factors such as heredity, age, 14 It’s often possible to successfully manage SAD with 15 body temperature, hormone regulation and the availability early intervention, treatment and lifestyle changes which 16 BCN Advantage of sunlight. may include: 17 18 The symptoms include depression, carbohydrate cravings, • Early assessment using a depression screening tool 19 increased appetite with weight gain, decreased interest in to clarify diagnosis 20 Blue Cross Complete work or significant activities of daily living, increased sleep, 21 social withdrawal and decreased energy and concentration. • Antidepressant medication with observation of behavior 22 by physician 23 Recent research by the National 24 Patient Care • Diet monitoring, especially carbohydrate intake Alliance on Mental Illness has found 25 that some people may experience • Exercise therapy to help the brain release chemicals 26 27 “reverse SAD”, where a relapse of to improve mood Behavioral Health 28 symptoms occurs in the summer • Stress management and relaxation techniques 29  rather than winter. The symptoms 30 • Adequate sleep may be insomnia, decreased appetite, 31 Quality Counts weight loss, agitation or anxiety. • Talk therapy to help identify and change negative 32 thoughts and behaviors that may exacerbate symptoms 33 Barriers to detection 34 and treatment 35 Pharmacy News As the seasons change the symptoms usually resolve. 36 may include Although some people may have the disorder indefinitely, 37 time constraints, continuous treatment usually improves outcomes. 38 competing demands 39 Billing Bulletin from other medical If you have any questions about SAD, you 40 problems, social may contact Quality Management by emailing 41 42 stigma, family [email protected] or by calling Quality Management at 248‑350‑6263. 43 Referral Roundup dysfunction, patient 44 attitude, community 45 factors and clinician 46 and practice factors. 47 Index 48 49 50 BCNprovidernews 51 NOVEMBER–DECEMBER 2014 52 Feedback quality counts 39 1 2 3 HEDIS 2014 results 4 5 ® The Healthcare Effectiveness Data and Information Set , A significant decrease was noted in the following 6 the most widely used set of performance measures in measures: 7 8 the managed care industry, was submitted to the National Commercial HMO Cover Story Committee for Quality Assurance® accreditation process. 9 • Comprehensive diabetic care 10 HEDIS® is part of an integrated system to establish – Nephropathy monitoring 11 accountability in managed care organizations. It was 12 Network Operations • Antidepressant medication management 13 originally designed to address private employers’ needs as – Acute phase 14 purchasers of health care and now has been adopted for 15 use by public purchasers, regulators and consumers. • Antidepressant medication management 16 BCN Advantage – Continuation phase 17 Significant improvement was noted in the following 18 • Advising smokers to quit measures: 19 Medicare 20 Blue Cross Complete Commercial HMO 21 • Weight assessment and counseling for nutrition • Comprehensive diabetic care 22 and physical activity – HgA1c poorly controlled >9.0 percent 23 Patient Care 24 – Nutrition only • Controlling high blood pressure 25 • Follow-up after hospitalization • Antidepressant medication management 26 – 7 day 27 Behavioral Health – Continuation phase 28 • Follow-up for children with ADHD • Persistence of beta blocker treatment after 29 – Initiation phase heart attack 30 31 Quality Counts • Follow-up for children with ADHD • Pharmacotherapy management of COPD 32 – Continuation phase – Bronchodilators 33  34 Medicare • Disease modifying anti-rheumatic therapy in 35 rheumatoid arthritis 36 Pharmacy News • Colorectal cancer screening 37 • Comprehensive diabetic care We would like to thank all of our practitioners for their 38 – Eye exam contribution toward providing quality care to our members 39 Billing Bulletin 40 • Follow-up after hospitalization and allowing the BCN staff to conduct the medical 41 – 7 day record reviews. 42 43 Referral Roundup • Glaucoma screening for older adults Primary care practitioners can still find opportunities to 44 • Osteoporosis management in women who had provide aggressive intervention in the management and 45 a fracture care of our members with diabetes, controlling high blood 46 Index pressure, and in ordering procedures for breast, cervical 47 • Use of high-risk medications in the elderly and colorectal cancer screening. It’s important that 48 – 1 prescription 49 members are brought in for needed services and tests, 50 BCNprovidernews • Use of high-risk medications in the elderly and that the information is documented in the member’s 51 NOVEMBER–DECEMBER 2014 – 2 prescriptions medical record. 52 • Use of spirometry testing for COPD Feedback Please see HEDIS 2014, continued on Page 40 quality counts 40 1 2 3 4 HEDIS 2014, continued from Page 39 5 6 7 We are actively involved in activities throughout the year 8 Cover Story that positively impact our HEDIS® rates including: 9 10 • Physician Performance Recognition Program which is NCQA revises HEDIS 11 tied to some of the HEDIS® measures measure for blood pressure 12 Network Operations 13 SM • Health e-Blue Web 14 In 2015, the Cholesterol Management for • Member reminder telephone calls and cards 15 Patients with Cardiovascular Conditions 16 BCN Advantage • Member and physician education measure will be retired. Also in 2015, the 17 Controlling High Blood Pressure measure will be 18 • Member health fairs changed to include the following for members 19 20 Blue Cross Complete • Chronic condition management programs with a diagnosis of hypertension before 21 June 30, 2014: • Care Management follow-up telephone calls/letters 22 23 • Age 18-85 years old whose BP is <140/90 Patient Care • Member incentive programs 24 25 ® • Age 60-85 years old with a diagnosis of • HEDIS /CAPHS Summit Meeting 26 diabetes whose BP is <140/90 27 28 Behavioral Health We look forward to working with you to promote continued • Age 60-85 years old without a diagnosis of improvement in all areas of patient care and service. 29 diabetes whose BP is <150/90 who has a 30 diagnosis of hypertension and whose blood 31 Quality Counts If you would like more information about HEDIS® contact pressure is adequately controlled during 2014 32 our Quality Management department: 33  34 • By phone at 248-350-6263 35 Pharmacy News 36 • By email at [email protected] 37 38 HEDIS® is a registered trademark of the National Committee for Quality Assurance. 39 Billing Bulletin 40 41 42 43 Referral Roundup 2014 Commercial HMO HEDIS® Results PDF 44 45 46 47 Index 48 49 ® 2014 BCN Advantage HEDIS Results PDF 50 BCNprovidernews 51 NOVEMBER–DECEMBER 2014 52 Feedback pharmacy news 41 1 2 3 Chantix and Nicotrol products require authorization 4 5 for coverage 6 7 8 Cover Story As the New Year approaches, some of your patients may When prescribing smoking cessation products for BCN 9 be thinking about giving up tobacco and may ask for your members, please help our members manage their 10 guidance and help. out‑of‑pocket costs by first prescribing a therapy that 11 doesn’t require prior authorization. 12 Network Operations Blue Care Network strongly supports members who are 13 trying to quit. We provide coverage for many different Quit rates for first-line smoking cessations 14 tobacco cessation therapies. Members must have a 15 therapies 16 BCN Advantage prescription for these therapies – including over-the-counter 17 versions – before we’ll provide coverage. Product Quit rate 18 Chantix (varenicline) 25 – 33% 19 As a reminder, BCN now requires prior authorization 20 Blue Cross Complete before we’ll cover prescriptions for Chantix, Nicotrol and Generic Nicoderm CQ (nicotine patch) 24 – 27% 21 Nicotrol NS. Members must try one of these therapies Generic Nicorette (nicotine gum) 19 – 26% 22 that are covered at no member cost share: generic Zyban, 23 Generic Nicorette (nicotine lozenge) 24% Patient Care Nicoderm CQ or Nicorette gum or lozenges. 24 Nicotrol (nicotine inhaler) 25% 25 26 For members who meet criteria, BCN will cover Chantix, Nicotrol NS (nicotine nasal spray) 27% Nicotrol and Nicotrol NS at no member cost share. 27 Behavioral Health Generic Zyban (bupropion) 24% 28 BCN’s criteria follow U.S. Department of Health and 29 Human Services practice guidelines on treating tobacco 30 References 31 use and dependence. The recommendations don’t Quality Counts 1. Tobacco Use and Dependence Guideline Panel. Treating tobacco use and 32 support the use of one agent over another. In addition, dependence: 2008 update. Rockville, MD. US Department of Health and 33 the guidelines show no significant difference in quit Human Services. May 2008 Available from: http://www.ahrq.gov/ 34 rates between the seven first-line medications for professionals/clinicians-providers/guidelines-recommendations/ 35 Pharmacy News smoking cessation. tobacco/clinicians/update/treating_tobacco_use08.pdf 36 37  38 39 Billing Bulletin 40 41 BCBSM and BCN drug lists updated, available online 42 43 Referral Roundup The Blue Cross Blue Shield of Michigan and Blue Care Network Pharmacy and Therapeutics Committee reviewed the 44 pharmaceutical products listed in the PDF below for inclusion in the BCBSM/BCN Custom Drug List 2014, Custom Select 45 Drug List 2014 and the BCN AdvantageSM HMO-POS Formulary. Please help ensure that our members get the care they 46 Index need by talking with them about their drug copayment or coinsurance. Note that many members with a commercial drug 47 benefit do not have coverage for Tier 3 drugs. 48 49 Blue Cross Blue Shield of Michigan and Blue Care Network regularly update 50 Comprehensive Formulary 51 BCNprovidernews their drug lists. For the most recent updates, go to bcbsm.com.rxinfo. NOVEMBER–DECEMBER 2014 Updates PDF 52 Feedback pharmacy news 42 1 2 3 4 Switch to generic Norco helps members save 5 In October 2013, Blue Care Network launched prior authorization requirements for hydrocodone combination products that 6 7 contain 300 mg of acetaminophen due to the high cost of the new formulations. Since this change went into effect, more 8 Cover Story than 99 percent of members who use these products are being prescribed the lower-cost generic Norco, which contains 9 325 mg of acetaminophen. 10 11 BCN appreciates the support we have received from our providers. Thank you for helping keep costs low for our members. 12 Network Operations 13 As a reminder, the Drug Enforcement Agency moved hydrocodone combination products to Schedule II from Schedule III 14 on Oct. 6, 2014. Any prescriptions for hydrocodone combination products issued before Oct. 6, 2014 and authorized for 15 refilling may be dispensed before April 8, 2015. 16 BCN Advantage 17 18 19 20 Blue Cross Complete 21 22 23 Patient Care BCN Pharmacy Clinical Help Desk to 24 25 handle BCN Advantage drug requests, 26 27 Behavioral Health grievances 28 29 Starting Jan. 1, 2015, BCN Pharmacy Clinical Help Desk will process BCN 30 AdvantageSM Part D appeals and grievances. This move allows all Part D drug 31 Quality Counts requests and grievance work to be processed by one centralized staff. 32 33 Once the change is in effect, prescribers can initiate appeals by telephone. 34 Prescribers may also provide clinical information over the phone. With the 35 Pharmacy News 36 appropriate clinical information available, the Help Desk staff may be able to 37  provide a determination during the initial call, unless review by a pharmacist 38 is required. 39 Billing Bulletin 40 When calling the BCN Pharmacy Clinical Help Desk, remember to have all 41 pertinent information available. This includes the enrollee’s name and member 42 ID number, medication name, diagnosis and rationale for the request. 43 Referral Roundup 44 The BCN Pharmacy Clinical Help Desk is available for providers Monday – Friday 45 from 8 a.m. to 8 p.m. The phone number is 1‑800‑437-3803. The fax number 46 for BCN Advantage is 1‑800‑459-8027. 47 Index 48 Members will continue to contact the Customer Service phone number on the 49 50 back of their member ID card for information regarding appeals and grievances. BCNprovidernews 51 NOVEMBER–DECEMBER 2014 52 Feedback pharmacy news 43 1 2 3 American Academy of Pediatrics updates Synagis guidelines 4 5 Blue Care Network follows guidelines from the American • Infants less than 24 months who are profoundly 6 7 immunocompromised during the RSV season, Academy of Pediatrics for the use of Synagis (palivizumab). 8 Cover Story Palivizumab was approved in 1998 and has reduced RSV children who required at least 28 days of oxygen 9 hospitalizations. AAP recently updated its Synagis guidance supplementation after birth and those who require 10 for prevention of respiratory syncytial virus. The guidance medical intervention (oxygen, chronic corticosteroids, 11 12 Network Operations was developed to implement palivizumab in the most diuretic therapy) cost‑effective way. 13 • Children younger than 12 months with pulmonary 14 Palivizumab is a monoclonal antibody given monthly to abnormalities or neuromuscular disease that impairs the 15 ability to clear secretions form upper airways 16 BCN Advantage prevent RSV during the RSV season in pre-term or high-risk 17 infants. RSV season in Michigan generally starts around The AAP also emphasizes that the risk of RSV disease 18 December 1 and continues for four to five months. 19 is higher in Alaskan Native American patients, and use 20 Blue Cross Complete High-risk infants were previously defined as infants has been broadened in these individuals as well as other 21 with bronchopulmonary dysplasia, those born at or selective American Indian populations. 22 before 35 weeks’ gestation age and children with 23 The guidance states a maximum of five monthly doses Patient Care hemodynamically significant congenital heart disease. 24 may be given to infants in the first year of life. This differs 25 In addition, it was indicated for children undergoing from the previous recommendations, where certain infants 26 cardiopulmonary bypass. required fewer doses. Although those born within the 27 Behavioral Health season may require fewer doses, palivizumab is no longer 28 Due to the immense advancement in neonatal care 29 since 1998, there has been a steady decline in RSV recommended for infants in their second year of life as 30 hospitalization both with and without prophylaxis. This it was in certain populations in the past. It is no longer 31 Quality Counts has changed the need for palivizumab. Because those recommended for prevention of health care-associated 32 previously high-risk infants are no longer at such a risk, RSV disease and is to be discontinued in any child who has 33 a breakthrough RSV hospitalization. 34 AAP has developed new criteria to identify infants at high 35 risk simply due to gestational age: Pharmacy News RSV surveillance data information is available at the CDC at 36 • Palivizumab is recommended for infants born before the following links: 37  38 29 weeks, 0 days’ gestation, who are younger than http://www.cdc.gov/features/dsRSV/index.html 39 Billing Bulletin 12 months at the start of RSV season. 40 http://www.cdc.gov/surveillance/nrevss/rsv/ 41 Palivizumab is no longer recommended for infants born at 42 29 weeks, 0 days’ gestation or later, but may be indicated 43 Referral Roundup if they meet any of the following conditions: References 44 1. BCN Policy, Palivizumab. 45 • Infants younger than 12 months with hemodynamically 46 significant congenital heart disease 2. Updated Guidance for Palivizumab Prophylaxis Among Infants and Young Index Children at Increased Risk of Hospitalization for Respiratory Syncytial 47 • Infants younger than 12 months with chronic lung Virus Infection. Pediatrics 2014; 134;415; originally published online 48 disease — defined as birth at before 32 weeks, 0 days, July 28, 2014 49 50 BCNprovidernews and less than 21 percent oxygen for at least 28 days 51 NOVEMBER–DECEMBER 2014 after birth 52 Feedback pharmacy news 44 1 2 3 4 Correction: Implementation for Walgreens Infusion 5 6 moved to 2015 7 8 Cover Story In the Sept.-Oct. 2014 issue, we said that Walgreens Infusion had been named the preferred provider of immunoglobulin 9 SM services for Blue Care Network and BCN Advantage members, effective Oct. 1, 2014. Implementation of this program 10 has been moved to 2015. We apologize for any confusion this may have caused. 11 12 Network Operations 13 14 15 Are your patients protected from measles? 16 BCN Advantage 17 Measles is making a comeback. 18 19 In 2014, 592 cases of measles have been confirmed in the United States. This may seem low; however, it’s the highest number 20 Blue Cross Complete of cases here in 20 years. No cases have been reported in Michigan as of June, but our neighbor to the south, Ohio has the 21 largest outbreak in the nation. 22 23 Patient Care The Centers for Disease Control and Prevention says two things are fueling this dramatic increase in cases: outbreaks in foreign 24 countries and the disease spreading through groups of people who are not vaccinated. 25 26 The disease was officially eliminated in 2000 from the United States, but 20 million cases occur 27 Behavioral Health around the world every year. There’s currently a large outbreak in the Philippines. 28 29 Almost all current cases can be traced to travelers who were exposed in another country 30 and brought the virus back home. Ninety percent of the U.S. cases this year were among 31 Quality Counts unvaccinated people. Because of the high risk of importing the disease, vaccination 32 recommendations for those planning international travel differ from the standard 33 recommendations. 34 35 Pharmacy News • Travelers 6 months or older should have evidence of immunity or be vaccinated before 36 leaving the US. 37  38 -- 6 to 11 months: One dose is recommended (a two‑dose revaccination is 39 Billing Bulletin recommended after the child’s first birthday) 40 -- 12 months and older: Two doses are recommended 41 • Space two-dose vaccinations at least 28 days apart. 42 43 Referral Roundup The full vaccination schedule is available on the CDC’s website. Please remind your 44 patients to allow enough time for vaccination when they’re planning to travel. 45 46 47 Index References 48 1. Gastañaduy PA, Redd SB, Fiebelkorn AP, et al. Measles – United States, January 1–May 23, 2014. MMWR [Internet]. 2014 Jun 6 [cited 2014 49 Jun 16]:63(22);496-9. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6322a4.htm?s_cid=mm6322a4_w 50 BCNprovidernews 2. McLean HQ, Fiebelkorn AP, Temte JL, et al. Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps, 2013: Summary 51 NOVEMBER–DECEMBER 2014 Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR [Internet]. 2013 Jun 14 [cited 2014 Jun 16]:62(RR04);1-34. 52 Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6204a1.htm Feedback 3. US Centers for Disease Control and Prevention website – http://www.cdc.gov/measles/cases-outbreaks.html; accessed Sept. 8, 2014. pharmacy news 45 1 2 3 4 BCN launches approval requirements for generic Skelaxin 5 6 Beginning Nov. 1, 2014, Blue Care Network requires A systematic review of comparative studies found no 7 prior authorization before we will cover metaxalone difference in clinical efficacy among the medications 8 Cover Story 9 (generic Skelaxin) for commercial members. Before in this class. Because most of the drugs in this class 10 BCN will approve coverage for metaxalone, the member cause sedation and some pose a serious risk of liver 11 must experience treatment failure or intolerance to toxicity and addiction, selection of an agent should be 12 Network Operations three of four alternative generic agents: chlorzoxazone, based on factors associated with the specific skeletal 13 cyclobenzaprine, methocarbamol or orphenadrine. muscle relaxant. 14 15 16 BCN Advantage On average, generic Skelaxin costs about 43 times as Due to metaxalone’s high cost and failure to demonstrate much as a prescription for other generic skeletal muscle greater efficacy over other products, we encourage you 17 18 relaxants. Metaxalone accounts for just 7 percent of to try more cost-effective agents first. Please consider 19 skeletal muscle relaxant use among BCN members but prescribing an alternative skeletal muscle relaxant when 20 Blue Cross Complete represents 91 percent of dollars spent annually on this your patient requires one of these agents. 21 drug class. 22 23 Patient Care Several cost-effective skeletal muscle relaxants are References 24 25 available to provide appropriate therapy to members 1. Chou, R and Peterson, K. Drug class review: skeletal muscle relaxants. while helping to manage drug costs and keep premiums 26 Oregon Health & Science University; May 2005. 27 in check. Behavioral Health 2. See, S and Ginzburg, R. Choosing a skeletal muscle relaxant. Am Fam 28 Physician. 2008 Aug; 78(3): 365 - 70. 29 Average Plan 30 Drug Cost/Prescription 31 Quality Counts 32 Generic Flexeril 33 $0.44 (cyclobenzaprine) 34 35 Generic Robaxin Pharmacy News $2.41 36 (methocarbamol) 37  38 Generic Parafon Forte $7.11 39 Billing Bulletin (chlorzoxazone) 40 41 Generic Norflex $16.19 42 (orphenadrine citrate) 43 Referral Roundup Generic Skelaxin 44 $279.50 45 (metaxalone) 46 47 Index 48 49 50 BCNprovidernews 51 NOVEMBER–DECEMBER 2014 52 Feedback billing bulletin 46 1 2 3 Billing Q&A 4 5 6 7 Question: Question: 8 Cover Story 9 If I have an appeal or inquiry on a BCBSM claim, can Where do I find information 10 I use the BCN clinical editing appeal form, submit it on BCN’s clinical edits and 11 to your address, and receive a response? the appeal process? 12 Network Operations 13 Answer: Answer: 14 No, Blue Care Network does not process Blue Cross The BCN Provider Manual contains a section on clinical 15 16 BCN Advantage claims. The clinical editing form in the BCN Provider editing. That section provides basic information on clinical Manual referring to the Grand Rapids address is strictly editing, as well as links to tools that can be used if there 17 for edits related to BCN or BCN AdvantageSM claims. are questions on edits. It is located in the Claims section of 18 19 If you have an appeal for a Blue Cross claim or an inquiry the manual. There are other links under the Billing section 20 Blue Cross Complete regarding an edit, it should be submitted to Blue Cross. of web‑DENIS that also may be useful. These links will 21 The appeal should be complete and submitted in writing. take you directly to information about modifiers, EX codes 22 The address for Blue Cross clinical editing appeals is: or to forms such as the Clinical Editing Appeal Form. The 23 Patient Care links also provide recommendations if an appeal is needed 24 25 Providers Appeals Unit – Mail Code 2005 or if a corrected claim may be sufficient. Blue Cross Blue Shield of Michigan 26 600 E. Lafayette BCN publishes regular updates in BCN Provider News and 27 Behavioral Health 28 Detroit, MI 48226-2998 on web‑DENIS. While changes may occur at any time 29 due to updates in billing and coding rules, they are most 30 prevalent at the time of code updates. 31 Quality Counts 32 BCN maintains its commitment to correct coding and 33 works to ensure that accurate updates are in its system on 34 Have a billing question? a timely basis. 35 Pharmacy News 36 If you have a general billing question, we want to 37 hear from you. Click on the envelope icon to open an 38 email, then type your question. It will be submitted to 39 Billing Bulletin BCN Provider News and we will answer your question 40 41  in an upcoming column, or have the appropriate person 42 contact you directly. Please do not include any personal 43 Referral Roundup health information, such as patient names or contract 44 numbers, in your question to us. 45 46 47 Index 48 49 50 BCNprovidernews 51 NOVEMBER–DECEMBER 2014 52 Feedback billing bulletin 47 1 2 3 4 5 BCN will reject old CMS 1500 (08/05) claim forms starting 6 7 Jan. 1, 2015 8 Cover Story 9 Claims for services to Blue Care Network members submitted on the old paper CMS‑1500 (08/05) form will be rejected 10 starting Jan. 1, 2015. The Status Claim Review Form will also be rejected starting on that date. 11 12 Network Operations As a reminder, BCN providers were asked to change to the new CMS‑1500 (02/12) form starting April 1, 2014. 13 14 If you are one of the few providers still using the old CMS‑1500 (08/05) form and the Status Claim Review Form, you’ll 15 16 BCN Advantage need to switch to the new CMS‑1500 (02/12) form by Jan. 1, 2015, or risk having your claims and status inquiries rejected. To submit a status inquiry for a BCN claim using the CMS‑1500 (02/12) form, complete Field 22 by entering the original 17 reference number for the resubmitted claim and the appropriate bill frequency code — either a “7” (to replace a prior claim) 18 19 or an “8” (to void or cancel a prior claim). For BCN claims, providers do not need to complete Field 19. 20 Blue Cross Complete 21 22 23 Patient Care 24 Locating negative balances 25 26 Clinical editing billing online 27 Behavioral Health 28 tips Negative balance reports for facility claims are available 29 online effective immediately. Negative balance reports for 30 In most issues we publish clinical editing billing professional claims will be available online by Dec. 1, 2014. 31 Quality Counts tips. This helps ensure that Blue Care Network 32 pays your claims accurately and that we receive See the PDF below for instructions on how to locate 33 reporting of the performed procedure. To view these reports. 34 the full content of the tips, click on the Clinical 35 Pharmacy News 36 editing billing tips below. Locating negative 37 This issue’s billing tips include: balances PDF 38 39 Billing Bulletin • Documentation of E&M services 40 41  • Use of anatomic modifiers 42 • Use of the most specific code 43 Referral Roundup 44 45 46 Please see Electronic changesClinical, continued editing on Page 47 47 Index 48 billing tips PDF 49 50 BCNprovidernews 51 NOVEMBER–DECEMBER 2014 52 Feedback referral roundup 48 1 2 3 4 Member compliance required before reauthorizing 5 6 positive airway pressure devices 7 Effective with requests for authorization initiated on or after Jan. 1, 2015, BCN HMOSM and BCN AdvantageSM members 8 Cover Story 9 who use positive airway pressure devices must show they’re complying with their treatment recommendations in order 10 to use the devices for longer than 90 days. Northwood, Inc., BCN’s durable medical equipment benefit manager, will 11 no longer authorize use of the devices for 12-month periods. 12 Network Operations 13 Durable medical equipment suppliers play a key role in coordinating the member’s compliance data. This information 14 will show whether the member is benefiting from the equipment and is complying with treatment recommendations. 15 The DME suppliers will make sure the member’s practitioner knows whether the member is complying. 16 BCN Advantage 17 Here’s how the new arrangements work: 18 19 Responsible 20 Blue Cross Complete When the PAP device is prescribed Between day 1 and day 90 party 21 22 Practitioner • Sends the initial request for authorization to • Manages the member, as appropriate 23 24 Patient Care a DME supplier that’s part of the Northwood • Sees the member for a face-to-face evaluation network 25 • Documents whether the member’s symptoms 26 Note: If you need assistance locating a network have improved 27 Behavioral Health provider, contact Northwood at 1‑800‑393‑6432. 28 • Determines whether the member needs to use 29 the equipment beyond 90 days 30 31 Quality Counts Northwood • Processes the request — 32 DME supplier • Delivers the equipment to the member • Receives the member’s compliance updates and 33 34 place them in the member’s file • Instructs the member on how to use the 35 Pharmacy News equipment • Contacts the practitioner for the order to extend 36 the authorization beyond 90 days 37 • Reviews the Northwood PAP compliance 38 acknowledgement letter with the member 39 Billing Bulletin • Has the member sign the letter 40 41 • Places the letter in the member’s file 42 43 Referral Roundup Member • Signs the agreement to indicate his or • Documents compliance by bringing the device’s 44  her intention to comply with treatment memory card to the DME supplier or uploading 45 recommendations and willingness to verify compliance data using online software 46 compliance 47 Index • Sees the practitioner for a face-to-face evaluation 48 within 90 days 49 50 BCNprovidernews 51 NOVEMBER–DECEMBER 2014 52 Feedback Please see positive airway pressure devices, continued on Page 49 referral roundup 49 1 2 3 positive airway pressure devices, continued from Page 48 4 5 If the practitioner has determined the PAP device Members are noncompliant with treatment 6 is needed for more than 90 days and the member’s recommendations if their usage information shows they 7 compliance has been verified during the first 90 days, the used their PAP device for less than four hours per night on 8 Cover Story DME supplier submits the completed Northwood PAP 70 percent of nights during each consecutive 30-day period 9 of the 90 days following receipt of equipment. 10 Therapy Reauthorization Request Form to Northwood. 11 No additional documentation is required. The DME Members who do not comply with treatment 12 Network Operations supplier should keep all compliance documentation and 13 recommendations, who have not had the face-to-face notes in the member’s medical record and make them 14 evaluation with their practitioner or whose symptoms available for audit as necessary. Benefits will be extended 15 have not improved may not be approved by the plan for 16 for the remaining rental months of the PAP device. BCN Advantage an extension of benefits. Members not approved for an 17 If the practitioner determines that the PAP device is extension must return the PAP device to the supplier or be 18 responsible for paying for the device when the authorized 19 needed for more than 90 days but the member did not 20 Blue Cross Complete verify his or her compliance during the first 90 days, the period ends. 21 DME supplier must submit the following to Northwood: 22 • The acknowledgment letter the member signed at the 23 Patient Care 24 initial visit 25 • The completed Northwood PAP Therapy Reauthorization New e-referral system is live 26 Request Form, including the date of the member’s 27 Please see news, information and training about the 28 Behavioral Health face‑to‑face evaluation with the practitioner new e-referral system on the e-referral website. 29 • The practitioner’s notes from the member’s face-to-face 30 evaluation 31 Quality Counts 32 • The compliance data from the first 90 days 33 34 35 Pharmacy News 36 37 38 39 Billing Bulletin 40 2015 BCN Referral and Clinical Review Program 41 42 effective January 1 43 Referral Roundup 44  The 2015 BCN Referral and Clinical Review Program will be effective Jan. 1, 2015. The document applies to 45 BCN HMOSM (commercial), BCN AdvantageSM HMO-POS and BCN AdvantageSM HMO products. 46 Index 47 There are no changes to the program effective Jan. 1, 2015. However, the program is updated as needed 48 throughout the year. The most current program is always available on the Web. 49 50 BCNprovidernews To access the 2015 program starting Jan. 1, please go to ereferrals.bcbsm.com and click on Clinical Review 51 NOVEMBER–DECEMBER 2014 & Criteria Charts. 52 Feedback referral roundup 50 1 2 Use these tips to transition PT, OT, ST cases continuing 3 4 into 2015 5 6 7 Blue Care Network has implemented a year-end transition Care that continues into 2015 8 Cover Story plan for the physical, speech and occupational therapy Physical, occupational and speech therapy providers 9 clinical review process. This process worked well for should enter their own referrals for therapy services for all 10 11 therapy providers and members in 2014; therefore, the patients receiving therapy services in December that will same strategy will apply for 2015. 12 Network Operations carry over into January 2015. The referral begin date should 13 Care that starts in November or December be the date of the first appointment in 2015. You may 14 enter the 2015 referral into e-referral in December 2014. 15 All 2014 treatment authorizations for PT, OT and ST will If you are unable to use e-referral, you may contact Care 16 BCN Advantage 17 end December 2014 for members whose coverage follows Management at 1‑800‑392‑2512. For more information a calendar-year plan. If an episode of care begins in 2014 18 or instructions on using e-referral, please contact your 19 and is expected to continue into 2015, the following apply: BCBSM/BCN provider consultant. Blue Cross Complete 20 • An initial evaluation or reevaluation for therapy isn’t 21 Approvals for 2015 must meet these requirements: necessary to continue an active episode of care 22 into 2015. • The member is an eligible BCN member on the date 23 24 Patient Care services are rendered. • You must enter a new referral either through e-referral 25 or by calling BCN Care Management before the first • Services received must be a benefit covered under the 26 treatment in 2015. member’s contract. 27 Behavioral Health 28 • A member does not need a new referral from the • Benefits must be available or remaining as defined by 29 member’s primary care physician to complete the active the member’s contract. 30 episode of care. 31 Quality Counts 32 Please see Tips, continued on Page 51 33 34 35 Pharmacy News 36 37 Tell us what you think about BCN Care Management — 38 39 Billing Bulletin you could win a prize! 40 41 We’d like to know how satisfied you are with BCN’s Care Management services and learn what we can improve 42 to better meet your needs and those of the BCN members you serve. Please take a few minutes to complete our 43 Referral Roundup BCN Care Management Provider Survey. 44  45 Participation in the survey is not necessary to win. The drawing is open to all active BCN providers. Enter by 46 Index completing the survey no later than Dec. 31, 2014, or by sending an e-mail with your name, phone number and 47 “Survey drawing” in the subject line to [email protected] by Dec. 31, 2014. 48 49 All entries must be received by Dec. 31, 2014. Two winners will be selected in a random drawing from among all 50 BCNprovidernews eligible entries. Each winner will receive a gift card in the amount of $250. The drawing will take place approximately 51 52 NOVEMBER–DECEMBER 2014 one week following the end of December. Winners will be notified by telephone or e-mail following the drawing. Feedback referral roundup 51 1 2 Tips, continued from Page 50 3 4 5 Therapists should enter the 2015 referral on e-referral with Speech Therapy 6 the following information: 7 Procedure code *92506 8 Cover Story Physical Therapy Start date Enter date of the first visit for 2015 9 10 Procedure code Submit applicable procedure code Count 1 11 Start date Enter date of the first visit for 2015 Date span 60 days 12 Network Operations 13 Count 1 • Requests automatically pend for speech therapy. 14 Date span 60 days Landmark processes speech provider referrals according 15 16 BCN Advantage to the established process and therapy providers receive • Category A and B therapy referrals are processed 17 a determination letter. 18 according to their tier level and therapists receive a • Speech therapy providers should submit a treatment 19 determination letter. 20 Blue Cross Complete plan as soon as they determine that care is required • Category C providers who have patients currently under 21 for 2015. Landmark reviews for medical necessity and 22 care or new patients who begin treatment in January sends a determination letter. 23 will receive a letter approving three therapy visits. The Patient Care 24 three-visit approval will be granted through Jan. 31, 2015. BCN Care Management accepts requests for transition 25 26 Be sure to submit a treatment plan prior to the third cases by phone or by e-referral. A transition case is a visit to avoid the risk of lapse in treatment due to lack 27 request for continued access to care for a member new 28 Behavioral Health of authorization. Beginning Feb. 1, 2015, new referrals to BCN and hasn’t seen the primary care physician but 29 revert to the established policy of one evaluation and one needs to continue with ongoing therapy that was started 30 visit for all new patients seen by Category C providers. while under a prior plan. Please call Care Management at 31 Quality Counts 32 1‑800‑392-2512. 33 Occupational Therapy 34 For members with plan year benefits 35 Procedure code Submit applicable procedure code 36 Pharmacy News Most BCN plans apply benefits on a calendar year basis, Start date Enter date of the first visit for 2015 37 but some groups administer benefits on a plan year with 38 Count 1 renewal dates other than January 1. Health care providers 39 Billing Bulletin Date span 60 days can verify this information when checking eligibility on 40 web‑DENIS or PARS (CAREN). If you identify a member 41 • Landmark processes occupational therapy referrals with a plan year other than January 1, a new referral isn’t 42 43 Referral Roundup according to the established process and therapy needed until that plan year ends. BCN and Landmark work 44  providers receive a determination letter. together to administer benefits accordingly. 45 46 47 Index 48 49 50 BCNprovidernews 51 NOVEMBER–DECEMBER 2014 52 Feedback *CPT codes, descriptions and two-digit modifiers only are copyright 2013 American Medical Association. All rights reserved. 52 index INDEX: NOVEMBER–DECEMBER 2014 1 2 BCN Advantage The Blues make it easier for members to manage BCN Advantage open enrollment period has begun...... Page 17 their own health plan at bcbsm .com...... Page 9 3 4 BCN Advantage benefit changes for 2015...... Page 18 CAREN has been replaced by improved IVR system called PARS. . . . Page 10 5 MyChoice Wellness HMO ...... Page 18 Reminder: Members in Blue Elect Plus plan do not need referrals. . . . Page 11 6 Bathroom safety items...... Page 18 Reminder: Healthy Blue Living members who complete 7 BCN Advantage has expanded its service area their requirements move to enhanced benefit level retroactively. . . . Page 12 for Individual and Group plans...... Page 19 Blue Care Network provides office staff incentives 8 Cover Story BCN Advantage introduces ConnectedCare HMO for tobacco cessation campaign...... Page 12 9 local network...... Page 20 BCN offices closed for holiday...... Page 13 10 Reminder: Conducted patient visits by year-end BCN releases videos to improve member experience...... Page 13 11 to close diagnosis gaps for 2014 incentive program...... Page 22 Don’t forget to reattest with CAQH every 120 days...... Page 14 12 Network Operations BCN and BCBSM offer $200 incentive for each Medicare Making changes or updates to facilities ...... Page 14 13 Advantage member with diabetes and hypertension New physical therapy laws won’t change Blues’ policy ...... Page 15 14 started on an ACEI or ARB...... Page 23 Private duty nursing is a covered benefit 15 Blue Care Network supports physicians with cholesterol for State of Michigan employees...... Page 15 16 management efforts...... Page 24 BCN Advantage Blue Care Network pays the lesser of our rate 17 What to do when a service is not covered or your submitted charges for PT, OT, ST therapy...... Page 15 18 and your patient still wants it ...... Page 25 Enrollment for BCBSM and BCN’s new freestanding 19 Behavioral health radiology center networks began Oct . 1...... Page 16 20 Blue Cross Complete Reminder: Blue Care Network’s Behavioral Health 21 Incentive Program documents are on web-DENIS...... Page 36 Patient care Help Blue Care Network reduce childhood obesity...... Page 30 22 ABA limit to be removed in 2015 for treatment of autism...... Page 37 Screen kids early to avoid cardiovascular disease...... Page 31 23 BCN clarifies behavioral health provider requirements ...... Page 37 Type 2 diabetes in children can be prevented...... Page 32 24 Patient Care Seasonal affective disorder can be treated...... Page 38 Medical policy updates ...... Page 32 25 Billing Bulletin Criteria corner...... Page 33 26 Billing Q&A...... Page 46 Diabetes patients require certain tests ...... Page 33 27 28 Behavioral Health Having a billing question?...... Page 46 Blue Care Network partners with Alere management BCN will reject old CMS 1500 (08/05) claim forms for CHF and COPD members...... Page 34 29 starting Jan . 1, 2015...... Page 47 Great American Smokeout is in November...... Page 35 30 Clinical editing billing tips...... Page 47 31 Pharmacy news Quality Counts Locating negative balances online...... Page 47 32 Chantix and Nicotrol products require authorization for coverage. . . . Page 41 33 Blue Cross Complete BCBSM and BCN drug lists updated, available online...... Page 41 34 Provider Recognition Program changes coming for 2015...... Page 26 Switch to generic Norco helps members save...... Page 42 35 Blue Cross Complete offers incentives BCN Pharmacy Clinical Help Desk to handle BCN Advantage 36 Pharmacy News for preventive health services...... Page 26 drug requests, grievances...... Page 42 37 State of Michigan requires providers to include BMI in registry. . . . Page 26 American Academy of Pediatrics updates Synagis guidelines. . Page 43 38 Blue Cross Complete offers incentive program Are your patients protected from measles...... Page 44 for postpartum and well-child visits ...... Page 27 39 Billing Bulletin Correction: Implementation for Walgreens Infusion 40 Complete a health risk assessment for members ...... Page 28 moved to 2015...... Page 44 41 Where to locate pharmacy information and formulary changes. . . . Page 28 BCN launches approval requirements for generic Skelaxin...... Page 45 Reminder: In some instances, Blue Cross Complete 42 Quality Counts 43 Referral Roundup combines two admissions into one for DRG reimbursement...... Page 29 Use Emdeon enrollment for EFT...... Page 29 HEDIS 2014 results...... Page 39 44 NCQA revises measure for blood pressure...... Page 40 45 Network operations Referral Roundup 46 The Blues to offer a variety of individual products for 2015...... Page 1 47 Member compliance required before reauthorizing Index Blue Cross Metro Detroit HMO provides new low cost coverage 48 to individuals in Southeast Michigan...... Page 3 positive airway pressure devices...... Page 48 49  Blue Cross introduces Metro Detroit EPO...... Page 5 2015 BCN Referral and Clinical Review Program effective January 1...... Page 49 50 Blue Care Network continues to offer PCP Focus in 2015...... Page 6 BCNprovidernews Use these tips to transition PT, OT, ST cases continuing into 2015. . . . Page 50 51 Embedded coinsurance maximum introduced for 2015...... Page 6 Tell us what you think about BCN Care Management...... Page 50 52 NOVEMBER–DECEMBER 2014 Checking member eligibility and benefits is crucial ...... Page 7 How to tell if you’re providing services Feedback for a BCN or Blue Cross member...... Page 8 WP 12050 NOV 14 R033124