like us on facebook connect with us on linkedin follow us on twitter March 02, 2022

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Michigan Prior Auth SB247 Up for Hearing March 3.

Click here to view hearing details.

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Spring Reimbursement Meeting - REGISTER TODAY!

Friday, April 29 at the Somerset Inn, Troy

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Are You Having a FEP Blue Cross Urgent Prior Auth Delay?

MSHO has worked with BCBSM and we have a solution!

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BCBSM Erroneous Reimbursement Denials “Exceeds Auth” When All Are Not Used

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WPS Oncology Related LCD Updates

March 2022

Updates that may be of interest to oncology including:
• Complex Drug Administration Coding and Multiple MolDx Revised Policies

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WPS Recent Oncology Related News

Part A, Part B and Part A/B News

Includes articles that may be of interest to oncology released in the past 2 weeks
• Also, Medicare Hot Links to 2022 Final Rules and the WPS Fee Schedules

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Join WPS for a Teleconference, Webinar or Seminar


• Infusion Services: Medical Review Overview and Coverage Criteria -- March 9, just before the MSHO webinar!

• Additional teleconferences, on Demand Training, and YouTube Training opportunities!

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Recent Oncology Related Articles

• Important CMS Redesigns Accountable Care Organization Model to Provide Better Care for People with Traditional Medicare
• CMS Expands Coverage of Lung Cancer Screening with Low Dose Computed Tomography
• Internet-Only Manual Updates (IOM) for Critical Care, Split/ Shared Evaluation and Management Visits, Teaching Physicians, and Physician Assistants
• Recent LearnResource & MedLearn Matters Articles

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Michigan RAC Information

Region 1 - Performant Recovery, Inc.

MORE RAC AUDITS REPORTED!!! All related to waste - not using the smallest vial available or not using the JW modifier! Be Careful!!

Newest approved issues listed on RAC website:
• Positron Emission Tomography for Initial Treatment Strategy in Oncologic Conditions
• Next Generation Sequencing Medical Necessity and Documentation Requirements

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Recent RAC Monitor Articles

This edition includes articles on:

• The CMS Appeals System Is Plagued with Appalling Contractor Performance
• Medicare Advantage Issues Making Headlines

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Recent Oncology Related News

• Claims with telehealth POS 10 are denying incorrectly 
• For BCN AdvantageSM members: Don't issue ABNs or bill with ABN modifiers
• Outpatient facilities must bill self-administered medications through Medicare Part D
• Submit prior authorization requests for prescription drugs through an ePA tool to avoid processing delays
• Enjaymo™, Vabysmo™ and Byooviz® to require prior authorization for Medicare Advantage members
• No need to submit new authorization requests for Neulasta® for HCPCS code J2506
• Register today for the March PGIP quarterly meeting
• Optum to perform outpatient facility audits on Blue Cross commercial claims starting in March 2022
• In March, AIM Specialty Health® to update clinical guidelines for prostate cancer imaging starting March 13
• Changes coming to preferred products for infliximab (reference product Remicade®) for Medicare Advantage members, starting April 1
• Changes coming to preferred products for pegfilgrastim (reference product Neulasta®) for commercial and Medicare Advantage members, starting April 1.
• Nyvepria™ and Rybrevant™ to require prior authorization for UAW Retiree Medical Benefits Trust members with Blue Cross non-Medicare plans starting May 16

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• The Record
• BCN Provider News

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Medicare Plus Blue

Monthly Status Report

Many updates/corrections. Listed below is a sampling of what you will find;
• 835 Recoupment isn't reflected on voucher
• 835 CARC 210 sanction amount is incorrect
• System is applying a denied authorization to a claim in error
• Claims are denying as duplicates against claims in a deleted status

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Payer Issue Tracking Page

Last Reviewed/Updated 3/2/22

Review the reported payer reimbursement issues including:
• Multiple Blue Cross and BCN Issues - PLEASE be sure to review!!!

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Recent Oncology Related News

Medicaid Updates Include:
• MSA Bulletin Updates
• Biller "B" Aware Notices
• No Zoladex Coverage for Michigan Medicaid Patients - NDC Not Rebate Eligible Here is What You Should Do For Your Patient

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Newsletters of Interest

• Aetna OfficeLink Updates
• Cigna
• Humana YourPractice
• UHC Network News

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Priority Health Update

• The C-Code billing only applies to the specific brand of Auromedics Cyclophosphamide
• New Provider Enrollment Requires 90 Calendar Days.
• Anatomic Modifiers Required Starting Apr. 1, 2022

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UnitedHealthcare Update

• Starting April 1st - Exchange Plans: Prior authorization requirements for radiation and chemotherapy services

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Managed Care Committee Reimbursement TIDBITS

Featuring this month: Humana

Tidbits regarding:
• Telehealth Infomation
• Prior Auth Exception within 72 hours
• New Provider Manual Effective March 15, 2022

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Recent Oncology Related FDA Approvals/Changes

Janssen Biotech's CARVYKTI™ (ciltacabtagene autoleucel) a BCMA-Directed CAR-T Immunotherapy for the Treatment of Patients with Relapsed or Refractory Multiple Myeloma. To learn more, click here

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March 2022, Frequently Asked Questions

• E & M - Counting time for a prior auth or peer-to-peer
•Split/Shared - NPP provides a more significant service, who are we required to bill under?
• Private Practice and the No Surprise Act
• April 1st Medicare Sequestration

MSHO MEMBERS - You can access and search previous FAQs! Scroll to the bottom of the Q & As to find out how!

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