Provider Update | 2023 year in reviewMonday, Jan 22, 2024
In this Provider Update, we’re sharing our top updates from 2023 to refresh your memory as we start the new year. Read up on Dexcom G7 coverage, updates on Dupixent quantities, drug shortages, Coordination of Benefits claims and a quick reminder for dental providers.
As of November 7, 2023, BC PharmaCare has added the Dexcom G7 Continuous Glucose Monitor (CGM) to its formulary requiring Special Authority (SA) approval. Dexcom G7 joins Dexcom G6 and FreeStyle Libre 2 as the third glucose monitoring system listed by BC PharmaCare. Pacific Blue Cross has aligned our Dexcom G7 prior authorization criteria with BC PharmaCare Special Authority criteria.
BC residents will be required to obtain BC PharmaCare SA approval in order to be eligible for Dexcom G7 coverage. Once approval is in place, claims will automatically be approved based on plan rules. Claims no longer need to be submitted manually by patients, as pharmacies will now be able to submit Dexcom G7 claims electronically under the PharmaCare published PINs:
Dexcom G7® Receiver
Dexcom G7® Sensor
Patients residing outside of BC may fill out the Dexcom G6/G7/FreeStyle Libre 2 INITIAL request form, if it’s their first-time request, or the RENEWAL request form to renew a previous approval.
We’ve made system updates to ensure that we’re following correct quantities for Dupixent claims, a prescription drug used to treat asthma, atopic dermatitis and other conditions, recently listed by BC PharmaCare.
We previously accepted pharmacy claims billed per syringe. As of October 17,2023, all electronic pharmacy claims for BC members must be submitted using the total volume of drug dispensed (by mL), to ensure accurate claim payment.
|Correct billing quantity
300 mg (150mg/mL)
2 mL per syringe
1.14 mL per syringe
On December 6, 2023, Health Canada published recommendations for prescribers and patients during drug shortages of Ozempic, Trulicity and Mounjaro. After engaging with the Canadian Pharmacists Association, the Canadian Society of Hospital Pharmacists, the College of Family Physicians of Canada and the Canadian Society of Endocrinology and Metabolism, BC PharmaCare and the Canadian Pharmacist Association (CPhA) have published notices on the recommendations, which include:
- Not to start new patients on these drugs*.
- *Unless there are no suitable alternatives and there is a clinical reason to do so.
- Consider an alternative drug for patients who require one of these drugs, as a continuous supply cannot be guaranteed.
Save time and mailing expenses by sending your Coordination of Benefits (COB) claims electronically to Pacific Blue Cross.
It’s important to ensure that all required information is submitted on the initial submission. When steps or necessary information is not included, we may not be able to validate and approve single or dual coverage with Pacific Blue Cross.
Here are some examples of common situations when missing information could cause delays with processing:
- When a patient has COB and they are the cardholder (dependent 00) for both plans, we need to know their employment status with both coverages to determine which plan is primary as well as the employment status of the cardholder (full-time, part-time or retiree).
- Pacific Blue Cross bases COB rules on the Canadian Life and Health Insurance Association guidelines. As such, if a person is a member (cardholder) of two plans, priority goes to:
- The plan where the member is an active full-time employee
- The plan where the member is an active part-time employee
- The plan where the member is a retiree
To prevent a delay in assessment, provide any pertinent information that will assist us in determining the order of payment. For paper submissions, you must include proof of payment (copy of the Explanation of Benefits) when another carrier is involved, which assists with the processing of a claim when deductibles or limitations are reached under the primary plan. If the primary plan is no longer in effect, please provide the termination date.
For electronic submissions, ensure that the COB 07 transaction is enabled in your practice management software or call your vendor to have them configure the COB 07 transaction for you.
|Pacific Blue Cross Insurance
|General Block of Business
Any client with possible overlapping coverage
Submit all documentation with COB information to PBC for review
- If the electronic EOB response includes payment adjudication responses, send to secondary coverage electronically.
If the electronic EOB response does not include payment adjudication responses, send to secondary coverage by paper.
Sign up for direct deposit on PROVIDERnet to save time and ensure fast payment processing. Payments are deposited directly into your business account on a weekly basis, so no more waiting for mail or visiting the bank!
Sign up today:
- Sign into your PROVIDERnet account. If you don’t have access, register for an account on PROVIDERnet.
- Once approved, activate your PROVIDERnet account.
Click on the Account tab and add your direct deposit information to our secure site.
Calling all dental providers:
- When you submit claims electronically, please confirm that the business address is up to date for seamless cheque payments.
- There’s no need to send predetermination for basic services.
- All receipts and claims must be submitted with the specific dental practitioner who has performed the services. This includes the full 9-digit practitioner number and the full name of the dental practitioner providing the services.
Visit us at the Pacific Dental Conference! We’ll be at Booth 257 from March 7-9, 2024.