State & FederalMedicare AdvantageAugust 31, 2019

Changes to PA requirements

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

Category: Medicare

Beginning December 1, 2019, prior authorization (PA) requirements will change some codes covered by Empire BlueCross BlueShield (Empire) for Medicare Advantage members. Federal and state law, state contract language and CMS guidelines (including definitions and specific contract provisions and exclusions) take precedence over these rules and must be considered first when determining coverage. Empire will deny claims that are noncompliant with the new rules.

 

PA requirements will be added to the following:

  • T1019 — Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant)
  • C9740 — Cystourethroscopy, with insertion of transprostatic implant; 4 or more implants
  • E0953 — Wheelchair accessory, lateral thigh or knee support, any type including fixed mounting hardware
  • E1031 — Rollabout chair, any and all types with castors 5 inches or greater
  • E1090 — High-strength lightweight wheelchair, detachable arms, desk or full-length, swing-away detachable footrests 
  • E1130 — Standard wheelchair, fixed full-length arms, fixed or swing-away detachable footrests 
  • E1140 — Wheelchair, detachable arms, desk or full-length, swing-away detachable footrests 
  • E1260 — Lightweight wheelchair, detachable arms (desk or full-length) swing-away detachable footrest 
  • E1285 — Heavy-duty wheelchair, fixed full-length arms, swing-away detachable footrest 
  • E1290 — Heavy-duty wheelchair, detachable arms (desk or full-length) swing-away detachable footrest
  • E2207 — Wheelchair accessory, crutch and cane holder
  • E2378 — Power wheelchair component, actuator, replacement only
  • K0039 — Leg strap, H style

 

Not all PA requirements are listed here. Detailed prior authorization requirements are available to contracted providers by accessing the Provider Self-Service Tool at https://www.availity.com. Contracted and noncontracted providers who are unable to access the Availity Portal may call the number on the back of your patient’s Empire ID card for PA requirements.

 

EBSCRNU-0043-19 August 2019

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PUBLICATIONS: September 2019 Empire Provider News