Medical policy and clinical guideline updates

These updates list the new and/or revised Empire BlueCross BlueShield (“Empire”) medical policies, clinical guidelines and reimbursement policies*.  The implementation date for each policy or guideline is noted for each section.  Implementation of the new or revised medical policy, clinical guideline or reimbursement policy is effective for all claims processed on and after the specified implementation date, regardless of date of service.  Previously processed claims will not be reprocessed as a result of the changes.  If there is any inconsistency or conflict between the brief description provided below and the actual policy or guideline, the policy or guideline will govern.

 

Federal and state law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over medical policy and clinical guidelines (and medical policy takes precedence over clinical guidelines) and must be considered first in determining eligibility for coverage.  The member’s contract benefits in effect on the date that the services are rendered must be used. This document supplements any previous medical policy and clinical guideline updates that may have been issued by Empire.  Please include this update with your Provider Manual for future reference.

 

Please note that medical policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication.  Empire’s medical policies and clinical guidelines can be found at empireblue.com.

 

*Note: These updates may not apply to all ASO Accounts as some accounts may have non-standard benefits that apply.

 

To view medical policies and utilization management guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program® (FEP®)), please visit www.fepblue.org > Policies & Guidelines.

 

Clinical Guideline Updates

 

New Clinical Guideline Effective 11-01-2021

(The following guideline is new and has been adopted.)

• CG-MED-89 – Home Parenteral Nutrition

 

Corrections to the Medical Policy Update section of the July 2021 Newsletter
In the July 2021 provider newsletter, providers were advised that SURG.00127 Sacroiliac Joint Fusion would be archived effective on September 12, 2021, with minimally invasive sacroiliac joint fusion transitioned to an AIM guideline and open sacroiliac joint fusion converted to a clinical UM guideline (CG-SURG-111 Open Sacroiliac Joint Fusion). We wanted to advise that this medical policy will be archived effective on July 30, 2021.

 

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