Provider notification for Utilization Management Authorization Rule Operations Workgroup Item 1326

Effective April 1, 2021, prior authorization (PA) requirements will change for multiple codes. The medical codes listed below will require PA by Empire BlueCross BlueShield HealthPlus for our members. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

PA requirements will be added to the following:

• 30117 — Excision/Destruction, Intranasal Lesion; Int Approach
• 30999 — Unlisted Proc, Nose
• 54401 — Insertion, Penile Prosthesis; Inflatable (Self-Contained)
• C1778 — Lead, neurostimulator (implantable)
• C1787 — Patient programmer, neurostimulator
• C2622 — Prosthesis, penile, noninflatable
• G0157 — Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes
• G2168 — Services performed by a physical therapist assistant in the home health setting in the delivery of a safe and effective physical therapy maintenance program, each 15 minutes
• G2169 — Services performed by an occupational therapist assistant in the home health setting in the delivery of a safe and effective occupational therapy maintenance program, each 15 minutes
• L8681 — Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only
• L8699 — Prosthetic Implant Nos

 

To request PA, you may use one of the following methods:

• Web: http://www.empireblue.com/nymedicaiddoc
• Fax: 1-800-964-3627
• Phone: 1-800-450-8753

 

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers by accessing the Precertification Lookup Tool on the Availity* Portal at https://www.availity.com or on the provider website at http://www.empireblue.com/nymedicaiddoc. Contracted and noncontracted providers who are unable to access Availity, may call Provider Services at 1-800-450-8753 for assistance with PA requirements.

 

* Availity, LLC is an independent company providing administrative support services on behalf of Empire BlueCross BlueShield HealthPlus.

 

NYE-NU-0279-20 December 2020