 Provider News New YorkApril 2019 Empire Provider NewsletterBeginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. You want what’s best for your patients’ health. So, it's challenging when a patient doesn't follow your prescribed treatment plan. Why do approximately 50% of patients with chronic illness stop taking their medications within one year of being prescribed1? What can be done differently? The missed opportunity may be that you’re only seeing and hearing the tip of the iceberg—the observable portion of the thoughts and emotions your patient is experiencing. The barriers that exist under the waterline -- the Titanic-sized, often invisible, patient self-talk that may not get discussed -- can create a misalignment between patient and provider.
So we’ve created an online learning experience for the skills and techniques that may help you navigate these uncharted patient waters. After completing the learning experience you’ll know how to see the barriers, use each appointment as an opportunity to build trust, and bring to light the concerns that may be occurring beneath the surface of your patient interactions. Understanding and addressing these concerns may help improve medication adherence—and you’ll earn CME credit along the way.
Take the next step. Go to MyDiversePatients.com > The Medication Adherence Iceberg: How to navigate what you can’t see to enhance your skills. The course is approximately one hour and accessible by smart phone, tablet or desktop at no cost.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health and preventive health guidelines, which are available to providers on our website. The guidelines, which are used for our Quality programs, are based on reasonable, medical evidence, and are reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research.
All guidelines are reviewed annually, and updated as needed. The current guidelines are available at empireblue.com/provider/ > “Find Resources in New York” > Provider Home > Health and Wellness > Practice Guidelines. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. In February, Empire introduced a new feature on Interactive Care Reviewer (ICR) that lets you request a clinical appeal for denied authorizations. Now instead of making a phone call or sending a fax you can save time making your request online! This feature is available for authorization requests that were submitted through ICR, phone or fax.
Here’s how easy it is to request a clinical appeal using ICR:
Logon to ICR from the Availity Portal and locate the case from ICR’s dashboard - My Organization Requests or through Check Case Status if the case was submitted by phone or fax.
- Select the Request Tracking ID link to open the case. If the case is eligible for an appeal you will see the Request Appeal menu option on the Case Overview screen.
- Select Request Appeal to open the Appeal Details screen and complete the required fields on the appeal template. (You also have the option of uploading attachments and images to support your request.)
- Select Submit.
Want to check the status of your clinical appeal?
The Check Appeal Status feature was added to ICR in December 2018.
- Select Check Appeal Status from the ICR top menu bar.
- Type the Appeal Case ID and Member ID in the allocated fields (do not include the alpha/numeric prefix).
- Select Submit.
The appeal status and detail of the decision will open on the bottom of the screen.
Additionally, you will be able to access letters associated with the appeal.
Need more information on how to navigate the new ICR Appeals features?
Download the ICR Clinical Appeals Reference Guide located on the Availity Portal. Select: Payer Spaces > Applications > Education and Reference Center > Communication and Education. Find the link to the reference guide below the ICR menu.
Additional Training:
If you are new to ICR or want to get a refresher please attend our monthly ICR webinar.
Register Here for the April webinar. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. In a continuation of our CRA reporting update in March 2019, Empire requests your assistance with respect to our Commercial Risk Adjustment (CRA) reporting processes. There are two approaches that we take (Retrospective and Prospective) that work to improve risk adjustment reporting accuracy. We are focusing on performing appropriate interventions and chart reviews for patients with undocumented Hierarchical Condition Categories (HCC), to close the documentation and coding gaps that we are seeing with our members enrolled in our Affordable Care Act (ACA) compliant plans.
With both our Prospective and Retrospective approaches, accurate documentation and coding are what we are encouraging physicians to achieve. As a physician for our members with ACA compliant plans, you play a vital role in the success of our CRA reporting processes and ACA compliance. When members visit your office, we encourage you to document ALL of the members’ health conditions, especially chronic diseases on the claim. As a result, there will be ongoing documentation that indicates these conditions are being properly assessed and managed. Additional benefits of accurate coding include:
- Reduced volume in medical chart requests in the future due to the increased level of specificity in documentation and coding, as part of our Retrospective approach; and
- Reduced volume of health assessment requests by ensuring your patients with our ACA compliant plans are seen for their annual exams each and every year, as part of our Prospective approach.
Please Note: It’s important to ensure that all diagnosis codes captured in your EMR system are included on the claims, and are not being truncated by your claims software management system. For example, some EMR systems may capture up to 12 diagnosis codes, but a claim system may only have the ability of capturing 4. If your claim system is truncating some of the listed diagnosis codes, please work with your vendor/clearing house to ensure all codes are being captured.
Reminder about ICD-10 CM coding
As you may be aware, the ICD-10 CM coding system serves multiple purposes including identification of diseases, justification of the medical necessity for services provided, tracking morbidity and mortality, and determination of benefits. Additionally, Empire uses ICD-10 CM codes submitted on health care claims to monitor health care trends and costs, disease management and clinical effectiveness of medical conditions.
We encourage you to follow the principles below for diagnostic coding to properly demonstrate medical necessity and complexity:
- Code the primary diagnosis, condition, problem or other reason for the medical service or procedure in the first diagnosis position of the claim whether on a paper claim form or the 837 electronic claim transaction, or point to the primary diagnosis by using the correct indicator/pointer.
- Include any secondary diagnosis codes that are actively managed during a face-to-face, provider-patient encounter, or any condition that impacts the provider’s overall management or treatment of that patient in the remaining positions.
- Include all chronic historical codes, as they must be documented each year under the ACA. (E.g. an amputee must be coded each and every year even if the visit is not addressing the amputated limb specifically).
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective for dates of service on and after June 29, 2019, the following updates will apply to the AIM Joint Surgery Clinical Appropriateness Guidelines.
- General Requirements
- Conservative management: For joint arthroplasty, clarification of conservative management options provide allowance for conservative management exception. Add intraarticular corticosteroid injections as an option. Remove ice or heat given that it is commonly performed in all patients and hence does not meet the threshold for a non-operative management modality as intended. Addition of physical therapy or home therapy requirement for all non-arthroplasty joint procedures based on preponderance of benefit over harm to conservative care. Remove MOON protocol conservative care requirement throughout the document based on feasibility and standards of practice
- Reporting of symptom severity: Inability felt too restrictive to allow for difficulty performing
- Tobacco Cessation: removed nicotine-free documentation requirement
- Subacromial Impingement Syndrome (without Rotator Cuff Tear)Cervical Decompression with or without Fusion
- Drop Arm Test removed due to lack of diagnostic accuracy for subacromial impingement
- Synovectomy/Debridement
- New indication for synovectomy/debridement based on review of the evidence and common clinical scenarios
- Tendinopathy of the Long Head of the Biceps – Tenodesis or Tenotomy
- Allows both techniques based on no evidence for net benefit of one over the other
- Allow a broader range of clinical symptoms and a lower threshold for imaging evidence of tendinopathy , no requirement for MR evidence as tendinopathy can be a clinical diagnosis
- Primary Total Hip Arthroplasty
- Addition of fracture management and hip arthrodesis
- Revision Total Hip Arthroplasty
- Addition of appropriate clinical scenarios based on clinical practice experience and evidence, align terminology to that used in the literature
- Resection Arthroplasty of the Hip, Femoral Head Ostectomy, or Girdlestone Resection Arthroplasty
- Addition of appropriate clinical scenarios based on clinical practice experience (limited evidence)
- Hip Arthroscopy
- Expanded appropriate techniques for FAI surgery to include acetabuloplasty and femoroplasty
- Arthroscopic Treatment of FAIS
- Radiographic and clinical criteria added to include symptoms related to FAI and the likelihood that surgery will be successful
- Elective Patellofemoral Arthroplasty
- New guideline for patellofemoral arthroplasty, a unicompartmental procedure based on evidence and standards of practice
- Revision of Prior Knee Arthroplasty
- Addition of appropriate clinical scenarios based on clinical practice experience and evidence, align terminology to that used in the literature
- Meniscal Repair or Meniscectomy
- Conservative requirement for degenerative meniscus tears
- Definition of acute meniscal tear and symptomatology
- More restrictive use of partial meniscectomy associated with osteoarthritis and degenerative tears
- Arthroscopically assisted lysis of adhesions
- New guideline based on evidence and clinical consensus
- Manipulation under anesthesia
- New guideline based on evidence and clinical consensus
- In-Office Diagnostic Arthroscopy (mi-eye 2™)
- Not medically necessary based on lack of evidence for net benefit
- Meniscal Allograft Transplantation of the Knee
- Collagen meniscal implants are considered not medically necessary
- Treatment of Osteochondral Defects
- New criteria for talar OCD based on lesion size and prior procedures
- Autologous chondrocyte implantation (ACI)
- Allow patellar surface ACI based on evidence for non-inferiority relative to trochlear surface lesions
- CPT Code additions
- CPT codes 27120, 27122, 27437, 27445, 27488, 29871, G0428, 28446, and 29892
As a reminder, ordering providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number: 1-877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.
Please note, this program does not apply to FEP.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines here. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective for dates of service on and after June 29, 2019, the following updates will apply to the AIM Sleep Disorder Management Clinical Appropriateness Guidelines.
- Reconfigured structure of BPAP with and without back-up rate feature criteria for patients with established central sleep apnea (CSA)
- Removed the criteria to try rate support for CSA
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number: 1-877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.
Please note, this program does not apply to FEP.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines here. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective for dates of service on and after June 29, 2019, the following updates will apply to the AIM Clinical Appropriateness Guidelines for Advanced Imaging of the Heart and AIM Clinical Appropriateness Guidelines for Arterial Ultrasound.
Advanced Imaging of the Heart
- Resting Transthoracic Echocardiography (TTE)
- o Changes made to address frequency of surveillance of LV function for cardio-oncology.
- TTE
- o Changes made to address frequency of surveillance echocardiography following transcatheter mitral valve repair. These recommendations follow CMS guidelines.
Arterial ultrasound
- Upper extremity arterial duplex
- o Indication added for creation of arteriovenous (AV) fistulae for dialysis
- Lower extremity arterial duplex
- o ACC guideline for management of peripheral arterial disease (2016) indicates that Duplex imaging should be performed only after the decision to revascularize has been made. There is no role for duplex imaging in the initial diagnosis of peripheral arterial disease. The current AIM guideline is not aligned with this position and the proposed changes address that malalignment.
- o Language changed to account for the fact that critical limb ischemia should include patients with non-healing ulcers and gangrene
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number: 1-877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.
Please note, this program does not apply to FEP.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines here. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective for dates of service on and after June 29, 2019, the following updates will apply to the AIM Advanced Imaging of the Head and Neck Clinical Appropriateness Guidelines.
- Sinusitis/rhinosinusitis
- Expanded the scope of complicated sinusitis
- Defined a minimal treatment requirement for uncomplicated sinusitis
- Identified reasons for repeat sinus imaging, aligned with Choosing Wisely
- Subacute sinusitis to be treated as more like acute or chronic rhinosinusitis based on the AAO-HNS acute sinusitis guideline
- Defined indications for preoperative planning for image navigation following a clinical policy statement on appropriate use from the AAO-HNS
- Removed CT screening for immunocompromised patients
- Infectious disease – not otherwise specified
- Added MRI TMJ to this indication
- Inflammatory conditions – not otherwise specified
- Allow MRI TMJ for suspected inflammatory arthritis following radiographs
- Trauma
- Radiograph requirement for suspected mandibular trauma
- MRI TMJ in trauma for suspected internal derangement in surgical candidates
- Neck mass(including lymphadenopathy)
- Align adult neck imaging guideline with AAO-HNS guideline
- Expand definition of neck mass beyond palpable (seen on laryngoscopy)
- Allow imaging for pediatric neck masses when initial ultrasound is not diagnostic
- Parathyroid adenoma
- Further defined the patient population that needs evaluation
- Removed the requirement for aberrant anatomy in preoperative planning
- Position CT as a diagnostic test after both ultrasound and parathyroid scintigraphy
- Remove MRI as a modality to evaluate based on lack of evidence
- Temporomandibular joint dysfunction
- Removed standalone “frozen jaw” indication
- Allow ultrasound in addition to radiographs as preliminary imaging
- Allow advanced imaging without preliminary radiographs or US in the setting of mechanical signs or symptoms
- Changed “Panorex” to “Radiographs” to allow for TMJ radiographs
- Added requirement for conservative treatment and planned intervention for suspected osteoarthritis
- Cerebrospinal fluid (CSF) leak of the skull base
- Added modalities and criteria to evaluate for CSF leak
- Dizziness or vertigo
- Add Tullio’s phenomenon for lateral semicircular canal dehiscence
- Expand definition of abnormal vestibular function testing
- Hearing loss
- Added indication for sudden onset hearing loss in adult patients
- More clearly delineated appropriate modalities based on types of hearing loss in pediatric patients
- Allow either CT or MRI for mixed hearing loss
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number: 1-877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.
Please note, this program does not apply to FEP.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current guidelines here. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. These updates list the new and/or revised 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.
Medical Policy Updates
Revised Medical Policies Effective 01-31-2019
(The following policies were revised to expand medical necessity indications or criteria.)
- DRUG.00071 - Pembrolizumab (Keytruda®)
- DRUG.00088 - Atezolizumab (Tecentriq®)
- OR-PR.00003 - Microprocessor Controlled Lower Limb Prostheses
Revised Medical Policy Effective 02-27-2019
(The following policy was revised to expand medical necessity indications or criteria.)
- SURG.00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Revised Medical Policies Effective 02-27-2019
(The following policies were reviewed and had no significant changes to the policy position or criteria.)
- ANC.00009 - Cosmetic and Reconstructive Services of the Trunk and Groin
- DME.00025 - Self-Operated Spinal Unloading Devices
- DRUG.00013 - Administration of Immunoglobulin as a Treatment of Recurrent Spontaneous Abortion
- DRUG.00027 - Ziconotide Intrathecal Infusion (Prialt®) for Severe Chronic Pain
- DRUG.00078 - Proprotein Convertase Subtilisin Kexin 9 (PCSK9) Inhibitors
- DRUG.00080 - Monoclonal Antibodies for the Treatment of Eosinophilic Conditions
- DRUG.00081 - Eteplirsen (Exondys 51®)
- DRUG.00082 - Daratumumab (DARZALEX®)
- GENE.00010 - Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status
- GENE.00016 - Gene Expression Profiling for Colorectal Cancer
- GENE.00034 - SensiGene® Fetal RhD Genotyping Test
- GENE.00036 - Genetic Testing for Hereditary Pancreatitis
- GENE.00037 - Genetic Testing for Macular Degeneration
- GENE.00039 - Genetic Testing for Frontotemporal Dementia (FTD)
- GENE.00046 - Prothrombin G20210A (Factor II) Mutation Testing
- LAB.00024 - Immune Cell Function Assay
- LAB.00034 - Serological Antibody Testing for Helicobacter Pylori
- MED.00002 - Selected Sleep Testing Services
- MED.00007 - Prolotherapy for Joint and Ligamentous Conditions
- MED.00013 - Parenteral Antibiotics for the Treatment of Lyme Disease
- MED.00065 - Hepatic Activation Therapy
- MED.00074 - Computer Analysis and Probability Assessment of Electrocardiographic-Derived Data
- MED.00091 - Rhinophototherapy
- MED.00092 - Automated Nerve Conduction Testing
- MED.00097 - Neural Therapy
- MED.00115 - Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management
- MED.00116 - Near-Infrared Spectroscopy Brain Screening for Hematoma Detection
- MED.00117 - Autologous Cell Therapy for the Treatment of Damaged Myocardium
- MED.00122 - Wilderness Programs
- RAD.00012 - Ultrasound for the Evaluation of the Paranasal Sinuses
- RAD.00053 - Cervical and Thoracic Discography
- REHAB.00003 - Hippotherapy
- SURG.00007 - Vagus Nerve Stimulation
- SURG.00036 - Fetal Surgery for Prenatally Diagnosed Malformations
- SURG.00047 - Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia
- SURG.00073 - Epiduroscopy
- SURG.00079 - Nasal Valve Suspension
- SURG.00097 - Vertebral Body Stapling for the Treatment of Scoliosis in Children and Adolescents
- SURG.00099 - Convection Enhanced Delivery of Therapeutic Agents to the Brain
- SURG.00100 - Cryoablation for Plantar Fasciitis and Plantar Fibroma
- SURG.00102 - Artificial Anal Sphincter for the Treatment of Severe Fecal Incontinence
- SURG.00106 - Ablative Techniques as a Treatment for Barrett’s Esophagus
- SURG.00111 - Axial Lumbar Interbody Fusion
- SURG.00112 - Occipital Nerve and Supraorbital Nerve Stimulation
- SURG.00122 - Venous Angioplasty with or without Stent Placement or Venous Stenting Alone
- SURG.00123 - Transmyocardial/Perventricular Device Closure of Ventricular Septal Defects
- SURG.00138 - Laser Treatment for Onychomycosis
- SURG.00146 - Extracorporeal Carbon Dioxide Removal
- THER-RAD.00008 - Neutron Beam Radiotherapy
- THER-RAD.00009 - Intraocular Epiretinal Brachytherapy
- TRANS.00004 - Cell Transplantation (Mesencephalic, Adrenal-Brain and Fetal Xenograft)
- TRANS.00008 - Liver Transplantation
- TRANS.00009 - Lung and Lobar Transplantation
- TRANS.00010 - Autologous and Allogeneic Pancreatic Islet Cell Transplantation
- TRANS.00026 - Heart/Lung Transplantation
- TRANS.00033 - Heart Transplantation
Archived Medical Policies Effective 03-21-2019
(The following policies have been archived and their content has been transferred to new Clinical UM Guidelines.)
- SURG.00115 - Keratoprosthesis [Note: Content transferred to CG-SURG-94 Keratoprosthesis]
- SURG.00117 - Sacral Nerve Stimulation (SNS) and Percutaneous Tibial Nerve Stimulation (PTNS) for Urinary and Fecal Incontinence; Urinary Retention [Note: Content transferred to CG-SURG-95 Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention]
- SURG.00136 - Intraocular Telescope [Note: Content transferred to CG-SURG-96 Intraocular Telescope]
New Medical Policy Effective 07-20-2019
(The policy below was created and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)
- LAB.00036 - Multiplex Autoantigen Microarray Testing for Systemic Lupus Erythematosus
Revised Medical Policies Effective 07-20-2019
(The policies below were revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)
- MED.00110 - Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment and Soft Tissue Grafting
- SURG.00037 - Treatment of Varicose Veins (Lower Extremity)
- TRANS.00035 - Mesenchymal Stem Cell Therapy for the Treatment of Joint and Ligament Disorders, Autoimmune, Inflammatory and Degenerative Diseases
Clinical Guideline updates
Revised Clinical Guidelines Effective 01-31-2019
(The following adopted guidelines were revised to expand medical necessity indications or criteria.)
- CG-DRUG-50 - Paclitaxel, protein-bound (Abraxane®)
- CG-DRUG-99 - Elotuzumab (Empliciti™)
- CG-SURG-27 - Sex Reassignment Surgery
- CG-SURG-83 - Bariatric Surgery and Other Treatments for Clinically Severe Obesity
Revised Clinical Guidelines Effective 02-27-2019
(The following adopted guidelines were revised to expand medical necessity indications or criteria.)
- CG-DRUG-106 - Brentuximab Vedotin (Adcetris®)
- CG-SURG-77 - Refractive Surgery
Revised Clinical Guidelines Effective 02-27-2019
(The following adopted guidelines were reviewed and had no significant changes to the policy position or criteria.)
- CG-ANC-04 - Ambulance Services: Air and Water
- CG-BEH-14 - Intensive In-home Behavioral Health Services
- CG-BEH-15 - Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
- CG-DME-10 - Durable Medical Equipment
- CG-DME-31 - Wheeled Mobility Devices: Wheelchairs-Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs)
- CG-DME-33 - Wheeled Mobility Devices: Manual Wheelchairs-Ultra Lightweight
- CG-DME-43 - High Frequency Chest Compression Devices for Airway Clearance
- CG-DRUG-01 - Off-Label Drug and Approved Orphan Drug Use
- CG-DRUG-28 - Alglucosidase alfa (Lumizyme®)
- CG-DRUG-29 - Hyaluronan Injections
- CG-DRUG-43 - Natalizumab (Tysabri®)
- CG-DRUG-82 - Prostacyclin Infusion Therapy and Inhalation Therapy for Treatment of Pulmonary Arterial Hypertension
- CG-DRUG-83 - Growth Hormone
- CG-DRUG-84 - Belimumab (Benlysta®)
- CG-DRUG-85 - Tesamorelin (Egrifta®)
- CG-DRUG-86 - Ocriplasmin (Jetrea®) Intravitreal Injection Treatment
- CG-DRUG-93 - Sarilumab (Kevzara®)
- CG-LAB-13 - Skin Nerve Fiber Density Testing
- CG-MED-23 - Home Health
- CG-OR-PR-05 - Myoelectric Upper Extremity Prosthetic Devices
- CG-SURG-03 - Blepharoplasty, Blepharoptosis Repair, and Brow Lift
- CG-SURG-70 - Gastric Electrical Stimulation
- CG-SURG-71 - Reduction Mammaplasty
- CG-SURG-72 - Endothelial Keratoplasty
- CG-SURG-75 - Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions
- CG-THER-RAD-07 - Intravascular Brachytherapy (Coronary and Noncoronary)
Adopted Clinical Guidelines Effective 03-21-2019
(The following guidelines were previously medical policies and have been adopted and have no significant changes.)
- CG-SURG-94 - Keratoprosthesis [Note: Content moved from SURG.00115 Keratoprosthesis.]
- CG-SURG-95 - Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention [Note: Content moved from SURG.00117 Sacral Nerve Stimulation (SNS) and Percutaneous Tibial Nerve Stimulation (PTNS) for Urinary and Fecal Incontinence; Urinary Retention.]
- CG-SURG-96 - Intraocular Telescope [Note: Content moved from SURG.00136 Intraocular Telescope.]
Revised Clinical Guideline Effective 07-01-2019
(The following adopted guideline was revised and might result in services that were previously covered but may now be found to be not medically necessary.)
- CG-DRUG-106 - Brentuximab Vedotin (Adcetris®)
Revised Clinical Guidelines Effective 07-20-2019
(The following adopted guidelines were revised and might result in services that were previously covered but may now be found to be not medically necessary.)
- CG-MED-73 - Hyperbaric Oxygen Therapy (Systemic/Topical)
- CG-SURG-27 - Sex Reassignment Surgery
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning with dates of service on or after July 1, 2019, Empire will implement the new facility reimbursement policy, Partial Hospitalization Program and Intensive Outpatient Program Services. This policy applies a limit of one (1) unit of service per day for partial hospitalization program and/or intensive outpatient programs. For more information about this new policy, visit the Reimbursement Policy page at empireblue.com/provider.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. In December we posted two articles regarding changes effective January 1, 2019 to our Individual Pathway Networks and a new Network called Blue Access. Both these networks have Gatekeeper models which involves the member choosing a PCP and referrals are needed to see most specialists.
Early claims may not have been impacted. Moving forward please be advised that claims submitted without necessary referrals will be denied according to our agreements and the member will be held harmless. Our Managed Care Referral Form can be found on empireblue.com/provider > Find Forms > General Forms.
Please contact the number on the back of the member’s card if you have any questions or concerns.
The attached table indicates Gatekeeper plans that currently require a referral.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective July 1, 2019, Empire will transition medical necessity review of rehabilitative (restoring function) and habilitative (enhancing function) services for fully insured members to AIM Specialty Health ® (AIM). Currently, OrthoNet LLC is performing medical necessity reviews for physical and occupational therapy services for Empire. These reviews will transition to AIM in addition to adding speech therapy service reviews.
AIM will manage Physical Therapy (PT), Occupational Therapy (OT) and Speech Therapy (ST) medical necessity reviews using the following Empire’s Clinical UM Guidelines: CG-REHAB-04 Physical Therapy, CG-REHAB-05 Occupational Therapy, and CG-REHAB-06 Speech-Language Pathology Services. Please note, this does not apply to procedures performed in an inpatient or observation setting, or on an emergent basis. The clinical criteria to be used for these reviews can be found on the Empire’s Provider portal Clinical UM Guidelines page. A complete list of CPT codes requiring prior authorization for the AIM Rehabilitative program is available on the AIM Rehabilitation microsite. There you can learn more about the program and access helpful information and tools such as order entry checklists and FAQs.
AIM will begin accepting prior authorization requests on June 17, 2019 for dates of service on and after July 1, 2019. To determine if prior authorization review is needed for an Empire member, please check online or call the prior authorization review number located on the back of the member ID card. As of July 1, 2019, self-funded accounts (ASO) that currently have the OrthoNet program will also be offered the AIM Rehabilitative program. The program will also be offered to new local self-funded accounts (ASO) to add to their members’ benefit package as of July 1, 2019.
Ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com.
- Call the AIM Contact Center toll-free number at 1-877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.
AIM Rehabilitation training webinars
Empire invites you to take advantage of a free informational webinar that will introduce you to the program and the robust capabilities of the AIM ProviderPortalSM. Go to the AIM Rehabilitation microsite to register for an upcoming webinar. If you have previously registered for other services managed by AIM, there is no need to register again. The training will be recorded and can be viewed at a time convenient for you! Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. For more information on copayment/coinsurance requirements and their applicable drug classes, drug lists and changes, prior authorization criteria, procedures for generic substitution, therapeutic interchange, step therapy or other management methods subject to prescribing decisions, and any other requirements, restrictions, or limitations that apply to using certain drugs, visit empireblue.com/pharmacyinformation. The commercial and marketplace drug lists are posted to the web site quarterly (the first of the month for January, April, July and October).
To locate Marketplace scroll down to “Select Drug Lists.” This drug list is also reviewed and updated regularly as needed.
FEP Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective for dates of service on and after July 1, 2019, the following specialty pharmacy codes from the current guideline will be included in our prior authoirzation review process.
Please note, inclusion of NDC code on your claim will shorten the claim processing time of drugs billed with a Not Otherwise Classified (NOC) code.
Empire’s prior authorization clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM), a separate company.
The following clinical guideline will be effective July 1, 2019.
|
Clinical Guideline
|
HCPCS or CPT Code(s)
|
NDC Code(s)
|
Drug
|
|
CG-THER-RAD-03
|
A9699, C9408
|
71258-0015-02 71258-0015-22
|
Azedra®
|
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The credentialing process must be completed before a practitioner begins seeing members and enters into a contractual relationship with a health care insurer. As part of our credentialing process, practitioners have certain rights as briefly outlined below.
Practitioners can request to:
- Review information submitted to support their credentialing application.
- Correct erroneous information regarding a credentialing application.
- Be notified of the status of credentialing or recredentialing applications.
The Council for Affordable Quality Healthcare (CAQH®*) universal credentialing process is used for all providers who contract with Empire BlueCross BlueShield HealthPlus (Empire). To apply for credentialing with Empire, go to the CAQH website at https://www.caqh.org and select CAQH ProView™. There is no application fee.
We encourage practitioners to begin the credentialing process as soon as possible when new physicians join a practice. Doing so will help minimize any disruptions to the practice and members’ claims.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Each year, we may reach out to you to ask what we are doing well and how we can continue to improve our services. We use this feedback to continually improve our operations and strengthen our relationship with our providers.
Thank you for participating in our network, for providing quality health care to our members and for your timely completion of any surveys you receive. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. For markets with carved-out pharmacy services, the applicable listings below are informational only.
Please share this notice with other members of your practice and office staff.
To search for specific policies or guidelines, visit https://www11.empireblue.com/ny_search.html.
Updates:
- CG-BEH-01 — Screening and Assessment for Autism Spectrum Disorders and Rett Syndrome was revised to add tests for metabolic markers in the blood, urine, tissue or other biologic materials (also known as metabolomics), including but not limited to Amino Acid Dysregulation Metabotype testing as not medically necessary.
- The following AIM Specialty Healthâ updates took effect as noted below:
- o Musculoskeletal interventional pain management (effective January 1, 2019)
- o Spine surgery (effective January 1, 2019)
- o Radiology (effective November 1, 2014)
- The following customizations to MCG Care Guidelines (22nd Edition) went into effect on January 16, 2019:
- o Behavioral Health Level of Care Guidelines
- o Inpatient and Surgical Care Care Guidelines — neonatology, orthopedics, thoracic surgery and pulmonary disease
- Customizations to the MCG Care Guidelines (23rd Edition) take effect on May 24, 2019.
- The InterQual 2019 version release takes effect on May 1, 2019.
Medical Policies
On November 21, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Empire BlueCross BlueShield HealthPlus (Empire).
|
Publish date
|
Medical Policy #
|
Medical Policy title
|
New or revised
|
|
12/12/2018
|
MED.00126
|
Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders
|
New
|
|
12/12/2018
|
DRUG.00090
|
Bezlotoxumab (ZINPLAVA™)
|
Revised
|
|
11/15/2018
|
MED.00109
|
Corneal Collagen Cross-Linking
|
Revised
|
|
12/12/2018
|
TRANS.00024
|
Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome
|
Revised
|
|
11/15/2018
|
SURG.00120
|
Internal Rib Fixation Systems
|
Revised
|
|
12/12/2018
|
SURG.00103
|
Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
|
Revised
|
|
11/15/2018
|
DRUG.00046
|
Ipilimumab (Yervoy®)
|
Revised
|
|
11/15/2018
|
DRUG.00075
|
Nivolumab (Opdivo®)
|
Revised
|
|
12/12/2018
|
DRUG.00062
|
Obinutuzumab (Gazyva®)
|
Revised
|
|
11/15/2018
|
DRUG.00071
|
Pembrolizumab (Keytruda®)
|
Revised
|
|
12/12/2018
|
SURG.00121
|
Transcatheter Heart Valve Procedures
|
Revised
|
Clinical UM Guidelines
On November 21, 2018, the MPTAC approved the following Clinical UM Guidelines applicable to Empire. These guidelines were adopted by the medical operations committee for Medicaid Managed Care members on January 3, 2019.
|
Publish date
|
Clinical UM Guideline #
|
Clinical UM Guideline title
|
New or revised
|
|
11/15/2018
|
CG-DRUG-88
|
Dupilumab (Dupixent®)
|
Revised
|
|
12/12/2018
|
CG-BEH-01
|
Screening and Assessment for Autism Spectrum Disorders and Rett Syndrome
|
Revised
|
|
12/12/2018
|
CG-DRUG-107
|
Pharmacotherapy for Hereditary Angioedema
|
Revised
|
|
12/12/2018
|
CG-DRUG-63
|
Levoleucovorin Products Previously title: Levoleucovorin Calcium (Fusilev®)
|
Revised
|
|
12/12/2018
|
CG-DRUG-65
|
Tumor Necrosis Factor Antagonists
|
Revised
|
|
12/12/2018
|
CG-DRUG-78
|
Antihemophilic Factors and Clotting Factors
|
Revised
|
|
12/12/2018
|
CG-GENE-01
|
Janus Kinase 2 (JAK2)V617F and JAK2 exon 12 Gene Mutation Assays Previous title: Janus Kinase 2 (JAK2) V617F Gene Mutation Assay
|
Revised
|
|
12/12/2018
|
CG-GENE-03
|
BRAF Mutation Analysis
|
Revised
|
|
12/12/2018
|
CG-LAB-14
|
Respiratory Viral Panel Testing in the Outpatient Setting
|
New
|
|
12/12/2018
|
CG-MED-78
|
Anesthesia Services for Interventional Pain Management Procedures
|
New
|
|
12/12/2018
|
CG-SURG-27
|
Sex Reassignment Surgery
|
Revised
|
|
12/12/2018
|
CG-SURG-60
|
Cervical Total Disc Arthroplasty
|
Revised
|
|
12/12/2018
|
CG-SURG-91
|
Minimally Invasive Ablative Procedures for Epilepsy
|
New
|
|
12/12/2018
|
CG-THER-RAD-03
|
Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy
|
Revised
|
|
1/3/2019
|
CG-MED-79
|
Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
|
New
|
|
1/3/2019
|
CG-MED-80
|
Positron Emission Tomography (PET) and PET/CT Fusion
|
New
|
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Summary of change: Effective June 1, 2019, we are updating our provider payment disbursement processes. Change Healthcare and PaySpan will no longer be used for electronic funds transfer (EFT) and electronic remittance advice (ERA) enrollment, and remittances are no longer accessible on their websites. These functions can now be accessed through the following:
- EFT: If you were enrolled for EFT before June 1, 2019, the enrollment was transferred. You should continue to receive EFT payments. If you are having issues receiving EFT, call the number on the back of the member's ID card:
- New EFT enrollment: To enroll, go to EnrollHub™, a Council for Affordable Quality Healthcare (CAQH) Solutions™ enrollment tool, at https://www.caqh.org/solutions/enrollhub. Please note the EFT enrollment process can take six to eight weeks. If you have issues enrolling, call the number on the back of the member's ID card.
- Virtual card: Providers receiving virtual cards from other lines of business for their tax ID will see this additional claim activity delivered as virtual cards.
- ERA/835: If you were enrolled for ERA before June 1, 2019, the enrollment has transferred. You should continue receiving ERAs through the same clearinghouse you have been using. If you are not receiving ERAs through the same clearinghouse, please call the E-Solutions Help Desk at 1-800-470-9630:
- New ERA enrollment and change management for existing ERA enrollments will be managed through Availity. If you aren’t registered for Availity, go to https://www.availity.com, select Register and follow the steps. Once logged into Availity, the administrator for the organization will select Enrollments Center in the My Account Dashboard on the home page, select ERA Enrollment in the Multi-Payer Enrollments section and follow the wizard and submit. After submitting the enrollment, you will be notified by email that enrollment is complete and start receiving 835s through Availity as of June 1, 2019. Please note the ERA enrollment process takes up to 48 hours. If you sign up for ERAs through Availity after June 1, 2019, and wish to receive ERAs June 1, 2019, to the date you signed up with Availity, please call the E-Solutions Help Desk at 1-800-470-9630.
- Providers will have access to Explanation of Payment letters (paper remittances) through the secure Availity Portal, effective June 1, 2019. You must be registered with Availity to view these remittances. If you aren’t registered, go to https://www.availity.com, select Register and follow the steps.
- Medicaid and Medicare remittance advices have been consolidated.
These enhancements offer providers streamlined reimbursement registration tools.
The following chart summarizes information about the new processes to enroll in EFT or ERA, or to update EFT and ERA transaction information after June 1, 2019.
Process to enroll or update electronic transactions after June 1, 2019
|
Type of transaction
|
How to enroll, update, change or cancel
|
Contact to resolve issues
|
|
EFT only
|
Use the EnrollHub™, a CAQH Solution™ enrollment tool, a secure EFT registration platform at: https://www.caqh.org/solutions/ enrollhub.
|
CAQH Provider Help Desk: 1-844-815-9763
Call the number on the back of the member's ID card.
|
|
Virtual card
|
Invitations previously sent via letter to selected Tax IDs. Enrollment in EFT would take the place of virtual card.
|
Questions: 1-800-833-7130
|
|
ERA only
|
Register for ERAs at https://www.availity.com.
|
Availity: 1-800-282-4548
E-Solutions Help Desk: 1-800-470-9630
|
Are providers required to enroll for EFT and ERA?
No, providers are not obligated to enroll for either EFT or ERA and will receive a paper check or virtual card accompanied with a remittance advice.
Is there a cost to providers for the changes to the EFT, virtual card and ERA?
There is no cost to providers from Empire BlueCross BlueShield (Empire). Providers should inquire with trading partners and other vendors they work with to understand additional steps or any changes to services.
Information and changes to expect
Medicaid and Medicare claim payments and recoveries with claim adjudication beginning June 1, 2019, will be incorporated into one remittance advice for paper or electronic payments. Checks and EFTs from Empire will also be combined. Medicaid and Medicare will be grouped separately on the paper remittance in a section for each product line:
- The back of the remittance advice will contain specific instructions on how to file Medicare appeals.
- Medicaid and Medicare claims are identified in the Claim Filing Indicator Code (CLP06 segment) on the ERA/835 for Medicaid with MC and Medicare with MB, MA or 16
- Effective June 1, 2019, we will discontinue the email notification providers currently receive when an EFT and ERA is issued.
- The PDF versions of paper remittances will be available on the secure Availity Portal (https://www.availity.com). Both provider and clearinghouse will 835s continue to be received through the EDI process.
- More information about retrieving copies of remittance advices will be available online. To access our tutorial, Remittance Inquiry Process Guide, go to our provider website and select the Training under Provider Support/Provider Education/Other Training resources. It will be available on June 1, 2019.
- Non-Federal Employee Program payments under $5 will be held for a maximum of 14 days to allow additional claims to combine to increase the overall payment amount.
- These changes will ensure efficiency and consistency between professional and facility claim payments.
- The Automated Clearing House batch header is changing. The payee name that appears on the EFT statement is changing and will be easily identifiable. This change does not impact payment to you in any way. You will now see EMPIRE BLUE 05C.
How do I access historical ERAs from Change Healthcare and PaySpan?
We are in the process of migrating all historical remittance advices to the secure Availity Portal (https://www.availity.com). We will notify you when the migration is complete. Please continue to use Change Healthcare and PaySpan to receive historical paper remittances prior to June 1, 2019.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. CPT Category II codes are supplemental tracking codes used to support quality patient care and performance management. CPT II codes are:
- Billed in the procedure code field in the same way as CPT Category I codes.
- Used to describe clinical components usually included in evaluation, management or clinical services.
- Billed with a $0 billable charge amount since they are not usually associated with any relative value.
Under this new incentive program, Empirew ill reimburse contracted Medicare Advantage providers for submitting select HEDIS®-related CPT Category II codes for eligible members.
Using these CPT Category II codes for Medicare Advantage members will:
- Help providers address clinical care opportunities.
- Facilitate timely and accurate claims payments.
Detailed information about this program, including a list of applicable codes, will be sent to providers.
ABSCARE-0006-19
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire has identified that providers often bill a duplicate Evaluation and Management (E/M) service on the same day as a procedure even when the same provider (or a provider with the same specialty within the same group TIN) recently billed a service or procedure which included an E/M for the same or similar diagnosis. The use of modifier 25 to support separate payment of this duplicate service is not consistent with correct coding or Empire’s policy on use of modifier 25.
Beginning with claims processed on or after May 1, 2019 Empire may deny the E/M service with a modifier 25 billed on the day of a related procedure when there is a recent service or procedure for the same or similar diagnosis on record.
If you believe a claim should be reprocessed because there are medical records for related visits that demonstrate an unrelated, significant and separately identifiable E/M service, please submit those medical records for consideration.
|