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Anthem, Inc., Empire BlueCross BlueShield’s parent company, has completed its acquisition of Beacon Health Options, a large behavioral health organization that serves more than 36 million people across the country. The company will operate as a wholly owned subsidiary of Anthem, Inc.

 

Bringing together our existing solid behavioral health business with Beacon’s successful model and support services creates one of the most comprehensive behavioral health networks in the country. It’s also an opportunity to offer best-in-class behavioral health capabilities and whole person care solutions in new and meaningful ways to help people live their best lives.

 

From the standpoint of our customers and providers at this time, it’s business as usual:

• Members should continue to call the customer service number on the back of their membership card or access their health plan’s website for online self-service.
• Providers should continue to use the provider service contact information, websites and online self-service portals as part of their agreement with either Anthem, Inc. or Beacon.
• There will be no immediate changes to the way Anthem, Inc, or Beacon manage their respective provider networks, contracts and fee arrangements. Anthem, Inc. and Beacon provider networks, contracts and fee arrangements will remain separate at this time.

 

We know our providers continue to expect more of their healthcare partner, and at Anthem, Inc., we aim to deliver more in return.

 

For more details, please see the press release.

A key goal of Empire BlueCross BlueShield’s (“Empire”) provider transparency initiatives is to improve quality while managing health care costs. One of the ways is through Empire’s value-based programs such as Enhanced Personal Health Care, Bundled Payment Programs, Oncology Medical Home, and so on – called the “Programs.”  Certain providers (“Value-Based Program Providers” also known as “Payment Innovation Providers”) in Empire’s various value-based programs receive quality, utilization and/or cost data, reports, and information about the health care providers (“Referral Providers”) to whom the Value-Based Program Providers may refer their patients covered under the Programs. If a Referral Provider is higher quality and/or lower cost, this component of the Programs should result in the provider getting more referrals from Value-Based Program Providers. The converse should be true if Referral Providers are lower quality and/or higher cost.

 

Providing this type of data, including comparative cost information, to Value Based Program Providers helps them make more informed decisions about managing health care costs and maintaining and improving quality of care. It also helps them succeed under the terms of the Programs.

 

Additionally, employers and group health plans (or their representatives or vendors) may also be given quality/cost/utilization information about Value Based Program Providers and Referral Providers so that they can better understand how their health care dollars are being spent and how their health benefits plans are being administered. This will, among other things, give them the opportunity to educate their employees and plan members about the benefits of using higher quality and/or lower cost health care providers.

 

Empire will share data on which it relied in making these quality/cost/utilization evaluations upon request, and will discuss it with Referral Providers - including any opportunities for improvement. For questions or support, please refer to your local Market Representative or Care Consultant.

At Empire BlueCross BlueShield (“Empire”), we continue to make changes to our public provider website to make it easier for you to find the information you need. The end of Q1 brings a few updates for the site at empireblue.com/provider:

• Information has been added to our website regarding Patient-Centered Specialty Care (PCSC) – Empire’s value-based payment program for cardiology, endocrinology and obstetrics/gynecology providers. You can find this information online as an extension of our broader patient-centered, value-based care program – Enhanced Personal Health Care (EPHC).
• Documents listed on the Prior Authorization page can be conveniently accessed via online links.
• Medicare Advantage will be live in the coming days. You will be able to view updated Medicare Advantage pages on the commercial public sites. Medical Policies (MP) and Clinical Utilization Management Guidelines (CUMG) now display on our newly designed Web pages.

 

If you have any questions, please contact Michelle Fraser at michelle.fraser@anthem.com or Nick Kizirnis at nick.kirzinis@anthem.com.

Effective July 1, 2020, we will upgrade to the 24th edition of MCG care guidelines for the following modules: Inpatient & Surgical Care (ISC), General Recovery Care (GRC), Chronic Care (CC) and Recovery Facility Care (RFC). The below tables highlight new guidelines and changes that may be considered more restrictive.

 

Goal Length of Stay (GLOS) Changes for Inpatient & Surgical Care (ISC)

 

Guideline	MCG Code	24th Edition GLOS	23rd Edition GLOS
Aortic Valve Replacement, Transcatheter	S-1320	2 days postoperative	3 days postoperative
Appendectomy, with Abscess or Peritonitis, by Laparoscopy	S-185	Ambulatory or 2 days postoperative	2 days postoperative
Appendectomy, without Abscess or Peritonitis, by Laparoscopy	S-175	Ambulatory postoperative	Ambulatory or 1 day postoperative
Repair of Pelvic Organ Prolapse	S-1020	Ambulatory postoperative	Ambulatory or 1 day postoperative
Urethral Suspension Procedures	S-850	Ambulatory postoperative	Ambulatory or 1 day postoperative
Appendectomy, with Abscess or Peritonitis, by Laparoscopy, Pediatric	P-30	Ambulatory or 2 days postoperative	2 or 3 days postoperative
Appendectomy, without Abscess or Peritonitis, by Laparoscopy, Pediatric	P-20	Ambulatory postoperative	Ambulatory or 1 day postoperative
Tibial Osteotomy, Child or Adolescent	S-1131	Ambulatory or 1 day postoperative	1 day postoperative

 

New Optimal Recovery Guidelines (ORGs) for Inpatient & Surgical Care (ISC) and New Behavioral Health Care (BHC) New Guidelines

Body System	Guideline Title	MCG - Code
Pediatrics	Appendectomy, with Abscess or Peritonitis, Pediatric	P-35
Pediatrics	Appendectomy, without Abscess or Peritonitis, Pediatric	P-25

 

Empire Customizations to MCG care guideline 24th Edition

Effective July 1, 2020, the following MCG care guideline 24th edition customizations will be implemented.

• Carotid Artery Stenting (W0165) – Clinical Indications were customized to reference CG-SURG-76 Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty

 

Visit empireblue.com/provider to view the Customizations to MCG Care Guidelines 24th Edition.

 

For questions, please contact the provider service number on the back of the member's ID card.

The "Level of Care Medical Necessity Reviews for Upper and Lower Endoscopies" article as noted on the April newsletter reminder postcard has been delayed and is not included in this newsletter. 

Effective June 1, 2020, prior authorization (PA) requirements will change for the following services to be covered for Empire BlueCross BlueShield HealthPlus members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services 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 codes:

• 0156U — Copy number (for example, intellectual disability, dysmorphology), sequence analysis
• 0157U — APC (APC regulator of WNT signaling pathway) (for example, familial adenomatosis polyposis [FAP]) mRNA sequence analysis (list separately in addition to code for primary procedure)
• 0158U — MLH1 (mutL homolog 1) (for example, hereditary nonpolyposis colorectal cancer, Lynch syndrome) mRNA sequence analysis (list separately in addition to code for primary procedure)
• 0159U — MSH2 (mutS homolog 2) (for example, hereditary colon cancer, Lynch syndrome) mRNA sequence analysis (list separately in addition to code for primary procedure)
• 0160U — MSH6 (mutS homolog 6) (for example, hereditary colon cancer, Lynch syndrome) mRNA sequence analysis (list separately in addition to code for primary procedure)
• 0161U — PMS2 (PMS1 homolog 2, mismatch repair system component) (for example, hereditary nonpolyposis colorectal cancer, Lynch syndrome) mRNA sequence analysis (list separately in addition to code for primary procedure)
• 0569T — Transcatheter tricuspid valve repair, percutaneous approach; initial prosthesis
• 0570T — Transcatheter tricuspid valve repair, percutaneous approach; each additional prosthesis during same session (list separately in addition to code for primary procedure)
• 0571T — Insertion or replacement of implantable cardioverter-defibrillator system with substernal electrode(s), including all imaging guidance and electrophysiological evaluation (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters), when performed
• 0572T — Insertion of substernal implantable defibrillator electrode
• 0587T — Percutaneous implantation or replacement of integrated single device neurostimulation system including electrode array and receiver or pulse generator, including analysis, programming, and imaging guidance when performed, posterior tibial nerve
• 0588T — Revision or removal of integrated single device neurostimulation system including electrode array and receiver or pulse generator, including analysis, programming, and imaging guidance when performed, posterior tibial nerve
• 64624 — Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed
• 81277 — Cytogenomic neoplasia (genome-wide) microarray analysis, interrogation of genomic regions for copy number and loss-of-heterozygosity variants for chromosomal abnormalities
• E0787 — External ambulatory infusion pump, insulin, dosage rate adjustment using therapeutic continuous glucose sensing
• E2398 — Wheelchair accessory, dynamic positioning hardware for back
• J0179 — Injection, brolucizumab- dbll, 1 mg

 

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

• Web: https://www.availity.com
• Fax: 1-800-964-3627
• Phone: 1-800-450-8753

 

Not all PA requirements are listed here. PA requirements are available to contracted providers by accessing the Provider Self-Service Tool at https://www.availity.com by visiting www.empireblue.com/nymedicaiddoc > Login. Contracted and noncontracted providers who are unable to access Availity* may call Provider Services at 1-800-450-8753 for PA requirements.

 

NYE-NU-0196-20 February 2020

On November 15, 2019, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Empire BlueCross BlueShield HealthPlus. These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting November 2019. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.*

 

* IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Empire BlueCross BlueShield HealthPlus.

 

NYE-NU-0199-20 February 2020

On December 18, 2019, and December 23, 2019, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Empire BlueCross BlueShield HealthPlus. These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting December 2019. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.

 

NYE-NU-0203-20 February 2020

 

Title: Update to corrected claims filing guidelines

The Corrected Claims reimbursement policy has been updated. Previously, the corrected claims timely filing standard was the following:

• For participating providers — 90 days from the date of service
• For nonparticipating providers — 15 months from the date of service

 

Effective August 1, 2020 we updated the corrected claims timely filing guidelines for Empire BlueCross BlueShield HealthPlus to follow the standard of 60 days from the date of payment for participating and nonparticipating providers.

 

NYE-NU-0193-20 February 2020

The Corrected Claims reimbursement policy has been updated. Previously, the corrected claims timely filing standard was the following:

• For participating providers — 90 days from the date of service
• For nonparticipating providers — 15 months from the date of service

 

Effective August 1, 2020 we updated the corrected claims timely filing guidelines for Empire BlueCross BlueShield HealthPlus to follow the standard of 60 days from the date of payment for participating and nonparticipating providers.

 

NYE-NU-0193-20 February 2020

The HEDIS® measure, Use of Imaging Studies for Low Back Pain (LBP), analyzes the percentage of patients 18 to 50 years of age during the measurement year with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis. The measure is used to determine whether imaging studies are overused to evaluate members with low back pain. The measure is an inverted rate. A higher score indicates appropriate treatment of low back pain.

 

Clinical guidelines for treating patients with acute low back pain recommend against the use of imaging in the absence of red flags (in other words, indications of a serious underlying pathology such as a fracture or tumor). Unnecessary or routine imaging is problematic because it is not associated with improved outcomes and exposes patients to unnecessary harms such as radiation exposure and further unnecessary treatment.

 

Measure exclusions:

Cancer Recent trauma Intravenous drug abuse Neurological impairment

HIV Spinal infection Major organ transplant Prolonged use of corticosteroids

 

Helpful tips:

Hold off on doing imaging for low back pain within the first six weeks, unless red flags are present.

 

Consider alternative treatment options prior to ordering diagnostic imaging studies, such as:

• Nonsteroidal anti-inflammatory drugs.
• Nonpharmacologic treatment, such as heat and massage.
• Exercise to strengthen the core and low back or physical therapy.

 

Other available resources:

• National Committee for Quality Assurance — NCQA.org
• Choosing Wisely — Choosingwisely.org
• American Academy of Family Physicians — AAFP.org

 

HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).

 

NYEPEC-2145-19 February 2020

Disease Management programs are designed to assist PCPs and specialists in caring for members with chronic health care needs. Empire BlueCross BlueShield HealthPlus provides members with continuous education on self-management, assistance in connecting to community resources, and coordination of care by a team of highly qualified professionals whose goal is to create a system of seamless health care interventions and communications for members.

 

Who is eligible?

Disease Management case managers provide support to members with:

• Behavioral health conditions such as depression, schizophrenia, bipolar disorder and substance use disorder.
• Diabetes.
• Heart conditions such as congestive heart failure, coronary artery disease and hypertension.
• HIV/AIDS.
• Pulmonary conditions such as asthma and chronic obstructive pulmonary disease.

 

Our case managers use member-centric motivational interviewing to identify and address health risks such as tobacco use and obesity to improve condition-specific outcomes. Interventions are rooted in evidence-based clinical practice guidelines from recognized sources. We implement continuous improvement strategies to increase evaluation, management and health outcomes.

 

We welcome your referrals. To refer a member to Disease Management:

• Call 1-888-830-4300 to speak directly to one of our team members.
• Fill out the Disease Management Referral Form located on the provider website and fax it to 1-888-762-3199 or submit electronically via the Availity Portal.

 

Your input and partnership are valued. Once your patient is enrolled, you will be notified by the assigned Disease Management case manager. You can also access your patient’s Disease Management care plan, goals and progress at any time via the Availity Portal through Patient360.

 

We are happy to answer any questions. Our registered nurse case managers are available Monday to Friday from 8:30 a.m. to 5:30 p.m. local time, and our confidential voicemail is available 24 hours a day, 7 days a week.

 

NYE-NU-0194-20 February 2020

 

As a participating provider, please be reminded of your contractual obligation to help ensure our members have prompt access to services. The provider manual is located on our provider website (www.empireblue.com/nymedicaiddoc) and contains our guidelines on access of care for PCPs, specialty care practitioners and behavioral health practitioner. We use several methods to monitor adherence to these standards. Monitoring is accomplished by:

• Assessing the availability of appointments via phone calls by our staff or designated vendor to the provider’s office.
• Analysis of member complaint data.
• Analysis of member satisfaction surveys.

 

The following information is excerpted from the provider manual for your review:

 

Physician/provider access goals and calendar requirements

One of our goals is to make accessing medical care easy for members by assuring a comprehensive network of physicians and providers close to their homes. As a result, we have implemented the following plan-wide geographic access goals as guidelines for our network. It is our goal to provide members with access to the following within our defined service areas:

• Two PCPs within five miles of each member
• Two OB/GYNs within eight miles of each member
• Full range of specialists (including non-MD allied providers) within 15 miles of each member

 

Calendar access requirements

 

PCPs

• Preventive care — For members scheduling periodic routine exams (well-care/preventive visits), appointments should be available within 45 calendar days of a member’s call. Examples of care provided to prevent illness or injury include routine physical examinations, immunizations, mammograms and Pap smears.
• Urgent care appointment with acute symptoms — Appointments should be available within 24 hours of the member’s call. Examples of care provided for a nonemergent illness or injury with acute symptoms that require immediate care include sprains, flu symptoms, minor cuts and wounds, sudden onset of stomach pain and severe, nonresolving headache.
• Routine care with symptoms — Members must have access to care within five days of their call.
• Routine check-up — Members must have access to care within 10 business days of their call. This consists of care provided for nonsymptomatic visits or follow-up.

 

• Though it is important for members to have the continuity of receiving care from their PCPs, there are occasions when you may not be available at a time that meets their scheduling needs. As a reminder, we now contract with walk-in centers and urgent care facilities, which are listed in our directory.

 

Specialists

• Urgent care appointment with acute symptoms — Appointments should be available within 24 hours of the member’s call. Examples of care provided for a nonemergent illness or injury with acute symptoms that require immediate care include sprains, flu symptoms, minor cuts and wounds, sudden onset of stomach pain and severe, nonresolving headache.
• Routine check-up — Members must have access to care within 15 calendar days of their call. Care provided for nonsymptomatic visits for health check.

 

Behavioral health providers

• Non-life threatening emergency needs — Members must be seen or have appropriate coverage directing the member within six hours. Emergent behavioral health care provided when a member is in crisis, experiencing acute distress and/or other symptoms, and needs immediate attention, but there is no risk of loss of life.
• Urgent needs — Members must be seen or have appropriate coverage directing the member within 24 hours. This includes nonemergent behavioral health illness that requires immediate care, member experiencing significant psychological distress with symptoms that impairs daily functioning, but there is no risk of loss of life.
• Initial routine office visit — Members must be seen within 10 business days. New patient nonurgent appointment scheduled after intake assessment or a direct referral from a treating practitioner.
• Follow-up routine visit — Members must be seen within five calendar days. Nonurgent behavioral health care includes when a member has been scheduled for a nonurgent consultation post-emergency room visit, post-inpatient care or requires services, including follow-up and existing medication management.

 

After-hours coverage

After-hours coverage, which is required by the Participating Provider Agreement, consists of an attendant or recording assisting the member in accessing urgent services outside of regular office hours. Note that telephone answering machines and voice mail are not acceptable means of providing access for members if the answering machine or voice mail message only refers members to the emergency room or to call 911.

 

The recording or live person must refer the patient to urgent care center, 911 or emergency room, and also provide the option to contact a live health care practitioner (via cell, pager, beeper, transfer system), get a call back for urgent instructions, or be transferred directly to the available practitioner or on-call practitioner.

 

Timely access to physicians is a major priority of our members and employer groups. The requirements adopted reflect not only their expectations, but market norms. We will be assessing physicians against these requirements through our customer satisfaction surveys and provider surveys, as well as follow-up on any members’ complaints received. However, we are sensitive to problems related to seasonal services, the varying nature of practice specialties, and the challenges faced by busy practices. If your office routinely fails to meet these access and after-hours standards, it is important that you document and we understand the reasons that the requirements are not met.

 

NYE-NU-0198-20 February 2020

Keep up with Medicaid news

Please continue to check Medicaid Provider Communications & Updates at www.empireblue.com/nymedicaiddoc

for the latest Medicaid information, including:

• SOMOS to manage delegated functions effective March 1, 2020
• Medical Policies and Clinical Utilization Management Guidelines update - November 2019

On November 15, 2019, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Empire BlueCross BlueShield. These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting November 2019. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.

 

IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Empire BlueCross BlueShield.

 

EBSCRNU-0095-20 February 2020

507833MUPENMUB

On December 18, 2019, and December 23, 2019, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Empire BlueCross BlueShield. These policies were developed, revised or reviewed to support clinical coding edits.

 

The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting December 2019. Visit Clinical Criteria to search for specific policies.

 

For questions or additional information, use this email.*

 

* IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Empire BlueCross BlueShield.

 

EBSCRNU-0098-20 February 2020

508037MUPENMUB

The Medicare Risk Adjustment Regulatory Compliance team at Empire BlueCross BlueShield offers two provider training programs regarding Medicare risk adjustment and documentation guidelines. Information for each training is outlined below.

 

Medicare Risk Adjustment and Documentation Guidance (General)

• When: The trainings will be offered the first Wednesday of each month from 1 p.m. to 2 p.m. ET (from January 8, 2020, to December 2, 2020).
• Learning objective: This onboarding training will provide an overview of Medicare risk adjustment, including the Risk Adjustment Factor and the Hierarchical Condition Category (HCC) model, with guidance on medical record documentation and coding.
• Credits: This live activity has been reviewed and is acceptable for up to 1 prescribed credit(s) by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

 

For those interested in joining us to learn how providers play a critical role in facilitating the risk adjustment process, register for one of the monthly training sessions at the link below:

 

Medicare Risk Adjustment and Documentation Guidance (General)

 

Note: Dates may be modified due to holiday scheduling.

 

Medicare Risk Adjustment, Documentation and Coding Guidance (Condition Specific)

• When: The trainings will be offered on the third Wednesday of every other month from noon to 1 p.m. ET (from January 15, 2020, to November 18, 2020).
• Learning objective:

This training series will provide in-depth disease information pertaining to specific conditions, including an overview of their corresponding hierarchical condition categories (HCC), with guidance on documentation and coding.

• Credits: This live series activity has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity

 

For those interested in joining us for this six-part training series, please see the list of topics and scheduled training dates below:

 

1. Red Flag HCCs Part 1 (January 15, 2020) — register for a recording of the session: Training will cover HCCs most commonly reported in error as identified by CMS (Chronic Kidney Disease Stage 5, Ischemic or Unspecified Stroke, Cerebral Hemorrhage, Aspiration and Specified Bacterial Pneumonias, Unstable Angina and Other Acute Ischemic Heart Disease, End-Stage Liver Disease).

• Link: Red Flag Hierarchical Condition Categories (HCCs), part one

1. Red Flag HCCs Part 2 (March 18, 2020): Training will cover HCCs most commonly reported in error as identified by CMS (Atherosclerosis of the Extremities with Ulceration or Gangrene, Myasthenia Gravis/Myoneural Disorders and Guillain-Barre Syndrome, Drug/Alcohol Psychosis, Lung and Other Severe Cancers, Diabetes with Ophthalmologic or Unspecified Manifestation)

• Link: Medicare Risk Adjustment Documentation and Coding Guidance: Red Flag HCC's Part 2

1. Neoplasms (May 20, 2020)

• Link: Neoplasms

1. Acute, Chronic and Status Conditions (July 15, 2020)

• Link: Acute, Chronic and Status Conditions

1. Diabetes Mellitus and Other Metabolic Disorders (September 16, 2020)

• Link: Diabetes Mellitus and Other Metabolic Disorders

1. TBD — This Medicare risk adjustment webinar will cover the critical topics and updates that surface during the year (November 18, 2020):

• Link: Topic TBD

 

EBSCRNU-0096-20 February 2020

507941MUPENMUB

Please continue to check Important Medicare Advantage Updates at empireblue.com/medicareprovider for the latest Medicare Advantage information, including:

• Information about the COVID-19 Virus Talking Points
• Coding tip for psychological and neuropsychological testing
• New MA Opioid Treatment Program benefit
• Medical Policies and Clinical Utilization Management Guidelines update - November 2019
• Prior authorization requirements: new 2020 codes for coverage and precertification